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Background: Patients with stable chest pain suspected of coronary artery disease (CAD) usually undergo multiple diagnostic tests to confirm or rule out obstructive CAD. Some tests may not effectively assess the presence of CAD, precluding optimal treatment. A diagnostic strategy of upfront computed tomography coronary angiography (CTCA) combined with optimal medical therapy (OMT) tailored to the extent of CAD may be superior to standard care in preventing major adverse cardiac events. Study design: The CLEAR-CAD trial is a prospective, open-label, multicentre, randomised, superiority trial of an upfront CTCA-guided strategy in 6444 patients presenting in an outpatient setting with suspected CAD compared with standard care, in approximately 30 participating centres in the Netherlands. The upfront CTCA-guided strategy consists of an initial CTCA which is assessed using the Coronary Artery Disease-Reporting and Data System (CAD-RADS 2.0). In patients without CAD (CAD-RADS 0) no specific cardiac medication is mandated. Patients with non-obstructive CAD (CAD-RADS 1–2) are treated with preventive OMT. Patients with obstructive CAD (CAD-RADS ≥ 3) are treated with preventive and anti-anginal OMT; in the presence of pharmacologically refractory symptoms patients undergo selective revascularisation after non-invasive functional imaging for myocardial ischaemia (≥ 10%). Patients with significant left main or proximal left anterior descending coronary artery stenosis on CTCA undergo direct invasive coronary angiography and subsequent revascularisation. The primary endpoint is the composite of all-cause death and myocardial infarction. Conclusion: The CLEAR-CAD trial is the first randomised study to investigate the efficacy of a combined upfront CTCA-guided medical and selective revascularisation strategy in an outpatient setting with suspected CAD compared with standard care. [ABSTRACT FROM AUTHOR]

In patients with suspected coronary artery disease (CAD), dynamic myocardial computed tomography perfusion (CTP) imaging combined with coronary CT angiography (CTA) has become a comprehensive diagnostic examination technique resulting in both anatomical and quantitative functional information on myocardial blood flow, and the presence and grading of stenosis. Recently, CTP imaging has been proven to have good diagnostic accuracy for detecting myocardial ischemia, comparable to stress magnetic resonance imaging and positron emission tomography perfusion, while being superior to single photon emission computed tomography. Dynamic CTP accompanied by coronary CTA can serve as a gatekeeper for invasive workup, as it reduces unnecessary diagnostic invasive coronary angiography. Dynamic CTP also has good prognostic value for the prediction of major adverse cardiovascular events. In this article, we will provide an overview of dynamic CTP, including the basics of coronary blood flow physiology, applications and technical aspects including protocols, image acquisition and reconstruction, future perspectives, and scientific challenges. Key Points: • Stress dynamic myocardial CT perfusion combined with coronary CTA is a comprehensive diagnostic examination technique resulting in both anatomical and quantitative functional information. • Dynamic CTP imaging has good diagnostic accuracy for detecting myocardial ischemia comparable to stress MRI and PET perfusion. • Dynamic CTP accompanied by coronary CTA may serve as a gatekeeper for invasive workup and can guide treatment in obstructive coronary artery disease. [ABSTRACT FROM AUTHOR]

With the trend towards childhood surgery in patients with Ebstein anomaly (EA), thorough imaging is crucial for patient selection. This study aimed to assess biventricular function by echocardiography and cardiac magnetic resonance (CMR) and compare EA severity classifications. Twenty-three patients (8–17 years) underwent echocardiography and CMR. Echocardiographic parameters included tricuspid annular plane systolic excursions (TAPSE), fractional area change of the functional right ventricle (fRV-FAC), fRV free wall peak systolic myocardial velocity (fRVs'), and tricuspid regurgitation (TR). End-diastolic and end-systolic volume (EDV resp. ESV), fRV- and LV ejection fraction (EF) and TR were obtained by CMR. EA severity classifications included displacement index, Celermajer index and the total-right/left-volume index. Median fRV-FAC was 38% (IQR 33–42). TAPSE and fRVs' were reduced in 39% and 75% of the patients, respectively. Echocardiographic TR was visually graded as mild, moderate, or severe in nine, six and eight patients, respectively. By CMR, median fRVEF was 49% (IQR 36–58) and TR was graded as mild, moderate, or severe in nine, twelve and two patients, respectively. In 70% of cases, fRV-EDV was higher than LV-EDV. LVEF was decreased in 17 cases (74%). There was excellent correlation between echocardiography-derived fRV-FAC and CMR-derived fRVEF (rho = 0.812, p < 0.001). While echocardiography is a versatile tool in the complex geometry of the Ebstein heart, it has limitations. CMR offers a total overview and has the advantage of reliable volume assessment of both ventricles. Comprehensive evaluation of pediatric patients with EA may therefore require a synergistic implementation of echocardiography and CMR. [ABSTRACT FROM AUTHOR]

