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We examined obstructive and nonobstructive plaque volumes in populations with subclinical and clinically manifested coronary artery disease (CAD) using quantitative computed tomography (QCT). 855 participants with CAD (274 asymptomatic individuals, 254 acute chest pain patients without acute coronary syndrome (ACS), and 327 patients with ACS) underwent QCT of proximal coronary segments to assess participant-level plaque volumes of dense calcium, fibrous, fibrofatty, and necrotic core tissue. Nonobstructive (<50% stenosis) plaque volumes were greater than obstructive plaque volumes, irrespective of population (all p <0.0001): Asymptomatic individuals (mean (95% CI)): 218 [190-250] vs. 16 [12-22] mm3; acute chest pain patients without ACS: 300 [263-341] vs. 51 [41-62] mm3; patients with ACS: 370 [332-412] vs. 159 [139-182] mm3. After multivariable adjustment, nonobstructive fibrous and fibrofatty tissue volumes were greater in acute chest pain patients without ACS compared to asymptomatic individuals (fibrous tissue: 122 [107-139] vs. 175 [155-197] mm3, p <0.01; fibrofatty tissue: 44 [38-50] vs. 71 [63-80] mm3, p <0.01. Necrotic core tissue was greater in ACS patients (29 [26-33] mm3) compared to both asymptomatic individuals (15 [13-18] mm3, p <0.0001) and acute chest pain patients without ACS (21 [18-24] mm3, p <0.05). Nonobstructive dense calcium volumes did not differ between the three populations: 29 [24-36], 29 [23-35], and 41 [34-48] mm3, p >0.3 respectively. Nonobstructive CAD was the predominant contributor to total atherosclerotic plaque volume in both subclinical and clinically manifested CAD. Nonobstructive fibrous, fibrofatty and necrotic core tissue volumes increased with worsening clinical presentation, while nonobstructive dense calcium tissue volumes did not. [ABSTRACT FROM AUTHOR]

Cardiac resynchronization therapy (CRT) improves symptoms, health-related quality of life and long-term survival in patients with systolic heart failure (HF) and shortens QRS duration. However, up to one third of patients attain no measurable clinical benefit from CRT. An important determinant of clinical response is optimal choice in left ventricular (LV) pacing site. Observational data have shown that achieving an LV lead position at a site of late electrical activation is associated with better clinical and echocardiographic outcomes compared to standard placement, but mapping-guided LV lead placement towards the site of latest electrical activation has never been investigated in a randomized controlled trial (RCT). The purpose of this study was to evaluate the effect of targeted positioning of the LV lead towards the latest electrically activated area. We hypothesize that this strategy is superior to standard LV lead placement. The DANISH-CRT trial is a national, double-blinded RCT (ClinicalTrials.gov NCT03280862). A total of 1,000 patients referred for a de novo CRT implantation or an upgrade to CRT from right ventricular pacing will be randomized 1:1 to receive conventional LV lead positioning preferably in a nonapical posterolateral branch of the coronary sinus (CS) (control group) or targeted positioning of the LV lead to the CS branch with the latest local electrical LV activation (intervention group). In the intervention group, late activation will be determined using electrical mapping of the CS. The primary endpoint is a composite of death and nonplanned HF hospitalization. Patients are followed for a minimum of 2 years and until 264 primary endpoints occurred. Analyses will be conducted according to the intention-to-treat principle. Enrollment for this trial began in March 2018, and per April 2023, a total of 823 patients have been included. Enrollment is expected to be complete by mid-2024. The DANISH-CRT trial will clarify whether mapping-guided positioning of the LV lead according to the latest local electrical activation in the CS is beneficial for patients in terms of reducing the composite endpoint of death or nonplanned hospitalization for heart failure. Results from this trial are expected to impact future guidelines on CRT. NCT03280862. [ABSTRACT FROM AUTHOR]

The coronary atheroma burden drives major adverse cardiovascular events (MACE) in patients with suspected coronary heart disease (CHD). However, a consensus on how to grade disease burden for effective risk stratification is lacking. The purpose of this study was to compare the effectiveness of common CHD grading tools to risk stratify symptomatic patients. We analyzed the 5-year outcome of 381 prospectively enrolled patients in the CORE320 international, multicenter study using baseline clinical and cardiac computer-tomography (CT) imaging characteristics, including coronary artery calcium score (CACS), percent atheroma volume, "high-risk" plaque, disease severity grading using the CAD-RADS, and two simplified CAD staging systems. We applied Cox proportional hazard models and area under the curve (AUC) analysis to predict MACE or hard MACE, defined as death, myocardial infarction, or stroke. Analyses were stratified by a history of CHD. Additional forward selection analysis was performed to evaluate incremental value of metrics. Clinical characteristics were the strongest predictors of MACE in the overall cohort. In patients without history of CHD, CACS remained the only independent predictor of MACE yielding an AUC of 73 (CI 67–79) vs. 64 (CI 57–70) for clinical characteristics. Noncalcified plaque volume did not add prognostic value. Simple CHD grading schemes yielded similar risk stratification as the CAD-RADS classification. Forward selection analysis confirmed prominent role of CACS and revealed usefulness of functional testing in subgroup with known CHD. In patients referred for invasive angiography, a history of CHD was the strongest predictor of MACE. In patients without history of CHD, a coronary calcium score yielded at least equal risk stratification vs. more complex CHD grading. • Risk factors and plaque metrics perform differently among patients with and without history of CHD. • Plaque burden assessment does not offer incremental value over clinical predictors in patients with known CHD. • CACS provides superior performance to risk stratify patients without history of CHD. • In symptomatic patients, risk stratification using CACS might deserve a more prominent role. [ABSTRACT FROM AUTHOR]

Absolute measures of myocardial blood flow (MBF) obtained with dynamic myocardial CT perfusion (DM-CTP) are underestimated when compared with reference standards. This is to some extent explained by incomplete extraction of iodinated contrast agent (iCA) to the myocardial tissue. We aimed to establish an extraction function for iCA, use the function to calculate MBF CT and to compare this with MBF measured with 82Rb positron emission tomography (PET). Healthy individuals without coronary artery disease (CAD) were examined with 82Rb PET and DM-CTP. The factors a and β of the generalized Renkin-Crone model were estimated using a non-linear least squares model. The factors providing the best fit for the data were subsequently used to calculate MBF CT. Of consecutive 91 individuals examined, 79 were eligible for analysis. The factors a and β providing the best fit of the nonlinear least-squares model to the data were a ​= ​0.614 and β ​= ​0.218 (R-squared ​= ​0.81). Conversion of the CT inflow parameter (K1) values using the derived extraction function resulted in a significant correlation between MBF measured during stress using CT and PET (P ​= ​0.039). In healthy individuals, flow estimates obtained with dynamic myocardial CT perfusion during stress were, after conversion to MBF using the extraction of iodinated CT contrast agent, correlated with absolute MBF quantified with 82Rb PET. TOC summary : Myocardial blood flow (MBF) obtained with dynamic myocardial CT perfusion is underestimated when compared with reference standards. This is partially explained by incomplete extraction of iodinated contrast to the myocardial tissue. We aimed to establish an extraction function for iodinated contrast in healthy individuals without coronary artery disease, use the function to calculate MBF and to compare this with MBF measured with 82Rb positron emission tomography. We found that flow estimates obtained with dynamic myocardial CT perfusion during stress were, after conversion to MBF using the extraction of iodinated contrast, correlated with absolute MBF quantified with 82Rb positron emission tomography. [ABSTRACT FROM AUTHOR]

