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Advances in cardiovascular computed tomography (CT) have resulted in an excellent ability to exclude coronary heart disease (CHD). Anatomical information, functional information, and spectral information can already be obtained with current CT technologies. Moreover, novel developments such as targeted nanoparticle contrast agents, photon-counting CT, and phase contrast CT will further enhance the diagnostic value of cardiovascular CT. This review provides an overview of current state of the art and future cardiovascular CT imaging.

Background: Health-related quality of life (HRQoL) is impaired in patients with stable angina but patients often present with other forms of chest pain. The aim of this study was to compare the pre-diagnostic HRQoL in patients with suspected coronary artery disease (CAD) according to angina type, gender, and presence of obstructive CAD.Methods: From the pilot study for the European DISCHARGE trial, we analysed data from 24 sites including 1263 patients (45.9% women, 61.1 ± 11.3 years) who were clinically referred for invasive coronary angiography (ICA; 617 patients) or coronary computed tomography angiography (CTA; 646 patients). Prior to the procedures, patients completed HRQoL questionnaires: the Short Form (SF)-12v2, the EuroQoL (EQ-5D-3 L) and the Hospital Anxiety and Depression Scale.Results: Fifty-five percent of ICA and 35% of CTA patients had typical angina, 23 and 33% had atypical angina, 18 and 28% had non-anginal chest discomfort and 5 and 5% had other chest discomfort, respectively. Patients with typical angina had the poorest physical functioning compared to the other angina groups (SF-12 physical component score; 41.2 ± 8.8, 43.3 ± 9.1, 46.2 ± 9.0, 46.4 ± 11.4, respectively, all age and gender-adjusted p < 0.01), and highest anxiety levels (8.3 ± 4.1, 7.5 ± 4.1, 6.5 ± 4.0, 4.7 ± 4.5, respectively, all adjusted p < 0.01). On all other measures, patients with typical or atypical angina had lower HRQoL compared to the two other groups (all adjusted p < 0.05). HRQoL did not differ between patients with and without obstructive CAD while women had worse HRQoL compared with men, irrespective of age and angina type.Conclusions: Prior to a diagnostic procedure for stable chest pain, HRQoL is associated with chest pain characteristics, but not with obstructive CAD, and is significantly lower in women.Trial Registration: Clinicaltrials.gov, NCT02400229. [ABSTRACT FROM AUTHOR]

Objectives: Contrast media (CM) extravasation is a well-known complication of CT angiography (CTA). Our prospective randomized control study aimed to assess whether a four-phasic CM administration protocol reduces the risk of extravasation compared to the routinely used three-phasic protocol in coronary CTA.Methods: Patients referred to coronary CTA due to suspected coronary artery disease were included in the study. All patients received 400 mg/ml iomeprol CM injected with dual-syringe automated injector. Patients were randomized into a three-phasic injection-protocol group, with a CM bolus of 85 ml followed by 40 ml of 75%:25% saline/CM mixture and 30 ml saline chaser bolus; and a four-phasic injection-protocol group, with a saline pacer bolus of 10 ml injected at a lower flow rate before the three-phasic protocol.Results: 2,445 consecutive patients were enrolled (mean age 60.6 ± 12.1 years; females 43.6%). Overall rate of extravasation was 0.9% (23/2,445): 1.4% (17/1,229) in the three-phasic group and 0.5% (6/1,216) in the four-phasic group (p = 0.034).Conclusions: Four-phasic CM administration protocol is easy to implement in the clinical routine at no extra cost. The extravasation rate is reduced by 65% with the application of the four-phasic protocol compared to the three-phasic protocol in coronary CTA.Key Points: • Four-phasic CM injection-protocol reduces extravasation rate by 65% compared to three-phasic. • The saline pacer bolus substantially reduces the risk of CM extravasation. • The implementation of four-phasic injection-protocol is at no cost. [ABSTRACT FROM AUTHOR]