Objective: To demonstrate imaging performance for cardiac MR imaging at 7 T using a coil array of 8 transmit/receive dipole antennas and 16 receive loops.Materials and methods: An 8-channel dipole array was extended by adding 16 receive-only loops. Average power constraints were determined by electromagnetic simulations. Cine imaging was performed on eight healthy subjects. Geometrical factor (g-factor) maps were calculated to assess acceleration performance. Signal-to-noise ratio (SNR)-scaled images were reconstructed for different combinations of receive channels, to demonstrate the SNR benefits of combining loops and dipoles.Results: The overall image quality of the cardiac functional images was rated a 2.6 on a 4-point scale by two experienced radiologists. Imaging results at different acceleration factors demonstrate that acceleration factors up to 6 could be obtained while keeping the average g-factor below 1.27. SNR maps demonstrate that combining loops and dipoles provides a more than 50% enhancement of the SNR in the heart, compared to a situation where only loops or dipoles are used.Conclusion: This work demonstrates the performance of a combined loop/dipole array for cardiac imaging at 7 T. With this array, acceleration factors of 6 are possible without increasing the average g-factor in the heart beyond 1.27. Combining loops and dipoles in receive mode enhances the SNR compared to receiving with loops or dipoles only. [ABSTRACT FROM AUTHOR]

Objectives: Relatively little is known about the incidence of long-term renal damage after renal denervation (RDN), a potential new treatment for hypertension. In this study the incidence of renal artery and parenchymal changes, assessed with contrast-enhanced magnetic resonance angiography (MRA) after RDN, is investigated.Methods: This study is an initiative of ENCOReD, a collaboration of hypertension expert centres. Patients in whom an MRA was performed before and after RDN were included. Scans were evaluated by two independent, blinded radiologists. Primary outcome was the change in renal artery morphology and parenchyma.Results: MRAs from 96 patients were analysed. Before RDN, 41 renal anomalies were observed, of which 29 mostly mild renal artery stenoses. After a median time of 366 days post RDN, MRA showed a new stenosis (25-49% lumen reduction) in two patients and progression of pre-existing lumen reduction in a single patient. No other renal changes were observed and renal function remained stable.Conclusions: We observed new or progressed renal artery stenosis in three out of 96 patients, after a median time of 12 months post RDN (3.1%). Procedural angiographies showed that ablations were applied near the observed stenosis in only one of the three patients.Key Points: • The incidence of vascular changes 12 months post RDN was 3.1%. • No renal vascular or parenchymal changes other than stenoses were observed. • Ablations were applied near the stenosis in only one of three patients. [ABSTRACT FROM AUTHOR]

Prior to atrial fibrillation (AF) ablation, computed tomography angiography (CTA) is increasingly used for left atrial appendage (LAA) thrombus detection. LAA filling defects on CTA may represent thrombus or incomplete contrast mixing with blood. A pre-bolus of contrast material with delay before the CTA contrast bolus can help distinguish between thrombus and incomplete contrast mixing. We present results from a double-contrast, single-phase CTA protocol used in our daily clinical practice. In patients who underwent AF ablation between 2011 and 2015, double-contrast, single-phase CTA was performed prior to ablation. Two contrast boluses (30 and 70 ml) with 25-s interbolus delay were administered followed by prospectively triggered cardiac CTA. Only patients with left atrial (LA) or LAA filling defects underwent transesophageal echocardiography (TEE) to rule out thrombus. Prior to ablation, 605 CTA-scans were performed (median radiation dose: 3.1 mSv). In 579 CTA-scans (95.7 %), the LA and LAA completely filled with contrast. In 26 CTA-scans (4.3 %) the LAA showed a filling defect whereby thrombus could not be excluded. In 2 of those 26 patients (7.7 % and 0.3 % of the total population), TEE verified LAA thrombus. Low-risk LAA filling defects on CTA (n = 7/26) with an inhomogeneous aspect, Houndsfield Unit values >100, and an indefinite border were all caused by incomplete contrast mixing. No thromboembolic complications occurred perioperatively or during 6 months follow-up. Prior to AF ablation, incidence of LAA filling defects on double-contrast, single-phase CTA is low. TEE remains warranted in all but low-risk filling defects to rule out thrombus. [ABSTRACT FROM AUTHOR]

