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Background: Patients with myocardial ischemia without obstructive coronary artery disease often have coronary microvascular dysfunction (CMD) and associated increased risk of cardiovascular (CV) events and anginal hospitalizations. Epicardial adipose tissue (EAT) covers much of the myocardium and coronary arteries and when dysfunctional, secretes proinflammatory cytokines and is associated with CV events. While oxidative stress and systemic inflammation are associated with CMD, the relationship between EAT and CMD in women is not well known., Methods: Women diagnosed with CMD (n = 21) who underwent coronary computed tomography with coronary artery calcium (CAC) scoring were compared to a reference group (RG) of women referred for CAC screening for preventive risk assessment (n = 181). EAT attenuation (Hounsfield units (HU)) was measured adjacent to the proximal right coronary artery, along with subcutaneous adipose tissue (SCAT). Two-sample t-tests with unequal variances were utilized., Results: Mean age of the CMD group was 56 ± 8 years and body mass index (BMI) was 31.6 ± 6.8 kg/m 2 . CV risk factors in the CMD group were prevalent: 67 % hypertension, 44 % hyperlipidemia, and 33 % diabetes. Both CMD and RG had similar CAC score (25.86 ± 59.54 vs. 24.17 ± 104.6; p = 0.21. In the CMD group, 67 % had a CAC of 0. Minimal atherosclerosis (CAD-RADS 1) was present in 76 % of women with CMD. The CMD group had lower EAT attenuation than RG (-103.3 ± 6.33 HU vs. -97.9 ± 8.3 HU, p = 0.009, respectively). There were no differences in SCAT attenuation. Hypertension, smoking history, age, BMI, and CAC score did not correlate with EAT in either of the groups., Conclusions: Women with CMD have decreased EAT attenuation compared to RG women. EAT-mediated inflammation and changes in vascular tone may be a mechanistic contributor to abnormal microvascular reactivity. Clinical trials testing therapeutic strategies to decrease EAT may be warranted in the management of CMD., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests:Puja K. Mehta reports financial support was provided by National Institutes of Health. Carlo N. De Cecco reports a relationship with Siemens Healthineers that includes: funding grants. Carlo N. De Cecco reports a relationship with Covanos, Inc. that includes: consulting or advisory. Carlo N. De Cecco reports a relationship with Bayer that includes: consulting or advisory. Carlo N. De Cecco reports a relationship with Xeos that includes: consulting or advisory. Habib Samady reports a relationship with Philips and Abbott Vascular that includes: consulting or advisory. Habib Samady reports a relationship with Covanos, Inc. that includes: equity or stocks. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Background and Aims: A small difference in epicardial adipose tissue (EAT) attenuation measured on computed tomography (CT) imaging has been reported between patients who suffered coronary events and event-free patients. EAT consists of beige adipose tissue functionally similar to brown adipose tissue and its attenuation may be affected by seasonal temperature variations and clinical factors., Methods: We retrospectively measured EAT attenuation on cardiac CT in 597 patients submitted to cardiac CT imaging for coronary artery calcium scoring. All scans were performed on the same CT scanner during the summer (June, July, August) or winter (December, January, February) months. EAT attenuation in Hounsfield units (HU) was assessed near the proximal right coronary artery in an area free of artifacts. For comparison, subcutaneous adipose tissue (SCAT) attenuation was measure along the midaxillary line., Results: The clinical and demographic characteristics of patients scanned during the summer (N = 253) and the winter (N = 344) months were similar. One third of patients were women, one quarter used statins and anti-hypertensive drugs and 30% were obese. The EAT attenuation was significantly lower during the summer than the winter months (-98.17 ± 6.94 HUs vs -95.64 ± 7.99 HUs; p<0.001). Sex, white race, body mass index, diabetes status, treatment with statins and anti-hypertensive agents significantly modulated the seasonal variation in EAT attenuation. SCAT attenuation was not affected by season or other factors., Conclusions: The measurement of EAT attenuation is complex and is affected by season, demographic and clinical factors. These factors may hinder the utilization of EAT attenuation as a biomarker of cardiovascular risk., (Copyright © 2021 Elsevier B.V. All rights reserved.)