Dynamic myocardial CT perfusion (CTP) has emerged as a potential strategy to combine anatomical and functional evaluation in a single modality. However, this method results in a high radiation dose. Dynamic CTP was performed in 56 patients with suspected or known ischemic heart disease of whom 48 had complete CT-data. Datasets with reduced sampling rate of 2- and 3 RR-intervals (2RR and 3RR) were constructed post hoc. Myocardial blood flow (MBF) estimates from the 2RR and 3RR datasets were compared with estimates based on the full dataset (1RR) using the two one-sided test of equivalence for paired samples. Significant equivalence was found for rest MBF LV (p ​< ​0.001), stress MBF LV (p ​< ​0.001) and for the CFR LV (p ​= ​0.005) when comparing 2RR blood flow estimates with the results based on the 1RR dataset. The 2RR reconstruction protocol led to an estimated reduction in radiation dose of 35.4 ​± ​3.8%. MBF can be quantitated with dynamic CTP using a sampling strategy of one volume for every second heartbeat. This strategy could lead to a significant reduction in radiation dose. Dynamic myocardial CT perfusion (CTP) has emerged as a new method for combined anatomic and functional evaluation of coronary artery disease in a single modality. However, a disadvantage of dynamic CTP is the applied radiation dose. This paper reports that dynamic CTP using a sampling strategy of one volume for every second heartbeat can produce results similar to a protocol using every beat. This is crucial information when trying to lower the radiation dose without affecting robustness of results. [Display omitted] [ABSTRACT FROM AUTHOR]

Background: Severity and extent of coronary artery disease (CAD) assessed by invasive coronary angiography (ICA) guide treatment and may predict clinical outcome in patients with non-ST-segment elevation acute coronary syndrome (NSTEACS).Objectives: This study tested the hypothesis that coronary computed tomography angiography (CTA) is equivalent to ICA for risk assessment in patients with NSTEACS.Methods: The VERDICT (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes) trial evaluated timing of treatment in relation to outcome in patients with NSTEACS and included a clinically blinded coronary CTA conducted prior to ICA. Severity of CAD was defined as obstructive (coronary stenosis ≥50%) or nonobstructive. Extent of CAD was defined as high risk (obstructive left main or proximal left anterior descending artery stenosis and/or multivessel disease) or non-high risk. The primary endpoint was a composite of all-cause death, nonfatal recurrent myocardial infarction, hospital admission for refractory myocardial ischemia, or heart failure.Results: Coronary CTA and ICA were conducted in 978 patients. During a median follow-up time of 4.2 years (interquartile range: 2.7 to 5.5 years), the primary endpoint occurred in 208 patients (21.3%). The rate of the primary endpoint was up to 1.7-fold higher in patients with obstructive CAD compared with in patients with nonobstructive CAD as defined by coronary CTA (hazard ratio [HR]: 1.74; 95% confidence interval [CI]: 1.22 to 2.49; p = 0.002) or ICA (HR: 1.54; 95% CI: 1.13 to 2.11; p = 0.007). In patients with high-risk CAD, the rate of the primary endpoint was 1.5-fold higher compared with the rate in those with non-high-risk CAD as defined by coronary CTA (HR: 1.56; 95% CI: 1.18 to 2.07; p = 0.002). A similar trend was noted for ICA (HR: 1.28; 95% CI: 0.98 to 1.69; p = 0.07).Conclusions: Coronary CTA is equivalent to ICA for the assessment of long-term risk in patients with NSTEACS. (Very Early Versus Deferred Invasive Evaluation Using Computerized Tomography in Patients With Acute Coronary Syndromes [VERDICT]; NCT02061891). [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the impact of initial deployment orientation of SAPIEN 3, Evolut, and ACURATE-neo transcatheter heart valves on their final orientation and neocommissural overlap with coronary arteries. Coronary artery access and redo transcatheter aortic valve replacement (TAVR) following initial TAVR may be influenced by transcatheter heart valve orientation. In this study the impact of transcatheter heart valve deployment orientation on commissural alignment was evaluated. Pre-TAVR computed tomography and procedural fluoroscopy were analyzed in 828 patients who underwent TAVR (483 SAPIEN 3, 245 Evolut, and 100 ACURATE-neo valves) from March 2016 to September 2019 at 5 centers. Coplanar fluoroscopic views were coregistered to pre-TAVR computed tomography to determine commissural alignment. Severe overlap between neocommissural posts and coronary arteries was defined as 0° to 20° apart. The SAPIEN 3 had 1 commissural post crimped at 3, 6, 9, and 12 o'clock. The Evolut "Hat" marker and ACURATE-neo commissural post at deployment were classified as center back (CB), inner curve (IC), outer curve (OC), or center front (CF) and matched with final orientation. Initial SAPIEN 3 crimped orientation had no impact on commissural alignment. Evolut "Hat" at OC or CF at initial deployment had less severe overlap than IC or CB (p < 0.001) against the left main (15.7% vs. 66.0%) and right coronary (7.1% vs. 51.1%) arteries. Tracking Evolut "Hat" at OC of the descending aorta (n = 107) improved OC at deployment from 70.2% to 91.6% (p = 0.002) and reduced coronary artery overlap by 36% to 60% (p < 0.05). ACURATE-neo commissural post at CB or IC during deployment had less coronary artery overlap compared to CF or OC (p < 0.001), with intentional alignment successful in 5 of 7 cases. This is the first systematic evaluation of commissural alignment in TAVR. More than 30% to 50% of cases had overlap with 1 or both coronary arteries. Initial SAPIEN 3 orientation had no impact on alignment, but specific initial orientations of Evolut and ACURATE improved alignment. Optimizing valve alignment to avoid coronary artery overlap will be important in coronary artery access and redo TAVR. [ABSTRACT FROM AUTHOR]

