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Objectives: The purpose of the study was to determine the effectiveness of a collaborative educational, continuous quality improvement (CQI) initiative to increase appropriate use of coronary computed tomography angiography (CCTA). Background: Potential overuse of CCTA has prompted multisociety appropriate use criteria (AUC) publications. Methods: This prospective, observational study was conducted with pre-intervention (July 2007 to June 2008), intervention (July 2008 to June 2010), and follow-up (July 2010 to December 2010) periods during which patients were enrolled in the Advanced Cardiovascular Imaging Consortium (ACIC) at 47 Michigan hospitals. Continuous education was provided to referring physicians. The possibility of losing third-party payer coverage in the absence of a measurable change in AUC was emphasized. AUC was compared between the 3 periods. Results: The study group included 25,387 patients. Compared with the pre-intervention period, there was a 23.4% increase in appropriate (61.3% to 80%, p < 0.0001), 60.3% decrease in inappropriate (14.6% to 5.8%, p < 0.0001), 40.8% decrease in uncertain (10.3% to 6.1%, p < 0.0001), and 41.7% decrease in unclassifiable (13.9% to 8.1%, p < 0.0001) scans during follow-up. Between pre-intervention and follow-up, change in CCTA referrals by provider specialty were cardiology (appropriate: 60.4% to 79.5%; inappropriate: 13% to 5.2%; p < 0.0001), internal medicine/family practice (appropriate: 51.1% to 70.4%; inappropriate: 20.2% to 12.5%; p < 0.0001), emergency medicine (appropriate: 83.6% to 91.6%; inappropriate: 9.1% to 0.6%; p < 0.0001), and other (appropriate: 61.1% to 83.2%; inappropriate: 18.6% to 5.9%; p < 0.0001). Conclusions: Application of a systematic CQI and emphasis on possible loss of coverage were associated with a significant improvement in the proportion of CCTA examinations meeting AUC across referring physician specialties. [ABSTRACT FROM AUTHOR]

Objective: Women with gestational diabetes mellitus (GDM) maintain a higher risk for recurrent GDM and overt diabetes. Overt diabetes is a risk factor for development of chronic kidney disease (CKD), but GDM alone, without subsequent development of overt diabetes, may also pose a risk for CKD.Research Design and Methods: This cross-sectional analysis included Kidney Early Evaluation Program (KEEP) participants from 2000 to 2009. Patient characteristics and kidney function among three categories (GDM alone, overt diabetes, and no history of diabetes) were compared. The prevalence of microalbuminuria, macroalbuminuria, and CKD stages 1-2 and 3-5 was assessed using logistic regression.Results: Of 37,716 KEEP female participants, 571 (1.5%) had GDM alone and 12,100 (32.1%) had overt diabetes. Women with GDM had a higher rate of microalbuminuria but not macroalbuminuria than their nondiabetic peers (10.0 vs. 7.7%) that was substantially lower than the 13.6% prevalence in diabetic women. In multivariate analysis, women with GDM alone, compared with nondiabetic women, demonstrated increased odds of CKD stages 1-2 (multivariate odds ratio 1.54 [95% CI 1.16-2.05]) similar to the odds for women with overt diabetes (1.68 [1.55-1.82]). In stratified analyses, age, race, BMI, and hypertension modified the odds for CKD stages 1-2 but not CKD stages 3-5 among women with GDM.Conclusions: Women with GDM alone have a higher prevalence of microalbuminuria than women without any history of diabetes, translating to higher rates of CKD stages 1-2. These results suggest that GDM, even in the absence of subsequent overt diabetes, may increase the risk for future cardiovascular and kidney disease. [ABSTRACT FROM AUTHOR]

Cardiac computed tomographic angiography (CCTA) is revolutionizing our approach to the identification and management of coronary artery atherosclerosis. CCTA has the unique ability to assess extracoronary cardiac findings within the standard field of view, including the anatomy of cardiac structures-the atria, ventricles, valves, pericardium, great vessels, and venous anatomy-and any related abnormalities. Appropriate clinical applications include evaluation of intermediate-risk patients with acute chest pain and those with suspected coronary anomalies, uninterpretable or equivocal stress test results, or suspected cardiac morphologic abnormalities. Optimization of this diagnostic examination requires close attention to details such as minimizing motion and attaining sufficient contrast opacification. Iso-osmolar contrast can help achieve maximum patient comfort with the smallest elevation of heart rate and variability, as well as minimize the risk of acute kidney injury. Newer scanning equipment and protocols have improved image quality in difficult cases, including obese patients and those with heavy coronary calcification or metal artifacts. Current imaging protocols have reduced exposure to ionizing radiation and continue to improve safety. [ABSTRACT FROM AUTHOR]

Purpose To examine the relationship between smoking status and coronary volume-to-myocardial mass ratio (V/M) among individuals with coronary artery disease (CAD) undergoing CT fractional flow reserve (CT-FFR) analysis. Materials and Methods In this secondary analysis, participants from the ADVANCE registry evaluated for suspected CAD from July 15, 2015, to October 20, 2017, who were found to have coronary stenosis of 30% or greater at coronary CT angiography (CCTA) were included if they had known smoking status and underwent CT-FFR and V/M analysis. CCTA images were segmented to calculate coronary volume and myocardial mass. V/M was compared between smoking groups, and predictors of low V/M were determined. Results The sample for analysis included 503 current smokers, 1060 former smokers, and 1311 never-smokers (2874 participants; 1906 male participants). After adjustment for demographic and clinical factors, former smokers had greater coronary volume than never-smokers (former smokers, 3021.7 mm 3 ± 934.0 [SD]; never-smokers, 2967.6 mm 3 ± 978.0; P = .002), while current smokers had increased myocardial mass compared with never-smokers (current smokers, 127.8 g ± 32.9; never-smokers, 118.0 g ± 32.5; P = .02). However, both current and former smokers had lower V/M than never-smokers (current smokers, 24.1 mm 3 /g ± 7.9; former smokers, 24.9 mm 3 /g ± 7.1; never-smokers, 25.8 mm 3 /g ± 7.4; P < .001 [unadjusted] and P = .002 [unadjusted], respectively). Current smoking status (odds ratio [OR], 0.74 [95% CI: 0.59, 0.93]; P = .009), former smoking status (OR, 0.81 [95% CI: 0.68, 0.97]; P = .02), stenosis of 50% or greater (OR, 0.62 [95% CI: 0.52, 0.74]; P < .001), and diabetes (OR, 0.67 [95% CI: 0.56, 0.82]; P < .001) were independent predictors of low V/M. Conclusion Both current and former smoking status were independently associated with low V/M. Keywords: CT Angiography, Cardiac, Heart, Ischemia/Infarction Clinical trial registration no. NCT02499679 Supplemental material is available for this article . © RSNA, 2024.