Background The RESCUE (Randomized Evaluation of Patients with Stable Angina Comparing Utilization of Noninvasive Examinations) trial was a randomized, controlled, multicenter, comparative efficacy outcomes trial designed to assess whether initial testing with coronary computed tomographic angiography (CCTA) is noninferior to single photon emission computed tomography (SPECT) myocardial perfusion imaging in directing patients with stable angina to optimal medical therapy alone or optimal medical therapy with revascularization. Methods and Results The end point was first major adverse cardiovascular event (MACE) (cardiac death or myocardial infarction), or revascularization. Noninferiority margin for CCTA was set a priori as a hazard ratio (HR) of 1.3 (95% CI=0, 1.605). One thousand fifty participants from 44 sites were randomized to CCTA (n=518) or SPECT (n=532). Mean follow-up time was 16.2 (SD 7.9) months. There were no cardiac-related deaths. In patients with a negative CCTA there was 1 acute myocardial infarction; in patients with a negative SPECT examination there were 2 acute myocardial infarctions; and for positive CCTA and SPECT, 1 acute myocardial infarction each. Participants in the CCTA arm had a similar rate of MACE or revascularization compared with those in the SPECT myocardial perfusion imaging arm, (HR, 1.03; 95% CI=0.61-1.75) ( P =0.19). CCTA segment involvement by a stenosis of ≥50% diameter was a better predictor of MACE and revascularization at 1 year ( P =0.02) than the percent reversible defect size by SPECT myocardial perfusion imaging. Four (1.2%) patients with negative CCTA compared with 14 (3.2%) with negative SPECT had MACE or revascularization ( P =0.03). Conclusions There was no difference in outcomes of patients who had stable angina and who underwent CCTA in comparison to SPECT as the first imaging test directing them to optimal medical therapy alone or with revascularization. CCTA was a better predictor of MACE and revascularization. Registration Information URL: https://www.clinicaltrials.gov/. Identifier: NCT01262625.

The role of diagnostic testing in triaging patients with stable ischemic heart disease continues to evolve towards recognizing the benefits of coronary CT angiography (CCTA) over functional testing. The SCOT-HEART (Scottish Computed Tomography of the HEART) trial highlights this paradigm shift finding a significant reduction of death from coronary heart disease or non-fatal myocardial infarction without a significant increased rate of invasive coronary angiography over a 5 year follow-up period when implementing CCTA with standard care vs standard care alone. The better negative predictive value and ability to identify nonobstructive coronary artery disease to optimize medical therapy highlight the benefits of a CCTA first strategy. With the advent of noninvasive fractional flow reserve (FFR) and widespread availability and ease of CT, CCTA continues to establish itself as a pivotal diagnostic exam for patients with stable ischemic heart disease. In this commentary, we review the SCOT-HEART trial and its impact on CCTA for patients with stable ischemic heart disease.

Non-invasive imaging plays a growing role in the diagnosis and management of ischemic heart disease from its earliest manifestations of endothelial dysfunction to myocardial infarction along the myocardial ischemic cascade. Experts representing the North American Society for Cardiovascular Imaging and the European Society of Cardiac Radiology have worked together to organize the role of non-invasive imaging along the framework of the ischemic cascade. The current status of non-invasive imaging for ischemic heart disease is reviewed along with the role of imaging for guiding surgical planning. The issue of cost effectiveness is also considered. Preclinical disease is primarily assessed through the coronary artery calcium score and used for risk assessment. Once the patient becomes symptomatic, other imaging tests including echocardiography, CCTA, SPECT, PET and CMR may be useful. CCTA appears to be a cost-effective gatekeeper. Post infarction CMR and PET are the preferred modalities. Imaging is increasingly used for surgical planning of patients who may require coronary artery bypass.