European Heart Journal – Cardiovascular Imaging was launched in 2012 as a multimodality cardiovascular imaging journal. It has gained an impressive impact factor of 8.366 during its first 5 years and is now established as one of the top 10 cardiovascular journals and has become the most important cardiovascular imaging journal in Europe. The most important studies from 2017 will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease. [ABSTRACT FROM AUTHOR]

The European Heart Journal – Cardiovascular Imaging was launched in 2012. It has gained an impressive impact factor of 8.336 during its first 6 years and is now established as one of the top 10 cardiovascular journals in the world and the most important cardiovascular imaging journal in Europe. The most important studies published in the journal in 2017 will be highlighted in two reports. Part I will focus on studies about myocardial function, coronary artery disease and myocardial ischaemia, and emerging techniques and applications in cardiovascular imaging, whereas Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease. [ABSTRACT FROM AUTHOR]

Coronary computed tomography angiography (CTA) has been established as an accurate method to non-invasively assess coronary artery disease (CAD). The proposed 'Coronary Artery Disease Reporting and Data System' (CAD-RADS) may enable standardised reporting of the broad spectrum of coronary CTA findings related to the presence, extent and composition of coronary atherosclerosis. The CAD-RADS classification is a comprehensive tool for summarising findings on a per-patient-basis dependent on the highest-grade coronary artery lesion, ranging from CAD-RADS 0 (absence of CAD) to CAD-RADS 5 (total occlusion of a coronary artery). In addition, it provides suggestions for clinical management for each classification, including further testing and therapeutic options. Despite some limitations, CAD-RADS may facilitate improved communication between imagers and patient caregivers. As such, CAD-RADS may enable a more efficient use of coronary CTA leading to more accurate utilisation of invasive coronary angiograms. Furthermore, widespread use of CAD-RADS may facilitate registry-based research of diagnostic and prognostic aspects of CTA.Key Points: • CAD-RADS is a tool for standardising coronary CTA reports. • CAD-RADS includes clinical treatment recommendations based on CTA findings. • CAD-RADS has the potential to reduce variability of CTA reports. [ABSTRACT FROM AUTHOR]

The multimodality cardiovascular imaging journal, European Heart Journal--Cardiovascular Imaging, was launched in 2012. It has gained an impressive impact factor of 5.99 during its 5 first years and is now established as the most important cardiovascular imaging journal in Europe. The most important studies from the journal's forth and fifth years will be highlighted in two reports. Part I of the review will focus on studies about myocardial function and risk prediction, myocardial ischaemia, and emerging techniques in cardiovascular imaging, while Part II will focus on valvular heart disease, heart failure, cardiomyopathies, and congenital heart disease. [ABSTRACT FROM AUTHOR]

Objectives: More than 3.5 million invasive coronary angiographies (ICA) are performed in Europe annually. Approximately 2 million of these invasive procedures might be reduced by noninvasive tests because no coronary intervention is performed. Computed tomography (CT) is the most accurate noninvasive test for detection and exclusion of coronary artery disease (CAD). To investigate the comparative effectiveness of CT and ICA, we designed the European pragmatic multicentre DISCHARGE trial funded by the 7th Framework Programme of the European Union (EC-GA 603266).Methods: In this trial, patients with a low-to-intermediate pretest probability (10-60 %) of suspected CAD and a clinical indication for ICA because of stable chest pain will be randomised in a 1-to-1 ratio to CT or ICA. CT and ICA findings guide subsequent management decisions by the local heart teams according to current evidence and European guidelines.Results: Major adverse cardiovascular events (MACE) defined as cardiovascular death, myocardial infarction and stroke as a composite endpoint will be the primary outcome measure. Secondary and other outcomes include cost-effectiveness, radiation exposure, health-related quality of life (HRQoL), socioeconomic status, lifestyle, adverse events related to CT/ICA, and gender differences.Conclusions: The DISCHARGE trial will assess the comparative effectiveness of CT and ICA.Key Points: • Coronary artery disease (CAD) is a major cause of morbidity and mortality. • Invasive coronary angiography (ICA) is the reference standard for detection of CAD. • Noninvasive computed tomography angiography excludes CAD with high sensitivity. • CT may effectively reduce the approximately 2 million negative ICAs in Europe. • DISCHARGE addresses this hypothesis in patients with low-to-intermediate pretest probability for CAD. [ABSTRACT FROM AUTHOR]