Abstract Objectives The authors sought to perform a randomized controlled trial to evaluate the clinical efficacy of combined examination with coronary computed tomography angiography (CTA) and computed tomography perfusion imaging (CTP) compared to coronary CTA alone. Background Stress myocardial CTP may increase diagnostic specificity when added to coronary CTA in patients suspected of having ischemic heart disease. Methods Patients recently hospitalized for acute-onset chest pain, who had acute coronary syndrome had been ruled out by normal electrocardiograms, normal troponin levels, and relief of symptoms, and who had a clinical indication for outpatient noninvasive testing, were screened for inclusion in the CATCH-2 (CArdiac cT in the treatment of acute CHest pain 2) trial (NCT02014311). Patients were randomized 1:1 to examination with coronary CTA or coronary CTA+CTP. The primary endpoint was the frequency of coronary revascularization among patients referred for invasive coronary angiography (ICA) based on index computed tomography evaluation. Secondary endpoints were invasive procedural complications at index-related ICA, post-index cardiac death, hospital admittance because of recurrence of chest pain, unstable angina pectoris, or acute myocardial infarction, ICA, and revascularization. Results Among 300 patients allocated to the coronary CTA+CTP group, 41 (14%) were referred for ICA compared with 89 (30%) allocated to coronary CTA (p < 0.0001). The primary endpoint occurred in 50% of coronary CTA+CTP patients versus 48% of invasively examined patients (p = 0.85). The total number of revascularizations was significantly lower in the coronary CTA+CTP group compared to the coronary CTA group (n = 20 [7%] vs. n = 42 [14%]; p = 0.0045). At median follow-up of 1.5 years, the occurrence of secondary endpoints was similar in the 2 groups. Conclusions A post-discharge diagnostic strategy of coronary CTA+CTP safely reduces the need for invasive examination and treatment in patients suspected of having ischemic heart disease. (CArdiac cT in the treatment of acute CHest pain 2–Myocardial CT Perfusion [CATCH2]; NCT02014311) Graphical abstract [ABSTRACT FROM AUTHOR]

Objectives The aim of this study was to assess the commissural alignment between bioprosthetic and native aortic valve leaflets following surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) and to investigate its impact on valvular function and coronary filling. Background Expansion and geometry have been shown to affect leaflets of implanted transcatheter aortic bioprosthesis, but commissural alignment has not been studied. Methods Pre- and post-procedural multidetector computed tomography (MDCT) of 28 SAVR patients and 212 TAVR patients were analyzed. Commissural alignment between the bioprosthetic (post) and native (pre) aortic valves was categorized as aligned (0° to 15° angle deviation) or as mild (15° to 30°), moderate (30° to 45°), or severe (45° to 60°) commissural misalignment (CMA). Results With SAVR, 27 of 28 cases (96%) were aligned and 1 had mild CMA. For all types of transcatheter heart valves (THVs), there was random valve implantation with regard to commissural alignment: 22% of THVs were aligned, 25% had mild CMA, 22% had moderate CMA, and 31% had severe CMA. The degree of commissural alignment was not associated with a difference in transvalvular gradient, paravalvular aortic regurgitation, or simulated coronary filling. However, there was a significantly higher rate of mild central aortic regurgitation in those THVs with moderate or greater CMA compared with those THV with mild or less CMA (7.8% vs. 1.1%; p = 0.03). Conclusions Commissural alignment is excellent in case of SAVR but random in case of TAVR. There is no association between CMA and transvalvular gradient or coronary filling; however, there is a significantly higher rate of mild central aortic regurgitation in case of moderate or greater CMA. [ABSTRACT FROM AUTHOR]

Aims To determine the diagnostic accuracy of semi-automatic quantitative metrics compared to expert reading for interpretation of computed tomography perfusion (CTP) imaging. Methods The CORE320 multicenter diagnostic accuracy clinical study enrolled patients between 45 and 85 years of age who were clinically referred for invasive coronary angiography (ICA). Computed tomography angiography (CTA), CTP, single photon emission computed tomography (SPECT), and ICA images were interpreted manually in blinded core laboratories by two experienced readers. Additionally, eight quantitative CTP metrics as continuous values were computed semi-automatically from myocardial and blood attenuation and were combined using logistic regression to derive a final quantitative CTP metric score. For the reference standard, hemodynamically significant coronary artery disease (CAD) was defined as a quantitative ICA stenosis of 50% or greater and a corresponding perfusion defect by SPECT. Diagnostic accuracy was determined by area under the receiver operating characteristic curve (AUC). Results Of the total 377 included patients, 66% were male, median age was 62 (IQR: 56, 68) years, and 27% had prior myocardial infarction. In patient based analysis, the AUC (95% CI) for combined CTA-CTP expert reading and combined CTA-CTP semi-automatic quantitative metrics was 0.87(0.84–0.91) and 0.86 (0.83–0.9), respectively. In vessel based analyses the AUC's were 0.85 (0.82–0.88) and 0.84 (0.81–0.87), respectively. No significant difference in AUC was found between combined CTA-CTP expert reading and CTA-CTP semi-automatic quantitative metrics in patient based or vessel based analyses(p > 0.05 for all). Conclusion Combined CTA-CTP semi-automatic quantitative metrics is as accurate as CTA-CTP expert reading to detect hemodynamically significant CAD. [ABSTRACT FROM AUTHOR]

Background Signs of pulmonary congestion obtained from cardiac computed tomography angiographic (coronary CTA) images have not previously been related to clinical congestion or outcome and the clinical value is, therefore, unknown. Our objective was to test the hypothesis that signs of pulmonary congestion predict clinical heart failure and adverse outcome in patients with myocardial infarction. Methods Coronary CTA was performed before invasive treatment in 400 prospectively included patients with non ST segment elevation myocardial infarction in an observational study. Using a previously described chest computed tomography evaluation algorithm, patients were classified as having “no congestion”, “mild to moderate congestion” or “severe congestion”. Results Using multivariate analyses, presence of pulmonary congestion on coronary CTA images was associated with age, female gender, left ventricular ejection fraction (LVEF) and left atrial size. The diagnostic accuracy for predicting clinical heart failure, defined as Killip class >1, was: sensitivity: 83%, specificity: 69%, positive predictive value: 25%, and negative predictive value: 97%. The median follow-up time was 50 months and the study end-point of death or hospitalization due to heart failure was reached in 68 (16%) patients. In a Cox proportional hazards model with adjustments for known risk factors and Killip class, the presence of “mild to moderate congestion” and “severe congestion” was independently associated with adverse outcome (Hazard ratio: 2.6 (95% CI:1.3–5.0) and 3.2 (1.3–7.5)). Conclusion Signs of pulmonary congestion on coronary CTA images are closely correlated to cardiac dysfunction, predict clinical heart failure, and provide prognostic value independent of LVEF and Killip class. [ABSTRACT FROM AUTHOR]