Objectives: To provide a comprehensive overview of all reported cardiac magnetic resonance (CMR) findings that predict clinical deterioration in pulmonary arterial hypertension (PAH).Methods: MEDLINE and EMBASE electronic databases were systematically searched for longitudinal studies published by April 2015 that reported associations between CMR findings and adverse clinical outcome in PAH. Studies were appraised using previously developed criteria for prognostic studies. Meta-analysis using random effect models was performed for CMR findings investigated by three or more studies.Results: Eight papers (539 patients) investigating 21 different CMR findings were included. Meta-analysis showed that right ventricular (RV) ejection fraction was the strongest predictor of mortality in PAH (pooled HR 1.23 [95 % CI 1.07-1.41], p = 0.003) per 5 % decrease. In addition, RV end-diastolic volume index (pooled HR 1.06 [95 % CI 1.00-1.12], p = 0.049), RV end-systolic volume index (pooled HR 1.05 [95 % CI 1.01-1.09], p = 0.013) and left ventricular end-diastolic volume index (pooled HR 1.16 [95 % CI 1.00-1.34], p = 0.045) were of prognostic importance. RV and LV mass did not provide prognostic information (p = 0.852 and p = 0.983, respectively).Conclusion: This meta-analysis substantiates the clinical yield of specific CMR findings in the prognostication of PAH patients. Decreased RV ejection is the strongest and most well established predictor of mortality.Key Points: • Cardiac magnetic resonance imaging is useful for prognostication in pulmonary arterial hypertension. • Right ventricular ejection fraction is the strongest predictor of mortality. • Serial CMR evaluation seems to be of additional prognostic importance. • Accurate prognostication can aid in adequate and timely intensification of PAH-specific therapy. [ABSTRACT FROM AUTHOR]

Objectives: Recent studies have proposed additional multidetector-row CT (MDCT) for prosthetic heart valve (PHV) dysfunction. References to discriminate physiological from pathological conditions early after implantation are lacking. We present baseline MDCT findings of PHVs 6 weeks post implantation.Methods: Patients were prospectively enrolled and TTE was performed according to clinical guidelines. 256-MDCT images were systematically assessed for leaflet excursions, image quality, valve-related artefacts, and pathological and additional findings.Results: Forty-six patients were included comprising 33 mechanical and 16 biological PHVs. Overall, MDCT image quality was good and relevant regions remained reliably assessable despite mild-moderate PHV-artefacts. MDCT detected three unexpected valve-related pathology cases: (1) prominent subprosthetic tissue, (2) pseudoaneurysm and (3) extensive pseudoaneurysms and valve dehiscence. The latter patient required valve surgery to be redone. TTE only showed trace periprosthetic regurgitation, and no abnormalities in the other cases. Additional findings were: tilted aortic PHV position (n = 3), pericardial haematoma (n = 3) and pericardial effusion (n = 3). Periaortic induration was present in 33/40 (83 %) aortic valve patients.Conclusions: MDCT allowed evaluation of relevant PHV regions in all valves, revealed baseline postsurgical findings and, despite normal TTE findings, detected three cases of unexpected, clinically relevant pathology.Key Points: • Postoperative MDCT presents baseline morphology relevant for prosthetic valve follow-up. • 83 % of patients show periaortic induration 6 weeks after aortic valve replacement. • MDCT detected three cases of clinically relevant pathology not found with TTE. • Valve dehiscence detection by MDCT required redo valve surgery in one patient. • MDCT is a suitable and complementary imaging tool for follow-up purposes. [ABSTRACT FROM AUTHOR]