Purpose: To compare the clinical use of coronary CT angiography (CCTA)-derived fractional flow reserve (FFR) in individuals with and without diabetes mellitus (DM)., Materials and Methods: This secondary analysis included participants (enrolled July 2015 to October 2017) from the prospective, multicenter, international The Assessing Diagnostic Value of Noninvasive CT-FFR in Coronary Care (ADVANCE) registry (ClinicalTrials.gov identifier, NCT02499679) who were evaluated for suspected coronary artery disease (CAD), with one or more coronary stenosis ≥30% on CCTA images, using CT-FFR. CCTA and CT-FFR findings, treatment strategies at 90 days, and clinical outcomes at 1-year follow-up were compared in participants with and without DM., Results: The study included 4290 participants (mean age, 66 years ± 10 [SD]; 66% male participants; 22% participants with DM). Participants with DM had more obstructive CAD (one or more coronary stenosis ≥50%; 78.8% vs 70.6%, P < .001), multivessel CAD (three-vessel obstructive CAD; 18.9% vs 11.2%, P < .001), and proportionally more vessels with CT-FFR ≤ 0.8 (74.3% vs 64.6%, P < .001). Treatment reclassification by CT-FFR occurred in two-thirds of participants which was consistent regardless of the presence of DM. There was a similar graded increase in coronary revascularization with declining CT-FFR in both groups. At 1 year, presence of DM was associated with higher rates of major adverse cardiovascular events (hazard ratio, 2.2; 95% CI: 1.2, 4.1; P = .01). However, no between group differences were observed when stratified by stenosis severity (<50% or ≥50%) or CT-FFR positivity., Conclusion: Both anatomic CCTA findings and CT-FFR demonstrated a more complex pattern of CAD in participants with versus without DM. Rates of treatment reclassification were similar regardless of the presence of DM, and DM was not an adverse prognostic indicator when adjusted for diameter stenosis and CT-FFR.Clinical trial registration no. NCT 02499679 Keywords: Fractional Flow Reserve, CT Angiography, Diabetes Mellitus, Coronary Artery Disease Supplemental material is available for this article. See also the commentary by Ghoshhajra in this issue.© RSNA, 2023., Competing Interests: Disclosures of conflicts of interest: G.S.G. Trainee editorial board member for Radiology: Cardiothoracic Imaging. G.T. Supported by the Fondation Vaudoise de Cardiologie and the SICPA Foundation. K.R.H. No relevant relationships. H.T. Grants from Canon Medical Systems and JSPS KAKENHI (grant no. 23K15150); speaking fee from HeartFlow Japan. S.L.S. Grants paid to institution from Edwards Lifesciences, Medtronic, HeartFlow; consulting fees from Edwards Lifesciences, Anteris Technologies, and Medtronic; equipment loan agreement from ViVitro Labs. P.B. Consulting fees from Edwards Lifesciences; L.M.H.K. Funding to department from HeartFlow; member of the Radiology: Cardiothoracic Imaging editorial board. B.L.N. Unrestricted institutional research grants from Siemens Healthineers and HeartFlow. J.J. No relevant relationships. M.G.R. Consulting fees from HeartFlow. G.P. Funding from HeartFlow. T.A.F. No relevant relationships. K.M.C. Institutional grant from HeartFlow; honoraria from Elucid Bioimaging. P.S.D. Grant to institution from HeartFlow; honorarium from UpToDate; support from Caption Health. W.H. Employee of HeartFlow; stock options in HeartFlow. H.M. No relevant relationships. N.P.R.S. No relevant relationships. K.N. Grants from Siemens Healthineers, GE HealthCare, and HeartFlow; consulting fees from Siemens Medical Solutions USA, Elucid, and Novartis; stock options in Lumen Therapeutics. J.J.B. No relevant relationships. T. Amano No relevant relationships. T.K. No relevant relationships. T. Akasaka No relevant relationships. T.R. Support (salary and equity) from HeartFlow. D.S.B. Software royalties from Cedars-Sinai; consulting fees from GE and Bayer. M.R.P. Grants from HeartFlow, Bayer, Janssen Pharmaceuticals, and Novartis; consulting fees from Bayer, Hanssen Pharmaceuticals, and Novartis. B.D.B. No relevant relationships. S.M. Employee and shareholder of HeartFlow. J.A.L. Grants from GE HealthCare; consulting fees and stock options from HeartFlow and Circle Cardiovascular Imaging; personal core lab services from Arineta; speaking fees from Philips and GE HealthCare; stock options in HeartFlow and Circle Cardiovascular Imaging, deputy editor for Radiology: Cardiothoracic Imaging., (© 2023 by the Radiological Society of North America, Inc.)

Competing Interests: Conflict of interest: None declared

Background: The ongoing novel coronavirus disease 2019 (COVID-19) pandemic has a significant mortality rate of 3-5%. The principal causes of multiorgan failure and death are cytokine release syndrome and immune dysfunction. Stress, anxiety, and depression has been aggravated by the pandemic and its resultant restrictions in day-to-day life which may contribute to immune dysregulation. Thus, immunity strengthening and the prevention of cytokine release syndrome are important for preventing and minimizing mortality in COVID-19 patients. However, despite a few specific remedies that now exist for the SARS-CoV-2virus, the principal modes of prevention include vaccination, masking, and holistic healing methods, such as yoga. Currently, extensive research is being conducted to better understand the neuroendocrinoimmunological mechanisms by which yoga alleviates stress and inflammation. This review article explores the anti-inflammatory and immune-modulating potentials of yoga, along with its role in reducing risk for immune dysfunction and impaired mental health., Methods: We conducted this narrative review from published literature in MEDLINE, EMBASE, COCHRANE databases. Screening was performed for titles and abstracts by two independent review authors; potentially eligible citations were retrieved for full-text review. References of included articles and articles of major non-indexed peer reviewed journals were searched for relevance by two independent review authors. A third review author checked the excluded records. All disagreements were resolved through discussion amongst review authors or through adjudication by a fourth review author. Abstracts, editorials, conference proceedings and clinical trial registrations were excluded., Observations: Yoga is a nonpharmacological, cost-effective, and safe intervention associated with several health benefits. Originating in ancient India, this vast discipline consists of postures (asanas), breathing techniques (pranayama), meditation (dhyana/dharana), and relaxation. Studies have demonstrated yoga's ability to bolster innate immunity and to inhibit cytokine release syndrome. As an intervention, yoga has been shown to improve mental health, as it alleviates anxiety, depression, and stress and enhances mindfulness, self-control, and self-regulation. Yoga has been correlated with numerous cardioprotective effects, which also may play a role in COVID-19 by preventing lung and cardiac injury., Conclusion and Relevance: This review paves the path for further research on yoga as a potential intervention for enhancing innate immunity and mental health and thus its role in prevention and adjunctive treatment in COVID-19., (© 2022. The Author(s).)

Objectives: This study is to determine the management and clinical outcomes of patients investigated with coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFR CT ) according to sex., Background: Women are underdiagnosed with conventional ischemia testing, have lower rates of obstructive coronary artery disease (CAD) at invasive coronary angiography (ICA), yet higher mortality compared to men. Whether FFR CT improves sex-based patient management decisions compared to CCTA alone is unknown., Methods: Subjects with symptoms and CAD on CCTA were enrolled (2015 to 2017). Demographics, symptom status, CCTA anatomy, coronary volume to myocardial mass ratio (V/M), lowest FFR CT values, and management plans were captured. Endpoints included reclassification rate between CCTA and FFR CT management plans, incidence of ICA demonstrating obstructive CAD (≥50% stenosis) and revascularization rates., Results: A total of 4,737 patients (n = 1,603 females, 33.8%) underwent CCTA and FFR CT . Women were older (age 68 ± 10 years vs. 65 ± 10 years; p < 0.0001) with more atypical symptoms (41.5% vs. 33.9%; p < 0.0001). Women had less obstructive CAD (65.4% vs. 74.7%; p < 0.0001) at CCTA, higher FFR CT (0.76 ± 0.10 vs. 0.73 ± 0.10; p < 0.0001), and lower likelihood of positive FFR CT ≤ 0.80 for the same degree stenosis (p < 0.0001). A positive FFR CT ≤0.80 resulted in equal referral to ICA (n = 510 [54.5%] vs. n = 1,249 [56.5%]; p = 0.31), but more nonobstructive CAD (n = 208 [32.1%] vs. n = 354 [24.5%]; p = 0.0003) and less revascularization (n = 294 [31.4%] vs. n = 800 [36.2%]; p < 0.0001) in women, unless the FFR CT was ≤0.75 where revascularization rates were similar (n = 253 [41.9%] vs. n = 715 [46.4%]; p = 0.06). Women have a higher V/M ratio (26.17 ± 7.58 mm 3 /g vs. 24.76 ± 7.22 mm 3 /g; p < 0.0001) that is associated with higher FFR CT independent of degree stenosis (p < 0.001). Predictors of revascularization included stenosis severity, FFR CT, symptoms, and V/M ratio (p < 0.001) but not female sex (p = 0.284)., Conclusions: FFR CT differs between the sexes, as women have a higher FFR CT for the same degree of stenosis. In FFR CT -positive CAD, women have less obstructive CAD at ICA and less revascularization, which is associated with higher V/M ratio. The findings suggest that CAD and FFR CT variations by sex need specific interpretation as these differences may affect therapeutic decision making and clinical outcomes. (Assessing Diagnostic Value of Non-invasive FFRCT in Coronary Care [ADVANCE]; NCT02499679)., Competing Interests: Author Disclosures This study was supported by HeartFlow, Inc., Redwood City, California, via individual Clinical Study Agreements with each enrolling institution and with the Duke Clinical Research Institute (DCRI) for Core Laboratory activities and Clinical Event Committee adjudication of adverse events. Dr. Fairbairn is on the Speakers Bureau for Heartflow. Dr. Hurwitz-Koweek is on the Speakers Bureau for Heartflow; and has unrestricted grant funding from Siemens and Heartflow. Dr. Nørgaard has received unrestricted institutional research grants from Siemens and HeartFlow. Dr. Nieman has received unrestricted institutional research grants from Siemens, Bayer, GE, and HeartFlow. Dr. Bax has received unrestricted research grants from Edwards Lifescience, Medtronic, Boston Scientific, Biotronik, and GE Healthcare; and is on the Speakers Bureau with Abbott. Dr. Pontone is a consultant for GE Healthcare; and has research grants from GE Healthcare and Heartflow. Dr. Raff has received institutional grants from HeartFlow. Dr. Chinnaiyan has received institutional grants from HeartFlow. Dr. Rabbat has received institutional grants from HeartFlow. Dr. Binukrishnan is on the Speakers Bureau for Heartflow. Dr. Rogers is an employee of and has equity in Heartflow. Dr. Berman has received unrestricted research support from Heartflow. Dr. Patel has received grants from HeartFlow, Jansen, Bayer, AstraZeneca, and NHLBI; and has served as a consultant for Jansen, Bayer, AstraZeneca, Genzyme, and Merck. Dr. Douglas has received institutional grants from HeartFlow. Dr. Leipsic is a consultant for and has stock options in Circle CVI and Heartflow. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Coronary computed tomography angiography (CCTA)-derived fractional flow reserve (FFR CT ) is an established tool for identifying lesion-specific ischemia that is now approved for use by the Japanese insurance system. However, current clinical reimbursement is strictly limited to institutions with designated appropriate use criteria (AUC). This study assessed differences in physicians' behavior (e.g., use and interpretation of FFR CT , final management) according to Japanese AUC and non-AUC site designation. Methods and Results: Of 5,083 patients in the ADVANCE Registry, 1,829 from Japan were enrolled in this study. Physicians' behavior after interrogating CCTA and FFR CT was analyzed separately according to AUC and non-AUC site designation. Compared with AUC sites, patients referred for FFR CT from non-AUC sites had a higher rate of negative FFR CT , less severe anatomic stenosis, and a slightly lower rate of management plan reclassification (51.2% vs. 61.3%), with near-identical utility in both groups. Actual care corresponded equally well to post-FFR CT plans in both groups. The likelihood of revascularization for positive or negative FFR CT was similar between the 2 groups. Importantly, AUC and non-AUC sites were equally unlikely to revascularize patients with negative FFR CT and stenosis >50% or patients with positive FFR CT and stenosis <50%. Conclusions: Compared with AUC sites, non-AUC sites had lower disease burden and reclassification of management plans, but nearly identical clinical integration. Actual care corresponded equally well to post-FFR CT recommendations at both sites., Competing Interests: H.M. declares speaker fees from Abbott Vascular Japan, Phillips, Zeon Medical, Boston Scientific Japan. H.O. declares payments for lectures, including service on speakers bureaus, from HeartFlow Inc. N.T. declares consulting fees from Abbott Vascular Japan, Boston Scientific Japan and KANEKA Medix Co. C.R. is an employee of and has equity in HeartFlow. G.R. has received an institutional research grant from HeartFlow. L.M.H.K. has received departmental grant funding from Siemens Healthineers, HeartFlow, Verily, and Mallinckrodt. B.L.N. has received institutional unrestricted grants from Siemens and HeartFlow. J.L. declares consultant and stock options with CIRCLE CVI and HeartFlow, and research support from GE Healthcare. H.I. is a member of the Editorial Board of Circulation Reports. Y.M. is an Associate Editor of Circulation Reports. The remaining authors declare no conflicts of interest., (Copyright © 2020, THE JAPANESE CIRCULATION SOCIETY.)