Aims: Patients admitted with chest pain are a diagnostic challenge because the majority does not have coronary artery disease (CAD). Assessment of CAD with coronary computed tomography angiography (CCTA) is safe, cost-effective, and accurate, albeit with a modest specificity. Stress myocardial computed tomography perfusion (CTP) has been shown to increase the specificity when added to CCTA, without lowering the sensitivity. This article describes the design of a randomized controlled trial, CATCH-2, comparing a clinical diagnostic management strategy of CCTA alone against CCTA in combination with CTP.Methods: Patients with acute-onset chest pain older than 50 years and with at least one cardiovascular risk factor for CAD are being prospectively enrolled to this study from 6 different clinical sites since October 2013. A total of 600 patients will be included. Patients are randomized 1:1 to clinical management based on CCTA or on CCTA in combination with CTP, determining the need for further testing with invasive coronary angiography including measurement of the fractional flow reserve in vessels with coronary artery lesions. Patients are scanned with a 320-row multidetector computed tomography scanner. Decisions to revascularize the patients are taken by the invasive cardiologist independently of the study allocation. The primary end point is the frequency of revascularization. Secondary end points of clinical outcome are also recorded.Discussion: The CATCH-2 will determine whether CCTA in combination with CTP is diagnostically superior to CCTA alone in the management of patients with acute-onset chest pain. [ABSTRACT FROM AUTHOR]

Objectives The aim of the CATCH (CArdiac cT in the treatment of acute CHest pain) trial was to investigate the long-term clinical impact of a coronary computed tomographic angiography (CTA)-guided treatment strategy in patients with recent acute-onset chest pain compared to standard care. Background The prognostic implications of a coronary CTA-guided treatment strategy have not been compared in a randomized fashion to standard care in patients referred for acute-onset chest pain. Methods Patients with acute chest pain but normal electrocardiograms and troponin values were randomized to treatment guided by either coronary CTA or standard care (bicycle exercise electrocardiogram or myocardial perfusion imaging). In the coronary CTA-guided group, a functional test was included in cases of nondiagnostic coronary CTA images or coronary stenoses of borderline severity. The primary endpoint was a composite of cardiac death, myocardial infarction (MI), hospitalization for unstable angina pectoris (UAP), late symptom-driven revascularizations, and readmission for chest pain. Results We randomized 299 patients to coronary CTA-guided strategy and 301 to standard care. After inclusion, 24 patients withdrew their consent. The median (interquartile range) follow-up duration was 18.7 (range 16.8 to 20.1) months. In the coronary CTA-guided group, 30 patients (11%) had a primary endpoint versus 47 patients (16%) in the standard care group (p = 0.04; hazard ratio [HR]: 0.62 [95% confidence interval: 0.40 to 0.98]). A major adverse cardiac event (cardiac death, MI, hospitalization for UAP, and late symptom-driven revascularization) was observed in 5 patients (2 MIs, 3 UAPs) in the coronary CTA-guided group versus 14 patients (1 cardiac death, 7 MIs, 5 UAPs, 1 late symptom-driven revascularization) in the standard care group (p = 0.04; HR: 0.36 [95% CI: 0.16 to 0.95]). Differences in cardiac death and MI (8 vs. 2) were insignificant (p = 0.06). Conclusions A coronary CTA-guided treatment strategy appears to improve clinical outcome in patients with recent acute-onset chest pain and normal electrocardiograms and troponin values compared to standard care with a functional test. (Cardiac-CT in the Treatment of Acute Chest Pain [CATCH]; NCT01534000 ) [ABSTRACT FROM AUTHOR]

Background Results on the association between P-wave duration and the risk of atrial fibrillation (AF) are conflicting. Objective The purpose of this study was to obtain a detailed description of the relationship between P-wave duration and the risk of AF. Methods Using computerized analysis of electrocardiograms from a large primary care population, we evaluated the association between P-wave duration and the risk of AF. Secondary end-points were death from cardiovascular causes and putative ischemic stroke. Data on drug use, comorbidity, and outcomes were collected from administrative registries. Results A total of 285,933 individuals were included. During median follow-up period of 6.7 years, 9550 developed AF, 9371 died of a cardiovascular cause, and 8980 had a stroke. Compared with the reference group (100–105 ms), individuals with very short (≤89 ms; hazard ratio [HR] 1.60, 95% confidence interval [CI] 1.41–1.81), intermediate (112–119 ms; HR 1.22, 95% CI 1.13–1.31), long (120–129 ms; HR 1.50, 95% CI 1.39–1.62), and very long P-wave duration (≥130 ms; HR 2.06, 95% CI 1.89–2.23) had an increased risk of incident AF. With respect to death from cardiovascular causes, we found an increased risk for very short (≤89 ms; HR 1.20, 95% CI 1.06–1.34), long (120–129 ms; HR 1.11, 95% CI 1.04–1.19), and very long P-wave duration (≥130 ms; HR 1.30, 95% CI 1.21–1.40) compared with the reference group (106–111 ms). Similar but weaker associations were found between P-wave duration and the risk of putative ischemic stroke. Conclusion In a large primary care population we found both short and long P-wave duration to be robustly associated with an increased risk of AF. [ABSTRACT FROM AUTHOR]

Background The reader confidence and diagnostic accuracy of coronary CT angiography (CCTA) can be compromised by the presence of calcified plaques and stents causing blooming artifacts. Compared to conventional invasive coronary angiography (ICA), this may cause an overestimation of stenosis severity leading to false-positive results. In a pilot study, we tested the feasibility of a new coronary calcium image subtraction algorithm in relation to reader confidence and diagnostic accuracy. Methods Forty-three patients underwent clinically indicated ICA and CCTA using a 320-detector row CT. Median Agatston score was 510. Two data sets were reconstructed: a conventional CCTA (CCTA conv ) and a subtracted CCTA (CCTA sub ), where calcifications detected on noncontrast images were subtracted from the CCTA. Reader confidence and concordance with ICA for identification of >50% stenosis were recorded. We defined target segments on CCTA conv as motion-free coronary segments with calcification or stent and low reader confidence. The effect of CCTA sub was assessed. No approval from the ethics committee was required according to Danish law. Results A total of 76 target segments were identified. The use of coronary calcium image subtraction improved the reader confidence in 66% of these segments. In target segments, specificity (86% vs 65%; P < .01) and positive predictive value (71% vs 51%, P = .03) were improved using CCTA sub compared to CCTA conv without loss in negative predictive value. Conclusions Our initial experience with coronary calcium image subtraction suggests that it is feasible and could lead to an improvement in reader confidence and diagnostic accuracy for identification of significant coronary artery disease. [ABSTRACT FROM AUTHOR]

Objectives The objective of this study was to test the hypothesis that the extent and severity of left ventricular myocardial hypoperfusion at rest, in addition to signs of left ventricular myocardial scar, are related to adverse long-term outcome in patients with non–ST-segment elevation myocardial infarction (NSTEMI). Background Multidetector computed tomography (MDCT) is a noninvasive test with a spatial resolution that allows for the assessment of transmural myocardial perfusion. In patients with suspected NSTEMI, the assessment of myocardial hypoperfusion could be clinically useful. Methods MDCT was performed at rest before invasive treatment in 396 patients with NSTEMI. The transmural involvement of left ventricular hypoperfusion, the presence of intramyocardial fat or calcification, a summed defect score adding the extent of left ventricular myocardial hypoperfusion (0 to 64 point scale), and the transmural attenuation ratio between the subendocardial and the subepicardial myocardium were assessed. The study endpoint was a combination of death and hospitalization due to heart failure. Results The median follow-up time of the study was 50 months, and the study endpoint was reached in 56 (15%) of the patients. In a Cox proportional hazards survival model with adjustments for known risk factors, both the summed defect score and transmural attenuation ratio were independently associated with adverse outcome (hazard ratio [HR]: 1.07; 95% confidence interval [CI]: 1.02 to 1.11; p = 0.004 and HR: 0.61; 95% CI: 0.44 to 0.85; p = 0.003, respectively). The presence of intramyocardial fat or calcification was also associated with adverse outcome (HR: 3.5; 95% CI: 1.2 to 10.7; p = 0.03) when compared with patients without any perfusion defect. Conclusions The extent and severity of left ventricular myocardial hypoperfusion at rest and signs of left ventricular myocardial scar assessed with MDCT before invasive treatment is strongly linked to adverse long-term outcome in patients with NSTEMI. [ABSTRACT FROM AUTHOR]