Objectives: Multimodal non-invasive imaging plays a key role in establishing a diagnosis of PHV endocarditis. The objective of this study was to provide a systematic review of the literature and meta-analysis of the diagnostic accuracy of TTE, TEE, and MDCT in patients with (suspected) PHV endocarditis. Methods: Studies published between 1985 and 2013 were identified via search and cross-reference of PubMed/Embase databases. Studies were included if (1) they reported on the non-invasive index tests TTE, TEE, or MDCT; (2) data was provided on PHV endocarditis as the condition of interest; and (3) imaging results were verified against either surgical inspection/autopsy or clinical follow-up reference standards, thereby enabling the extraction of 2-by-2 tables. Results: Twenty articles (including 496 patients) met the inclusion criteria for PHV endocarditis. TTE, TEE, and MDCT + TEE had a pooled sensitivity/specificity for vegetations of 29/100 %; 82/95 %, and 88/94 %, respectively. The pooled sensitivity/specificity of TTE, TEE, and MDCT + TEE for periannular complications was 36/93 %, 86/98 %, and 100/94 %, respectively. Conclusions: TEE showed good sensitivity and specificity for establishing a diagnosis of PHV endocarditis. Although MDCT data are limited, this review showed that MDCT in addition to TEE may improve sensitivity in detecting life-threatening periannular complications. Key Points: • Multimodal imaging is an important ingredient of diagnostic workup for PHV endocarditis. • Transthoracic and transesophageal echography may miss life-threatening periannular complications. • MDCT can improve sensitivity for the detection of life-threatening periannular complications. [ABSTRACT FROM AUTHOR]

Objectives: Retrospective ECG-gated multidetector-row computed tomography (MDCT) is increasingly used for the assessment of prosthetic heart valve (PHV) dysfunction, but is also hampered by PHV-related artefacts/cardiac arrhythmias. Furthermore, it is performed without nitroglycerine or heart rate correction. The purpose was to determine whether MDCT performed before potential redo-PHV surgery is feasible for concomitant coronary artery stenosis assessment and can replace invasive coronary angiography (CAG). Methods: PHV patients with CAG and MDCT were identified. Based on medical history, two groups were created: (I) patients with no known coronary artery disease (CAD), (II) patients with known CAD. All images were scored for the presence of significant (>50 %) stenosis. CAG was the reference test. Results: Fifty-one patients were included. In group I ( n = 38), MDCT accurately ruled out significant stenosis in 19/38 (50 %) patients, but could not replace CAG in the remaining 19/38 (50 %) patients due to non-diagnostic image quality ( n = 16) or significant stenosis ( n = 3) detection. In group II ( n = 13), MDCT correctly found no patients without significant stenosis, requiring CAG imaging in all. MDCT assessed patency in 16/19 (84 %) grafts and detected a hostile anatomy in two. Conclusion: MDCT performed for PHV dysfunction assessment can replace CAG (100 % accurate) in approximately half of patients without previously known CAD. Key Points: • Retrospective MDCT is increasingly used for prosthetic heart valve dysfunction assessment • In case of PHV reoperation, invasive coronary angiography is also required • MDCT can replace CAG in 50 % of patients without coronary artery disease • When conclusive for coronary assessment, MDCT stenosis rule out is highly accurate • Replacing CAG saves associated risks of distant embolization of thrombi or vegetations [ABSTRACT FROM AUTHOR]

Echocardiography may miss prosthetic heart valve (PHV) endocarditis which advocates for novel imaging techniques to improve diagnostic accuracy and patient outcome. The purpose of this study was to determine the complementary diagnostic value of cardiac computed tomography angiography (CTA) to the clinical routine workup including transthoracic and transesophageal echocardiography (TTE/TEE) in patients with suspected PHV endocarditis and its impact on patient treatment. A diagnostic prospective cross-sectional study was chosen as design. Besides clinical routine workup (including TTE/TEE), CTA was performed to assess its diagnostic accuracy and complementary diagnostic/therapeutic value. For the diagnostic accuracy, the reference standard was surgical findings or clinical follow-up. To determine the complementary diagnostic/therapeutic value an expert-panel was used as reference standard. Twenty-eight patients were included. CTA resulted in a major diagnostic change in six patients (21 %) mainly driven by novel detection of mycotic aneurysms by CTA. Furthermore, treatment changes occurred in seven patients (25 %) compared to clinical routine workup. Diagnostic accuracy of routine clinical workup plus CTA was superior to clinical routine workup alone for the detection of PHV endocarditis in general, vegetations and peri-annular extension. This study demonstrates that CTA and clinical workup including TTE and TEE are complementary in patients with PHV endocarditis. Therefore, CTA imaging has to be considered after clinical routine workup in patients with a high suspicion on PHV endocarditis. [ABSTRACT FROM AUTHOR]

