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Patients with atrial fibrillation (AF) and oral anticoagulation (OAC) failure may benefit from left atrial appendage closure (LAAC), however, the evidence is scarce. We report outcomes of LAAC in patients with OAC failure compared to those with classic indications of OAC contraindications.Prospective registry of LAAC with Amplatzer or WATCHMAN device followed by dual antiplatelet therapy (DAPT) was analyzed (05.2014-11.2019). The study group included patients with OAC failure defined as stroke/TIA/PE/LAA thrombus (n = 39) during OAC, whereas the control group consisted of patients with OAC contraindications (n = 156). Structured follow-up at 3, 6, and 12 months was done.The study group compared to controls was younger [73 (IQR, 62-77) vs 74 (IQR, 68-81) years, P = 0.046], with higher CHAPatients after LAAC for OAC failure and unremarkable prior bleeding history presented with high residual stroke and low bleeding risks. Therefore concomitant long-term OAC or prolonged DAPT should strongly be considered in this population.

ackground: The extent of myocardial ischemia is the crucial prognostic factor for interventional treatment decision making for coronary artery disease. The ability of computed tomography per-fusion (CTP) to provide the missing volumetric information and its clinical value remains unknown.The study aimed to compare a novel ischemic volume quantification method based on dynamic computed tomography perfusion (VOL CTP) with other CT-based imaging modalities for revascularization prediction.In this prospective study, 53 (25 females, 63.5 [8.5] years old) consecutive symptomatic patients with 50%-90% coronary artery stenosis (n ≥1) on coronary computed tomography angiography underwent computed-tomography-derived fractional flow reserve (CT-FFR) analysis and dynamic CTP. We calculated the percentage of myocardial ischemia on the CTP-derived images. A 10% cut-off was used to define functionally significant ischemia. The outcomes include coronary revas-cularization during the follow-up of 2.5 (interquartile range, 1.4-2.8) years. Physicians were blinded to the results of CTP and CT-FFR.Of the 53 patients in the study (68 arteries with 50%-90% stenosis), 16 underwent revascularization (12 elective, 4 event-driven). In the CTP quantitative analysis, 26 patients had ischemia. Overall, 18 patients had ischemia ≥10% on volumetric ischemia quantification based on dynamic computed tomography perfusion (VOL CTP), and 28 patients had CT-FFR0.8. VOL CTP, standard CTP, CT-FFR, and computed tomography coronary angiography (CTA) ≥70% performed well for the prediction of total revascularization. Area under the curve was 0.973 vs. 0.865, vs. 0.793, vs. 0.668, respectively. The VOL CTP with ≥10% cut-off was superior to the CT-FFR, standard CTP, and CTA ≥70% (P0.001; P = 0.002 and P0.001 respectively).VOL CTP quantification is feasible and adds important, actionable information to that provided by standard CTP or CT-FFR in patients with 50%-90% coronary artery stenosis.

Background Compared with invasive fractional flow reserve (FFR), coronary CT angiography (cCTA) is limited in detecting hemodynamically relevant lesions. cCTA-based FFR (CT-FFR) is an approach to overcome this insufficiency by use of computational fluid dynamics. Applying recent innovations in computer science, a machine learning (ML) method for CT-FFR derivation was introduced and showed improved diagnostic performance compared to cCTA alone. We sought to investigate the influence of stenosis location in the coronary artery system on the performance of ML-CT-FFR in a large, multicenter cohort. Methods Three hundred and thirty patients (75.2% male, median age 63 years) with 502 coronary artery stenoses were included in this substudy of the MACHINE (Machine Learning Based CT Angiography Derived FFR: A Multi-Center Registry) registry. Correlation of ML-CT-FFR with the invasive reference standard FFR was assessed and pooled diagnostic performance of ML-CT-FFR and cCTA was determined separately for the following stenosis locations: RCA, LAD, LCX, proximal, middle, and distal vessel segments. Results ML-CT-FFR correlated well with invasive FFR across the different stenosis locations. Per-lesion analysis revealed improved diagnostic accuracy of ML-CT-FFR compared with conventional cCTA for stenoses in the RCA (71.8% [95% confidence interval, 63.0%–79.5%] vs. 54.8% [45.7%–63.8%]), LAD (79.3 [73.9–84.0] vs. 59.6 [53.5–65.6]), LCX (84.1 [76.0–90.3] vs. 63.7 [54.1–72.6]), proximal (81.5 [74.6–87.1] vs. 63.8 [55.9–71.2]), middle (81.2 [75.7–85.9] vs. 59.4 [53.0–65.6]) and distal stenosis location (67.4 [57.0–76.6] vs. 51.6 [41.1–62.0]). Conclusion In a multicenter cohort with high disease prevalence, ML-CT-FFR offered improved diagnostic performance over cCTA for detecting hemodynamically relevant stenoses regardless of their location.

Current European Society of Cardiology guidelines indicate specific target low-density lipoprotein cholesterol (LDL-C) levels for different cardiovascular risk categories in terms of prevention. However, the target for high-density lipoprotein cholesterol (HDL-C) and triglycerides have not been established.The study aim to investigate the associations betweenHDL-C,triglycerides andcoronary plaquescharacteristics.This is a prospective single-center study with enrolled consecutive patients with newly diagnosed significant (≥1stenosis ≥50%) CAD on CTCA. Patients had lipids andCTCA analysis, including high-risk plaque (HRP) features: low-attenuation plaque (LAP), napkin-ring sign (NRS), positive remodeling (PR) and spotty calcium (SC), type of plaque (calcified, noncalcified, mixed), and their composition (calcified, fibrous, fibro-fatty, necrotic core).The study included 300 patients (191 men, 66 [8] years). 66% of them took lipid-lowering therapy. HRPwere found in 208 patients. There was no association between LDL-C, plaque composition and HRP presence. There was a negative correlation between HDL-Cand fibro-fatty and necrotic core plaque components (P = 0.0002, P = 0.0009). There was a positive correlation between triglycerides and necrotic core (P = 0.038). There were differences in HDL-C and triglycerides in patients with and without NRS (47 vs. 53 mg/dl, P = 0.0002 and 128 vs. 109 mg/dl, P = 0.02). In logistic regression, HDL-C (odds ratio [OR], 0.95;95% confidence interval [CI], 0.93-‒0.98; P0.001), triglycerides (OR, 1.00; 95% CI, 1.00-‒1.01; P = 0.02), and male sex (OR, 3.04; 95% CI, 1.41-‒6.52; P = 0.004) were NRS predictors. In multivariable regression only HDL-C (OR, 0.96; 95% CI, 0.93-‒0.99; P = 0.02) was an independendent predictor of NRS, despite statin therapy.Lower HDL-C and higher triglycerides were associated with NRS presence and more necrotic core plaque component in coronary plaques in patients with newly diagnosed CAD.

