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Background: The association between high-risk plaque (HRP) on coronary computed tomography angiography (CTA) and the level of perivascular inflammation has not been fully investigated., Methods: Patients who underwent both CTA and optical coherence tomography (OCT) were included. The level of perivascular inflammation was assessed by pericoronary adipose tissue (PCAT) attenuation at two levels: lesion-specific and the proximal segment of the culprit vessel. HRP features included positive remodeling (PR), low-attenuation plaque (LAP), napkin-ring sign (NRS), and spotty calcification (SC)., Results: OCT features of plaque vulnerability were evaluated in culprit vessels. A total of 1360 lesions (413 culprit lesions and 947 non-culprit lesions) from 413 patients were evaluated. Lesion-specific PCAT attenuation was higher in lesions with any HRP feature except SC (present vs. absent: PR -71.3 ​± ​10.1 vs. -74.1 ​± ​11.7, P ​< ​0.001; LAP -71.7 ​± ​9.9 vs. -73.0 ​± ​11.4, P ​= ​0.025; NRS -70.3 ​± ​9.6 vs. -72.9 ​± ​11.1, P ​= ​0.001; and SC -71.9 ​± ​9.9 vs. -73.0 ​± ​11.5, P ​= ​0.082). After adjusting for confounders, only PR was associated with higher lesion-specific PCAT attenuation. The number of lesions with PR significantly correlated with higher levels of perivascular inflammation measured by culprit vessel PCAT attenuation. The number of lesions with PR was associated with higher lipid index and macrophage grade at culprit vessels., Conclusions: Among 4 HRP features, only PR was significantly associated with higher lesion-specific PCAT attenuation. The number of plaques with PR correlated with the level of perivascular inflammation and vulnerability., Trial Registration: clinicaltrials.gov Identifier: NCT04523194., Competing Interests: Declaration of competing interest Dr. Jang reports receiving educational grants from Abbott Vascular. Dr. Ferencik has received consulting fees from Siemens Healthineers, HeartFlow, Elucid, and Biomarin, stock options from Elucid, and is on the advisory board of Cleerly. All other authors have no relationships relevant to the contents of this paper to disclose., (Copyright © 2025 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Competing Interests: Declaration of competing interest Maros Ferencik reports consulting fees from Siemens Healthineers, Elucid, Heartflow, BioMarin, and Cleerly, advisory board Cleerly, and stock options Elucid. ADC reports consulting from Amgen, Siemens Healthineers and Cleerly, equity in Cleerly and grant support from GW Heart and Vascular Institute. MCW is supported by the British Heart Foundation (FS/ICRF/20/26002). MCW has given talks for Canon Medical Systems, Siemens Healthineers, GE Healthcare, and Novartis and performed consultancy for FEOPS and Canon Medical Systems. The remaining authors declare no relevant competing interests.

Backgrounds: Coronary computed tomography angiography (CTA) allows for the assessment of atherosclerotic plaque burden across the entire coronary vasculature. No studies have examined the relationship between the underlying pathology of the culprit lesion and total plaque burden in patients with acute coronary syndromes. The aim of this study was to compare the total plaque burden between patients with plaque rupture versus plaque erosion., Methods: A total of 232 patients who presented with their first non-ST-segment elevation acute coronary syndrome and underwent both CTA and optical coherence tomography imaging before intervention were selected. Quantitative analysis was performed using semi-automated software (Autoplaque version 3.0, Cedars-Sinai Medical Center). An attenuation of <30 Hounsfield units defined low-density non-calcified plaque (LDNCP). All 3 vessels were assessed using the modified 17-segment American Heart Association model for coronary segment classification., Results: Among 232 patients, 125 (53.9%) had plaque rupture and 107 (46.1%) had plaque erosion. Total plaque burden (48.2 [39.8-54.9] % vs. 44.1 [38.6-50.0] %, P ​= ​0.006), total non-calcified plaque (NCP) burden (46.6 [39.1-53.3] % vs. 43.0 [37.6-49.2] %, P ​= ​0.013), total LDNCP burden (2.3 [1.4-3.0] % vs. 1.7 [1.2-2.6] %, P ​= ​0.016), and total calcified plaque (CP) burden (0.8 [0.1-1.6] % vs. 0.4 [0.0-1.4] %, P ​= ​0.047) were significantly greater in patients with culprit plaque rupture than in those with culprit plaque erosion., Conclusion: Patients with plaque rupture, compared with those with plaque erosion, had a greater total plaque burden, NCP burden, LDNCP burden, and CP burden., Clinical Trial Registration: URL: https://www., Clinicaltrials: gov; Unique identifier: NCT04523194., Competing Interests: Declaration of competing interest Disclosures: Dr. Niida received a grant from the Japan Heart Foundation/Bayer Yakuhin Research Grant Abroad. Outside the present study, Dr. Dey has received software royalties from Cedars-Sinai Medical Center and has a patent. Dr. Ferencik has received consulting fees from Siemens Healthineers, HeartFlow, and Elucid and stock options from Elucid. Dr. Jang has received educational grants from Abbott Vascular and a consulting fee from Svelte Medical Systems. The remaining authors have nothing to disclose., (Copyright © 2024 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: The relationship between plaque burden and microscopic characterization of plaque features as it pertains to clinical presentation has not been fully investigated. The aim of this study was to compare the relationship between plaque burden and plaque vulnerability in patients with acute coronary syndromes (ACS) versus chronic coronary syndrome (CCS)., Methods: Patients who underwent both coronary computed tomography angiography (CTA) and optical coherence tomography (OCT) before coronary intervention were enrolled. All plaques were detected in culprit vessels using CTA, and total plaque volume (TPV) and OCT features were assessed at the corresponding sites. All plaques were divided into three groups according to the tertile levels of TPV (low TPV: <96.5 ​mm 3 , moderate TPV: 96.5-164.7 ​mm 3 , high TPV: ≥164.8 ​mm 3 )., Results: A total of 990 plaques were imaged by OCT in 419 patients: 445 plaques in 190 (45.3%) patients with ACS and 545 in 229 (54.7%) with CCS. Macrophage was more prevalent in plaques with greater TPV in patients who presented with ACS but not in those who presented with CCS (low vs. moderate vs. high TPV group: macrophage 57.4% vs. 71.8% vs. 82.4% in ACS; 63.4% vs. 67.8% vs. 66.7% in CCS; interaction P ​= ​0.004). Lipid arc increased as TPV increased, especially in patients who presented with ACS. Conversely, the layer index increased as TPV increased in patients with CCS., Conclusion: Greater plaque burden was closely related to higher levels of plaque vulnerability in ACS and greater volume of layered plaque in CCS., Trial Registration: clinicaltrials.gov Identifier: NCT04523194., Competing Interests: Declaration of competing interest Dr. Jang reports receiving educational grants from Abbott Vascular. Dr. Ferencik has received consulting fees from Siemens Healthineers, HeartFlow, Elucid, and Biomarin, stock options from Elucid, and is on the advisory board of Cleerly. All other authors have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: Coronary artery calcification is an integral part of atherosclerosis. It has been suggested that early coronary artery calcification is associated with active inflammation, and advanced calcification forms as inflammation subsides. Inflammation is also an important factor in plaque vulnerability. However, the relationship between coronary artery calcium burden, vascular inflammation, and plaque vulnerability has not been fully investigated., Objectives: This study aimed to correlate calcified plaque burden (CPB) at the culprit lesion with vascular inflammation and plaque vulnerability., Methods: Patients with coronary artery disease who had both computed tomography angiography and optical coherence tomography were included. The authors divided the patients into 4 groups: 1 group without calcification at the culprit lesion; and 3 groups based on the CPB tertiles. CPB was calculated as calcified plaque volume divided by vessel volume in the culprit lesion. The authors compared pericoronary adipose tissue (PCAT) attenuation for vascular inflammation and optical coherence tomography-derived vulnerable features among the 4 groups., Results: Among 578 patients, the highest CPB tertile showed significantly lower PCAT attenuation of culprit vessel compared with the other groups. The prevalence of features of plaque vulnerability (including lipid-rich plaque, macrophage, and microvessel) was also lowest in the highest CPB tertile. In the patients with calcification, higher age, statin use, and lower PCAT attenuation were independently associated with CPB., Conclusions: Greater calcium burden is associated with a lower level of vascular inflammation and plaque vulnerability. A greater calcium burden may represent advanced stable plaque without significant inflammatory activity. (Massachusetts General Hospital and Tsuchiura Kyodo General Hospital Coronary Imaging Collaboration; NCT04523194)., Competing Interests: Funding Support and Author Disclosures Dr Fujimoto was supported by fellowship grants from the Uehara Memorial Foundation (Tokyo, Japan) and the Fukuda Foundation for Medical Technology (Tokyo, Japan). Dr Ferencik has received consulting fees from Siemens Healthineers, Elucid, Heartflow, and BioMarin; served on the advisory board for Cleerly; and has stock options for Elucid. Dr Jang has received educational grants from Abbott Vascular; his research has been supported by Mrs Gillian Gray through the Allan Gray Fellowship Fund in Cardiology and by Mukesh and Priti Chatter through the Chatter Foundation. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

In current clinical practice, qualitative or semi-quantitative measures are primarily used to report coronary artery disease on cardiac CT. With advancements in cardiac CT technology and automated post-processing tools, quantitative measures of coronary disease severity have become more broadly available. Quantitative coronary CT angiography has great potential value for clinical management of patients, but also for research. This document aims to provide definitions and standards for the performance and reporting of quantitative measures of coronary artery disease by cardiac CT., Competing Interests: Declaration of competing interest Héctor M. García-García reports the following Institutional grant support: Biotronik, Boston Scientific, Medtronic, Abbott, Neovasc, Shockwave, Phillips and Corflow; Consultancy fee from Boston Scientific, Abbott and Amgen. Koen Nieman acknowledges support from the NIH (NIH R01- HL141712; NIH R01 - HL146754), and reports unrestricted institutional research support from Siemens Healthineers, Bayer, HeartFlow Inc, Novartis unrelated to this work, consulting for Novartis and Siemens Medical Solutions USA, Artrya, Cleerly, Elucid, and equity in Lumen Therapeutics. Maksymilian P. Opolski reports institutional grant support from B. Braun; consulting for Boston Scientific and proctorship for Boston Scientific, Terumo and Biotronik. Michelle Williams has given talks for Canon Medical Systems, Siemens Healthineers and Novartis. Damini Dey has received software royalties from Cedars-Sinai Medical Center and is supported by grants from the NIH/NHLBI (1R01HL148787-01A1 and 1R01HL151266). Jonathon Leipsic is a consultant and holds stock options in HeartFlow Inc., is a consultant to Circle CVI and has received modest corelab personal fees from Arineta and has received modest speaking fees from GE Healthcare and Philips HealthCare. Michael T Lu reports institutional research support from the American Heart Association (18UNPG34030172; 810,966), AstraZeneca, Ionis, Johnson & Johnson Innovation, Kowa, the National Academy of Medicine, and the NIH (U01HL123339; U24HL164284; R33HL141047; R01HL164629). Maros Ferencik received grant support from the American Heart Association and National Institutes of Health. Maros Ferencik received consulting fees HeartFlow, Elucid, Siemens Healthineers., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Positive remodeling is an integral part of the vascular adaptation process during the development of atherosclerosis, which can be detected by coronary computed tomography angiography (CTA)., Methods: A total of 426 patients who underwent both coronary CTA and optical coherence tomography (OCT) were included. Four machine learning (ML) models, gradient boosting machine (GBM), random forest (RF), deep learning (DL), and support vector machine (SVM), were employed to detect specific plaque features. A total of 15 plaque features assessed by OCT were analyzed. The variable importance ranking was used to identify the features most closely associated with positive remodeling., Results: In the variable importance ranking, lipid index and maximal calcification arc were consistently ranked high across all four ML models. Lipid index and maximal calcification arc were correlated with positive remodeling, showing pronounced influence at the lower range and diminishing influence at the higher range. Patients with more plaques with positive remodeling throughout their entire coronary trees had higher low-density lipoprotein cholesterol levels and were associated with a higher incidence of cardiovascular events during 5-year follow-up (Hazard ratio 2.10 [1.26-3.48], P ​= ​0.004)., Conclusion: Greater lipid accumulation and less calcium burden were important features associated with positive remodeling in the coronary arteries. The number of coronary plaques with positive remodeling was associated with a higher incidence of cardiovascular events., Competing Interests: Declaration of competing interest Dr. Jang reports receiving educational grants from Abbott Vascular and consulting fees from Svelte Medical Systems, Inc. Dr. Ferencik has received consulting fees from Siemens Healthineers, HeartFlow, and Elucid. All other authors have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Pulmonary arteriovenous malformations (PAVMs) occur in 30% to 50% of patients with hereditary hemorrhagic telangiectasia. Clinical presentations vary from asymptomatic disease to complications resulting from the right to left shunting of blood through the PAVM such as paradoxical stroke, brain abscesses, hypoxemia, and cardiac failure. Radiology plays an important role both in the diagnosis and treatment of PAVM. Based on different clinical scenarios, the appropriate imaging study has been reviewed and is presented in this document. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2024 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Although patients with high-risk plaque (HRP) on coronary computed tomography angiography (CTA) are reportedly at increased risk for future cardiovascular events, individual HRP features have not been systematically validated against high-resolution intravascular imaging., Objectives: The aim of this study was to correlate HRP features on CTA with plaque characteristics on optical coherence tomography (OCT)., Methods: Patients who underwent both CTA and OCT before coronary intervention were enrolled. Plaques in culprit vessels identified by CTA were evaluated with the use of OCT at the corresponding sites. HRP was defined as a plaque with at least 2 of the following 4 features: positive remodeling (PR), low-attenuation plaque (LAP), napkin-ring sign (NRS), and spotty calcification (SC). Patients were followed for up to 3 years., Results: The study included 448 patients, with a median age of 67 years and of whom 357 (79.7%) were male, and 203 (45.3%) presented with acute coronary syndromes. A total of 1,075 lesions were analyzed. All 4 HRP features were associated with thin-cap fibroatheroma. PR was associated with all OCT features of plaque vulnerability, LAP was associated with lipid-rich plaque, macrophage, and cholesterol crystals, NRS was associated with cholesterol crystals, and SC was associated with microvessels. The cumulative incidence of the composite endpoint (target vessel nontarget lesion revascularization and cardiac death) was significantly higher in patients with HRP than in those without HRP (4.7% vs 0.5%; P = 0.010)., Conclusions: All 4 HRP features on CTA were associated with features of vulnerability on OCT. (Massachusetts General Hospital and Tsuchiura Kyodo General Hospital Coronary Imaging Collaboration; NCT04523194)., Competing Interests: Funding Support and Author Disclosures Dr Jang’s research has been supported by Mrs. Gillian Gray through the Allan Gray Fellowship Fund in Cardiology and by Mukesh and Priti Chatter through the Chatter Foundation; and Dr Jang has received educational grants from Abbott Vascular and consulting fees from Svelte Medical Systems. Dr Ferencik has received consulting fees from Siemens Healthineers, HeartFlow, and Elucid. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Abdominal aortic aneurysm (AAA) is defined as abnormal dilation of the infrarenal abdominal aortic diameter to 3.0 cm or greater. The natural history of AAA consists of progressive expansion and potential rupture. Although most AAAs are clinically silent, a pulsatile abdominal mass identified on physical examination may indicate the presence of an AAA. When an AAA is suspected, an imaging study is essential to confirm the diagnosis. This document reviews the relative appropriateness of various imaging procedures for the initial evaluation of suspected AAA. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Acute onset of a cold, painful leg, also known as acute limb ischemia, describes the sudden loss of perfusion to the lower extremity and carries significant risk of morbidity and mortality. Acute limb ischemia requires rapid identification and the management of suspected vascular compromise and is inherently driven by clinical considerations. The objectives of initial imaging include confirmation of diagnosis, identifying the location and extent of vascular occlusion, and preprocedural/presurgical planning. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

This document discusses preprocedural planning for transcatheter aortic valve replacement, evaluating the imaging modalities used in initial imaging for preprocedure planning under two variants 1) Preintervention planning for transcatheter aortic valve replacement: assessment of aortic root; and 2) Preintervention planning for transcatheter aortic valve replacement: assessment of supravalvular aorta and vascular access. US echocardiography transesophageal, MRI heart function and morphology without and with IV contrast, MRI heart function and morphology without IV contrast and CT heart function and morphology with IV contrast are usually appropriate for assessment of aortic root. CTA chest with IV contrast, CTA abdomen and pelvis with IV contrast, CTA chest abdomen pelvis with IV contrast are usually appropriate for assessment of supravalvular aorta and vascular access. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Coronary artery disease reporting and data system (CAD-RADS) predicts future cardiovascular events in patients with coronary artery disease (CAD). However, information on vascular inflammation and vulnerability remains scarce., Methods: Patients who underwent coronary computed tomography angiography (CTA) and optical coherence tomography (OCT) prior to coronary intervention were enrolled. All three coronary arteries were evaluated for CAD-RADS score and pericoronary adipose tissue (PCAT) attenuation, while the culprit vessel was analyzed for plaque vulnerability by OCT., Results: A total of 385 patients with 915 lesions were divided into two groups based on CAD-RADS score: 103 (26.8%) were categorized as CAD-RADS 4b/5 and 282 (73.2%) as CAD-RADS ≤4a. Patients with CAD-RADS 4b/5 had a higher level of PCAT attenuation (mean of 3 coronary arteries) than those with CAD-RADS ≤4a (-68.4 ​± ​6.7 HU vs. -70.1 ​± ​6.5, P ​= ​0.022). The prevalence of macrophage was higher, and lipid index was greater in patients with CAD-RADS 4b/5 than CAD-RADS ≤4a (94.2% vs. 83.0%, P ​= ​0.004, 1845 vs. 1477; P ​= ​0.003). These associations were significant in the culprit vessels of patients with chronic coronary syndrome but not in those with acute coronary syndromes., Conclusions: Higher CAD-RADS score was associated with higher levels of vascular inflammation and plaque vulnerability., Competing Interests: Declaration of competing interest Dr. Jang reports receiving educational grants from Abbott Vascular and consulting fees from Svelte Medical Systems, Inc. Dr. Ferencik has received consulting fees from Siemens Healthineers, HeartFlow, and Elucid. All other authors have no relationships relevant to the contents of this paper to disclose., (Copyright © 2023 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: As cardiovascular computed tomography (CCT) practice evolves, the demand for specialists continues to increase. However, CCT training remains variable globally with limited contemporaneous data to understand this heterogeneity. We sought to understand the role of CCT globally and the training available to underpin its use., Methods: We performed two consecutive surveys of cardiology and radiology physicians, two years apart, utilizing the Society of Cardiovascular Computed Tomography (SCCT) website, weblinks, social media platforms, and meeting handouts to maximize our response rate. We compared United States (US)-based vs. international responses to understand global similarities and differences in practice and training in the surveys., Results: 235 respondents (37% trainees and 63% educators/non-trainees) initiated the first survey with 174 (74%) completing the core survey, with 205 providing their work location (114 US and 91 international). Eighty-four percent (92/110) of educator respondents stated a need for increased training opportunities to meet growing demand. Dedicated training fellowships are heterogenous, with limited access to structural heart imaging training, despite structural scanning being performed within institutions. The lack of a standardized curriculum was identified as the main obstacle to effective CCT learning, particularly in the US, with web-based learning platforms being the most popular option for improving access to CCT training. 