Objective: The usefulness of coronary computed tomography angiography (CTA) for the evaluation of coronary artery disease (CAD) in patients with diabetes is ambiguous. We therefore performed a meta-analysis of studies reporting event rates and hazard ratios (HR) to determine the prognostic value of CTA in this patient population.Research Design and Methods: We searched PubMed and Embase up to November 2015. Study subjects' characteristics, events (all-cause mortality or cardiac death, nonfatal myocardial infarction, unstable angina pectoris, stroke, revascularization), and events excluding revascularization were collected. We calculated the prevalence of obstructive and nonobstructive CAD on CTA, annualized event rates, and pooled unadjusted and adjusted HR using a generic inverse random model.Results: Eight studies were eligible for inclusion into this meta-analysis, with 6,225 participants (56% male; weighted age, 61 years) with a follow-up period ranging from 20 to 66 months. The prevalence of obstructive CAD, nonobstructive CAD, and no CAD was 38%, 36%, and 25%, respectively. The annualized event rate was 17.1% for obstructive CAD, 4.5% for nonobstructive CAD, and 0.1% for no CAD. Obstructive and nonobstructive CAD were associated with an increased HR of 5.4 and 4.2, respectively. A higher HR for obstructive CAD was observed in studies including revascularization compared with those that did not (7.3 vs. 3.7, P = 0.124).Conclusions: CTA in patients with diabetes allows for safely ruling out future events, and the detection of CAD could allow for the identification of high-risk patients in whom aggressive risk factor modification, medical surveillance, or elective revascularization could potentially improve survival. [ABSTRACT FROM AUTHOR]

Aims Peroxynitrite-matrix metalloproteinase ( MMP) signalling has been shown to contribute to myocardial ischaemia/reperfusion injury and heart failure and to be influenced by hyperlipidaemia in preclinical models. Therefore, here we investigated the correlation between the markers of peroxynitrite- MMP signalling and hyperlipidaemia in patients with significant coronary stenosis. Methods Five minutes before percutaneous coronary intervention ( PCI), arterial blood samples were collected from 36 consecutive patients with coronary artery disease ( CAD) selected for elective PCI. Results Serum nitrotyrosine positively correlated with MMP-9 activity ( r = 0·54, P = 0·01), but not with MMP-2 activity. Nitrotyrosine positively correlated with total ( r = 0·58; P < 0·01) and LDL cholesterol ( r = 0·55; P < 0·01), serum triglyceride ( r = 0·47; P < 0·05), and creatinine ( r = 0·42; P < 0·05) and negatively correlated with HDL cholesterol ( r = −0·46; P < 0·05) and with left ventricular ejection fraction ( LVEF; r = −0·55; P < 0·05), respectively. MMP-2 activity correlated positively with total ( r = 0·55; P < 0·05) and LDL cholesterol ( r = 0·45; P < 0·05). In statin-treated patients, a significantly reduced serum nitrotyrosine was found as compared to statin naives; however, MMP activities and serum cholesterol levels were not different. MMP-9 activity correlated with urea nitrogen ( r = 0·42; P < 0·05) and LVEF ( r = −0·73; P < 0·01). Serum creatinine correlated negatively with LVEF ( r = −0·50, P < 0·01). Conclusions This is the first demonstration that (i) serum nitrotyrosine correlates with MMP-9 activity, (ii) lipid parameters correlate with nitrotyrosine and MMP-2 activity, (iii) myocardial function correlates with creatinine, nitrotyrosine and MMP-9 activity, and (iv) creatinine correlates with nitrotyrosine and urea nitrogen with MMP-9 activity in patients with CAD. Studying the biomarkers of peroxynitrite- MMP pathway in large prospective trials may reveal their diagnostic avails. [ABSTRACT FROM AUTHOR]