We aimed to establish the feasibility and safety of dynamic computed tomography perfusion (CTP) in patients with chronic total occlusion (CTO) undergoing percutaneous coronary intervention (PCI). Ten consecutive CTO patients with preserved left ventricular ejection fraction (≥50%) underwent regadenoson dynamic CTP prior to and at least 3 months after successful CTO recanalization. Quantitative absolute and indexed values of stress myocardial blood flow (MBF) were measured for each myocardial segment, and perfusion defect size was defined by the number of segments with indexed MBF ≤0.78. The control group comprised 10 subjects without ischemia on CTP. Out of 20 CTP studies with 320 segments, 311 segments (97.2%) were interpretable. The dose-length product for CTP was 589.5 ​± ​144.3 mGy cm, and no severe adverse reactions to either regadenoson or contrast were observed. Successful PCI resulted in a significant increase in stress MBF in CTO (101.8 [82.9–127.1] vs. 158.4 [132.6–172] ml/100ml/min, p ​= ​0.004). Overall, there were significant reductions in both CTO and total defect size post-PCI (5 [5–6] vs. 1 [0.3–2] and 6 [5–8.5] vs. 1.5 [1–3.8] segments, both p ​= ​0.002). In segment analysis, the indexed MBF was lowest in the pre-PCI CTO group (0.90 [0.53–1.0]), followed by post-PCI CTO group (0.96 [0.88–1.0]) and the control group (0.98 [0.94–1.0]). Dynamic CTP is feasible and safe, and shows large perfusion defects in patients with CTO. While ischemic burden can be significantly improved after successful CTO PCI, it is still larger as compared with normal myocardium. NCT04465526 The Influence of Coronary Chronic Total Occlusion on Myocardial Perfusion on Computed Tomography (COPACABANA).

Coronary computed tomography angiography (CTA) has high diagnostic accuracy in ruling out significant stenosis of coronary arteries. The additional use of CTA- derived FFR further enhances diagnostic utility of coronary CTA. Some of the patients interrogated non-invasively have diseased coronary arteries and undergo further diagnostic testing, including invasive coronary angiography (ICA). Patients with one vessel disease may benefit from invasive interrogation limited to the diseased vessel only.In 100 patients, we analysed the impact of a "diseased-vessel-only", selective invasive diagnostic approach in patients undergoing ICA following coronary CTA (and CT-FFR) as compared to the traditional, "full ICA" approach. Our aim was to compare contrast volume and radiation dose used during ICA in both scenarios, seeking potential benefit for the patient in reducing those values by "diseased-vessel-only" approach.Sensitivity, specificity, positive predictive value and negative predictive value of CTA in prediction of subsequent revascularization were 96%, 75%, 51% and 99%, respectively, and for CT-FFR 90%, 90%, 69% and 97%, respectively. Using CTA as a method to guide ICA would reduce contrast volume and estimated radiation dose (ED), by 35% and 42.0% respectively (P0.0001 for both). Taking into consideration CT-FFR results, contrast volume would be reduced by 57% and ED by 69% (P0.0001 for both).These real-world data support the concept that vessels with50% diameter stenosis in QCT and hemodynamically insignificant in CTA-derived FFR may be skipped during ICA. Such approach would result in substantial reductions in contrast media volume used, as well as patient's exposure to radiation during during ICA, while not leading to missed diagnoses.

Background: Transcatheter left atrial appendage closure (LAAC) is performed in patients unsuitable for long-term anticoagulation, predominantly due to prior bleeding events. The study aimed to investigate the incidence and predictors of clinically significant bleeding (CSB) post-LAAC. Methods: Consecutive patients after LAAC with an Amplatzer or WATCHMAN device were analyzed (05.2014–11.2019). Bleeding was classified as CSB when associated with at least one of the following: death, ≥2 g/dL hemoglobin drop, ≥2 blood units transfusion, critical anatomic site, or hospitalization/invasive procedure. Results: Among 195 patients (age 74 (68–80), 43.1% females, HAS-BLED score 2.0 (2.0–3.0)), during median follow-up of 370 (IQR, 358–392) days, there were 15 nonprocedural CSBs in 14 (7.2%) patients. Of those, 9 (60.0%) occurred during postprocedural dual antiplatelet therapy (DAPT) (median 46 (IQR: 16–60) days post-LAAC) vs. 6 (40%) after DAPT discontinuation (median 124 (81–210) days post-LAAC), translating into annualized CSB rates of 14.0% (per patient-year on DAPT) vs. 4.6% (per patient-year without DAPT). In 92.9% (13/14) of patients, the post-LAAC nonprocedural CSB was a recurrence from the same site as bleeding pre-LAAC. In the multivariable model, admission systolic blood pressure (SBP) > 127 mmHg (HR = 10.73, 1.37–84.26, p = 0.024), epistaxis history (HR = 5.84, 1.32–25.89, p = 0.020), permanent atrial fibrillation (AF) (HR = 4.55, 1.20–17.20, p = 0.025), and prior gastrointestinal bleeding (HR = 3.35, 1.01–11.08, p = 0.048) predicted post-LAAC CSB. Conclusions: Nonprocedural CSBs after LAAC, with a similar origin as the pre-LAAC bleedings, were observed predominantly during postprocedural DAPT and predicted by elevated admission SBP, prior epistaxis, permanent AF, and gastrointestinal bleeding history. Whether a more reserved post-LAAC antiplatelet regimen and stringent blood pressure control may improve LAAC outcomes remains to be studied.