In patients with chronic chest pain in the setting of high probability of coronary artery disease (CAD), imaging has major and diverse roles. First, imaging is valuable in determining and documenting the presence, extent, and severity of myocardial ischemia, hibernation, scarring, and/or the presence, site, and severity of obstructive coronary lesions. Second, imaging findings are important in determining the course of management of patients with suspected chronic myocardial ischemia and better defining those patients best suited for medical therapy, angioplasty/stenting, or surgery. Third, imaging is also necessary to determine the long-term prognosis and likely benefit from various therapeutic options by evaluating ventricular function, diastolic relaxation, and end-systolic volume. Imaging studies are also required to demonstrate other abnormalities, such as congenital/acquired coronary anomalies and severe left ventricular hypertrophy, that can produce angina in the absence of symptomatic coronary obstructive disease due to atherosclerosis. Clinical risk assessment is necessary to determine the pretest probability of CAD. Multiple methods are available to categorize patients as low, medium, or high risk for developing CAD. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment., (Copyright © 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care., (Copyright © 2016 Society of Cardiovascular Computed Tomography and the American College of Radiology. Published by Elsevier Inc. All rights reserved.)

The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care., (Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Primary imaging options in patients at low risk for coronary artery disease (CAD) who present with undifferentiated chest pain and without signs of ischemia are functional testing with exercise or pharmacologic stress-based electrocardiography, echocardiography, or myocardial perfusion imaging to exclude myocardial ischemia after rule-out of myocardial infarction and early cardiac CT because of its high negative predictive value to exclude CAD. Although possible, is not conclusive whether triple-rule-out CT (CAD, pulmonary embolism, and aortic dissection) might improve the efficiency of patient management. More advanced noninvasive tests such as cardiac MRI and invasive imaging with transesophageal echocardiography or coronary angiography are rarely indicated. With increased likelihood of noncardiac causes, a number of diagnostic tests, among them ultrasound of the abdomen, MR angiography of the aorta with or without contrast, x-ray rib views, x-ray barium swallow, and upper gastrointestinal series, can also be appropriate. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every three years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. This recommendation is based on excellent evidence, including several randomized comparative effectiveness trials and blinded observational cohort studies., (Copyright © 2015 American College of Radiology. Published by Elsevier Inc. All rights reserved.)

Background: Accurate coronary artery calcium scoring improves risk stratification in some strata of the population., Objective: We evaluated individual and combined effects of reader experience, heart rate, vessel displacement, and trajectory on computed tomography (CT) Agatston score, calcium volume, and calcium mass in a cardiac phantom model., Methods: A cardiac motion phantom was scanned with a 64-slice CT scanner with artificial electrocardiogram gating with combinations of the following: heart rates 60, 80, and 100 beat/min; vessel displacement of 1.25 and 2.5 cm; and multiple vessel trajectories of craniocaudal, right-left, anteroposterior, right coronary artery (RCA), left anterior descending, and left circumflex (LCX). Calcium quantification was done by 2 different readers with the use of 3 methods: Agatston, calcium volume, and calcium mass., Results: Heart rate, coronary displacement, and trajectory had significant effects on all 3 techniques, with a general decrease in score as the heart rate increased. A vessel displacement of 2.5 cm decreased the Agatston score by 16% (P < 0.0001) and LCX motion decreased the score by 17% (P < 0.0001). Combined effects often resulted in larger differences; for example, a heart rate of 60 beat/min, vessel displacement of 1.25 cm, and RCA motion resulted in an Agatston score of 907, whereas with a heart rate of 100 beat/min, vessel displacement of 2.5 cm, and LCX motion the score was 604., Conclusion: The calcium score is affected by heart rate, vessel displacement, and trajectory., (Copyright © 2012 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Increased aortic pulse wave velocity (PWV) results from loss of arterial compliance and is associated with unfavorable outcomes. Applanation tonometry (AT) is the most frequently applied method to assess PWV and deduce aortic compliance. The goal of this study was to compare the reproducibility of PWV measurements obtained with: (1) cross-correlation analysis of phase contrast magnetic resonance (PCMR) velocity data, and (2) applanation tonometry (AT). PWV was measured twice with each modality in 13 normal young volunteers (controls) and 9 older patients who had undergone a CT exam to evaluate coronary artery calcium. The coefficient of variation (CoV) between measurements was computed for each modality. There was no significant difference in PWV values obtained with AT and PCMR in controls or patients. The inter-scan reproducibility of PCMR was superior to AT in the controls (CoV: 3.4 ± 2.3% vs. 6.3 ± 4.0%, P = 0.03) but not in the older patients (7.4 ± 8.0% vs. 9.9 ± 9.6%, P = 0.32). PWV values were higher in patients than controls (5.6 ± 1.2 vs. 9.7 ± 2.8, P = 0.002). PCMR and AT yielded similar values for PWV in patients and volunteers. PCMR showed a superior reproducibility in young subjects but not in older patients.