148 trainees initiated the second survey with 107 (72%) completing the core components (51% North America, 49% international). Only 68% said they would be able to meet their required CCT education needs via their training program. Obstacles in obtaining CCT training again included a lack of a developed curriculum (51%), a lack of dedicated training time (35%), and a lack of local faculty expertise (31%). There was regional variability in access to CCT training, and, in contrast to the first survey, most (89%) felt 1:1 live review of cases with trained/expert reader was most useful for improving CCT training alongside formal curriculum/live lectures (72%)., Conclusions: There is a need to expand dedicated CCT training globally to meet the demand for complex CCT practice. Access to CCT education (didactic and 1:1 case-based teaching from expert faculty), implementation of recently published global training curricula, and increased teaching resources (web-based) as an adjunct to existing experiential learning opportunities, are all deemed necessary to address current educational shortfalls., Competing Interests: Declaration of competing interest The authors declare no relevant competing interests. N. Madan: None. D. J. Hur: None. M. P. Gannon: None. S. Gupta: None. J. R. Weir-McCall: None. C. Johns: None. A. Kumar: None. P. Nagpal: None. E. Fentanes: None. J. Lee: None. A. D. Choi: None. M. Ferencik: None. C. D. Maroules: None. T. C. Villines: None. E. D. Nicol: None., (Published by Elsevier Inc.)

As the incidence of thoracoabdominal aortic pathology (aneurysm and dissection) rises and the complexity of endovascular and surgical treatment options increases, imaging follow-up of patients remains crucial. Patients with thoracoabdominal aortic pathology without intervention should be monitored carefully for changes in aortic size or morphology that could portend rupture or other complication. Patients who are post endovascular or open surgical aortic repair should undergo follow-up imaging to evaluate for complications, endoleak, or recurrent pathology. Considering the quality of diagnostic data, CT angiography and MR angiography are the preferred imaging modalities for follow-up of thoracoabdominal aortic pathology for most patients. The extent of thoracoabdominal aortic pathology and its potential complications involve multiple regions of the body requiring imaging of the chest, abdomen, and pelvis in most patients. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2023 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Cardio-Oncology is a rapidly growing sub-specialty of medicine, however, there is very limited guidance on the use of cardiac CT (CCT) in the care of Cardio-Oncology patients. In order to fill in the existing gaps, this Expert Consensus statement comprised of a multidisciplinary collaboration of experts in Cardiology, Radiology, Cardiovascular Multimodality Imaging, Cardio-Oncology, Oncology and Radiation Oncology aims to summarize current evidence for CCT applications in Cardio-Oncology and provide practice recommendations for clinicians., Competing Interests: Conflict of interest The authors declare that they don't have conflicts of interest related to the contents of this document to declare. Please refer to Appendix 1 for disclosures about relationships with industry for each author., (Copyright © 2022 Society of Cardiovascular Computed Tomography. All rights reserved.)

Arterial claudication is a common manifestation of peripheral artery disease. This document focuses on necessary imaging before revascularization for claudication. Appropriate use of ultrasound, invasive arteriography, MR angiography, and CT angiography are discussed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Breast cancer is the most common malignancy in women in the United States, with surgical options including lumpectomy and mastectomy followed by breast reconstruction. Deep inferior epigastric perforator (DIEP) flap is a muscle-sparing perforator free flap breast reconstruction technique, which uses the deep inferior epigastric artery (DIEA) perforators to create a vascular pedicle. Multiple perforators are identified by preoperative imaging, which are typically ranked based on size, location, and intramuscular course. The goal of preoperative imaging is to aid the surgical team in preoperative planning given the variability of the DIEA perforator branches anatomy between patients. The objective of this document is to review the imaging modalities that can be used preoperatively to identify the optimal perforator and thereby reduce intraoperative complications, reduce postoperative complications, and improve clinical outcomes. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation., (Copyright © 2022 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Pretest probability (PTP) calculators utilize epidemiological-level findings to provide patient-level risk assessment of obstructive coronary artery disease (CAD). However, their limited accuracies question whether dissimilarities in risk factors necessarily result in differences in CAD. Using patient similarity network (PSN) analyses, we wished to assess the accuracy of risk factors and imaging markers to identify ≥50% luminal narrowing on coronary CT angiography (CCTA) in stable chest-pain patients., Methods: We created four PSNs representing: patient characteristics, risk factors, non-coronary imaging markers and calcium score. We used spectral clustering to group individuals with similar risk profiles. We compared PSNs to a contemporary PTP score incorporating calcium score and risk factors to identify ≥50% luminal narrowing on CCTA in the CT-arm of the PROMISE trial. We also conducted subanalyses in different age and sex groups., Results: In 3556 individuals, the calcium score PSN significantly outperformed patient characteristic, risk factor, and non-coronary imaging marker PSNs (AUC: 0.81 vs. 0.57, 0.55, 0.54; respectively, p ​< ​0.001 for all). The calcium score PSN significantly outperformed the contemporary PTP score (AUC: 0.81 vs. 0.78, p ​< ​0.001), and using 0, 1-100 and ​> ​100 cut-offs provided comparable results (AUC: 0.81 vs. 0.81, p ​= ​0.06). Similar results were found in all subanalyses., Conclusion: Calcium score on its own provides better individualized obstructive CAD prediction than contemporary PTP scores incorporating calcium score and risk factors. Risk factors may not be able to improve the diagnostic accuracy of calcium score to predict ≥50% luminal narrowing on CCTA., Competing Interests: Declaration of competing interest Kolossváry: None. Mayrhofer: None. Ferencik: Research grant from the AHA (Fellow to Faculty Award 13FTF16450001). Karády: None. Pagidipati: Grant support from Novo Nordisk. Shah: None. Nanna: Research grant from the American College of Cardiology Foundation supported by the George F. and Ann Harris Bellows Foundation and from the National Institute on Aging/National Institutes of Health from R03AG074067 (GEMSSTAR award). Foldyna: None. Douglas: Grant support from HeartFlow. Hoffmann: Grants from HeartFlow and Kowa Pharmaceuticals. Lu: Research support to the institution from AstraZeneca, MedImmune, and Kowa., (Copyright © 2022 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: Increased inflammation and myocardial injury can be observed in the absence of myocardial infarction or obstructive coronary artery disease (CAD)., Objectives: The authors determined whether biomarkers of inflammation and myocardial injury-interleukin (IL)-6 and high-sensitivity cardiac troponin (hs-cTn)-were associated with the presence and extent of CAD and were independent predictors of major adverse cardiovascular events (MACEs) in stable chest pain., Methods: Using participants from the PROMISE trial, the authors measured hs-cTn I and IL-6 concentrations and analyzed computed tomography angiography (CTA) images in the core laboratory for CAD characteristics: significant stenosis (≥70%), high-risk plaque (HRP), Coronary Artery Disease Reporting and Data System (CAD-RADS) categories, segment involvement score (SIS), and coronary artery calcium (CAC) score. The primary endpoint was a composite MACE (death, myocardial infarction, or unstable angina)., Results: The authors included 1,796 participants (age 60.2 ± 8.0 years; 47.5% men, median follow-up 25 months). In multivariable linear regression adjusted for atherosclerotic cardiovascular disease (ASCVD) risk, hs-cTn was associated with HRP, stenosis, CAD-RADS, and SIS. IL-6 was only associated with stenosis and CAD-RADS. hs-cTn above median (1.5 ng/L) was associated with MACEs in univariable analysis (HR: 2.1 [95% CI: 1.3-3.6]; P = 0.006), but not in multivariable analysis adjusted for ASCVD and CAD. IL-6 above median (1.8 ng/L) was associated with MACEs in multivariable analysis adjusted for ASCVD and HRP (HR: 1.9 [95% CI: 1.1-3.3]; P = 0.03), CAC (HR: 1.9 [95% CI: 1.0-3.4]; P = 0.04), and SIS (HR: 1.8 [95% CI: 1.0-3.2]; P = 0.04), but not for stenosis or CAD-RADS. In participants with nonobstructive CAD (stenosis 1%-69%), the presence of both hs-cTn and IL-6 above median was strongly associated with MACEs (HR: 2.5-2.7 after adjustment for CAD characteristics)., Conclusions: Concentrations of hs-cTn and IL-6 were associated with CAD characteristics and MACEs, indicating that myocardial injury and inflammation may each contribute to pathways in CAD pathophysiology. This association was most pronounced among participants with nonobstructive CAD representing an opportunity to tailor treatment in this at-risk group. (PROspective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE]; NCT01174550)., Competing Interests: Funding Support and Author Disclosures The PROMISE trial was funded by grants R01HL098237, R01HL098236, R01HL98305, and R01HL098235 from the National Heart, Lung, and Blood Institute (NHLBI). The funding source had no role in the design and conduct of this study, study analyses and interpretation of the data, the drafting and editing of the manuscript and its final contents, approval of the manuscript, and the decision to submit the manuscript for publication. The views expressed in this article do not necessarily represent the official views of the NHLBI. This article was prepared while Dr Ginsburg was employed at Duke University. The opinions expressed in this article are the author’s own and do not reflect the view of the National Institutes of Health, the Department of Health and Human Services, or the United States government. Dr Ferencik has received a grant from the American Heart Association, National Institutes of Health; and has received consulting fees from Biograph, Inc. Dr Bittner was supported by a grant from the National Institutes of Health/NHLBI (5K24HL113128). Dr Lu has received grant support from the American Roentgen Ray Society Scholarship during the conduct of the study; and has received personal fees from PQBypass outside of the submitted work. Dr Meyersohn was supported by National Institutes of Health/NHLBI (T32 HL076136). Dr Douglas has received grant support from HeartFlow; and has served on a data and safety monitoring board for GE HealthCare outside of the submitted work. Dr Hoffmann has received grants from the American College of Radiology Imaging Network and HeartFlow during the conduct of the study, and from Siemens Healthcare outside of the submitted work. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: The purpose of this study was to develop a risk prediction model for patients with nonobstructive CAD., Background: Among stable chest pain patients, most cardiovascular (CV) events occur in those with nonobstructive coronary artery disease (CAD). Thus, developing tailored risk prediction approaches in this group of patients, including CV risk factors and CAD characteristics, is needed., Methods: In PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) computed tomographic angiography patients, a core laboratory assessed prevalence of CAD (nonobstructive 1% to 49% left main or 1% to 69% stenosis any coronary artery), degree of stenosis (minimal: 1% to 29%; mild: 30% to 49%; or moderate: 50% to 69%), high-risk plaque (HRP) features (positive remodeling, low-attenuation plaque, and napkin-ring sign), segment involvement score (SIS), and coronary artery calcium (CAC). The primary end point was an adjudicated composite of unstable angina pectoris, nonfatal myocardial infarction, and death. Cox regression analysis determined independent predictors in nonobstructive CAD., Results: Of 2,890 patients (age 61.7 years, 46% women) with any CAD, 90.4% (n = 2,614) had nonobstructive CAD (mean age 61.6 yrs, 46% women, atherosclerotic cardiovascular disease [ASCVD] risk 16.2%). Composite events were independently predicted by ASCVD risk (hazard ratio [HR]: 1.03; p = 0.001), degree of stenosis (30% to 69%; HR: 1.91; p = 0.011), and presence of ≥2 HRP features (HR: 2.40; p = 0.008). Addition of ≥2 HRP features to: 1) ASCVD and CAC; 2) ASCVD and SIS; or 3) ASCVD and degree of stenosis resulted in a statistically significant improvement in model fit (p = 0.0036; p = 0.0176; and p = 0.0318; respectively). Patients with ASCVD ≥7.5%, any HRP, and mild/moderate stenosis had significantly higher event rates than those who did not meet those criteria (3.0% vs. 6.2%; p = 0.007)., Conclusions: Advanced coronary plaque features have incremental value over total plaque burden for the discrimination of clinical events in low-risk stable chest pain patients with nonobstructive CAD. This may be a first step to improve prevention in this cohort with the highest absolute risk for CV events., Competing Interests: Funding Support and Author Disclosures The PROMISE trial was supported by grants from the National Heart Lung and Blood Institute, Bethesda, Maryland: R01HL098237, R01HL098236, R01HL098305, and R01HL098235. Dr Taron is funded by the Deutsche Forschungsgemeinschaft (German Research Foundation; TA 1438/1-2); and is on the Speakers Bureau for Siemens Healthcare, unrelated to this work. Dr Osborne has received grant support from the National