Objective: To investigate the feasibility of subtractionless first-pass single contrast medium dose (0.1 mmol/kg) peripheral magnetic resonance angiography (MRA) at 1.5 T using two-point Dixon fat suppression and compare it with conventional subtraction MRA in terms of image quality. Methods: Twenty-eight patients (13 male, 15 female; mean age ± standard deviation, 66 ± 16 years) with known or suspected peripheral arterial disease underwent subtractionless and subtraction first-pass MRA at 1.5 T using two-point Dixon fat suppression. Results were compared with regard to vessel-to-background contrast. A phantom study was performed to assess the signal-to-noise ratio (SNR) of both MRA techniques. Two experienced observers scored subjective image quality. Agreement regarding subjective image quality was expressed in quadratic weighted κ values. Results: Vessel-to-background contrast improved in all anatomical locations with the subtractionless method versus the subtraction method (all P < 0.001). Subjective image quality was uniformly higher with the subtractionless method (all P < 0.03, except for the aorto-iliac arteries for observer 1, P = 0.052). SNR was 15 % higher with the subtractionless method (31.9 vs 27.6). Conclusion: This study demonstrates the feasibility of subtractionless first-pass single contrast medium dose lower extremity MRA. Moreover, both objective and subjective image quality are better than with subtraction MRA. Key Points: • MRA is increasingly used for vascular applications. • Dixon imaging offers an alternative to image subtraction for fat suppression. • Subtractionless first-pass peripheral MRA is possible using two-point Dixon fat suppression. • Subtractionless peripheral MRA is possible at 1.5 T a single contrast medium dose. • Subtractionless first-pass peripheral MRA provides good image quality with few non-diagnostic studies. [ABSTRACT FROM AUTHOR]

Objectives: To compare native aortic (AV) and mitral valve (MV) image quality on limited-dose retrospectively ECG-gated CTA of the thoracoabdominal aorta reconstructed with iterative reconstruction (IR) and filtered back projection (FBP). Methods: Fifty patients underwent routine care retrospectively ECG-gated thoracoabdominal limited-dose 256-slice CTA. At 30 % (systole) and 75 % (diastole) of the R-R interval AV and MV were reconstructed using FBP and IR. Objective image quality [density and noise (SD of density measurement)] was measured. Two independent observers scored subjective valve image quality using four-point Likert scales. Results: IR significantly decreased image noise, but did not alter the aorta and interventricular septum density. Interobserver variability was moderate to good. Valve image quality was scored at least moderate in most cases. IR scored one or two Likert scale points higher than FBP in 10 (first observer) and 27 (second observer) scores. Conversely, IR scored one Likert scale point lower than FBP in 1 (first observer) and 4 (second observer) scores. Conclusions: Limited-dose retrospectively ECG-gated thoracoabdominal CTA enables moderate to excellent evaluation of AV and MV in most patients, in addition to the primary diagnostic question. Image quality is further improved by IR. Key Points: • Thoracoabdominal computed tomographic angiography demonstrates both the aortic and mitral valves. • Iterative reconstruction decreases image noise and increases the SNR/CNR of thoracoabdominal CTA. • Limited-dose retrospectively gated CTA enables moderate-excellent left-sided valvular evaluation. • Iterative CT image reconstruction improves subjective native aortic and mitral valvular evaluation. [ABSTRACT FROM AUTHOR]

Multidetector-row computed tomography (MDCT) image quality (IQ) of the commonly implanted Sapien prosthesis was assessed both in vitro and in vivo. The prosthesis was imaged in an in vitro model with a 256-slice CT system under pulsatile conditions using three protocols (1) retrospectively ECG-gating at 120 kV/600 mAs and (2) 140 kV/406 mAs, and (3) prospective triggering at 120 kV/210 mAs (10 acquisitions per protocol). After reconstruction in three perpendicular planes, IQ of the supra-,peri-,sub-,and intraprosthetic as well as leaflet regions was scored on a four-point scale (1 = non-diagnostic, 2 = moderate, 3 = good and 4 = excellent) by two observers. IQ was also assessed for twenty-one post-operative scans. The in vitro scans of the two retrospective protocols and twenty-one in vivo scans were analyzed during systole and diastole. The prospectively triggered scans were analyzed during diastole. Except for the valve leaflets in 5 systolic reconstructions, the in vitro scores were moderate to excellent. In vivo, 7 systolic and 3 diastolic reconstructions of the valve leaflets were non-diagnostic as well as 3 peri-prosthetic regions in diastole. All other scores were moderate to excellent. The Sapien prosthesis surrounded by a radiopaque stainless steel stent can be visualized with MDCT with moderate to good IQ, except for the valve leaflet region that has generally non-diagnostic or moderate IQ. [ABSTRACT FROM AUTHOR]