Objectives The authors sought to study the impact of diet and lifestyle intervention on changes in atherosclerotic plaque volume and composition. Background Lifestyle and diet modification are the leading strategies to manage coronary artery disease; however, their direct impact on atherosclerosis remains unknown. Coronary plaque composition is related to the risk of future cardiovascular events independent of stenosis severity and can be conveniently evaluated with computed tomography angiography (CTA). Methods We enrolled 92 patients (41% women; mean age 60 ± 7.7 years) with nonobstructive ( 351 HU), fibrous plaque (151 to 350 HU), and fibrofatty plaque combined with necrotic core (-30 to 150 HU), referred to as noncalcified plaque. Results Percent atheroma volume increased in the control arm (Δ = +1.1 ± 3.4%; p = 0.033) versus no significant change in the experimental arm (Δ = +1.0% ± 4.2%; p = 0.127; intergroup p = 0.851). There was a reduction in noncalcified plaque in both the experimental arm (Δ = −51.3 ± 79.5 mm3 [−1.7 ± 2.7%]; p Conclusions Controlled diet and lifestyle intervention together with OMT may slow the progression of atherosclerosis and reduce noncalcified plaque volume compared to OMT alone. (Dietary Intervention to Stop Coronary Atherosclerosis in Computed Tomography [DISCO-CT]; NCT02571803 )

Hospital-based health technology assessment (HB-HTA) is a scientific approach to inform decisions on investments in health technologies across multiple medical specialties at a hospital level. HB-HTA is not currently practiced in Poland. This study aimed to assess the need for HTA in Polish hospitals, including perceived benefits and challenges of adoption of HB-HTA in Poland, expected demand for training in HB-HTA, and perception of incentives to foster HB-HTA adoption. Study data were gathered using the computer-assisted telephone interview (CATI) technique. Between June and August 2021, 50 interviews were conducted: 52% of respondents had over 10 years of experience, and 40% comprised the highest degree reference hospitals. A high or moderate need for HB-HTA was reported by 86% of managers. The ability to indicate valuable and affordable medical technologies was the main reported benefit of HB-HTA (90%). The main obstacle to the adoption of HB-HTA was the shortage of competent staff (84%). The most important incentives to adopt HB-HTA were free training and premium financing from the National Health Fund. There is a clear need for HB-HTA in Polish hospitals despite some important obstacles.

Purpose The quantitative RESOLVE (Risk prEdiction of Side branch OccLusion in coronary bifurcation interVEntion) score derived from coronary computed tomography angiography (coronary CTA) was developed as a noninvasive and accurate prediction tool for side branch (SB) occlusion in coronary bifurcation intervention. We aimed to determine the ability of a visually estimated CTA-derived RESOLVE score (V-RESOLVE score) to predict SB occlusion in coronary bifurcation intervention. Materials and methods The present study included 363 patients with 400 bifurcation lesions. CTA-derived V-RESOLVE score was derived and compared with the quantitative CTA-derived RESOLVE score. The scoring systems were divided into quartiles, and classified as the high-risk and non-high-risk groups. SB occlusion was defined as any decrease in thrombolysis in myocardial infarction flow grade after main vessel stenting. Results In total, 28 SB occlusions (7%) occurred. The concordance between visual and quantitative CTA analysis showed poor to excellent agreement (weighted κ range: 0.099 to 0.867). The area under the receiver operating curve for the prediction of SB occlusion was significantly higher for the CTA-derived V-RESOLVE score than for quantitative CTA-derived RESOLVE score (0.792 vs. 0.709, P=0.049). The total net reclassification index was 42.7% (P=0.006), and CTA-derived V-RESOLVE score showed similar capability to discriminate between high-risk group (18.6% vs. 13.8%, P=0.384) and non-high-risk group (3.8% vs. 4.9%, P=0.510) as compared with quantitative CTA-derived RESOLVE score. Conclusions Visually estimated CTA-derived V-RESOLVE score is an accurate and easy-to-use prediction tool for the stratification of SB occlusion in coronary bifurcation intervention.

Familial hypercholesterolemia (FH) is a monogenic, autosomal dominant disorder that results in a rise of low‑density lipoprotein cholesterol (LDL‑C) and markedly increased risk of premature atherosclerotic cardiovascular disease. FH is relatively common, treatable, and its clinical course can be improved through early detection and timely initiation of lipid‑lowering medications. The clinical picture of FH is highly variable, with a heterogeneous phenotype even within a single family, ranging from patients with very early onset of major cardiovascular events to those who do not develop overt cardiovascular disease even at an old age. We summarized studies indicating that atherosclerotic involvement in the coronary arteries and lower extremities is higher in FH patients than in the general population. There is a paucity of data regarding the relationship between FH and the incidence of atherosclerosis in other vascular beds. There are no studies systematically evaluating several vascular beds in asymptomatic patients with FH. Providing a systematic characteristic of patients with FH with respect to the presence and extent of atherosclerotic lesions in different vascular beds may have implications for daily practice not only for patients with FH but also for a larger number of patients with very high plasma LDL‑C concentrations.

Background: The use of regadenoson in dynamic computed tomography perfusion (CTP) and magnetic resonance myocardial perfusion imaging (MR MPI) is off‑label. Aims: The study aimed to assess the safety of regadenoson with theophylline reversal during CTP and MR MPI in patients with coronary artery disease (CAD). Methods: In this prospective study, patients with 1 or more intermediate coronary artery stenoses on computed tomography angiography underwent CTP and MR MPI with 0.4 mg of regadenoson. After examinations, 200 mg of theophylline was given intravenously in 100 ml of saline. Changes in blood pressure (BP) and heart rate (HR) were repeatedly assessed. All side effects and adverse events were recorded. Results: Out of 106 examinations in 53 patients (25 females, 63.5 [8.5] years), all were diagnostic. There were no deaths, myocardial infarctions, severe arrhythmias, high‑grade atrioventricular blocks, or bronchospasms. The most common symptoms were palpitations (17%), hot flushing (8%), chest discomfort (4%), and mild dyspnea (3%). There were no differences between baseline and peak BP. There was an increase in median (interquartile range) peak HR after regadenoson as compared with baseline (MR MPI, 63 [59–75] bpm vs 93 [86–102] bpm; P < 0.001; and CTP, 65 [60–70] bpm vs 95 [86–107] bpm; P < 0.001). The hemodynamic response to regadenoson and its side effects were completely reversible by theophylline. Conclusions: Regadenoson may be a safe vasodilator for CTP and MR MPI in patients with CAD. The administration of theophylline after perfusion is safe and reverses side effects of regadenoson.