Objective: Epicardial adipose tissue (EAT) has been implicated in the pathogenesis of coronary atherosclerosis. The association of EAT volume with type of coronary artery plaque on computed tomography angiography (CTA) is not known., Methods: Coronary artery calcium (CAC) scoring and EAT volume measurement were performed on 214 consecutive patients (mean age 54+/-14 years) referred for coronary CTA. CAC was performed on non-contrast images, while EAT volume, the severity of luminal stenoses, and plaque characterization were assessed using contrast-enhanced CTA images. EAT volume was also indexed to body surface area (EAT-i)., Results: EAT volume correlated with age, height, body mass index (BMI), and CAC score. EAT volume increased significantly with the severity of luminal stenosis (p<0.001), and in patients with no plaques, calcified, mixed, and non-calcified plaques (62+/-33mL, 63+/-22mL, 98+/-47mL, and 99+/-36mL, respectively, p<0.001). The EAT volume was significantly larger in patients with mixed or non-calcified plaques compared to patients with calcified plaques or no plaques (all p<0.01 or smaller). The trend remained significant after adjustment for traditional risk factors for coronary artery disease. In adjusted models EAT was an independent predictor of CAC [exp(B)=3.916, p<0.05], atherosclerotic plaques of any type [exp(B)=4.532, p<0.01], non-calcified plaques [exp(B)=3.849, p<0.01], and obstructive CAD [exp(B)=3.824, p<0.05]. The above results were unchanged after replacing EAT with EAT-i., Conclusion: EAT volume was larger in the presence of obstructive CAD and non-calcified plaques. These data suggest that EAT is associated with the development of coronary atherosclerosis and potentially the most dangerous types of plaques., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

A high prevalence of obesity exists in National Football League (NFL) players as determined by body mass index (BMI). It is not established whether increased BMI is associated with a greater prevalence of cardiovascular (CV) risk factors or coronary atherosclerosis in former NFL players than in nonathletes. This study compared CV risk factors and coronary atherosclerosis in retired NFL players to 2 groups of community controls, the population-based Dallas Heart Study and the preventive medicine cohort, the Aerobics Center Longitudinal Study. Retired NFL players (n = 201) were matched for ethnicity, age, and BMI (Aerobics Center Longitudinal Study, age only). CV risk factors were assessed by survey and screening visit. Coronary atherosclerosis was measured by computed tomography as coronary artery calcium (CAC). Compared to population-based controls, retired NFL players had a significantly lower prevalence of diabetes, hypertension, sedentary lifestyle, and metabolic syndrome, yet a higher prevalence of impaired fasting glucose and hyperlipidemia. However, there was no significant difference in the prevalence of detectable CAC (46% vs 48.3%, p = 0.69) or distribution of CAC (0 to 10, 10 to 100, 100 to 400, > or =400, p = 0.11). Comparing retired NFL players to the physically active preventive medicine controls, there was no difference in the amount of CAC. In retired NFL players, age and hyperlipidemia, not body size, were the most significant predictors of CAC. In conclusion, despite their large body size, retired NFL players do not have a greater prevalence of CV risk factors or amount of CAC than community controls.

Current guidelines and literature on screening for coronary artery calcium for cardiac risk assessment are reviewed for both general and special populations. It is shown that for both general and special populations a zero score excludes most clinically relevant coronary artery disease. The importance of standardization of coronary artery calcium measurements by multidetector CT is discussed.

It has become commonplace to try to gear the intensity of preventive measures to the degree of risk. It is, however, problematic to merely use traditional risk factors to gauge risk in the individual patient because the tools currently in use are based on population estimates and they may not directly apply to the individual being assessed. Indeed, it is not unusual for patients at low to intermediate risk to suffer unexpected events, whereas some high-risk patients appear unusually healthy. Imaging for atherosclerosis may offer an alternative to this approach. Often, there is a large discrepancy between the burden of atherosclerosis estimated with coronary artery calcium or intima-media thickness and the risk of future cardiovascular events estimated with the Framingham risk score. This may justify some of the clinical discrepancy. Here, we review the current evidence surrounding the use of coronary artery calcium for risk prediction.