Abstract: Background: Image noise and multiple sources of artifact may affect the accurate interpretation of myocardial CT perfusion (CTP) studies. Although artifact within the image is often time dependent, tissue characteristics remain unchanged irrespective of cardiac phase. Objective: We assessed a new technique of 4-dimensional, spatiotemporal analysis, using redundant time domain information within additional phase acquisitions to reduce CTP image noise. Methods: Four-dimensional analysis was assessed in a static phantom and in 10 CTP studies with invasive fractional flow reserve (FFR) correlation. For each voxel within the CTP study the distribution of local Hounsfield values was measured in both time and space with the use of a customized program within MATLAB software. These values were filtered to eliminate those likely to represent noise or rapidly changing beam hardening artifact. All CTP images were acquired within a single heartbeat with 320 detector-row CT. Image noise was quantified as the SD of voxel values within myocardial segments. Contrast was measured between normal and abnormal vascular territories as assessed by FFR. Results: The mean image noise within the unprocessed CTP images was 30 HU (range, 23–42 HU). After 4-dimensional filtering the mean image noise was 22 HU (range, 15–29 HU). The mean reduction in image noise was 28% (P < 0.001). The mean contrast between normally perfused and ischemic segments was not significantly changed. The mean increase in contrast-to-noise ratio between ischemic territories and the myocardial average was 52% (P < 0.001). Conclusion: Four-dimensional analysis of CTP significantly reduces image noise and may assist in the assessment of myocardial perfusion studies. [Copyright &y& Elsevier]

Background: Left ventricular (LV), right ventricular (RV), and left atrial (LA) volumes and functions contain important prognostic information in ischemic heart disease. Because multidetector computed tomography (MDCT) has high spatial resolution, this method may be optimal to obtain this information. Objective: We evaluated automated assessment for MDCT, by comparing it with cardiac magnetic resonance (CMR). Methods: Fifty-three patients with previous myocardial infarction were scanned with 1.5 Tesla CMR and 64-slice MDCT. End-diastolic volume, end-systolic volume, stroke volume, and ejection fraction (EF) were assessed for the left and right ventricle with automatic MDCT software and manual CMR software. LV myocardial mass and cyclic changes in LA volume were derived. Results: The mean age of patients was 61 ± 10 years, 40 (75%) were men. Automated MDCT segmentation was possible in all but 2 patients. The average duration of image processing was 21 ± 4 minutes by CMR and 11 ± 4 minutes by MDCT. Bland-Altman plots showed good agreement between MDCT and CMR with only small bias. LVEF by CMR was 56% ± 10% and by MDCT 61% ± 11%, mean difference of −5% (limits of agreement, −18% to 8%), and P < 0.001. RVEF by CMR was 60% ± 5% and by MDCT 56% ± 8%, mean difference of 5% (limits of agreement, −10% to 20%), and P < 0.001. LA fractional change by CMR was 49% ± 9% and by MDCT 45% ± 9%, mean difference of 4% (limits of agreement, −12% to 20%), and P ≤ 0.001. Conclusion: LV, RV, and LA volumes and functions may be evaluated fast and reliably with the use of automated assessment and cardiac MDCT, with good agreement to CMR. Accurate assessment of cardiac chambers with MDCT appears possible in clinical practice. [Copyright &y& Elsevier]

Abstract: Multidetector coronary computed tomography angiography (CTA) is a promising modality for widespread clinical application because of its noninvasive nature and high diagnostic accuracy as found in previous studies using 64 to 320 simultaneous detector rows. It is, however, limited in its ability to detect myocardial ischemia. In this article, we describe the design of the CORE320 study (“Combined coronary atherosclerosis and myocardial perfusion evaluation using 320 detector row computed tomography”). This prospective, multicenter, multinational study is unique in that it is designed to assess the diagnostic performance of combined 320-row CTA and myocardial CT perfusion imaging (CTP) in comparison with the combination of invasive coronary angiography and single-photon emission computed tomography myocardial perfusion imaging (SPECT-MPI). The trial is being performed at 16 medical centers located in 8 countries worldwide. CT has the potential to assess both anatomy and physiology in a single imaging session. The co-primary aim of the CORE320 study is to define the per-patient diagnostic accuracy of the combination of coronary CTA and myocardial CTP to detect physiologically significant coronary artery disease compared with (1) the combination of conventional coronary angiography and SPECT-MPI and (2) conventional coronary angiography alone. If successful, the technology could revolutionize the management of patients with symptomatic CAD. [Copyright &y& Elsevier]

Objectives: We sought to test the hypothesis that measures of left atrial (LA) function are independent predictors of mortality in patients with acute myocardial infarction. Background: Left atrial maximal volume (LAmax) is known to predict mortality in patients with acute myocardial infarction. In a previous pilot study, however, we found that LA function in terms of fractional change and left atrial ejection fraction (LAEF) assessed by multidetector computed tomography (MDCT) is more closely related to clinical heart failure than LAmax. Methods: We prospectively included 384 patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI) who underwent retrospectively gated, 64-slice MDCT coronary angiography and subsequent measurements of LA size and function. All patients were treated according to the current guidelines based on invasive coronary angiography. Patients were followed for a minimum of 2 years. The study endpoint was all-cause mortality. Results: The median follow-up time was 36 months (range 10 to 1,551 days). During follow-up, 35 (9%) patients died. Overall, 1- and 2-year survival in the study cohort was 97% and 94%. LA size and mechanical function was obtained in all patients: mean LAmax was 55 ± 11 ml/m2, LA minimal volume 31 ± 11 ml/m2, fractional change 45 ± 9%, and LAEF 32 ± 9%. Using a Cox proportional hazards model with adjustments for age, number of diseased coronary vessels, left ventricular ejection fraction (LVEF), and Killip class, both fractional change (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.45 to 0.94) and LAEF (HR: 0.63; 95% CI: 0.44 to 0.91) remained independent predictors of mortality. In contrast to this, LAmax was not significantly associated with an increased risk of mortality in this population. Conclusions: In a low-risk group of patients with NSTEMI, reduced LA function is an independent predictor of mortality and provides prognostic value incremental to that of LAmax. [Copyright &y& Elsevier]