Background The clinical relevance and anatomic characteristics of intracavitary coronary arteries coursing within the right ventricle (RV) are largely unknown. Objectives The aim of our study was to assess the clinical and computed tomographic characteristics of patients diagnosed with intracavitary coronary arteries coursing within RV (intra-RV coronaries). Methods Electronic records from a single high-volume cardiac center were retrospectively screened for the presence of intra-RV coronaries among consecutive patients who underwent coronary computed tomography angiography (coronary CTA) from 2008 to 2019. Results Overall, 31,748 coronary CTA reports were evaluated, and 17 subjects with intra-RV coronaries were identified. None of these patients was referred for subsequent invasive coronary angiography. One patient underwent coronary artery bypass grafting, 1 patient had a history of percutaneous coronary intervention, and 1 patient had a concomitant coronary anomaly: left circumflex coronary artery originating from the right coronary artery. All of the involved coronaries (n = 17) were the left anterior descending coronary arteries (LADs). Typical segmental coronary course within RV was along the border between free RV wall and interventricular septum (beneath interventricular groove), often within trabeculae carneae of the RV. Only the midsegment and distal segment of the LAD traversed within the RV. The mean ± SD distance from the aorta to the coronary entrance into the RV was 74.5 ± 17.1 mm, whereas the mean ± SD intra-RV coronary length was 25.1 ± 14.0 mm. Conclusions Intra-RV course of the coronaries in an adult CTA population is an infrequent anatomical variant involving LAD. It may require additional attention during interventional and surgical interventions.

Objectives To assess the incremental value of quantitative plaque features measured from computed tomography angiography (CTA) for predicting side branch (SB) occlusion in coronary bifurcation intervention. Methods We included 340 patients with 377 bifurcation lesions in the post hoc analysis of the CT-PRECISION registry. Each bifurcation was divided into three segments: the proximal main vessel (MV), the distal MV, and the SB. Segments with evidence of coronary plaque were analyzed using semi-automated software allowing for quantitative analysis of coronary plaque morphology and stenosis. Coronary plaque measurements included calcified and noncalcified plaque volumes, and corresponding burdens (respective plaque volumes × 100%/vessel volume), remodeling index, and stenosis. Results SB occlusion occurred in 28 of 377 bifurcation lesions (7.5%). The presence of visually identified plaque in the SB segment, but not in the proximal and distal MV segments, was the only qualitative parameter that predicted SB occlusion with an area under the curve (AUC) of 0.792. Among quantitative plaque parameters calculated for the SB segment, the addition of noncalcified plaque burden (AUC 0.840, p = 0.003) and low-density plaque burden (AUC 0.836, p = 0.012) yielded significant improvements in predicting SB occlusion. Using receiver operating characteristic curve analysis, optimal cut-offs for noncalcified plaque burden and low-density plaque burden were > 33.6% (86% sensitivity and 78% specificity) and > 0.9% (89% sensitivity and 73% specificity), respectively. Conclusions CTA-derived noncalcified plaque burden, when added to the visually identified SB plaque, significantly improves the prediction of SB occlusion in coronary bifurcation intervention. Trial registration ClinicalTrials.gov Identifier: NCT03709836 registered on October 17, 2018.

The Medina classification is used to determine the presence of significant stenosis (≥50%) within each of the 3 arterial segments of coronary bifurcation in invasive coronary angiography (ICA). The utility of coronary computed tomography angiography (coronary CTA) for assessment of Medina classification is unknown. We aimed to compare the agreement and reproducibility of Medina classification between ICA and coronary CTA, and evaluate its ability to predict side branch (SB) occlusion following percutaneous coronary intervention (PCI). In total 363 patients with 400 bifurcations were included, and 28 (7%) SB occlusions among 26 patients were noted. Total agreement between CTA and ICA for assessment of Medina class was poor (kappa = 0.189), and discordance between both modalities was noted in 253 (63.3%) lesions. Larger diameter ratio between main vessel and SB in CTA, and larger bifurcation angle in ICA were independently associated with discordant Medina assessment. Whereas the interobserver agreement on Medina classification in CTA was moderate (kappa = 0.557), only fair agreement (kappa = 0.346) was observed for ICA. Finally, Medina class with any proximal involvement of main vessel and SB (1.X.1) on CTA or ICA was the most predictive of SB occlusion following PCI with no significant differences between both modalities (area under the curve 0.686 vs 0.663, p = 0.693, respectively). In conclusion, Medina classification was significantly affected by the imaging modality, and coronary CTA improved reproducibility of Medina classification compared with ICA. Both CTA and ICA-derived Medina class with any involvement of the proximal main vessel and SB was predictive of SB occlusion following PCI.

Objectives This study was conducted to investigate the influence of coronary artery calcium (CAC) score on the diagnostic performance of machine-learning–based coronary computed tomography (CT) angiography (cCTA)–derived fractional flow reserve (CT-FFR). Background CT-FFR is used reliably to detect lesion-specific ischemia. Novel CT-FFR algorithms using machine-learning artificial intelligence techniques perform fast and require less complex computational fluid dynamics. Yet, influence of CAC score on diagnostic performance of the machine-learning approach has not been investigated. Methods Four hundred eighty-two vessels from 314 patients (62.3 ± 9.3 years, 77% male) who underwent cCTA followed by invasive FFR were investigated from the MACHINE (Machine Learning based CT Angiography derived FFR: a Multi-center Registry) registry data. CAC scores were quantified using the Agatston convention. The diagnostic performance of CT-FFR to detect lesion-specific ischemia was assessed across all Agatston score categories (CAC 0, >0 to Results The diagnostic accuracy of CT-FFR versus invasive FFR was superior to cCTA alone on a per-vessel level (78% vs. 60%) and per patient level (83% vs. 73%) across all Agatston score categories. No statistically significant differences in the diagnostic accuracy, sensitivity, or specificity of CT-FFR were observed across the categories. CT-FFR showed good discriminatory power in vessels with high Agatston scores (CAC ≥ 400) and high performance in low-to-intermediate Agatston scores (CAC >0 to 0 to Conclusions Machine-learning–based CT-FFR showed superior diagnostic performance over cCTA alone in CAC with a significant difference in the performance of CT-FFR as calcium burden/Agatston calcium score increased. (Machine Learning Based CT Angiography Derived FFR: a Multicenter, Registry [MACHINE] NCT02805621).