Objectives: This study sought to examine the feasibility, safety, clinical outcomes, and costs associated with computed tomography-derived fractional flow reserve (FFR CT ) in acute chest pain (ACP) patients in a coronary computed tomography angiography (CTA)-based triage program., Background: FFR CT is useful in determining lesion-specific ischemia in patients with stable ischemic heart disease, but its utility in ACP has not been studied., Methods: ACP patients with no known coronary artery disease undergoing coronary CTA and coronary CTA with FFR CT were studied. FFR CT  ≤0.80 was considered positive for hemodynamically significant stenosis., Results: Among 555 patients, 297 underwent coronary CTA and FFR CT (196 negative, 101 positive), whereas 258 had coronary CTA only. The rejection rate for FFR CT was 1.6%. At 90 days, there was no difference in major adverse cardiac events (including death, nonfatal myocardial infarction, and unexpected revascularization after the index visit) between the coronary CTA and FFR CT groups (4.3% vs. 2.7%; p = 0.310). Diagnostic failure, defined as discordance between the coronary CTA or FFR CT results with invasive findings, did not differ between the groups (1.9% vs. 1.68%; p = NS). No deaths or myocardial infarction occurred with negative FFR CT when revascularization was deferred. Negative FFR CT was associated with higher nonobstructive disease on invasive coronary angiography (56.5%) than positive FFR CT (8.0%) and coronary CTA (22.9%) (p < 0.001). There was no difference in overall costs between the coronary CTA and FFR CT groups ($8,582 vs. $8,048; p = 0.550)., Conclusions: In ACP, FFR CT is feasible, with no difference in major adverse cardiac events and costs compared with coronary CTA alone. Deferral of revascularization is safe with negative FFR CT , which is associated with higher nonobstructive disease on invasive angiography., (Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Noninvasive fractional flow reserve derived from coronary CT angiography (FFR CT ) is increasingly used in patients with coronary artery disease as a gatekeeper to the catheterization laboratory. While there is emerging evidence of the clinical benefit of FFR CT in patients with moderate coronary disease as determined with coronary CT angiography, there has been less focus on interpretation, reporting, and integration of FFR CT results into routine clinical practice. Because FFR CT analysis provides a plethora of information regarding pressure and flow across the entire coronary tree, standardized criteria on interpretation and reporting of the FFR CT analysis result are of crucial importance both in context of the clinical adoption and in future research. This report represents expert opinion and recommendation on a standardized FFR CT interpretation and reporting approach. Published under a CC BY 4.0 license., Competing Interests: Disclosures of Conflicts of Interest: B.L.N. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: has received unrestricted institutional research grants from Siemens and HeartFlow; travel expenses covered at TCT 2017 by HeartFlow (no personal payment). Other relationships: disclosed no relevant relationships. T.A.F. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: has been an invited speaker sponsored by HeartFlow. Other relationships: disclosed no relevant relationships. R.D.S. disclosed no relevant relationships. M.G.R. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: author is consultant for HeartFlow. Other relationships: disclosed no relevant relationships. B.K. Activities related to the present article: has been an invited speaker at symposiums sponsored by Canon Medical, Medtronic, and St Jude, and has received research funding from Canon Medical. Activities not related to the present article: disclosed no relevant relationships. Other relationships: disclosed no relevant relationships. J.M.J. disclosed no relevant relationships. K.N. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: unrestricted institutional research support from HeartFlow, Siemens, GE, and Bayer; coverage of travel expenses to the present study results at the TCT in 2018 by HeartFlow; Steering committee ADVANCE registry for HeartFlow (unpaid). Other relationships: disclosed no relevant relationships. K.M.C. Activities related to the present article: institution receives grant from HeartFlow. Activities not related to the present article: Medical Advisory Board for HeartFlow (no personal compensation); institution receives grants from HeartFlow. Other relationships: disclosed no relevant relationships. N.P.S. disclosed no relevant relationships. H.M. disclosed no relevant relationships. J.L. Activities related to the present article: disclosed no relevant relationships. Activities not related to the present article: has received speaker honoraria from GE Healthcare, served as a consultant for Edwards Lifesciences, and served as a consultant and has stock options in Circle CVI and HeartFlow; has core laboratory contracts with Edwards Lifesciences, Medtronic, Abbott, Noevasc; research support from Edwards. Other relationships: disclosed no relevant relationships. G.R. disclosed no relevant relationships., (2019 by the Radiological Society of North America, Inc.)

Purpose of Review: There are numerous gender- and sex-based differences that contribute to the increased morbidity and mortality related to atherosclerotic cardiovascular disease (ASCVD) in women. Early detection of risk and targeted management of atherosclerotic disease is fundamental to reduce ASCVD risk and improve outcomes in women. In this review, we examine the utility of cardiac computed tomography (CT) and coronary CT angiography (CTA) in three ASCVD scenarios including coronary artery calcium scoring for risk stratification in asymptomatic women, and coronary CTA for diagnosis and prognosis of stable ischemic heart disease and acute chest pain. The risks of radiation exposure and the potential applications of novel technologies in women are explored., Recent Findings: CTA provides the capabilities of early recognition and management of nonobstructive coronary artery disease (CAD). Recent advancements in plaque composition and morphology further enhance the prognostic yield from coronary CTA. Innovations in stress perfusion and computational fluid dynamics allow for evaluation of physiological measures of ischemia. In addition, developments in artificial intelligence (AI) may also help unlock a deeper understanding of atherosclerosis and risk in women. Coronary CTA is an accurate and useful modality for early detection and management of ASCVD in women. Novel technologies hold great promise for furthering our understanding of sex-specific pathophysiology and potential improvement in clinical management and outcomes.