Objective The aim of the study was to determine the relationship of various thoracic fat depots with the presence and extent of coronary artery plaque and circulating biomarkers. Methods In 342 patients (52 ± 11 years, 61% male, BMI 29.1 ± 5.9 kg/m2) with coronary computed tomography (CT), angiography, we measured the fat volume in four thoracic depots (pericoronary, epicardial, periaortic, extracardiac), assessed coronary plaque, and determined the circulating levels of C-reactive protein, tumor necrosis factor alpha, plasminogen activator inhibitor-1, monocyte chemoattractant protein-1, and adiponectin. The extent of coronary plaque was classified into three groups: 0, 1−3, and >3 segments. Results Patients with plaque ( n =169, 49%) had higher volumes of all four fat depots as compared to patients without plaque (all P < 0.01), despite similar BMI ( P = 0.18). Extracardiac fat was most strongly correlated with BMI ( r = 0.45, P < 0.001), while pericoronary fat was least ( r = 0.21, P < 0.001). Only pericoronary fat remained associated with coronary plaque in adjusted analyses. Inflammatory biomarkers showed a positive correlation with pericoronary fat (all P < 0.0001), whereas adiponectin was not associated with this fat compartment ( P = 0.60) and showed a negative correlation with all other fat depots (all P < 0.001). Conclusions Pericoronary fat is independently associated with coronary artery disease (CAD). Its correlation with inflammatory biomarkers suggests that while systemic inflammation plays a role in the pathogenesis of CAD, there are additional local effects that may exist. [ABSTRACT FROM AUTHOR]

Most acute coronary syndromes are caused by sudden luminal thrombosis due to atherosclerotic plaque rupture or erosion. Preventing such an event seems to be the only effective strategy to reduce mortality and morbidity of coronary heart disease. Coronary lesions prone to rupture have a distinct morphology compared with stable plaques, and provide a unique opportunity for noninvasive imaging to identify vulnerable plaques before they lead to clinical events. The submillimeter spatial resolution and excellent image quality of modern computed tomography (CT) scanners allow coronary atherosclerotic lesions to be detected, characterized, and quantified. Large plaque volume, low CT attenuation, napkin-ring sign, positive remodelling, and spotty calcification are all associated with a high risk of acute cardiovascular events in patients. Computation fluid dynamics allow the calculation of lesion-specific endothelial shear stress and fractional flow reserve, which add functional information to plaque assessment using CT. The combination of morphologic and functional characteristics of coronary plaques might enable noninvasive detection of vulnerable plaques in the future. [ABSTRACT FROM AUTHOR]

Aims To compare the accuracy of two plaque delineation methods for coronary computed tomographic angiography (CTA) to identify lipid-core plaque (LCP) using histology as the reference standard. Methods and results Five ex vivo hearts were analysed by CTA and histology. LCP was defined by histology as fibroatheroma with core diameter/circumference >200 μm/>60° and cap thickness <450 μm. In CTA, plaque was manually delineated either as the difference between the inner and outer vessel walls (Method A) or as a direct tracing of plaque (Method B). Low-attenuation plaque was defined as an area with <90 Hounsfield units. Of 446 co-registered cross-sections, 55 (12%) contained LCP. In CTA, low-attenuation plaque area was larger as assessed with Method A compared with Method B (difference: 120 ± 60%). Although low-attenuation plaque was associated with the presence of LCP, the delineation Method B yielded higher diagnostic accuracy than Method A [area under the curve (AUC): 0.831 vs. 0.780, respectively, P = 0.005]. After excluding ‘normal’ cross-sections by CTA (n = 117), AUC for detecting LCP became similar between both methods (0.767 vs. 0.729, P = 0.07, respectively). Conclusion Low-attenuation plaque in CTA is a diagnostic tool for LCP but prone to error if plaque is defined as the area between the inner and outer vessel walls and normal cross-sections are included in the assessment. [ABSTRACT FROM PUBLISHER]