Background Clinical and safety outcomes of the strategy employing coronary computed tomography angiography (CCTA) as the first-choice imaging test have recently been demonstrated in the recently published CAT-CAD randomized, prospective, single-center study. Based on prospectively collected data in this patient population, we aimed to perform an initial cost analysis of this approach. Methods 120 participants of the CAT-CAD trial (age:60.6 ± 7.9 years, 35% female) were included in the analysis. We analyzed medical resource use during the diagnostic and therapeutic episode of care. We prospectively estimated the cumulative cost for each strategy by multiplying the number of resources by standardized costs in accordance to medical databases and the 2015 Procedural Reimbursement Payment Guide. Results The total cost of coronary artery disease (CAD) diagnosis was significantly lower in the CCTA group as compared to the direct invasive coronary angiography (ICA) group ($50,176 vs $137,032) with corresponding per-patient cost of $836 vs $2,284, respectively. Similarly, the entire diagnostic and therapeutic episode of care was significantly less expensive in the CCTA group ($227,622 vs $502,827) with corresponding per-patient cost of $4630 vs $8,380, respectively. Overall, the application of CCTA as a first-line diagnostic test in stable patients with indications to ICA resulted in a 63% reduction of CAD diagnosis costs and a 55% reduction composite of diagnosis and treatment costs during 90-days follow-up. Conclusions Application of CCTA as the first-line anatomic test in patients with suspected significant CAD decreased the total costs of diagnosis. This is likely attributable to reduced numbers of invasive tests and hospitalisations. Initial cost analysis of the CAT-CAD randomized trial suggests that this approach may provide significant cost savings for the entire health system.

Aim of this study involved assessment of the intensive intervention concerning lifestyle based on the DASH diet model on plasma concentration of CXCL4 chemokine among patients with coronary atherosclerosis.The Dietary Intervention to Stop Coronary Atherosclerosis in Computed Tomography Study randomized patients with stable CAD to an interventional group (n = 41), where DASH diet was implemented and the control group (n = 40) without dietary intervention. Dietary counselling was provided to DASH group during all 6 control visits within 6 months of observation. During the study, body weight and body composition were controlled using the bioimpedance method. CXCL4 concentration was determined with the use of ELISA test. Within the DASH group, a significant decrease in body weight, a decrease in high sensitivity C-reactive protein concentration (-0.32 ± 2.8 mg/l; p 0.05), as well as a decrease in CXCL4 concentration (-3.35 ± 3.4 ng/ml; p 0.0001) were observed. Occurring changes were not statistically significant within the control group.DASH diet lessens CXCL4 concentration among patients with a stable CAD, however, further research is necessary in order to confirm aforementioned results and evaluate the impact on atherosclerotic plaque. THIS TRIAL WAS REGISTERED AT: www.clinicaltrials.gov as NCT02571803.

The CAT-CAD trial showed that coronary computed tomography angiography (CTA) in patients with a high prevalence of coronary artery disease (CAD) and indications for invasive coronary angiography (ICA) reduces the number of patients undergoing ICA by two-thirds and nearly eradicates non-actionable ICAs. However, the long-term benefits of this non-invasive strategy remain unknown.To evaluate the long-term efficacy and safety of a non-invasive strategy employing coronary CTA vs. ICA as the first-line imaging test in stable patients with a high clinical likelihood of obstruc-tive CAD.The long-term outcomes were evaluated for 36 months following randomization and included the efficacy outcome (analyzed as the composite of major adverse cardiovascular events (MACE): all-cause death, acute coronary syndrome, unplanned coronary revascularization, urgent hospitalization for a cardiovascular reason, a stroke) and the safety outcome (analyzed as a cumulative incidence of serious adverse events).One hundred and twenty participants at a mean age of 60.6 (7.9) years (female, 35.0%) were randomized with an allocation ratio of 1:1 to coronary CTA and direct ICA as the first-line anatomical test for suspected obstructive CAD. There were no significant differences between both diagnostic strategies neither in terms of the long-term efficacy (MACE occurrence: 15.5% in coronary CTA group vs. 16.7% in ICA group; log-rank P = 0.89) nor the long-term safety (cumulative number of serious adverse events: 36 vs. 38; P = 0.79, respectively).Long-term follow-up of the randomized CAT-CAD trial confirms that the strategy employing coronary CTA is an effective and safe, non-invasive, outpatient-based alternative to ICA for patients with a high clinical likelihood of obstructive CAD.

Monocyte chemotactic protein-1 (MCP-1) plays an important role in the entire atherosclerotic process, from atherogenesis to destabilisation of the atherosclerotic plaque. The purpose of this study is to evaluate the effect of the dietary approaches to stop hypertension (DASH) diet in patients with coronary artery disease on the MCP-1 plasma concentration and to evaluate the potential usefulness of this chemokine as a marker of change in the volume and composition of coronary plaque. Material and method. As part of the dietary intervention to stop coronary atherosclerosis in computed tomography (DISCO-CT) study, patients were randomised to an intervention group (n = 40) in which the DASH diet was introduced, and to a control group (n = 39) with no dietary intervention. In the DASH group, dietary counselling was provided at all follow-up visits within 12 months of the follow-up period. MCP-1 plasma concentration was determined using enzyme-linked immunosorbent assay (ELISA). Coronary plaque analysis was performed using a semi-automated plaque analysis software system (QAngioCT, Medis, the Netherlands). Results. In the DASH group, MCP-1 plasma concentration significantly decreased by 34.1 pg/mL (p = 0.01), while in the control group, the change in MPC-1 was not significant. Significant inverse correlations were revealed for the change in MCP-1 plasma concentration and change in the consumption of vitamin C and dietary fibre both in the DASH (r = −0.519, p = 0.0005, r = −0.353, p = 0.025, respectively) and in the control group (r = −0.488 p = 0.001, r = −0.502, p = 0.001, respectively). In patients with the highest decrease in percent atheroma volume (PAV), a significant positive correlation was observed between the change in MCP-1 plasma concentration and changes in PAV (r = 0.428, p = 0.033) and calcified plaque component (r = 0.468, p = 0.018), while the change in noncalcified plaque component correlated inversely with change in MCP1 (r = −0.459, p = 0.021). Conclusion. Dietary intervention based on the DASH diet model reduces the MCP-1plasma concentration, mostly due to an increased intake of plant-derived, fibre-rich foods and antioxidants. The change in MCP-1 plasma concentration seems to reflect changes in the atheroma volume and proportions between the calcified and non-calcified plaque elements.