Purpose of Review: Despite the significant decline in cardiovascular disease (CVD) rates owing to recognition of risk factors, timely and appropriate therapy for acute events, and improved medical therapy, it remains the leading cause of death globally. Novel risk factors and modifications must be considered in the development and progression of CVD. The purpose of this review is to delineate the association between psychological and mental stress and CVD., Recent Findings: Stress has been implicated as a significant risk factor in both the acceleration of atherosclerosis and a trigger for acute CVD events. In the last decade, a growing body of evidence has been accumulated on the biological, neuroanatomical, and neurophysiological effects of stress and the benefits of cultivating resilience. The pathophysiology of stress is complex and involves the brain, autonomic nervous system, and the endocrine system, with associated metabolic, inflammatory, and hemostatic abnormalities., Summary: Most practice guidelines do not recognize the importance of screening for stress in primary and secondary CVD prevention. There is a paucity of large, scalable, and cost-effective approaches for stress intervention. Two potential strategies are required for reducing stress: strategies that are population-based, and narrower targeted strategies for clinical practice.

Background: Coronary computed tomography angiography (cCTA)-derived fractional flow reserve (FFR CT ) is a promising diagnostic method for the evaluation of coronary artery disease (CAD). However, clinical data regarding FFR CT in Japan are scarce, so we assessed the clinical impact of using FFR CT in a Japanese population.Methods and Results:The ADVANCE registry is an international prospective FFR CT registry of patients suspected of CAD. Of 5,083 patients, 1,829 subjects enrolled from Japan were analyzed. Demographics, symptoms, cCTA, FFR CT , treatment strategy, and 90-day major cardiovascular events (MACE) were assessed. Reclassification of treatment strategy between cCTA alone and cCTA+FFR CT occurred in 55.8% of site investigations and in 56.9% in the core laboratory analysis. Patients with positive FFR (FFR CT ≤0.80) were less likely to have non-obstructive disease on invasive coronary angiography than patients with negative FFR (FFR CT >0.80) (20.5% vs. 46.1%, P=0.0001). After FFR CT , 67.0% of patients with positive results underwent revascularization, whereas 96.1% of patients with negative FFR CT were medically treated. MACE occurred in 5 patients with positive FFR CT , but none occurred in patients with negative FFR CT within 90 days., Conclusions: In this Japanese population, FFR CT modified the treatment strategy in more than half of the patients. FFR CT showed potential for stratifying patients suspected of CAD properly into invasive or non-invasive management pathways.

This expert consensus statement from the Society of Cardiovascular Computed Tomography (SCCT) provides an evidence synthesis on the use of computed tomography (CT) imaging for diagnosis and risk stratification of coronary artery disease in women. From large patient and population cohorts of asymptomatic women, detection of any coronary artery calcium that identifies females with a 10-year atherosclerotic cardiovascular disease risk of >7.5% may more effectively triage women who may benefit from pharmacologic therapy. In addition to accurate detection of obstructive coronary artery disease (CAD), CT angiography (CTA) identifies nonobstructive atherosclerotic plaque extent and composition which is otherwise not detected by alternative stress testing modalities. Moreover, CTA has superior risk stratification when compared to stress testing in symptomatic women with stable chest pain (or equivalent) symptoms. For the evaluation of symptomatic women both in the emergency department and the outpatient setting, there is abundant evidence from large observational registries and multi-center randomized trials, that CT imaging is an effective procedure. Although radiation doses are far less for CT when compared to nuclear imaging, radiation dose reduction strategies should be applied in all women undergoing CT imaging. Effective and appropriate use of CT imaging can provide the means for improved detection of at-risk women and thereby focus preventive management resulting in long-term risk reduction and improved clinical outcomes., (Copyright © 2018 Society of Cardiovascular Computed Tomography. All rights reserved.)

Background: To date, the clinical utility of coronary computed tomography angiography (CTA)-derived fractional flow reserve (FFRCT) has been limited to trials and single center experiences. We herein report the incidence of abnormal FFRCT (≤0.80) and the relationship of lesion-specific ischemia to subject demographics, symptoms, and degree of stenosis in the multicenter, prospective ADVANCE registry., Methods: One thousand patients with suspected angina having documented coronary artery disease on coronary CTA and clinically referred for FFR CT were prospectively enrolled in the registry. Patient demographics, symptom status, coronary CTA and FFR CT findings were recorded. Univariate and multivariate analyses were performed to investigate the predictors related to abnormal FFR CT ., Results: FFR CT data were analyzed in 952 patients (95.2%). Overall, 51.1% patients had a positive FFR CT value (≤0.80). Patients with ≥3 risk factors had a significantly higher rate of abnormal FFR CT than those with <3 risk factors (60.2% vs. 43.9%, p = 0.0001). On multivariate analysis, baseline diabetes (odds ratio [OR] 1.52, 95% confidence interval [CI] 1.04-2.21, p = 0.030) and hypertension (OR 1.56, 95%CI 1.14-2.14, p = 0.005) were both predictive of abnormal FFR CT . In addition, >70% stenosis was significantly associated with low FFR CT (OR 31.16, 95%CI 12.25-79.22, p < 0.0001) vs. <30% stenosis. Notably, stenosis 30-49% vs. <30% had an increased likelihood of ischemia (OR 3.74, 95%CI 1.52-9.17, p < 0.0001)., Conclusions: In this real-world registry, CT angiographic stenosis severity in addition to baseline cardiovascular risk factors conferred an increased likelihood of an abnormal FFR CT . Importantly, however, mild CT angiographic stenoses were noted to have an increased hazard for ischemia and the converse holding true for more severe stenoses as well., (Copyright © 2018 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Cardiovascular imaging plays a central role in the diagnosis and treatment of cardiovascular disease. Recently, increased emphasis has been placed on quality in cardiovascular imaging, and it is becoming a central priority for various stakeholders, including patients, physicians, and payers. The changing health care landscape and associated challenges imposed on cardiac imagers, including reductions in reimbursement and growing need for pre-authorization, have also helped bring quality metrics to the forefront. Continuous quality improvement initiatives provide the framework for the team of physicians, technical staff members, administrators, and other health care professionals to deliver high-quality care. Efforts to improve quality in cardiac imaging have started to form the foundation for numerous research studies in this arena, and although few in number, randomized control trials have begun to emerge. This review highlights quality improvement studies focusing on appropriate use education, reporting, and radiation dose reduction in cardiovascular imaging., (Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Coronary CT angiography (CTA) is a reliable tool for the detection of coronary artery disease (CAD) that conveys significant prognostic information. It does not provide data on the hemodynamic significance of a given lesion, particularly in intermediate-grade stenosis. Fractional flow reserve by CT (FFR CT ) can accurately predict the hemodynamic significance of coronary lesions. The primary objective of this registry is to determine whether the integration of FFR CT as an adjunct to coronary CTA will lead to a significant change in the management of CAD in patients with stable angina., Methods: The ADVANCE Registry is a multi-center, prospective registry designed to evaluate utility, clinical outcomes and resource utilization following FFR CT -guided treatment in clinically stable, symptomatic patients diagnosed with CAD by coronary CTA. Approximately 5000 patients will be enrolled from up to 50 sites in Europe, USA, Canada and Asia. Requirement for enrollment is the presence of atherosclerosis on coronary CTA. For each enrolled patient, a clinical management review committee will use data from coronary CTA and FFR CT to determine the management plan using the following criteria: (a) optimal medical therapy, (b) percutaneous coronary intervention, (c) coronary artery bypass graft surgery, or (d) more information required. The primary endpoint of the registry is the reclassification rate between the management plan based on coronary CTA alone versus CTA plus FFR CT . The secondary endpoints of the registry include the evaluation of the rate of invasive coronary angiography (ICA), revascularization, major adverse coronary events, resource utilization, cumulative radiation dose exposure and the rate of ICA without obstructive CAD at 3-year follow-up., Conclusions: The ADVANCE registry is designed to assess the real-world impact of FFR CT on the clinical management of stable CAD when used along with coronary CTA., (Copyright © 2016 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Opinion Statement: Acute chest pain (ACP) represents a clinical as well as economic challenge, often resulting in time-consuming, expensive evaluations to avoid missed diagnosis of acute coronary syndromes (ACSs). Coronary CT angiography (CTA) is an attractive noninvasive technique for use in the emergency department (ED) due to its high accuracy and negative predictive value. Recent studies have demonstrated that coronary CTA can aid in safe, rapid, and cost-efficient triage of these patients. Additional applications of plaque characterization, fractional flow analysis, and CT perfusion imaging hold promise in providing incremental data in patients with suspected ACS. In this review, we examine the data for the use of coronary CTA in acute chest pain, novel applications of the technology, and best practice for its use in the ED.

Due to the discrepancy between higher symptom burden and lower disease prevalence, the diagnosis of coronary artery disease (CAD) in women is challenging. Cardiac CT can be particularly useful in CAD diagnosis and risk stratification in women. In this review, we explore cardiac CT in women with and without symptoms and for adjudication of functional tests. Novel CT technologies such as fractional flow reserve and stress perfusion imaging and their potential for usefulness in women are also examined.