Multislice CT evaluation of prosthetic heart valves (PHV) is limited by PHV-related artifacts. We assessed the influence of different kV settings, a metal artifact reduction filter (MARF) and an iterative reconstruction algorithm (IR) on PHV-induced artifacts in an in vitro model. A Medtronic-Hall tilting disc and St Jude bileafet PHV were imaged using a 64-slice scanner with 100 kV/165 mAs, 120 kV/100 mAs, 140 kV/67 mAs at an equal CTDI. Images were reconstructed with (1) filtered back projection (FBP), (2) IR, (3) MARF and (4) MARF and IR. Hypo- and hyperdense artifacts volumes (mean mm ± SD) were quantified with 2 thresholds (≤−50 and ≥175 Hounsfield Units). Image noise was measured and the presence of secondary artifacts was scored by 2 observers independently. Mean hypodense artifacts for the Medtronic-Hall/St Jude valve (FBP) were 966 ± 23/1,738 ± 21 at 100 kV, 610 ± 13/991 ± 12 at 120 kV, and 420 ± 9/634 ± 9 at 140 kV. Compared to FBP, hypodense artifact reductions for IR were 9/8 %, 10/7 % and 12/6 % respectively, for MARF 92 %/84 %, 89/81 % and 86/77 % respectively; for MARF + IR 94/85 %, 92/82 %, and 90/79 % respectively. Mean hyperdense artifacts for the Medtronic-Hall/St Jude valve were 5,530 ± 48/6,940 ± 70 at 100 kV, 5,120 ± 42/6,250 ± 53 at 120 kV, and 5,011 ± 52/6,000 ± 0 at 140 kV. Reductions for IR were 2/2 %, 2/3 % and 3/4 % respectively, for MARF were 9/30 %, 0/25 %, 5/22 % respectively, MARF + IR 12/32 %, 4/27 % and 7/25 % respectively. Secondary artifacts were found in all MARF images. Image noise was reduced in the IR images. In vitro PHV-related artifacts can be reduced by increasing kV despite maintaining identical CTDI. Although MARF is more effective than IR, it induces secondary artifacts. [ABSTRACT FROM AUTHOR]

Multidetector-row CT is promising for prosthetic heart valve (PHV) assessment but retrospectively ECG-gated scanning has a considerable radiation dose. Recently introduced iterative reconstruction (IR) algorithms may enable radiation dose reduction with retained image quality. Furthermore, PHV image quality on the CT scan mainly depends on extent of PHV artifacts. IR may decrease streak artifacts. We compared image noise and artifact volumes in scans of mechanical PHVs reconstructed with conventional filtered back projection (FBP) to lower dose scans reconstructed with IR. Four different PHVs (St. Jude, Carbomedics, ON-X and Medtronic Hall) were scanned in a pulsatile in vitro model. Ten retrospectively ECG-gated CT scans were performed of each PHV at 120 kV, 600 mAs (high-dose CTDI 35.3 mGy) and 120 kV, 300 mAs (low-dose CTDI 17.7 mGy) on a 64 detector-row scanner. Diastolic and systolic images were reconstructed with FBP (high and low-dose) and the IR algorithm (low-dose only). Hypo- and hyperdense artifact volumes were determined using two threshold filters. Image noise was measured. Mean hypo- and hyperdense artifact volumes (mm) were 1,235/5,346 (high-dose FBP); 2,405/6,877 (low-dose FBP) and 1,218/5,333 (low-dose IR). Low-dose IR reconstructions had similar image noise compared to high-dose FBP (16.5 ± 1.7 vs. 16.3 ± 1.6, mean ± SD, respectively, P = 1.0). IR allows ECG-gated PHV imaging with similar image noise and PHV artifacts at 50% less dose compared to conventional FBP in an pulsatile in vitro model. [ABSTRACT FROM AUTHOR]