Introduction Despite their significance, the prevalence and the incidence of vulnerable plaques in coronary arteries, as well as their natural history, remain poorly known. Aim To evaluate the prevalence, incidence and evolution of napkin-ring sign (NRS), and to establish factors associated with its presence, progression, or regression, in patients with suspected coronary artery disease (CAD). Material and methods The study is based on a single-center prospective registry. Eighty-nine patients with suspected CAD underwent two computed tomography angiography (CTA) examinations within an interval of at least 24 months. High-risk plaque was defined by the presence of a low-attenuation area adjacent to the coronary lumen, surrounded by a ring of higher attenuation - NRS. Results At the baseline 53 NRS were observed in 22 (25%) patients, 7 (8%) patients had single NRS and 15 (17%) had multiple NRS. After the follow-up period, there were 68 NRS in 32 patients. In 18 patients progression was observed with 23 additional NRS. Presence of single NRS and diabetes were independent predictors of NRS progression. Conclusions The number of NRS plaque tends to increase over time in patients with suspected CAD. The progression may be predicted by the presence of diabetes or single NRS.

Objectives This study compared the safety and diagnostic yield of a selective referral strategy using coronary computed tomographic angiography (CCTA) compared with a direct referral strategy using invasive coronary angiography (ICA) as the index procedure. Background Among patients presenting with signs and symptoms suggestive of coronary artery disease (CAD), a sizeable proportion who are referred to ICA do not have a significant, obstructive stenosis. Methods In a multinational, randomized clinical trial of patients referred to ICA for nonemergent indications, a selective referral strategy was compared with a direct referral strategy. The primary endpoint was noninferiority with a multiplicative margin of 1.33 of composite major adverse cardiovascular events (blindly adjudicated death, myocardial infarction, unstable angina, stroke, urgent and/or emergent coronary revascularization or cardiac hospitalization) at a median follow-up of 1-year. Results At 22 sites, 823 subjects were randomized to a selective referral and 808 to a direct referral strategy. At 1 year, selective referral met the noninferiority margin of 1.33 (p = 0.026) with a similar event rate between the randomized arms of the trial (4.6% vs. 4.6%; hazard ratio: 0.99; 95% confidence interval: 0.66 to 1.47). Following CCTA, only 23% of the selective referral arm went on to ICA, which was a rate lower than that of the direct referral strategy. Coronary revascularization occurred less often in the selective referral group compared with the direct referral to ICA (13% vs. 18%; p Conclusions In stable patients with suspected CAD who are eligible for ICA, the comparable 1-year major adverse cardiovascular events rates following a selective referral and direct referral strategy suggests that both diagnostic approaches are similarly effective. In the selective referral strategy, the reduced use of ICA was associated with a greater diagnostic yield, which supported the usefulness of CCTA as an efficient and accurate method to guide decisions of ICA performance. (Coronary Computed Tomographic Angiography for Selective Cardiac Catheterization [CONSERVE]; NCT01810198)

Introduction Growing role of coronary computed tomography angiography (CTA) as a diagnostic tool in patients with suspected coronary artery disease (CAD) calls for better recognition of its value in clinical decision making as compared to the gold standard of invasive coronary angiography (ICA). Aim To assess the diagnostic value of quantitative coronary computed tomography angiography (QCT) as compared to quantitative coronary angiography (QCA) for the prediction of coronary revascularization. Material and methods In this prospective observational study we included 100 patients who underwent ICA following CTA. Quantitative diameter stenosis analysis (qCTA) was performed with Syngo.via (Siemens Medical Systems) software by an experienced investigator blinded to results of ICA. Quantitative Coronary Angiography (QCA) was chosen to define %DS in a repetitive manner. ICA images were submitted to Qangio XA (Medis, Leiden, The Netherlands) software for QCA analysis. Results Eighty out of 400 analysed vessels were revascularized. Per-vessel diagnostic accuracy, sensitivity, specificity, PPV an NPV were 80%, 98%, 73%, 48% and 99% for QCT and 81%, 99%, 73%, 48% and 100% for QCA, respectively, for the prediction of revascularization. AUC was similar: 0.88 for QCT and 0.89 for QCA (p = NS). Conclusions These real-world data support the concept that CTA is as precise in prediction of coronary revascularization as ICA. This may add to the discussion about CTA having the potential to replace ICA for diagnosing vessels qualified for intervention, reserving the invasive diagnostic approach for those with the highest probability of revascularization.

OBJECTIVES: In this international, multicenter study, using third-generation dual-source computed tomography (CT), we investigated the diagnostic performance of dynamic stress CT myocardial perfusion imaging (CT-MPI) in addition to coronary CT angiography (CTA) compared to invasive coronary angiography (ICA) and invasive fractional flow reserve (FFR).BACKGROUND: CT-MPI combined with coronary CTA integrates coronary artery anatomy with inducible myocardial ischemia, showing promising results for the diagnosis of hemodynamically significant coronary artery disease in single-center studies.METHODS: At 9 centers in Europe, Japan, and the United States, 132 patients scheduled for ICA were enrolled; 114 patients successfully completed coronary CTA, adenosine-stress dynamic CT-MPI, and ICA. Invasive FFR was performed in vessels with 25% to 90% stenosis. Data were analyzed by independent core laboratories. For the primary analysis, for each coronary artery the presence of hemodynamically significant obstruction was interpreted by coronary CTA with CT-MPI compared to coronary CTA alone, using an FFR of ≤0.80 and angiographic severity as reference. Territorial absolute myocardial blood flow (MBF) and relative MBF were compared using C-statistics.RESULTS: ICA and FFR identified hemodynamically significant stenoses in 74 of 289 coronary vessels (26%). Coronary CTA with ≥50% stenosis demonstrated a per-vessel sensitivity, specificity, and accuracy for the detection of hemodynamically significant stenosis of 96% (95% CI: 91-100), 72% (95% CI: 66-78), and 78% (95% CI: 73-83), respectively. Coronary CTA with CT-MPI showed a lower sensitivity (84%; 95% CI: 75-92) but higher specificity (89%; 95% CI: 85-93) and accuracy (88%; 95% CI: 84-92). The areas under the receiver-operating characteristic curve of absolute MBF and relative MBF were 0.79 (95% CI: 0.71-0.86) and 0.82 (95% CI: 0.74-0.88), respectively. The median dose-length product of CT-MPI and coronary CTA were 313 mGy·cm and 138 mGy·cm, respectively.CONCLUSIONS: Dynamic CT-MPI offers incremental diagnostic value over coronary CTA alone for the identification of hemodynamically significant coronary artery disease. Generalized results from this multicenter study encourage broader consideration of dynamic CT-MPI in clinical practice. (Dynamic Stress Perfusion CT for Detection of Inducible Myocardial Ischemia [SPECIFIC]; NCT02810795).