Institutes of Health (KL2TR002542) and Intrinsic Imaging, for unrelated work. Dr Meyersohn has received support from the National Institutes of Health/National Heart, Lung, and Blood Institute (T32 HL076136). Dr Lu has received consulting fees with PQBypass, a research grant from the Nvidia Corporation Academic Program, work as a co-investigator on research funded by AstraZeneca and Kowa, and grant support from the American Heart Association Precision Medicine Institute (18UNPG34030172) and the Harvard University Center for AIDS Research (NIH/NIAID 5P30AI060354-14). Dr Ferencik has received grant support from the American Heart Association (13FTF16450001). Dr Pagidipati has received research grants from Amgen, AstraZeneca, Baseline Study, Boehringer Ingelheim, Duke Clinical Research Institute, Eli Lilly & Company, Novo Nordisk Pharmaceutical Company, Regeneron Pharmaceuticals, Sanofi, and Verily Sciences Research Company; and consulting fees from AstraZeneca, Boehringer Ingelheim, Esperion Therapeutics, Eli Lilly & Company, and Novo Nordisk Pharmaceutical Company. Dr Douglas has received a research grant from HeartFlow. Dr Hoffmann has received a grant from the National Institutes of Health (K24HL113128), research support on behalf of the Massachusetts General Hospital from Duke University, HeartFlow, Kowa Company, and MedImmune/AstraZeneca; and consulting fees from Duke University and Recor Medical unrelated to this research. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Objectives: This study sought to quantify and compare the decline in volumes of cardiovascular procedures between the United States and non-U.S. institutions during the early phase of the coronavirus disease-2019 (COVID-19) pandemic., Background: The COVID-19 pandemic has disrupted the care of many non-COVID-19 illnesses. Reductions in diagnostic cardiovascular testing around the world have led to concerns over the implications of reduced testing for cardiovascular disease (CVD) morbidity and mortality., Methods: Data were submitted to the INCAPS-COVID (International Atomic Energy Agency Non-Invasive Cardiology Protocols Study of COVID-19), a multinational registry comprising 909 institutions in 108 countries (including 155 facilities in 40 U.S. states), assessing the impact of the COVID-19 pandemic on volumes of diagnostic cardiovascular procedures. Data were obtained for April 2020 and compared with volumes of baseline procedures from March 2019. We compared laboratory characteristics, practices, and procedure volumes between U.S. and non-U.S. facilities and between U.S. geographic regions and identified factors associated with volume reduction in the United States., Results: Reductions in the volumes of procedures in the United States were similar to those in non-U.S. facilities (68% vs. 63%, respectively; p = 0.237), although U.S. facilities reported greater reductions in invasive coronary angiography (69% vs. 53%, respectively; p < 0.001). Significantly more U.S. facilities reported increased use of telehealth and patient screening measures than non-U.S. facilities, such as temperature checks, symptom screenings, and COVID-19 testing. Reductions in volumes of procedures differed between U.S. regions, with larger declines observed in the Northeast (76%) and Midwest (74%) than in the South (62%) and West (44%). Prevalence of COVID-19, staff redeployments, outpatient centers, and urban centers were associated with greater reductions in volume in U.S. facilities in a multivariable analysis., Conclusions: We observed marked reductions in U.S. cardiovascular testing in the early phase of the pandemic and significant variability between U.S. regions. The association between reductions of volumes and COVID-19 prevalence in the United States highlighted the need for proactive efforts to maintain access to cardiovascular testing in areas most affected by outbreaks of COVID-19 infection., Competing Interests: Funding Support and Author Disclosures This work was supported by the International Atomic Energy Agency. Dr. Blankstein has previously received research support from Amgen and Astellas Inc. Dr. Ferencik has been previously supported by U.S. National Institutes of Health (NIH) and American Heart Association; and is a consultant for Biograph, Inc. Dr. Nørgaard has previously received unrestricted institutional research grants from Siemens and HeartFlow. Dr. Maurovich-Horvat has been a shareholder of Neumann Medical Ltd. Dr. Einstein has previously received grants from NIH, International Atomic Energy Agency, Canon Medical Systems, Roche Medical Systems, WL Gore, and GE Health care; consultant for WL Gore; on the Speakers Bureau for Ionetix; has received travel/accommodations/meeting expenses from HeartFlow; and is a stockholder in Emergent BioSolutions Inc. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2021 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Nontraumatic aortic disease can be caused by a wide variety of disorders including congenital, inflammatory, infectious, metabolic, neoplastic, and degenerative processes. Imaging examinations such as radiography, ultrasound, echocardiography, catheter-based angiography, CT, MRI, and nuclear medicine examinations are essential for diagnosis, treatment planning, and assessment of therapeutic response. Depending upon the clinical scenario, each of these modalities has strengths and weaknesses. Whenever possible, the selection of a diagnostic imaging examination should be based upon the best available evidence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment. The purpose of this document is to assist physicians select the most appropriate diagnostic imaging examination for nontraumatic aortic diseases., (Copyright © 2021 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Coronary computed tomographic angiography (CCTA) provides a wealth of clinically meaningful information beyond anatomic stenosis alone, including the presence or absence of nonobstructive atherosclerosis and high-risk plaque features as precursors for incident coronary events. There is, however, no uniform agreement on how to identify and quantify these features or their use in evidence-based clinical decision-making. This statement from the Society of Cardiovascular Computed Tomography and North American Society of Cardiovascular Imaging addresses this gap and provides a comprehensive review of the available evidence on imaging of coronary atherosclerosis. In this statement, we provide standardized definitions for high-risk plaque (HRP) features and distill the evidence on the effectiveness of risk stratification into usable practice points. This statement outlines how this information should be communicated to referring physicians and patients by identifying critical elements to include in a structured CCTA report - the presence and severity of atherosclerotic plaque (descriptive statements, CAD-RADS™ categories), the segment involvement score, HRP features (e.g., low attenuation plaque, positive remodeling), and the coronary artery calcium score (when performed). Rigorous documentation of atherosclerosis on CCTA provides a vital opportunity to make recommendations for preventive care and to initiate and guide an effective care strategy for at-risk patients., (Copyright © 2020. Published by Elsevier Inc.)