With the growing use of electronic medical records, the trend of diagnostic imaging reporting is toward a more structured format. Advantages include improved quality and consistency of the reporting and ease of data mining. The essential elements of a structured report are provided and illustrated for coronary artery computed tomographic angiograms.

Coronary artery calcium (CAC) accumulation, a marker of atherosclerosis burden, differs significantly among patients of different ethnicities. It has been proposed that CAC scores can be used to assess the number of life years lost or gained by an individual with a given amount of coronary artery calcium. Therefore, we sought to develop a method to calculate the coronary age of an individual based on the extent of CAC in this subject compared to that of individuals of the same race, age and sex. We used median CAC scores from previously published data from the Multi-Ethnic Study of Atherosclerosis (MESA) to derive the predicted coronary age of subjects from 4 ethnic groups (White, Black, Hispanic and Chinese) of both sexes. With this method a 50-year-old white man with a CAC score of 40 has a coronary age of a 61-year-old white man; for a black man with a score of 40 the coronary age is 70. This method should allow patients to better understand the prognostic significance of their test results and may ensure a better compliance with preventive regimens.

Methods of noninvasive evaluation of coronary artery disease-including multidetector row computed tomography, electron beam computed tomography, magnetic resonance imaging, and nuclear studies (single photon emission computed tomography, positron emission tomography)-are reviewed.

Objective: The potential clinical impact of variability in the measurement of coronary artery calcification with sequential MDCT was evaluated using Agatston, volume, and mass scoring algorithms., Subjects and Methods: Fifty-six patients were imaged twice using an identical prospectively ECG-triggered sequential scanning protocol. The Agatston, volume, and mass scores were computed by two observers independently. In addition, a patient's total Agatston score was referenced to an age- and sex-stratified database to determine a percentile ranking. Interscan, interobserver, and intraobserver variability and the resultant impact on patients' risk stratifications were assessed., Results: Significant interscan differences were found for all mean coronary calcium scores (Wilcoxson's signed rank test, p <0.0001). Although the median percentage of interscan variability was low for all scoring methods, the interquartile range was wide, indicating significant variability in the data. Median scores (lower quartile-upper quartile) for observers 1 and 2, respectively, were as follows: Agatston, 5% (0-79%) and 6% (0-83%); volume, 12% (0-51%) and 12% (0-57%); and mass, 14% (0-57%) and 14% (0-58%). Interobserver and intraobserver differences between mean calcium scores were not significant, and consequently, lower interobserver and intraobserver variabilities (narrow interquartile ranges of 0-5%) were observed for all scores. Despite significant interscan differences in calcium scores, the percentile ranking assigned to the two scans differed in only 13% of patients. Interobserver differences resulted in a change in the percentile ranking in 7-9% of patients, whereas intraobserver differences caused a change in only 5% of patients., Conclusion: The accuracy of sequential MDCT for coronary calcium quantification is sufficient in most cases for stratification of patient risk.

Coronary artery calcification assessed by computed tomography is an emerging marker of coronary atherosclerosis. The authors examined the association of coronary calcium scores with traditional and nontraditional cardiovascular risk factors. In 1999-2000, they measured coronary artery calcium in 360 participants free of known coronary artery disease who had participated in 2 centers of the Atherosclerosis Risk in Communities (ARIC) Study. They related coronary calcium scores to risk factors measured in 1987-1989. Most traditional risk factors were associated with the coronary calcium score. For example, the multivariately adjusted odds ratio for an elevated score (> or = 100 versus < 100) was 3.5-fold greater per 10 years of age, 3.2-fold greater in men than in women, 3.1-fold greater with diabetes (statistically nonsignificant), and 1.4- to 1.7-fold greater per standard deviation greater increments of plasma cholesterol and pack-years of cigarettes smoked. Carotid artery intima-media thickness also was positively associated with coronary calcification. In contrast, a wide variety of hemostatic and inflammatory markers and serum chemistry values were unrelated to calcium scores. These findings reaffirmed the established role of traditional risk factors in the etiology of coronary artery disease, as assessed by computed tomography, but did not identify any important nontraditional risk factors.