OBJECTIVES This study aimed to find imaging risk features for device related-pulmonary artery (PA) injury (DR-PAI) in patients after left atrial appendage closure (LAAC). BACKGROUND Cardiac tamponade resulting from DR-PAI is a rare but life-threatening complication of LAAC. METHODS In vitro analysis of Amplatzer™ Amulet™ (Abbott, MN) device was done. Measurements of the distance between PA and Amplatzer lobe at its middle part, distal part, and along the stabilizing wires' trajectory (wires-to-PA distance) were taken in 100 consecutive patients on post-LAAC computed tomography (CT) studies. Clinical outcomes were collected. RESULTS In vitro analysis indicated that both middle and distal lobe had to be in close PA proximity (

Background Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease that manifests as the presence of beaded or focal lesions in medium or small-sized arteries and may also include arterial dissection, aneurysm, and tortuosity. FMD could be revealed in various manifestations, however limited data on the involvement of the thoracic aorta is reported. Purpose To measure and evaluate involvement of thoracic aorta in patients with FMD. Methods We analysed aortas of 144 consecutive patients (mean age 50.2±14.0, 116 women) with confirmed FMD in at least one vascular bed. The control group consisted of 144 (mean age 50.5±14.0, 116 women) age and sex matched individuals. All patients underwent detailed clinical evaluation including angio-CT scan including aortic valve, thoracic aorta and coronary arteries. We measured the aortic valve annulus, sinus of valsalva, sinotubular junction, the diameters of ascending and descending aorta, aortic unfolding, the height of ostium of RCA and LCA and diameter of right and left coronary artery ostia in patients with fibromuscular dysplasia and compared them to matched controls. Results The FMD group had significantly smaller dimensions of aortic valve annulus and sinus of Valsalva than control group (2.3 [2.1–2.6] vs 2.9 [2.7–3.1] p Conclusions Patients with fibromuscular dysplasia display smaller dimensions of aortic valve and larger diameter of ascending and descending aorta as compared to control subjects. Despite the predominant clinical significance of focal pathologies in FMD patients, the disease may display a specific, pan-vascular phenotype. Funding Acknowledgement Type of funding source: None

Background Fibromuscular dysplasia (FMD) is a non-atherosclerotic arterial disease characterized by the presence of string-of-beads or focal stenosis. Other FMD-related lesions include arterial dissections, aneurysms, and tortuosity. However, limited data are available on the involvement of coronary arteries in pts diagnosed with “extra-coronary” FMD. Purpose To examine FMD-related coronary artery involvement, coronary artery lesions and coronary tortuosity in patients with a diagnosis of “extra-coronary” FMD. Methods In a case control study we enrolled 103 (age 45.7±13.2, 82 women) consecutive patients with a diagnosis of FMD, in whom atherosclerotic coronary artery disease was excluded on the basis of coronary CTA, and 96 (age 47.3±12.2, 75 women) sex- and age-matched controls without coronary atherosclerosis based on CTA imaging (Siemens Force 2x192 scanner). Detailed analysis of coronary arteries was assessed, with detailed analysis of arterial tortuosity, defined as curves >30 OR >45 OR >90 degrees. Tortuosity Index (TI) was defined as number of curves x artery length (centerline) / vector artery start-end. Each arterial tortuosity evaluation was performed per coronary segment AND per artery. Size (area, length) of coronary arteries was also measured. Results Intravessel symmetry sign and cork-screw sign were more common in arteries of FMD patients than in controls (5.4% vs 1.3%, p30 degrees) (0.777; 95% CI:0.713 to 0.833) or TI (0.794; 95% CI: 0.731 to 0.848), both in distal LAD. For the distal LAD indices, the best sensitivity and specificity values were for ≥4 curves (sens. 74%, spec. 72%) or for a TI >5.6 (sens. 55%, spec. 94%), respectively. These predictive values were confirmed after correction for potential confounders. Interestingly, neither proximal LAD or proximal LCx number of curves or TI were related to FMD. No difference was found in terms of areas of coronary arteries between FMD patients and controls, with the only exception of LM (20.8±6.6 vs 17.9±5.8, p=0.002). Mean coronary artery lenght was significantly different between controls and patients with FMD (respectively LM 8.4±4.2 vs 9.8±4.5, p=0.022; LAD 117.8±28.6 vs 109.1±30.2, p=0.042; LCx 85.2±43.9 vs 62.9±31.4, p Conclusions Distal and not proximal coronary arterial tortuosity is related to FMD. Coronary tortuosity defined as 4 distal LAD curves or a TI >5.6 are highly specific for FMD. Funding Acknowledgement Type of funding source: None

Background Lifestyle and diet modification are the forefront in the management of coronary artery disease (CAD), however, there is no data whether they may stop progression of atheroslcerosis. Some coronary plaque characteristics are known to increase the risk of future cardiovascular events independently of coronary stenosis severity. These plaques are characterized by the presence of lipids and necrotic elements, and can be identified with coronary computed tomography angiography (CTA). Purpose To study the effect of intensive dietary intervention on changes in atherosclerotic plaque volume and composition. Methods We enrolled 89 patients (41% women, mean age 60±7.7 years) with nonobstructive coronary lesions (351 HU), fibrous plaque (151 to 350 HU), and fibrofatty plaque plus necrotic core (−100 to 150 HU), regarded as the vulnerable plaque component. Results Total plaque volume did not change significantly in any group (p=0.41; Figure 1A). Percent atheroma volume increased in the control arm vs. no significant change in the experimental arm, with no significant intergroup difference (p=0.79; Figure 1B). Vulnerable plaque component decreased in both subgroups, by 52.9±82.2 mm3 in the experimental vs. 20.8±58.5 mm3 in the control arm, and there was a significant difference in the reductions between the groups (p=0.04; Figure 1C). Fibrous plaque volume and dense calcium volume did not change significantly in any group (+9.5±117.8 mm3 in the experimental vs. +7.6±92.1 mm3 in the control arm, p=0.93, and +33±68.9 mm3 vs. +30.2±52.5 mm3, p=0.78, respectively). Conclusions Intensive diet intervention atop OMT can stop the progression of atherosclerosis and lead to a significant reduction in vulnerable plaque component compared to OMT alone. Figure 1 Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Institute of Cardiology in Warsaw, Poland