Objectives: The purpose of this study was to compare Coronary Artery Disease Reporting and Data System (CAD-RADS) to traditional stenosis categories and the coronary artery calcium score (CACS) for predicting cardiovascular events in patients with stable chest pain and suspected coronary artery disease (CAD)., Background: The 2016 CAD-RADS has been established to standardize the reporting of CAD on coronary CT angiography (CTA)., Methods: PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial participants' CTAs were assessed by a central CT core laboratory for CACS, traditional stenosis-based categories, and modified CAD-RADS grade including high-risk coronary plaque (HRP) features. Traditional stenosis categories and CAD-RADS grade were compared for the prediction of the composite endpoint of death, myocardial infarction, or hospitalization for unstable angina over a median follow-up of 25 months. Incremental prognostic value over traditional risk factors and CACS was assessed., Results: In 3,840 eligible patients (mean age: 60.4 ± 8.2 years; 49% men), 3.0% (115) experienced events. CAD-RADS (concordance statistic [C-statistic] 0.747) had significantly higher discriminatory value than traditional stenosis-based assessments (C-statistic 0.698 to 0.717; all p for comparison ≤0.001). With no plaque (CAD-RADS 0) as the baseline, the hazard ratio (HR) for an event increased from 2.43 (95% confidence interval [CI]: 1.16 to 5.08) for CAD-RADS 1 to 21.84 (95% CI: 8.63 to 55.26) for CAD-RADS 4b and 5. In stepwise nested models, CAD-RADS added incremental prognostic value beyond ASCVD risk score and CACS (C-statistic 0.776 vs. 0.682; p < 0.001), and added incremental value persisted in all CACS strata., Conclusions: These data from a large representative contemporary cohort of patients undergoing coronary CTA for stable chest pain support the prognostic value of CAD-RADS as a standard reporting system for coronary CTA., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

The purpose of this review is to summarize the work published by the Journal of Cardiovascular Computed Tomography (JCCT) for the year 2019, highlighting original research and new guidelines., Competing Interests: Declaration of competing interest CNC receives research support from and has received speaker fees from Siemens Healthineers. JAL serves as a consultant and holds stock options with Circle CVI and HeartFlow and receives research support from GE Healthcare. JKM receives funding from the Dalio Foundation, NIH, and GE Healthcare. JKM also serves on the scientific advisory board of Arineta and GE Healthcare, and has an equity interest in Cleerly., (Copyright © 2020 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: Randomized trials have shown favorable clinical outcomes for coronary CT angiography (CTA) in patients with suspected acute coronary syndrome (ACS). Our goal was to estimate the cost-effectiveness of coronary CTA as compared to alternative management strategies for ACP patients over lifetime., Methods: Markov microsimulation model was developed to compare cost-effectiveness of competitive strategies for ACP patients: 1) coronary CTA, 2) standard of care (SOC), 3) AHA/ACC Guidelines, and 4) expedited emergency department (ED) discharge protocol with outpatient testing. ROMICAT-II trial was used to populate the model with low to intermediate risk of ACS patient data, whereas diagnostic test-, treatment effect-, morbidity/mortality-, quality of life- and cost data were obtained from the literature. We predicted test utilization, costs, 1-, 3-, 10-year and over lifetime cardiovascular morbidity/mortality for each strategy. We determined quality adjusted life years (QALY) and incremental cost-effectiveness ratio. Observed outcomes in ROMICAT-II were used to validate the short-term model., Results: Estimated short-term outcomes accurately reflected observed outcomes in ROMICAT-II as coronary CTA was associated with higher costs ($4,490 vs. $2,513-$4,144) and revascularization rates (5.2% vs. 2.6%-3.7%) compared to alternative strategies. Over lifetime, coronary CTA dominated SOC and ACC/AHA Guidelines and was cost-effective compared to expedited ED protocol ($49,428/QALY). This was driven by lower cardiovascular mortality (coronary CTA vs. expedited discharge: 3-year: 1.04% vs. 1.10-1.17; 10-year: 5.06% vs. 5.21-5.36%; respectively)., Conclusion: Coronary CTA in patients with suspected ACS renders affordable long-term health benefits as compared to alternative strategies., (Copyright © 2020 Society of Cardiovascular Computed Tomography. All rights reserved.)