Aims: This study was designed to determine whether coronary CT angiography (CTA) can detect features of plaque disruption in clinically stable patients and to compare lesion prevalence and features between stable patients and those with acute coronary syndrome (ACS)., Methods: We retrospectively identified patients undergoing CTA, followed by invasive coronary angiography (ICA) within 60 days. Quantitative 3-vessel CTA lesion analysis was performed on all plaques ≥25% stenosis to assess total plaque volume, low attenuation plaque (LAP, <50 HU) volume, and remodelling index. Plaques were qualitatively assessed for CTA features of disruption, including ulceration and intra-plaque dye penetration (IDP). ICA was employed as a reference standard for disruption. A total of 145 (94 ACS and 51 stable) patients were identified. By CTA, plaque disruption was evident in 77.7% of ACS cases. Although more common among those with ACS, CTA also detected plaque disruption in 37.3% of clinically stable patients (P < 0.0001)., Conclusions: Clinically stable patients commonly manifest plaques with features of disruption as determined by CTA. Though the prevalence of plaque disruption is less than patients with ACS, these findings support the concept that some clinically stable patients may harbour 'silent' disrupted plaques. These findings may have implications for detection of 'at risk' plaques and patients., (Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2015. For permissions please email: journals.permissions@oup.com.)

Aims: Coronary computed tomographic angiography (CCTA) has become an important tool for non-invasive diagnosis of coronary artery disease (CAD). Coronary dominance can be assessed by CCTA; however, the predictive value of coronary dominance is controversially discussed. The aim of this study was to evaluate the prevalence and prognosis of coronary dominance in a large prospective, international multicentre cohort of patients undergoing CCTA., Methods and Results: The study population consisted of 6382 patients with or without CAD (47% females, 53% males, mean age 56.9 ± 12.3 years) who underwent CCTA and were followed over a period of 60 months. Right or left coronary dominance was determined. Right dominance was present in 91% (n = 5817) and left in 9% (n = 565) of the study population. At the end of follow-up, outcome in patients with obstructive CAD (>50% luminal stenosis) and right dominance was similar compared with patients with left dominance [hazard ratio (HR) 0.46, 95% CI 0.16-1.32, P = 0.15]. Furthermore, no differences were observed for the type of coronary dominance in patients with non-obstructive CAD (HR 0.95, 95% CI 0.41-2.21, P = 0.8962) or normal coronary arteries (HR 1.04, 95% CI 0.68-1.59, P = 0.9). Subgroup analysis in patients with left main disease revealed an elevated hazard of the combined endpoint for left dominance (HR 6.45, 95% CI 1.66-25.0, P = 0.007), but not for right dominance., Conclusion: In our study population, survival after 5 years of follow-up did not differ significantly between patients with left or right coronary dominance. Thus, assessment of coronary vessel dominance by CCTA may not enhance risk stratification in patients with normal coronary arteries or obstructive CAD, but may add prognostic information for specific subpopulations., (© The Author 2015. Published by Oxford University Press on behalf of the European Society of Cardiology.)

Objectives: This study sought to evaluate the diagnostic yield of triple rule out (TRO) versus coronary computed tomography angiography (CTA) scanning in patients with acute chest pain enrolled in a large statewide registry., Background: Although TRO scans provide simultaneous evaluation of coronary artery disease (CAD), pulmonary embolism (PE), and aortic disease (AD), their use is not well defined., Methods: Patients undergoing TRO or coronary CTA at 53 Michigan institutions for acute chest pain (in the emergency department or inpatient setting) in the ACIC (Advanced Cardiovascular Imaging Consortium) were included. Demographic characteristics, scan findings, and image quality parameters were compared between coronary CTA and TRO scans. The primary outcome was diagnostic yield, defined as obstructive CAD (>50% stenosis), PE, or AD; secondary outcomes were radiation dose, contrast volume, and image quality., Results: From July 2007 to September 2013, 12,834 patients underwent computed tomography scanning (TRO, n = 1,555; coronary CTA, n = 11,279). The TRO group had more women (57.1% vs. 47.8%, p < 0.001). Diagnostic yield was similar (TRO, 17.4% vs. coronary CTA, 18.3%; p = 0.37), driven by CAD (15.5% vs. 17.2%, p = 0.093); PE and AD were 1.1% and 0.4% (p = 0.004) and 1.7% and 1.1% (p = 0.046). TRO had higher median radiation (9.1 mSv vs. 6.2 mSv; p < 0.0001) and mean contrast (113 ± 6 ml vs. 89 ± 17 ml; p < 0.0001) doses. Nondiagnostic images were frequent in TRO (9.4% vs. 6.5%; p < 0.0001). In emergency department patients, PE and AD were more often detected on TRO. Among inpatients, there were no differences in overall yield or in that of PE, AD, or CAD., Conclusions: TRO was associated with slightly higher yield of PE and AD, specifically in the emergency department. This benefit comes with higher nondiagnostic image quality, radiation, and contrast doses. Although TRO may be of value in selected patients, its indiscriminate use is not warranted. The appropriate use of TRO needs to be further defined. (Advanced Cardiovascular Imaging Consortium [ACIC]; NCT00640068)., (Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: β-Blockers are often used for heart rate control during coronary CT angiography (CTA). Increased frequency and severity of allergic reactions to radiocontrast media (RCM) have been reported with concomitant use of β-blockers., Objectives: The objectives of this study were to determine whether there is a higher incidence of allergic reactions to low-osmolar nonionic RCM in patients undergoing coronary CTA with concomitant β-blockers and to define the overall incidence and severity of allergic reactions in patients undergoing coronary CTA with and without a history of allergy to RCM., Methods: Patients undergoing coronary CTA at 47 institutions participating in the Advanced Cardiovascular Imaging Consortium registry were analyzed. The incidence and severity of allergic reactions were compared between those patients who did and those who did not receive β-blockers, as well as in subgroups of patients with and without a history of prior allergy to RCM., Results: The incidence of allergic reaction in patients who received β-blockers was 45 of 23,867 (0.19%) compared with those who did not receive β-blockers, which was 9 of 5232 (0.17%; P = .84; odds ratio = 1.1). Of the patients with history of allergy to RCM, 4 of 706 patients (0.6%) on β-blockers experienced allergic reactions compared to 1 of 77 patients (1.3%) without β-blockers (P = .40; odds ratio = 0.43)., Conclusions: β-Blocker pretreatment had no effect on the frequency or severity of allergic reaction in patients undergoing coronary CTA, even in patients with a past history of allergy to RCM., (Copyright © 2015 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: We sought to study the feasibility of establishing a comprehensive, mostly self-directed yoga program in a hospital and its dose-effect relationship on cardiovascular risk factors and quality of life (QoL) measures over six months., Methods: Yoga-based techniques (Advanced Yoga Practices; AYP; advancedyogapractices.com) were taught in 12 biweekly group sessions and self-directed practice at home was emphasized. Cardiovascular risk factors were elucidated by interview and review of medical history. Quality of life (QoL) outcomes included the SF-36, the Cohen Perceived Stress Scale (CPSS), and the Hospital Anxiety and Depression Scale (HADS). Risk factors and QoL measures were compared in participants at baseline and six months, as well as between those practicing ≥ 7 times versus < 7 times per week., Results: A total of 22 individuals (19 women, mean age 59 ± 8.7 years) completed the study. At six months, changes were noted in the Mental Component Scale (MCS) of the SF-36 (p=0.0004) and the CPSS (p = 0.022). A greater improvement in CPSS was noted in those practicing ≥ 7 times versus < 7 times a week (p=0.045). No changes were noted in cardiovascular risk factors., Conclusions: The prescription of a self-directed yoga program was feasible in a hospital setting and resulted in improvement in QoL measures at six months. Practicing more than seven times per week correlated with greater improvement in the perception of stress. Thus, at least a once-daily dose of AYP techniques for a significant improvement in perceived stress is an appropriate dose to employ and study in hospital settings.