Objectives: This study sought to determine whether the classification of human coronary atherosclerotic plaques with T1, T2, and ultrashort echo time (UTE) cardiac magnetic resonance (CMR) would correlate well with atherosclerotic plaque classification by histology. Background: CMR has been extensively used to classify carotid plaque, but its ability to characterize coronary plaque remains unknown. In addition, the detection of plaque calcification by CMR remains challenging. Here, we used T1, T2, and UTE CMR to evaluate atherosclerotic plaques in fixed post-mortem human coronary arteries. We hypothesized that the combination of T1, T2, and UTE CMR would allow both calcified and lipid-rich coronary plaques to be accurately detected. Methods: Twenty-eight plaques from human donor hearts with proven coronary artery disease were imaged at 9.4-T with a T1-weighted 3-dimensional fast low-angle shot (FLASH) sequence (250-μm resolution), a T2-weighted rapid acquisition with refocused echoes (RARE) sequence (in-plane resolution 0.156 mm), and an UTE sequence (300-μm resolution). Plaques showing selective hypointensity on T2-weighted CMR were classified as lipid-rich. Areas of hypointensity on the T1-weighted images, but not the UTE images, were classified as calcified. Hyperintensity on the T1-weighted and UTE images was classified as hemorrhage. Following CMR, histological characterization of the plaques was performed with a pentachrome stain and established American Heart Association criteria. Results: CMR showed high sensitivity and specificity for the detection of calcification (100% and 90%, respectively) and lipid-rich necrotic cores (90% and 75%, respectively). Only 2 lipid-rich foci were missed by CMR, both of which were extremely small. Overall, CMR-based classification of plaque was in complete agreement with the histological classification in 22 of 28 cases (weighted κ = 0.6945, p < 0.0001). Conclusions: The utilization of UTE CMR allows plaque calcification in the coronary arteries to be robustly detected. High-resolution CMR with T1, T2, and UTE contrast enables accurate classification of human coronary atherosclerotic plaque. [Copyright &y& Elsevier]

Abstract: Objective: Pericoronary adipose tissue (PCAT) may create a pro-inflammatory state, contributing to the development of coronary artery disease (CAD). We sought to evaluate the feasibility of a novel volumetric PCAT quantification method using a novel threshold based computed tomography approach. In addition we determined the relation between PCAT volumes and CAD. Methods: In 51 patients (49.5±5.1 years, 64.8% male) who underwent 64-slice MDCT, we measured threshold-based PCAT volumes using distance and anatomic-based methods. Using the most reproducible method, we performed the proximal 40-mm distance measurement in three groups as stratified by coronary plaque and high-sensitivity C-reactive protein (hs-CRP) levels: Group 1 (presence of coronary plaque, hs-CRP >2.0mg/L); an intermediate group (Group 2, no plaque, hs-CRP >2.0mg/L); and Group 3 (no plaque, hs-CRP<1.0mg/L). We compared PCAT volumes to the presence of coronary plaque on a patient (n =51) and vessel (n =153) basis. On a subsegment basis (n =1224), we compared PCAT volume to the presence of plaque as well as plaque morphology. Results: Distance-based PCAT volume measurements yielded excellent reproducibility with intra-observer intraclass correlation (ICC) of 0.997 and inter-observer ICC of 0.951. On a both a per-patient and per-vessel analysis, adjusted PCAT volume was greater in patients with plaque (Group 1) than without plaque (Groups 2 and 3, p <0.001). No difference in PCAT volume was seen between high and low hs-CRP groups without plaque (p =0.51). Adjusted PCAT volumes were higher in subsegments with plaque as compared without (p <0.001). Additionally, adjusted PCAT volume was greatest in subsegments with mixed plaque followed by non-calcified plaque, calcified plaque, and the lowest volume in segments with no plaque (p <0.001). Conclusion: In this proof-of-concept study, threshold based PCAT volume assessment is feasible and highly reproducible. PCAT volume is increased in patients and vessels with coronary plaques. Surrounding vessel subsegments with coronary plaque, particularly mixed plaques, have greatest PCAT volume and highlight the effect of local PCAT in the development of coronary atherosclerosis. [Copyright &y& Elsevier]