Background: Non-invasive fractional flow reserve (FFR CT ) derived from coronary computed tomography angiography (CTA) permits hemodynamic evaluation of coronary stenosis and may improve efficiency of assessment in stable chest pain patients. We determined feasibility of FFR CT in the population of acute chest pain patients and assessed the relationship of FFR CT with outcomes of acute coronary syndrome (ACS) and revascularization and with plaque characteristics., Methods: We included 68 patients (mean age 55.8 ± 8.4 years, 71% men) from the ROMICAT II trial who had ≥50% stenosis on coronary CTA or underwent additional non-invasive stress test. We evaluated coronary stenosis and high-risk plaque on coronary CTA. FFR CT was measured in a core laboratory., Results: We found correlation between anatomic severity of stenosis and FFR CT ≤0.80 vs. FFR CT >0.80 (severe stenosis 84.8% vs. 15.2%; moderate stenosis 33.3% vs. 66.7%; mild stenosis 33.3% vs. 66.7% patients). Patients with severe stenosis had lower FFR CT values (median 0.64, 25th-75th percentile 0.50-0.75) as compared to patients with moderate (median 0.84, 25th-75th percentile, p < 0.001) or mild stenosis (median 0.86, 25th-75th percentile 0.78-0.88, p < 0.001). The relative risk of ACS and revascularization in patients with positive FFR CT ≤0.80 was 4.03 (95% CI 1.56-10.36) and 3.50 (95% CI 1.12-10.96), respectively. FFR CT ≤0.80 was associated with the presence of high-risk plaque (odds ratio 3.91, 95% CI 1.55-9.85, p = 0.004) after adjustment for stenosis severity., Conclusion: Abnormal FFR CT was associated with the presence of ACS, coronary revascularization, and high-risk plaque. FFR CT measurements correlated with anatomic severity of stenosis on coronary CTA and were feasible in population of patients with acute chest pain., (Copyright © 2019 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Objectives: The goal of this study was to examine associations between concentrations of high-sensitivity troponin I (hsTnI) (measured by using a single-molecule counting method) and obstructive coronary artery disease (CAD) in 1,844 stable, symptomatic outpatients with suspected CAD randomized to undergo coronary computed tomography angiography (CTA) in the PROMISE (Prospective Multicenter Imaging Study for Evaluation of Chest Pain) trial., Background: Elevated concentrations of hsTnI are associated with CAD in patients with myocardial infarction. The meaning of hsTnI concentrations in stable symptomatic outpatients is not well understood., Methods: Clinical characteristics and CTA results (including coronary artery calcium [CAC] scores) were expressed across hsTnI quartiles. Determinants of hsTnI concentration were identified. Multivariable logistic regression identified independent predictors of obstructive CAD 50 (≥50% stenosis in any vessel) and CAD 70 (≥70% stenosis or ≥50% left main)., Results: The median hsTnI concentration was 1.5 ng/l; nearly all (98.5%) subjects had measurable hsTnI, and 6.1% had concentrations ≥99th percentile concentration for this assay (6 ng/l). Higher CAC scores, as well as more prevalent and diffuse CAD, was seen in upper hsTnI quartiles (all p < 0.001). Independent predictors of hsTnI concentrations included age, sex, and CAC score (all p < 0.05). After adjusting for demographic and clinical characteristics, log-transformed hsTnI concentrations were associated with obstructive CAD 50 (odds ratio: 1.15 per interquartile range; p = 0.02) and CAD 70 (odds ratio: 1.25 per interquartile range; p = 0.001)., Conclusions: In stable symptomatic outpatients undergoing nonemergent coronary CTA for the diagnosis of suspected CAD, higher concentrations of hsTnI were associated with increasing presence and severity of coronary atherosclerosis. (Prospective Multicenter Imaging Study for Evaluation of Chest Pain [PROMISE]; NCT01174550)., (Copyright © 2019 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

A broad range of nonatherosclerotic diseases affect the peripheral arteries. The appropriate initial diagnostic imaging studies vary, depending upon the clinical presentation and suspicion of disease. Accurate vascular imaging relies upon visualization of the vessel lumen, vessel wall, and surrounding soft-tissue structures, with some modalities also offering the ability to characterize blood flow direction and velocity. Furthermore, nonvascular findings are often paramount in supporting a suspected clinical syndrome or guiding surgical management. The scenarios discussed in this document include the initial evaluation of suspected popliteal entrapment syndrome, external iliac artery endofibrosis, lower-extremity inflammatory vasculitides, dissection or connective tissue disease, noninflammatory vascular disease, and vascular trauma. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2019 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Proteasome inhibitors used in the treatment of multiple myeloma act primarily through the disruption of intrinsic cellular protein quality maintenance, resulting in proteotoxic stress, cellular dysfunction, and, ultimately, cell death. We assessed whether evidence has shown off-target myocardial dysfunction related to the administration of bortezomib-based chemotherapy for multiple myeloma., Patients and Methods: Patients aged 18 to 70 years who were free of significant cardiovascular disease were included. They underwent evaluations before and after each dose of bortezomib to assess for clinical, subclinical, and transient cardiotoxicity using echocardiography and serum biomarker measurement. Cardiac magnetic resonance imaging was performed at 3 separately defined intervals. The primary modality for determining subclinical myocardial dysfunction was echocardiographic assessment of the global longitudinal strain (GLS)., Results: Eleven patients (7 men) with an average age of 55 years were included. No evidence of cumulative myocardial dysfunction was found using echocardiographic markers, primarily GLS (average change in absolute GLS, -1.17; P = .064). Additionally, no echocardiographic evidence of transient cardiotoxicity was found. The left ventricular ejection fraction (LVEF) also did not show any significant changes (ΔLVEF, -2.17%; P = .15). Magnetic resonance imaging confirmed no changes in structure or function (ΔLVEF, -2.6%; P = .54) and extracellular volume fraction (Δ = 2%; P = .46). The serum biomarker levels also did not change significantly over time., Conclusion: We did not observe cardiotoxicity from bortezomib-based chemotherapy despite very intensive evaluation with multiple modalities. Neither cumulative nor transient alterations were found in our metrics, suggesting that bortezomib is safe from a cardiovascular standpoint for patients free of cardiovascular disease., (Copyright © 2018 Elsevier Inc. All rights reserved.)