The authors sought to study the impact of diet and lifestyle intervention on changes in atherosclerotic plaque volume and composition.Lifestyle and diet modification are the leading strategies to manage coronary artery disease; however, their direct impact on atherosclerosis remains unknown. Coronary plaque composition is related to the risk of future cardiovascular events independent of stenosis severity and can be conveniently evaluated with computed tomography angiography (CTA).We enrolled 92 patients (41% women; mean age 60 ± 7.7 years) with nonobstructive (70% stenosis) coronary atherosclerosis identified by CTA. Participants were randomized (1:1) to either the DISCO (Dietary Intervention to Stop Coronary Atherosclerosis in Computed Tomography) intervention group (systematic follow-up by a dietitian to adhere to the Dietary Approaches to Stop Hypertension nutrition model together with optimal medical therapy [OMT]) or the control group (OMT alone). In all patients, CTA was repeated after 66.9 ± 13.7 weeks. The outcome was change (Δ) in atheroma volume and plaque composition. Based on atherosclerotic tissue attenuation ranges in Hounsfield units (HU), the following components of coronary plaque were distinguished: dense calcium (351 HU), fibrous plaque (151 to 350 HU), and fibrofatty plaque combined with necrotic core (-30 to 150 HU), referred to as noncalcified plaque.Percent atheroma volume increased in the control arm (Δ = +1.1 ± 3.4%; p = 0.033) versus no significant change in the experimental arm (Δ = +1.0% ± 4.2%; p = 0.127; intergroup p = 0.851). There was a reduction in noncalcified plaque in both the experimental arm (Δ = -51.3 ± 79.5 mmControlled diet and lifestyle intervention together with OMT may slow the progression of atherosclerosis and reduce noncalcified plaque volume compared to OMT alone. (Dietary Intervention to Stop Coronary Atherosclerosis in Computed Tomography [DISCO-CT]; NCT02571803).

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.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.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.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.Clinicaltrials.gov, NCT02400229.

Purpose Little is known about ethnic differences in the size of coronary arteries in disease-free individuals. Our aim was to compare coronary artery dimensions between Asian and Caucasian population without atherosclerosis. Methods One hundred and twelve Caucasian patients without any discernible atherosclerosis detected on coronary computed tomography angiography were matched with 112 Asian patients using sex, age, coronary dominance pattern and body surface area (BSA). Maximal and minimal lumen areas (LA) and diameters (LD) of proximal and middle coronary segments were measured, and the mean values were used for analyses. Results Caucasians had larger LA and LD than Asian patients in all proximal coronary segments. Overall, the mean difference in LA and LD was 11.4 % and 5.2 %, respectively. Significant differences were observed for all proximal segments (left anterior descending: 13 % and 6%, left circumflex 14 % and 8% and right coronary artery 8% and 4% for LA and LD), but not for mid segments. The greatest difference between Caucasians and Asians was found in left main coronary artery (LMCA) LA (21.2 ± 6.5 vs.16.8 ± 5.4 mm2, p Conclusion In subjects without atherosclerosis, Asians have smaller dimensions of all proximal coronary arteries, most prominently displayed in LMCA, than the Caucasians regardless of age, sex, or body size.

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 p p 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.

There are plenty of data on morphology and lumen dimensions of diseased coronary arteries. However, information on normal coronary vessel anatomy is scarce. We provided computed tomography angiography-derived reference values of lumen dimensions in proximal and middle coronary segments in a healthy population with respect to gender and vessel dominance. Consecutive 2,849 computed tomography angiography examinations were reviewed to identify 201 subjects (77 men, patient age 50 ± 13 years) whose coronary arteries were free from any sign of atherosclerosis (calcium score 0, no detectable plaque). For all proximal and middle coronary segments, lumen areas (LAs) and lumen diameters were measured. Coronary vessel segmentation and dominance pattern were defined using the Syntax Score. Normal values of LAs and lumen diameters were significantly smaller for women compared with men except for the proximal right coronary artery and the left main coronary artery (LMCA) (20.2 ± 6.6 mm2 vs 23.0 ± 6.1 mm2, p = 0.0003, and 5.0 ± 0.8 mm vs 5.4 ± 0.7 mm, p = 0.0001). The lower limit of normal for the LMCA (defined as mean LA - 2 standard deviations) equaled 7.0 and 10.8 mm2 for women and men, respectively. Subjects with left (vs right) coronary dominance had significantly larger areas and diameters of the LMCA (26.2 ± 9.2 mm2 vs 20.7 ± 6.0 mm2, p = 0.0017, and 5.7 ± 1.0 mm vs 5.1 ± 0.7 mm, p = 0.0017, respectively) and proximal left circumflex (13.8 ± 2.7 mm2 vs 10.4 ± 3.8 mm2, p = 0.0001, and 4.2 ± 0.4 mm vs 3.6 ± 0.7 mm, p = 0.0001, respectively) and smaller areas and diameters of the proximal right coronary artery (7.1 ± 2.0 mm2 vs 13.3 ± 3.6 mm2, p

OBJECTIVE Despite coronary calcifications being a major factor affecting the diagnostic accuracy of coronary computed tomography angiography (CTA), there is a lack of established criteria for categorizing calcifications. We aimed to evaluate patterns of coronary calcification based on quantitative radiodensity and size parameters to provide coronary calcium categories and assess their impact on the accuracy of coronary CTA. METHODS AND RESULTS We analyzed length, maximum thickness, volume, mean density, and maximum density of coronary calcium and divided each of these parameters into tertiles. Subsequently, we summarized the tertiles for each individual calcification and divided them into 3 equal groups of: mild, moderate, and severe calcification. The accuracy of coronary CTA was defined as the difference between the measurements obtained on coronary CTA versus the reference of intravascular ultrasound (IVUS). We evaluated 252 coronary calcifications within 97 arteries of 60 patients. There was an expected increase in size and density values for mild versus moderate versus severe calcifications, but there was no difference in IVUS measured minimum lumen area among the 3 groups. Of note, coronary CTA significantly underestimated IVUS minimum lumen area measurement by 1.2 ± 1.6 mm (14.6 ± 23.1%, P < 0.001) for severe calcifications and by 0.5 ± 2.0 mm (3.7 ± 32.1%, P = 0.021) for moderate calcifications. Within mild calcifications, the difference was not significant. CONCLUSION Based on their dimensional and radiodensity characteristics, our analysis revealed patterns of individual coronary artery calcifications that affected the accuracy of coronary CTA measurements; coronary CTA inaccuracy was associated with the presence of moderate or severe calcifications, but not mild calcifications.