Objectives: Multidetector computed tomography (MDCT) has diagnostic value for the evaluation of prosthetic heart valve (PHV) dysfunction but it is hampered by artefacts. We hypothesised that image acquisition using prospective triggering instead of retrospective gating would reduce artefacts related to pulsating PHV. Methods: In a pulsatile in vitro model, a mono- and bileaflet PHV were imaged using 256 MDCT at 60, 75 and 90 beats per minute (BPM) with either retrospective gating (120 kV, 600 mAs, pitch 0.2, CTDI 39.8 mGy) or prospective triggering (120 kV, 200 mAs, CTDI 13.3 mGy). Two thresholds (>175 and <−45HU), derived from the density of surrounding structures, were used for quantification of hyper- and hypodense artefacts. Image noise and artefacts were compared between protocols. Results: Prospective triggering reduced hyperdense artefacts for both valves at every BPM ( P = 0.001 all comparisons). Hypodense artefacts were reduced for the monoleaflet valve at 60 ( P = 0.009), 75 ( P = 0.016) and 90 BPM ( P = 0.001), and for the bileaflet valves at 60 ( P = 0.001), 90 ( P = 0.001) but not at 75 BPM ( P = 0.6). Prospective triggering reduced image noise at 60 ( P = 0.001) and 75 ( P < 0.03) but not at 90 BPM. Conclusions: Compared with retrospective gating, prospective triggering reduced most artefacts related to pulsating PHV in vitro. Key Points: • Computed tomographic images are often degraded by prosthetic heart valve- induced artefacts • Prospective triggering reduces prosthetic heart valve- induced artefacts in vitro • Artefact reduction at 90 beats per minute occurs without image noise reduction • Prospective triggering may improve CT image quality of moving hyperdense structures [ABSTRACT FROM AUTHOR]

Objectives: Patients with prosthetic heart valves may require assessment for coronary artery disease. We assessed whether valve artefacts hamper coronary artery assessment by multidetector CT. Methods: ECG-gated or -triggered CT angiograms were selected from our PACS archive based on the presence of prosthetic heart valves. The best systolic and diastolic axial reconstructions were selected for coronary assessment. Each present coronary segment was scored for the presence of valve-related artefacts prohibiting coronary artery assessment. Scoring was performed in consensus by two observers. Results: Eighty-two CT angiograms were performed on a 64-slice ( n = 27) or 256-slice ( n = 55) multidetector CT. Eighty-nine valves and five annuloplasty rings were present. Forty-three out of 1160 (3.7%) present coronary artery segments were non-diagnostic due to valve artefacts (14/82 patients). Valve artefacts were located in right coronary artery (15/43; 35%), left anterior descending artery (2/43; 5%), circumflex artery (14/43; 32%) and marginal obtuse (12/43; 28%) segments. All cobalt-chrome containing valves caused artefacts prohibiting coronary assessment. Biological and titanium-containing valves did not cause artefacts except for three specific valve types. Conclusions: Most commonly implanted prosthetic heart valves do not hamper coronary assessment on multidetector CT. Cobalt-chrome containing prosthetic heart valves preclude complete coronary artery assessment because of severe valve artefacts. Key Points: • Most commonly implanted prosthetic heart valves do not hamper coronary artery assessment • Prosthetic heart valve composition determines the occurrence of prosthetic heart valve-related artefacts • Björk-Shiley and Sorin tilting disc valves preclude diagnostic coronary artery segment assessment [ABSTRACT FROM AUTHOR]

Prosthetic heart valve (PHV) dysfunction is a rare, but potentially life-threatening, complication. In clinical practice, PHV dysfunction poses a diagnostic dilemma. Echocardiography and fluoroscopy are the imaging techniques of choice and are routinely used in daily practice. However, these techniques sometimes fail to determine the specific cause of PHV dysfunction, which is crucial to the selection of the appropriate treatment strategy. Multidetector-row CT (MDCT) can be of additional value in diagnosing the specific cause of PHV dysfunction and provides valuable complimentary information for surgical planning in case of reoperation. Cardiac magnetic resonance imaging (CMR) has limited value in the evaluation of biological PHV dysfunction. In this Review, we discuss the use of established imaging modalities for the detection of left-sided mechanical and biological PHV dysfunction and discuss the complementary role of MDCT in this context. [ABSTRACT FROM AUTHOR]