Purpose: To determine the clinical outcomes of women and men with nonobstructive coronary artery disease ( CAD coronary artery disease ) with coronary computed tomographic (CT) angiography data in patients who were similar in terms of CAD coronary artery disease risk factors, angina typicality, and CAD coronary artery disease extent and distribution., Materials and Methods: Institutional review board approval was obtained for all participating sites, with either informed consent or waiver of informed consent. In a prospective international multicenter cohort study of 27 125 patients undergoing coronary CT angiography at 12 centers, 18 158 patients with no CAD coronary artery disease or nonobstructive (<50% stenosis) CAD coronary artery disease were examined. Men and women were propensity matched for age, CAD coronary artery disease risk factors, angina typicality, and CAD coronary artery disease extent and distribution, which resulted in a final cohort of 11 462 subjects. Nonobstructive CAD coronary artery disease presence and extent were related to incident major adverse cardiovascular events ( MACE major adverse cardiovascular events ), which were inclusive of death and myocardial infarction and were estimated by using multivariable Cox proportional hazards models., Results: At a mean follow-up ± standard deviation of 2.3 years ± 1.1, MACE major adverse cardiovascular events occurred in 164 patients (0.6% annual event rate). After matching, women and men experienced identical annualized rates of myocardial infarction (0.2% vs 0.2%, P = .72), death (0.5% vs 0.5%, P = .98), and MACE major adverse cardiovascular events (0.6% vs 0.6%, P = .94). In multivariable analysis, nonobstructive CAD coronary artery disease was associated with similarly increased MACE major adverse cardiovascular events for both women (hazard ratio: 1.96 [95% confidence interval { CI confidence interval }: 1.17, 3.28], P = .01) and men (hazard ratio: 1.77 [95% CI confidence interval : 1.07, 2.93], P = .03)., Conclusion: When matched for age, CAD coronary artery disease risk factors, angina typicality, and nonobstructive CAD coronary artery disease extent, women and men experience comparable rates of incident mortality and myocardial infarction.

Purpose: To assess whether gradations of left ventricular (LV) ejection fraction (LVEF) and volumes measured with coronary computed tomography (CT) would augment risk stratification and discrimination for incident mortality., Materials and Methods: This study was approved by the institutional review board, and informed consent was obtained when required. Subjects without known coronary artery disease (CAD) who underwent cardiac CT angiography with quantitative LV measurements were categorized according to LVEF (≥ 55%, 45%-54.9%, 35%-44.9%, or <35%). LV end-systolic volume (LVESV) and LV end-diastolic volume (LVEDV) were classified as normal (≥ 90 mL) or abnormal (≥ 200 mL). CAD extent and severity was categorized as none, nonobstructive, obstructive (≥ 50%), one-vessel, two-vessel, and three-vessel or left main disease. LVEF and volumes were assessed for risk prediction and discrimination of future mortality by using Cox hazards model and receiver operating characteristic curve analysis, respectively., Results: During a follow-up of 2.0 years ± 0.9, 7758 patients (mean age, 58.5 years ± 13.0; 4220 male patients [54.4%]) were studied. At multivariable analysis, worsening LVEF was independently associated with mortality for moderately (hazard ratio = 3.14, P < .001) and severely (hazard ratio = 5.19, P < .001) abnormal ejection fraction. LVEF demonstrated improved discrimination for mortality (Az = 0.816) when compared with CAD risk factors alone (Az = 0.781) or CAD risk factors plus extent and severity. At multivariable analysis of a subgroup of 3706 individuals, abnormal LVEDV (hazard ratio = 4.02) and LVESV (hazard ratio = 6.46) helped predict mortality (P < .001). Similarly, LVESV and LVEDV demonstrated improved discrimination when compared with CAD risk factors or CAD extent and severity (P < .05)., Conclusion: LV dysfunction and volumes measured with cardiac CT angiography augment risk prediction and discrimination for future mortality., (© RSNA, 2014.)

Background: Coronary artery calcium (CAC) is a well-established predictor of clinical outcomes for population screening. Limited evidence is available as to its predictive value in symptomatic patients without obstructive coronary artery disease (CAD). The aim of the current study was to assess the prognostic value of CAC scores among symptomatic patients with nonobstructive CAD., Methods: From the COronary Computed Tomographic Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter (CONFIRM) registry, 7,200 symptomatic patients with nonobstructive CAD (<50% coronary stenosis) on coronary-computed tomographic angiography were prospectively enrolled and followed for a median of 2.1 years. Patients were categorized as without (0% stenosis) or with (>0% but <50% coronary stenosis) a luminal stenosis. CAC scores were calculated using the Agatston method. Univariable and multivariable Cox proportional hazard models were employed to estimate all-cause mortality and/or myocardial infarction (MI). Four-year death and death or MI rates were 1.9% and 3.3%., Results: Of the 4,380 patients with no luminal stenosis, 86% had CAC scores of <10 while those with a luminal stenosis had more prevalent and extensive CAC with 31.9% having a CAC score of ≥100. Among patients with no luminal stenosis, CAC was not predictive of all-cause mortality (P = .44). However, among patients with a luminal stenosis, 4-year mortality rates ranged from 0.8% to 9.8% for CAC scores of 0 to ≥400 (P < .0001). The mortality hazard was 6.0 (P = .004) and 13.3 (P < .0001) for patients with a CAC score of 100-399 and ≥400. In patients with a luminal stenosis, CAC remained independently predictive in all-cause mortality (P < .0001) and death or MI (P < .0001) in multivariable models containing CAD risk factors and presenting symptoms., Conclusions: CAC allows for the identification of those at an increased hazard for death or MI in symptomatic patients with nonobstructive disease. From the CONFIRM registry, the extent of CAC was an independent estimator of long-term prognosis among symptomatic patients with luminal stenosis and may further define risk and guide preventive strategies in patients with nonobstructive CAD.

Objectives: To establish current radiation dose levels with contemporary scanners capable of prospectively triggered or high-pitch spiral scan modes to previous generation scanners among patients evaluated for coronary artery disease, pulmonary embolism, aortic disease, and "triple rule out" in a large population of patients at multiple centers., Background: Previous small-scale studies with carefully controlled scan protocols report that CT scanners that facilitate prospectively triggered scanning and provide high-pitch spiral CT scan modes drastically lower radiation doses. However, diagnostic reference levels should be selected by medical bodies on the basis of large surveys of representative sites and reviewed at appropriate time intervals., Methods: Scan data including dose and image quality parameters were collected retrospectively from 64 slice scanners (control) and prospectively after sites installed 128-slice dual-source scanners with high-pitch capability (study). Protocol selection was purposely not specified to survey "real world" results. Blinded quantitative image analysis was performed on every fifth scan., Results: From April 2011 to March 2012, 2085 patients at 9 sites completed the study: 1051 coronary artery disease (509 control, 542 study), 528 pulmonary embolism (267 control, 261 study), 419 aortic disease (268 control, 151 study), and 87 triple rule out (53 control, 34 study). There was a significant reduction in median dose-length product (DLP) from 669 mGy ∙ cm (interquartile range [IQR]: 419-1026 mGy ∙ cm) in the control group to 260 mGy ∙ cm (IQR: 159-441 mGy ∙ cm) in the study group, a reduction by 61% (P < .0001) and was lower in all categories. No significant differences were noted in image quality., Conclusion: Use of advanced scanners facilitating prospectively triggered or high-pitch spiral scan modes results in marked dose reduction across a variety of cardiovascular studies, with no compromise in image quality. These findings may contribute to new target dose recommendations in societal guidelines., (Copyright © 2014 Society of Cardiovascular Computed Tomography. Published by Elsevier Inc. All rights reserved.)