An amendment to this paper has been published and can be accessed via the original article. [ABSTRACT FROM AUTHOR]

CT myocardial perfusion imaging (CTP) represents one of the newly developed CT-based techniques but its cost-effectiveness in the clinical pathway is undefined. The aim of the study is to evaluate the usefulness of combined evaluation of coronary anatomy and myocardial perfusion in intermediate to high-risk patients for suspected CAD or with known disease in terms of clinical decision-making, resource utilization and outcomes in a broad variety of geographic areas and patient subgroups. CTP-PRO study is a cooperative, international, multicentre, prospective, open-label, randomized controlled study evaluating the cost-effectiveness of a CCTA+CTP strategy (Group A) versus usual care (Group B) in intermediate-high risk patients with suspected or known CAD who undergo clinically indicated diagnostic evaluation. A total sample size of 2000 subjects will be enrolled and followed up for 24 months. The primary endpoint is the reclassification rate of CCTA in group A due to the addition of CTP. The secondary endpoint will be the comparison between groups in terms of non-invasive and invasive downstream testing, prevalence of obstructive CAD at ICA, revascularization, cumulative ED and overall cost during the follow-up at 1- and 2-years. The tertiary endpoint will be the comparison between each group in terms of MACE and cost-effectiveness at 1- and 2-years. The study will provide information to patients, health care providers and other stakeholders about which strategy could be more effective in the diagnosis of suspected CAD in intermediate to high-risk patients or in the symptomatic patients with known CAD and previous history of revascularization. • CTP-PRO study is a prospective, randomized study evaluating the cost-effectiveness of a CCTA+CTP strategy (Group A) versus usual care (Group B). • A total sample size of 2000 subjects will be enrolled and followed up for 24 months. • •Primary endpoint: reclassification rate of CCTA in group B due to the addition of CTP. • Secondary endpoint: comparison of downstream testing, prevalence of obstructive CAD, revascularization, cumulative ED and overall cost. • Tertiary endpoint: comparison between each group in terms of MACE and cost-effectiveness at 1- and 2-years. [ABSTRACT FROM AUTHOR]

Objective: A bidirectional relationship exists between psychiatric disorders and cardiovascular diseases, however less is known with regards to personality traits. Accumulating data suggest that affective temperaments are both associated with psychiatric and somatic diseases. The aim of our study was to evaluate the associations between different affective temperaments and the presence of coronary atherosclerosis.Methods: 200 consecutive patients referred to coronary computed tomography angiography (CCTA) due to suspected coronary artery disease (CAD) were included in our study. Medical history and demographic parameters were recorded and all patients completed the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) and the Beck Depression Inventory (BDI). The presence of coronary artery disease was evaluated based on the CCTA images.Results: 39 patients were free of any coronary atherosclerosis (CCTA-) and 161 had coronary atherosclerosis (CCTA+). Hyperthymic affective temperament score was higher in CCTA- subjects as compared to CCTA+ (13.1±3.0 vs 11.5±4.6, p=0.010, respectively). Hyperthymic affective temperament score showed a significant independent, inverse relationship with coronary atherosclerosis (OR: 0.91 CI: 0.82-0.99, p=0.04).Conclusion: Our results suggest that hyperthymic affective temperament is independently associated with the absence of CAD. It requires further research to delineate the mechanism mediating the effect of hyperthymia on better coronary artery health and establishing potential biochemical or behavioral factors, both of which could be exploited for prevention and treatment purposes. But it is plausible, that the evaluation of affective temperaments have importance both in relation with psychiatric and cardiovascular disorders. [ABSTRACT FROM AUTHOR]