Objectives: We sought to determine whether the amount of noncalcified plaque (NCP) in nonobstructive coronary lesions as detected by multidetector computed tomography (MDCT) was a predictor of future coronary events. Background: Patients presenting with non–ST-segment elevation myocardial infarction (NSTEMI) frequently have multiple coronary plaques, which may be detected with MDCT. Methods: We included 312 consecutive patients presenting with NSTEMI, who underwent 64-slice MDCT coronary angiography and coronary artery calcium scoring before invasive coronary angiography. All patients were treated according to current guidelines based on an invasive treatment approach. Quantitative measurements of plaque composition and volume were performed by MDCT in all nonobstructive coronary lesions. The endpoint was cardiac death, acute coronary syndrome, or symptom-driven revascularization. Results: After a median follow-up of 16 months, 23 patients had suffered a cardiac event. Age, male sex, and diabetes mellitus were all associated with an increasing amount of NCP. In a multivariate regression analysis for events, the total amount of NCP in nonobstructive lesions was independently associated with an increased hazard ratio (1.18/100-mm3 plaque volume increase, p = 0.01). Contrary to this, neither Agatston score nor the amount of calcium in nonobstructive lesions was associated with an increased risk. Conclusions: Multidetector computed tomography plaque imaging identified patients at increased risk of recurrent coronary events after NSTEMI by measuring the total amount of NCP in nonobstructive lesions. The amount of calcified plaque was not associated with an increased risk. [ABSTRACT FROM AUTHOR]

Abstract: Left atrial (LA) maximal volume contains prognostic information in patients with heart failure and acute myocardial infarction. However, only few studies have investigated the detailed mechanical function of the LA in these patients. We assessed the feasibility of evaluating LA volume and mechanical function with Multi Slice Computed Tomography (MSCT) in patients with ischemic heart disease. Furthermore, the LA and left ventricular (LV) function was evaluated in relation to signs of clinical heart failure. Methods and results: MSCT was performed in 40 patients with sinus rhythm and ischemic heart disease. We enrolled 20 patients with reduced LV ejection fraction (LVEF≤45%) and 20 with preserved LVEF (>45%). LA volumes, reservoir, channel and pump function were measured. Interobserver variation for LA volume measures was 1.5% (SD: 6.6%). In patients with reduced LVEF, LA volumes were larger throughout the cardiac cycle (LA-max 66.8 ml/m2 vs 57.4 ml/m2 and LA-min: 45.8 ml/m2 vs 31.6 ml/m2, p <0.05) and LA reservoir and pump function were all significantly impaired (Fractional change: 43% vs 31%, LAEF 31% vs 19%, p <0.05). Patients with clinical signs of heart failure during hospitalisation had significantly lower LAEF than patients without (16(9)% vs. 30(17)% p <0.05). In a multivariate linear regression analyses the presence of clinical signs of heart failure and reduced LVEF were independent determinants of impaired LA reservoir and pump function (p <0.05). Conclusion: Reproducible assessment of LA size and mechanical function throughout the cardiac cycle using MSCT is feasible and potentially useful clinically. [ABSTRACT FROM AUTHOR]

Abstract: Background: Multidetector computed tomography (MDCT) of the heart provides both anatomical and functional information. The objective of this study was to evaluate the accuracy of quantitative assessment of left ventricular contractile function in relation to two-dimensional transthoracic echocardiography (TTE). Materials and methods: Sixty-four patients with known or suspected coronary artery disease underwent ECG-gated 64-slice MDCT and TTE. Regional left ventricular contractile function was measured by percent systolic wall thickening (SWT) in 16 myocardial segments using MDCT, and compared with visual evaluation of wall motion score (WMS) by TTE. Global SWT by MDCT was calculated as the mean SWT of all myocardial segments and compared with wall motion index (WMI) by TTE. Results: Eight hundred and eleven segments (81%) were classified as normokinetic, 142 (14%) as hypokinetic, 41 (4%) as akinetic and 5 (0.5%) as dyskinetic by TTE. A significant inverse linear trend was found between regional SWT by MDCT and WMS by TTE (p <0.001). Sensitivity and specificity for the identification of regional abnormalities of contractile function were 76% and 78%, respectively. A linear correlation between global SWT by MDCT and WMI by TTE was found (r =−0.8, p <0.001). Sensitivity and specificity for the identification of WMI>1.5 using global SWT was 91% and 94%, respectively. Conclusion: Quantification of systolic wall thickening by MDCT provides functional information, which is well correlated to visual assessment of global left ventricular contractile function by TTE. [Copyright &y& Elsevier]

Background: Women with previous preeclampsia have an increased risk of coronary artery disease later in life.Objectives: This study aimed to determine the prevalence of coronary atherosclerosis in younger women with previous preeclampsia in comparison with women from the general population.Methods: Women aged 40-55 years with previous preeclampsia were matched 1:1 on age and parity with women from the general population. Participants completed an extensive questionnaire, a clinical examination, and a coronary computed tomography angiography (CTA). The main study outcome was the prevalence of any coronary atherosclerosis on coronary CTA or a calcium score >0 in case of a nondiagnostic coronary CTA.Results: A total of 1,417 women, with a mean age of 47 years, were included (708 women with previous preeclampsia and 709 control subjects from the general population). Women with previous preeclampsia were more likely to have hypertension (284 [40.1%] vs 162 [22.8%]; P < 0.001), dyslipidemia (338 [47.7%] vs 296 [41.7%]; P = 0.023), diabetes mellitus (24 [3.4%] vs 8 [1.1%]; P = 0.004), and high body mass index (27.3 ± 5.7 kg/m2 vs 25.0 ± 4.2 kg/m2; P < 0.001). Cardiac computed tomography was performed in all women. The prevalence of any coronary atherosclerosis was higher in the preeclampsia group (193 [27.4%] vs 141 [20.0%]; P = 0.001) with an OR: 1.41 (95% CI: 1.08-1.85; P = 0.012) after adjustment for age, dyslipidemia, diabetes mellitus, smoking, body mass index, menopause, and parity.Conclusions: Younger women with previous preeclampsia had a slightly higher prevalence of coronary atherosclerosis compared with age- and parity-matched women from the general population. Preeclampsia remained an independent risk factor after adjustment for traditional cardiovascular risk factors. (The CoPenHagen PREeClampsia and cardIOvascUlar diSease study [CPH-PRECIOUS]; NCT03949829). [ABSTRACT FROM AUTHOR]

Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality worldwide and challenges the capacity of health care systems globally. Atherosclerosis is the underlying pathophysiological entity in two-thirds of patients with CVD. When considering that atherosclerosis develops over decades, there is potentially great opportunity for prevention of associated events such as myocardial infarction and stroke. Subclinical atherosclerosis has been identified in its early stages in young individuals; however, there is no consensus on how to prevent progression to symptomatic disease. Given the growing burden of CVD, a paradigm shift is required—moving from late management of atherosclerotic CVD to earlier detection during the subclinical phase with the goal of potential cure or prevention of events. Studies must focus on how precision medicine using imaging and circulating biomarkers may identify atherosclerosis earlier and determine whether such a paradigm shift would lead to overall cost savings for global health. [Display omitted] • Early-stage subclinical atherosclerosis can be identified in young individuals, but evidence-based strategies are needed to prevent progression of disease and clinical events. • Precision medicine using imaging and circulating biomarkers could facilitate early identification of atherosclerosis and the development of curative interventions. • A paradigm shift based on these principles could reduce the global burden of CVD with enormous implications for population health. [ABSTRACT FROM AUTHOR]

It is unknown whether high-sensitivity C-reactive protein (hs-CRP) predicts outcome depending on implanted stent type. We investigated the prognostic value of hs-CRP in relation to type of stent implanted in patients with ST-segment elevation myocardial infarction (STEMI). Immediately before primary percutaneous coronary intervention (pPCI), 301 patients had blood drawn. Patients were categorized according to hs-CRP levels and combination of hs-CRP (≤2 vs >2 mg/L) and stent type (bare metal stent [BMS] vs drug-eluting stent [DES]). Hs-CRP >2 mg/L (median, hazard ratio 2.7, 95% confidence interval 1.3 to 5.6, p = 0.007) and the combined variable of hs-CRP >2 mg/L and BMS (hazard ratio 2.4, 95% confidence interval 1.2 to 4.5, p = 0.006) independently predicted the composite end point of death and MI at 36-month follow-up. There was a significant interaction (p = 0.006) for hs-CRP and stent type. Survival analysis demonstrated significant differences for occurrence of death and MI: 4.8% in BMS + CRP ≤2 mg/L, 11.9% in DES + CRP ≤2 mg/L, 17.6% in DES + CRP >2 mg/L, and 27.9% in BMS + CRP >2 mg/L. None of the 14 stent thromboses occurred in patients with BMS + CRP ≤2 mg/L. In conclusion, preprocedure hs-CRP predicts outcome after pPCI in patients with STEMI. Our hypothesis-generating data indicate that BMS implantation should be preferred when hs-CRP is ≤2 mg/L and DES when hs-CRP is >2 mg/L to decrease long-term adverse outcomes including stent thrombosis in patients with STEMI treated with pPCI. These findings need confirmation in larger randomized clinical trials. [ABSTRACT FROM AUTHOR]

Although the descending aortic diameter is larger in smokers, data about thoracic aortic growth is missing. Our aim is to present the distribution of thoracic aortic growth in smokers and to compare it with literature of the general population. Current and ex-smokers aged 50–70 years from the longitudinal Danish Lung Cancer Screening Trial, were included. Mean and 95th percentile of annual aortic growth of the ascending aortic (AA) and descending aortic (DA) diameters were calculated with the first and last non-contrast computed tomography scans during follow-up. Determinants of change in aortic diameter over time were investigated with linear mixed models. A total of 1987 participants (56% male, mean age 57.4 ± 4.8 years) were included. During a median follow-up of 48 months, mean AA and DA growth rates were comparable between males (AA 0.12 ± 0.31 mm/year and DA 0.10 ± 0.30 mm/year) and females (AA 0.11 ± 0.29 mm/year and DA 0.13 ± 0.27 mm/year). The 95th percentile ranged from 0.42 to 0.47 mm/year, depending on sex and location. Aortic growth was comparable between current and ex-smokers and aortic growth was not associated with pack-years. Our findings are consistent with aortic growth rates of 0.08 to 0.17 mm/years in the general population. Larger aortic growth was associated with lower age, increased height, absence of medication for hypertension or hypercholesterolemia and lower Agatston scores. This longitudinal study of smokers in the age range of 50–70 years shows that ascending and descending aortic growth is approximately 0.1 mm/year and is consistent with growth in the general population. • In current and ex-smokers, the ascending and descending aorta grows on average 0.1 mm/year • Aortic growth was comparable between current and ex-smokers and was not associated with pack-years • Thoracic aortic growth in smokers is consistent with cross-sectional data from the general population • Annual growth did not statistically significantly differ between males and females • Based on 95th percentiles, aortic growth of 0.5 mm/year can be considered the upper limit of normal [ABSTRACT FROM AUTHOR]

Abstract Background The association between low bone mineral density (BMD) and the presence of coronary artery calcium (CAC) as a marker of atherosclerosis is unclear. The aim of this study was to assess the potential relationship between volumetric thoracic bone mineral density and coronary calcification in a large population of men and women. Methods Participants from the Copenhagen General Population Study underwent multidetector computed tomography. Volumetric thoracic BMD and CAC were assessed in the same scan. CAC was measured using calibrated mass score (cMS). cMS was dichotomized as cMS = 0 or cMS > 0. The association between BMD and cMS was analyzed using multiple logistic regression in men, premenopausal and postmenopausal women. The model was adjusted for age, BMI, hypertension, hypercholesterolemia, diabetes, known cardiovascular disease and smoking. Results Of 2548 eligible participants, 1163 men and 1385 women, mean age 61 ± 10 were included in the study. Mean BMD was 138 ± 46 mg/cm3 for men and 151 ± 49 mg/cm3 women. In 696 men (67%) and 537 women (41%) cMS was found to be above zero. For men, a decrease in BMD of 100 mg/cm3 was associated to an odds ratio of 1.49 for cMS > 0 (95% confidence interval: 1.04–2.13, P = 0.03). In postmenopausal women, a decrease in BMD of 100 mg/cm3 was associated to an odds ratio of 1.47 for MS > 0 (95% confidence interval: 1.04–2.08, P = 0.03). For premenopausal women, no significant association was found between BMD and cMS (odds ratio = 0.74, 95% confidence interval: 0.36–1.52, P = 0.4). Conclusion Bone mineral density and coronary calcification are inversely related in both men and postmenopausal women, supporting the hypothesis that a direct relation between bone loss and development of atherosclerosis exists irrespective of gender. Highlights • Bone mineral density and coronary calcification can be measured in a single CT scan. • An inverse relation between bone loss and atherosclerosis exist regardless of gender. • It may only be detected using calibrated mass scoring and not the Agatston score. [ABSTRACT FROM AUTHOR]