Background: Coronary artery disease (CAD) diagnosis by coronary computed tomographic angiography (CCTA) is useful for identification of symptomatic diabetic individuals at heightened risk for death. Whether CCTA-detected CAD enables improved risk assessment of asymptomatic diabetic individuals beyond clinical risk factors and coronary artery calcium scoring (CACS) remains unexplored., Methods: From a prospective 12-center international registry of 27,125 individuals undergoing CCTA, we identified 400 asymptomatic diabetic individuals without known CAD. Coronary stenosis by CCTA was graded as 0%, 1-49%, 50-69%, and ≥70%. CAD was judged on a per-patient, per-vessel and per-segment basis as maximal stenosis severity, number of vessels with ≥50% stenosis, and coronary segments weighted for stenosis severity (segment stenosis score), respectively. We assessed major adverse cardiovascular events (MACE) - inclusive of mortality, nonfatal myocardial infarction (MI), and late target vessel revascularization ≥90 days (REV) - and evaluated the incremental utility of CCTA for risk prediction, discrimination and reclassification., Results: Mean age was 60.4 ± 9.9 years; 65.0% were male. At a mean follow-up 2.4 ± 1.1 years, 33 MACE occurred (13 deaths, 8 MI, 12 REV) [8.25%; annualized rate 3.4%]. By univariate analysis, per-patient maximal stenosis [hazards ratio (HR) 2.24 per stenosis grade, 95% confidence interval (CI) 1.61-3.10, p < 0.001], increasing numbers of obstructive vessels (HR 2.30 per vessel, 95% CI 1.75-3.03, p < 0.001) and segment stenosis score (HR 1.14 per segment, 95% CI 1.09-1.19, p < 0.001) were associated with increased MACE. After adjustment for CAD risk factors and CACS, maximal stenosis (HR 1.80 per grade, 95% CI 1.18-2.75, p = 0.006), number of obstructive vessels (HR 1.85 per vessel, 95% CI 1.29-2.65, p < 0.001) and segment stenosis score (HR 1.11 per segment, 95% CI 1.05-1.18, p < 0.001) were associated with increased risk of MACE. Beyond age, gender and CACS (C-index 0.64), CCTA improved discrimination by maximal stenosis, number of obstructive vessels and segment stenosis score (C-index 0.77, 0.77 and 0.78, respectively). Similarly, CCTA findings improved risk reclassification by per-patient maximal stenosis [integrated discrimination improvement (IDI) index 0.03, p = 0.03] and number of obstructive vessels (IDI index 0.06, p = 0.002), and by trend for segment stenosis score (IDI 0.03, p = 0.06)., Conclusion: For asymptomatic diabetic individuals, CCTA measures of CAD severity confer incremental risk prediction, discrimination and reclassification on a per-patient, per-vessel and per-segment basis., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: A best-practice intervention previously demonstrated significant dose reduction over a period of one year. We sought to evaluate whether this reduction would be incremental and sustained by promoting new scanner technology in the context of an ongoing quality improvement program during a 3-year period in a statewide registry of coronary computed tomography angiography., Methods and Results: In this prospective, controlled, nonrandomized study involving 11 901 patients at 15 Michigan centers participating in the Advanced Cardiovascular Imaging Consortium, radiation doses and image quality were compared between the following periods: control (May to June 2008) versus follow-up I (July 2008 to June 2009) and follow-up I versus follow-up II (July 2009 to April 2011). Intervention during these study periods included continuous education, feedback, and mandatory participation in this initiative. The median radiation dose remained unchanged from control to follow-up I: dose-length product of 697 (interquartile range, 407-1163) to 675 (interquartile range, 418-1146) mGy·cm (P=0.93). With the introduction of newer technology in follow-up I period, there was incremental 31% decrease during follow-up II to median dose-length product of 468 (interquartile range, 292-811) mGy·cm (P<0.0001). No significant change was noted in the percentage of diagnostic quality scans from follow-up I (92%) to follow-up II (92.7%)., Conclusions: Although ongoing application of a best-practice algorithm was associated with sustaining previously achieved targets, the use of newer scanner technology resulted in incremental radiation dose reduction in a statewide coronary computed tomography angiography registry without image quality degradation. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique identifier: NCT00640068.

Patients with chronic kidney disease have a worse cardiovascular prognosis than those without. The aim of this study was to determine the incremental prognostic value of coronary computed tomographic angiography in predicting mortality across the entire spectrum of renal function in patients with known or suspected coronary artery disease (CAD). A large international multicenter registry was queried, and patients with left ventricular ejection fraction (LVEF) and creatinine data were screened. National Cholesterol Education Program Adult Treatment Panel III risk was calculated. Coronary computed tomographic angiographic results were evaluated for CAD severity (normal, nonobstructive, or obstructive) and an LVEF <50%. Patients were followed for the end point of all-cause mortality. Among 5,655 patients meeting the study criteria, follow-up was available for 5,572 (98.9%; median follow-up duration 18.6 months). All-cause mortality (66 deaths) significantly increased with every 10-unit decrease in renal function (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.07 to 1.41). All-cause mortality occurred in 0.33% of patients without coronary atherosclerosis, 1.82% of patients with nonobstructive CAD, and 2.43% of patients with obstructive CAD. Multivariate Cox proportional-hazards models revealed that impaired renal function (HR 2.29, 95% CI 1.65 to 3.18), CAD severity (HR 1.81, 95% CI 1.31 to 2.51), and an abnormal LVEF (HR 4.16, 95% CI 2.45 to 7.08) were independent predictors of all-cause mortality. In conclusion, coronary computed tomographic angiographic measures of CAD severity and the LVEF provide effective risk stratification across a wide spectrum of renal function. Furthermore, renal dysfunction, CAD severity, and the LVEF have additive value for predicting all-cause death in patients with suspected obstructive CAD., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Aims: Obesity is associated with the presence of coronary artery disease (CAD) risk factors and cardiovascular events. We examined the relationship between body mass index (BMI) and the presence, extent, severity, and risk of CAD in patients referred for coronary computed tomographic angiography (CCTA)., Methods and Results: We evaluated 13,874 patients from a prospective, international, multicentre registry of individuals without known CAD undergoing CCTA. We compared risk factors, CAD findings, and risk of all-cause mortality and non-fatal myocardial infarction (MI) amongst individuals with underweight (18.5-20.0 kg/m(2)), normal (20.1-24.9 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (≥30 kg/m(2)) BMI. The mean follow-up was 2.4 ± 1.2 years with 143 deaths and 193 MIs. Among underweight, normal weight, overweight, and obese individuals, there was increasing prevalence of diabetes (7 vs.10% vs. 12 vs. 19%), hypertension (37 vs. 40% vs. 46 vs. 59%), and hyperlipidaemia (48 vs. 52% vs. 56 vs. 56%; P < 0.001 for trend). After multivariable adjustment, BMI was positively associated with the prevalence of any CAD [odds ratio (OR) 1.25 per +5 kg/m(2), 95% confidence interval (CI): 1.20-1.30, P < 0.001] and obstructive (≥50% stenosis) CAD (OR: 1.13 per +5 kg/m(2), 95% CI: 1.08-1.19, P < 0.001); a higher BMI was also associated with an increased number of segments with plaque (+0.26 segments per +5 kg/m(2), 95% CI: 0.22-0.30, P < 0.001). Larger BMI categories were associated with an increase in all-cause mortality (P = 0.004), but no difference in non-fatal MI. After multivariable adjustment, a higher BMI was independently associated with increased risk of MI (hazards ratio: 1.28 per +5 kg/m(2), 95% CI: 1.12-1.45, P < 0.001)., Conclusions: Amongst patients with suspected CAD referred for CCTA, individuals with increased BMI have greater prevalence, extent, and severity of CAD that is not fully explained by the presence of traditional risk factors. A higher BMI is independently associated with increased risk of intermediate-term risk of myocardial infarction.

Objectives: This study sought to examine patterns of follow-up invasive coronary angiography (ICA) and revascularization (REV) after coronary computed tomography angiography (CCTA)., Background: CCTA is a noninvasive test that permits direct visualization of the extent and severity of coronary artery disease (CAD). Post-CCTA patterns of follow-up ICA and REV are incompletely defined., Methods: We examined 15,207 intermediate likelihood patients from 8 sites in 6 countries; these patients were without known CAD, underwent CCTA, and were followed up for 2.3 ± 1.2 years for all-cause mortality. Coronary artery stenosis was judged as obstructive when ≥50% stenosis was present. A multivariable logistic regression was used to estimate ICA use. A Cox proportional hazards model was used to estimate all-cause mortality., Results: During follow-up, ICA rates for patients with no CAD to mild CAD according to CCTA were low (2.5% and 8.3%), with similarly low rates of REV (0.3% and 2.5%). Most ICA procedures (79%) occurred ≤3 months of CCTA. Obstructive CAD was associated with higher rates of ICA and REV for 1-vessel (44.3% and 28.0%), 2-vessel (53.3% and 43.6%), and 3-vessel (69.4% and 66.8%) CAD, respectively. For patients with <50% stenosis, early ICA rates were elevated; over the entirety of follow-up, predictors of ICA were mild left main, mild proximal CAD, respectively, or higher coronary calcium scores. In patients with <50% stenosis, the relative hazard for death was 2.2 (p = 0.011) for ICA versus no ICA. Conversely, for patients with CAD, the relative hazard for death was 0.61 for ICA versus no ICA (p = 0.047)., Conclusions: These findings support the concept that CCTA may be used effectively as a gatekeeper to ICA., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The predictive value of coronary computed tomographic angiography (cCTA) in subjects without chest pain syndrome (CPS) has not been established. We investigated the prognostic value of coronary artery disease detection by cCTA and determined the incremental risk stratification benefit of cCTA findings compared with clinical risk factor scoring and coronary artery calcium scoring (CACS) for individuals without CPS., Methods and Results: An open-label, 12-center, 6-country observational registry of 27 125 consecutive patients undergoing cCTA and CACS was queried, and 7590 individuals without CPS or history of coronary artery disease met the inclusion criteria. All-cause mortality and the composite of all-cause mortality and nonfatal myocardial infarction were measured. During a median follow-up of 24 months (interquartile range, 18-35 months), all-cause mortality occurred in 136 individuals. After risk adjustment, compared with individuals without evidence of coronary artery disease by cCTA, individuals with obstructive 2- and 3-vessel disease or left main coronary artery disease experienced higher rates of death and composite outcome (P<0.05 for both). Both CACS and cCTA significantly improved the performance of standard risk factor prediction models for all-cause mortality and the composite outcome (likelihood ratio P<0.05 for all), but the incremental discriminatory value associated with their inclusion was more pronounced for the composite outcome and for CACS (C statistic for model with risk factors only was 0.71; for risk factors plus CACS, 0.75; for risk factors plus CACS plus cCTA, 0.77). The net reclassification improvement resulting from the addition of cCTA to a model based on standard risk factors and CACS was negligible., Conclusions: Although the prognosis for individuals without CPS is stratified by cCTA, the additional risk-predictive advantage by cCTA is not clinically meaningful compared with a risk model based on CACS. Therefore, at present, the application of cCTA for risk assessment of individuals without CPS should not be justified.