Objectives: Multidetector CT (MDCT) has shown potential for prosthetic heart valve (PHV) assessment. We assessed the image quality of different PHV types to determine which valves are suitable for MDCT evaluation.Methods: All ECG-gated CTs performed in our institutions since 2003 were reviewed for the presence of PHVs. After reconstruction in 3 specific PHV planes, image quality of the supravalvular, perivalvular, subvalvular and valvular regions was scored on a four-point scale (1 = non-diagnostic, 2 = moderate, 3 = good and 4 = excellent) by two independent observers.Results: Eighty-four CT examinations (66 cardiac, 18 limited-dose aortic protocols) of 83 patients with a total of 91 PHVs in the aortic (n = 71), mitral (n = 17), pulmonary (n = 1) and tricuspid (n = 2) position were included. CT was performed on a 16-slice (n = 4), 64-slice (n = 28) or 256-slice (n = 52) MDCT system. Median image quality scores for the supra-, peri- and subvalvular regions and valvular detail were (3.5, 3.3, 3.5 and 3.5, respectively) for bileaflet PHV; (3.0, 3.0, 3.5 and 3.0, respectively) for Medtronic Hall PHV; (1.0, 1.0, 1.0 and 1.0, respectively) for Björk-Shiley and Sorin monoleaflet PHV and (3.5, 3.5, 4.0 and 2.0 respectively) for biological PHV.Conclusion: Currently implanted PHVs have good image quality on MDCT and are suitable for MDCT evaluation. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin).We conducted a prospective, blinded, observational, multicentre study. Patients aged 30–80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS).A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74–100), 56% (45–68), 98% (87–100), 35% (29–41) and 0.83 (0.73–0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings.The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins.Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions.Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Methods: To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin).We conducted a prospective, blinded, observational, multicentre study. Patients aged 30–80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS).A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74–100), 56% (45–68), 98% (87–100), 35% (29–41) and 0.83 (0.73–0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings.The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins.Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions.Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Results: To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin).We conducted a prospective, blinded, observational, multicentre study. Patients aged 30–80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS).A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74–100), 56% (45–68), 98% (87–100), 35% (29–41) and 0.83 (0.73–0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings.The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins.Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions.Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Conclusion: To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin).We conducted a prospective, blinded, observational, multicentre study. Patients aged 30–80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS).A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74–100), 56% (45–68), 98% (87–100), 35% (29–41) and 0.83 (0.73–0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings.The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins.Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions.Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Clinical relevance statement: To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin).We conducted a prospective, blinded, observational, multicentre study. Patients aged 30–80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS).A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74–100), 56% (45–68), 98% (87–100), 35% (29–41) and 0.83 (0.73–0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings.The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins.Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions.Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Trial registration: To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin).We conducted a prospective, blinded, observational, multicentre study. Patients aged 30–80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS).A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74–100), 56% (45–68), 98% (87–100), 35% (29–41) and 0.83 (0.73–0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings.The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins.Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions.Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Key Points: To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin).We conducted a prospective, blinded, observational, multicentre study. Patients aged 30–80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS).A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74–100), 56% (45–68), 98% (87–100), 35% (29–41) and 0.83 (0.73–0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings.The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins.Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions.Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Graphical Abstract: To determine whether coronary computed tomography angiography (CCTA) can improve the diagnostic work-up of patients with acute chest pain and inconclusively high-sensitivity troponins (hs-troponin).We conducted a prospective, blinded, observational, multicentre study. Patients aged 30–80 years presenting to the emergency department with acute chest pain and inconclusively elevated hs-troponins were included and underwent CCTA. The primary outcome was the diagnostic accuracy of ≥ 50% stenosis on CCTA to identify patients with type-1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS).A total of 106 patients (mean age 65 ± 10, 29% women) were enrolled of whom 20 patients (19%) had an adjudicated diagnosis of type-1 NSTE-ACS. In 45 patients, CCTA revealed non-obstructive coronary artery disease (CAD) or no CAD. Sensitivity, specificity, negative predictive value (NPV), positive predictive value and area-under-the-curve (AUC) of ≥ 50% stenosis on CCTA to identify patients with type 1 NSTE-ACS, was 95% (95% confidence interval: 74–100), 56% (45–68), 98% (87–100), 35% (29–41) and 0.83 (0.73–0.94), respectively. When only coronary segments with a diameter ≥ 2 mm were considered for the adjudication of type 1 NSTE-ACS, the sensitivity and NPV increased to 100%. In 8 patients, CCTA enabled the detection of clinically relevant non-coronary findings.The absence of ≥ 50% coronary artery stenosis on CCTA can be used to rule out type 1 NSTE-ACS in acute chest pain patients with inconclusively elevated hs-troponins. Additionally, CCTA can help improve the diagnostic work-up by detecting other relevant conditions that cause acute chest pain and inconclusively elevated hs-troponins.Coronary CTA (CCTA) can safely rule out type 1 non-ST-segment elevation acute coronary syndrome (NSTE-ACS) in patients presenting to the ED with acute chest pain and inconclusively elevated hs-troponins, while also detecting other relevant non-coronary conditions.Clinicaltrials.gov (NCT03129659). Registered on 26 April 2017Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology.Acute chest discomfort is a common presenting complaint in the emergency department.CCTA achieved very high negative predictive values for type 1 NSTE-ACS in this population.CCTA can serve as an adjunct for evaluating equivocal ACS and evaluates for other pathology. [ABSTRACT FROM AUTHOR]