Aims: Type 1 diabetes is associated with increased cardiovascular (CV) morbidity and mortality, and cardiovascular autonomic neuropathy (CAN) is an important CV risk factor. The study aimed to explore associations between CAN and altered cardiac chamber sizes in persons with type 1 diabetes.Methods: This was a cross-sectional study of 71 asymptomatic, normoalbuminuric participants with long-term type 1 diabetes (39 with CAN, determined by >1 abnormal autonomic function test) examined with cardiac multi detector computed tomography scans, which allowed measurements of left ventricular mass and all four cardiac chamber volumes. Cardiac chambers were indexed according to body surface area (ml/m2 or g/m2).Results: Persons with and without CAN had mean ± SD age of 57 ± 7 and 50 ± 8 years (p < 0.001) and diabetes duration of 36 ± 11 and 32 ± 9 years (p < 0.05), respectively. Increasing autonomic dysfunction, evaluated by decrease in heart rate variability during deep breathing (in beats per minute), was associated with larger right (-0.5, 95% CI -1.0 to -0.0, p < 0.05) and trend towards larger left (-0.4, 95% CI -0.8-0.0, p < 0.1) ventricular volumes in multivariable linear regression.Conclusions: Our results suggest that impaired autonomic function may be associated with modest enlargement of ventricular volumes; this might be an early sign of progression towards heart failure. [ABSTRACT FROM AUTHOR]

Objective: Population studies have shown coronary calcium score to improve risk stratification in subjects suspected for cardiovascular disease. The aim of this work was to assess the validity of multidetector computed tomography (MDCT) for measurement of calibrated mass scores (MS) in a phantom study, and to investigate inter-scanner variability for MS and Agaston score (AS) recorded in a population study on two different high-end MDCT scanners.Materials and Methods: A calcium phantom was scanned by a first (A) and second (B) generation 320-MDCT. MS was measured for each calcium deposit from repeated measurements in each scanner and compared to known physical phantom mass. Random samples of human subjects from the Copenhagen General Population Study were scanned with scanner A (N=254) and scanner B (N=253) where MS and AS distributions of these two groups were compared.Results: The mean total MS of the phantom was 32.9±0.8mg and 33.1±0.9mg (p=0.43) assessed by scanner A and B respectively - the physical calcium mass was 34.0mg. Correlation between measured MS and physical calcium mass was R2=0.99 in both scanners. In the population study the median total MS was 16.8mg (interquartile range (IQR): 3.5-81.1) and 15.8mg (IQR: 3.8-63.4) in scanner A and B (p=0.88). The corresponding median total AS were 92 (IQR: 23-471) and 89 (IQR: 40-384) (p=0.64).Conclusion: Calibrated calcium mass score may be assessed with very high accuracy in a calcium phantom by different generations of 320-MDCT scanners. In population studies, it appears acceptable to pool calcium scores acquired on different 320-MDCT scanners. [ABSTRACT FROM AUTHOR]

Background Myocardial CT perfusion (CTP) has been validated as an incremental diagnostic predictor over coronary computed tomography angiography (CTA) in assessing hemodynamically significant stenosis. Objectives To assess the diagnostic performance of CTA and CTP alone versus combined CTA–CTP stratified by Morise's pre-test probability and coronary artery calcium (CAC, Agatston) score. Methods 381 individuals (153 low/intermediate-risk for CAD, 83 high-risk, 145 known CAD) were further stratified based on CAC score cut-offs of 1–399 and ≥ 400. Area under the curve for receiver operating characteristics (AUC) was calculated to assess the diagnostic performance. Reference standards were QCA ≥ 50% stenosis + corresponding SPECT summed stress score ≥ 1. Results In both pre-test risk groups with an Agatston score of 1–399, AUCs of CTA–CTP were not significantly different than that from CTA alone. In the low/intermediate-risk group with CAC score 1–399, AUC for CTA–CTP (89) was higher than that for CTP (76, p = 0.003) alone. In the same group with CAC score ≥ 400, AUCs were higher for CTA–CTP (97) than that for CTA (88, p = 0.030) and CTP (83, p = 0.033). In high risk/known CAD patients with CAC 1–399, diagnostic performance for CTA–CTP (77) was superior to CTP (71, p = 0.037) alone. In the high risk/known CAD group with CAC score ≥ 400, AUCs for combined imaging were higher (86) than that for CTA (75, p < 0.001) as well as CTP (78, p = 0.020). Conclusions The incremental diagnostic accuracy of CTP over CTA persists in patients across severity spectra of pre-test probability of CAD and coronary artery calcification. In patients with severe coronary calcification (CAC score ≥ 400), combined CTA–CTP has better diagnostic accuracy than CTA and CTP alone. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to compare long-term clinical outcomes after implantation of drug-eluting stents (DES) and bare-metal stents (BMS) in patients with ST-segment elevation myocardial infarction (STEMI). Background: The evidence of long-term efficacy and safety after implantation of DES in patients with complex lesions is scarce. Methods: We randomly assigned 626 patients with STEMI referred within 12 h to have a DES or a BMS implanted in the infarct-related lesion with or without distal protection during primary percutaneous coronary intervention. Results: At 3 years, target lesion revascularization was 6.1% in the DES group compared with 16.3% in the BMS group (p < 0.001), and the rate of major adverse cardiac events was 11.5% versus 18.2%, respectively (p = 0.02). Whereas all-cause mortality did not differ significantly, the rate of cardiac death was higher in the DES group, 6.1% versus 1.9% for the BMS group (p = 0.01). The occurrence of reinfarction, stroke, and stent thrombosis was similar. Conclusions: Implantation of DES in patients with STEMI reduces the long-term rate of major adverse cardiac events compared with BMS, but patients with DES had a higher risk of cardiac death not attributed to myocardial infarction or stent thrombosis. (Drug Elution and Distal Protection During Percutaneous Coronary Intervention in ST Elevation Myocardial Infarction [DEDICATION]; NCT00192868) [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to evaluate the use of distal protection during percutaneous coronary intervention (PCI) for ST-segment elevation myocardial infarction (STEMI) in native coronary vessels. Background: Embolization of material from the infarct-related lesion during PCI may result in impaired myocardial perfusion and worsen the prognosis. Previous attempts to protect the microcirculation during primary PCI have had conflicting results. Methods: We randomly assigned 626 patients with STEMI referred within 12 h to have PCI performed with (n = 312) or without (n = 314) distal protection. The primary end point was complete (≥70%) ST-segment resolution detected by continuous ST-segment monitoring. Blood levels of troponin-T and creatine kinase-MB were monitored before and after the procedure, and echocardiographic determination of the left ventricular wall motion index (WMI) was performed before discharge. Results: Patients were well matched in terms of demographic and angiographic baseline characteristics. There was no significant difference in the occurrence of the primary end point (76% vs. 72%, p = 0.29), no difference in maximum troponin-T (4.8 μg/l and 5.0 μg/l, p = 0.87) or maximum creatine kinase-MB (185 μg/l and 184 μg/l, p = 0.99), and no difference in median WMI (1.70 vs. 1.70, p = 0.35). The rate of major adverse cardiac and cerebral events (MACCE) 1 month after PCI was 5.4% with distal protection and 3.2% with conventional treatment (p = 0.17). Conclusions: The routine use of distal protection by a filterwire system during primary PCI does not seem to improve microvascular perfusion, limit infarct size, or reduce the occurrence of MACCE (Drug Elution and Distal Protection During Percutaneous Coronary Intervention in ST Elevation Myocardial Infarction; NCT00192868). [Copyright &y& Elsevier]