Background: Coronary computed tomography angiography (CCTA) is an emerging noninvasive anatomical method for evaluation of patients with suspected coronary artery disease (CAD). Multicenter clinical registries are key to efforts to establish the role of CCTA in CAD diagnosis and management. The Advanced Cardiovascular Imaging Consortium (ACIC) is a statewide, multicenter collaborative quality initiative with the intent to establish quality and appropriate use of CCTA in Michigan., Methods: The ACIC is sponsored by the Blue Cross Blue Shield of Michigan/Blue Care Network, and its 47 sites include imaging centers that offer CCTA and meet established structure and process standards for participation. Patients enrolled include those with suspected ischemia with or without known CAD, and individuals across the entire spectrum of CAD risk. Patient demographics, history, CCTA scan-related data and findings, and 90-day follow-up data are entered prospectively into a centralized database with strict validation tools and processes. Collaborative quality initiatives include radiation dose reduction and appropriate CCTA use by education and feedback to participating sites and referring physicians., Conclusions: Across a wide range of institutions, the ACIC permits evaluation of "real-world" utilization and effectiveness of CCTA and examines an alternative, nontraditional approach to utilization management wherein physicians and payers collaborate to address the growing problem of cardiac imaging overutilization., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Objectives: This study was conducted to evaluate the correlation between stress test results and coronary computed tomography angiography (CCTA) findings and comparative diagnostic performance of the 2 modalities in patients undergoing invasive coronary angiography (ICA)., Background: Recent data suggest that only a third of patients undergoing ICA have obstructive coronary artery disease (CAD); accurate pre-ICA risk stratification is needed., Methods: At 47 centers participating in the ACIC (Advanced Cardiovascular Imaging Consortium) in Michigan, patients without known CAD who were undergoing CCTA within 3 months of a stress test were studied. Demographics, risk factors, symptoms, and stress test results were correlated with obstructive CAD (>50% stenosis) on CCTA and ICA., Results: Among 6,198 patients (age 56 ± 12 years, 48% men), >50% stenosis was seen in 1,158 (18.7%) on CCTA. Independent predictors included male sex (odds ratio [OR]: 2.37, 95% confidence interval [CI]: 1.83 to 3.06), current smoking (OR: 2.23, 95% CI: 1.57 to 3.17), older age (OR per 10-year increment: 2.14, 95% CI: 1.89 to 2.41), hypertension (OR: 1.8, 95% CI: 1.37 to 2.34), and typical angina (OR: 1.48, 95% CI: 1.03 to 2.12). Stress test results were not predictive. Among patients undergoing ICA (n = 621), there was a strong correlation of ICA with CCTA findings (OR: 9.09, 95% CI: 5.57 to 14.8, p < 0.001), but not stress results (OR: 0.79, 95% CI: 0.56 to 1.11, p = 0.17)., Conclusions: Stress test findings did not predict obstructive CAD on CCTA, observed in <20% of patients in this large study group. The strong association of CCTA with ICA suggests that it may serve as an effective "gatekeeper" to invasive testing in patients needing adjudication of stress test results. (Advanced Cardiovascular Imaging Consortium: A Collaborative Quality Improvement Project [ACIC]; NCT00640068)., (Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Isolated left ventricular (LV) apical hypoplasia is a recently described congenital abnormality characterized by: (1) a truncated and spherical LV configuration with rightward bulging of the interventricular septum, (2) deficiency of the myocardium within the LV apex with adipose tissue infiltrating the apex, (3) origin of the papillary muscle in the flattened anterior apex, and (4) elongation of the right ventricle wrapping around the deficient LV apex. In this report, we demonstrate these characteristic features with cardiac magnetic resonance imaging and summarize the existing information on isolated LV apical hypoplasia., (© 2011 Wiley Periodicals, Inc.)

Objectives: The purpose of this study was to compare the efficiency, cost, and safety of a diagnostic strategy employing early coronary computed tomographic angiography (CCTA) to a strategy employing rest-stress myocardial perfusion imaging (MPI) in the evaluation of acute low-risk chest pain., Background: In the United States, >8 million patients require emergency department evaluation for acute chest pain annually at an estimated diagnostic cost of >$10 billion., Methods: This multicenter, randomized clinical trial in 16 emergency departments ran between June 2007 and November 2008. Patients were randomly allocated to CCTA (n = 361) or MPI (n = 338) as the index noninvasive test. The primary outcome was time to diagnosis; the secondary outcomes were emergency department costs of care and safety, defined as freedom from major adverse cardiac events in patients with normal index tests, including 6-month follow-up., Results: The CCTA resulted in a 54% reduction in time to diagnosis compared with MPI (median 2.9 h [25th to 75th percentile: 2.1 to 4.0 h] vs. 6.3 h [25th to 75th percentile: 4.2 to 19.0 h], p < 0.0001). Costs of care were 38% lower compared with standard (median $2,137 [25th to 75th percentile: $1,660 to $3,077] vs. $3,458 [25th to 75th percentile: $2,900 to $4,297], p < 0.0001). The diagnostic strategies had no difference in major adverse cardiac events after normal index testing (0.8% in the CCTA arm vs. 0.4% in the MPI arm, p = 0.29)., Conclusions: In emergency department acute, low-risk chest pain patients, the use of CCTA results in more rapid and cost-efficient safe diagnosis than rest-stress MPI. Further studies comparing CCTA to other diagnostic strategies are needed to optimize evaluation of specific patient subsets. (Coronary Computed Tomographic Angiography for Systematic Triage of Acute Chest Pain Patients to Treatment [CT-STAT]; NCT00468325)., (Copyright © 2011 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Large multicenter studies validating the prognostic value of coronary computed tomographic angiography (CCTA) and left ventricular ejection fraction (LVEF) are lacking. We sought to confirm the independent and incremental prognostic value of coronary artery disease (CAD) severity measured using 64-slice CCTA over LVEF and clinical variables., Methods and Results: A large international multicenter registry (CONFIRM Registry) was queried, and CCTA patients with LVEF data on CCTA were screened. Patients with a history of myocardial infarction, coronary revascularization, or cardiac transplantation were excluded. The National Cholesterol Education Program-Adult Treatment Panel III risk was calculated for each patient, and CCTA was evaluated for CAD severity (normal, nonobstructive, non-high-risk, or high-risk CAD) and LVEF <50%. Patients were followed for an end point of all-cause mortality; 27 125 patients underwent CCTA at 12 participating centers, with a total of 14 064 patients meeting the analysis criteria. Follow-up was available for 13 966 (99.3%) patients (mean follow-up of 22.5 months; 95% confidence interval, 22.3 to 22.7 months). All-cause mortality (271 deaths) occurred in 0.65% of patients without coronary atherosclerosis, 1.99% of patients with nonobstructive CAD, 2.90% of patients with non-high-risk CAD, and 4.95% for patients with high-risk CAD. Multivariable analysis confirmed that LVEF <50% (hazard ratio, 2.74; 95% confidence interval, 2.12 to 3.51) and CAD severity (hazard ratio,1.58; 95% confidence interval, 1.42 to 1.76) were predictors of all-cause mortality, and CAD severity had incremental value over LVEF and clinical variables., Conclusions: Our results demonstrate that CCTA measures of CAD severity and LVEF have independent prognostic value. Incorporation of CAD severity provides incremental value for predicting all-cause death over routine clinical predictors and LVEF in patients with suspected obstructive CAD.

Background: Coronary CT angiography (CCTA) is an excellent tool for noninvasive assessment of coronary arteries in low- to intermediate-risk individuals. However, the accuracy of CCTA heavily depends on image quality. Our objective was to develop and validate a tool to predict pre-CCTA risk of obtaining an uninterpretable result in symptomatic patients., Methods and Results: Among 8585 symptomatic patients, we identified variables independently associated with the presence of at least 1 uninterpretable major coronary segment to create the uninterpretable risk score (URS). This risk score was developed using both clinical variables and patient variables acquired at the time the CCTA was performed (heart rate and coronary calcium). The URS was then prospectively validated among an additional 915 symptomatic patients. The URS was predictive of uninterpretable results in both the development and the validation cohorts. For every 4-point increase in the URS (range, 0 to 12), the rate of at least 1 uninterpretable coronary segment per 100 CCTA studies increased ≈1.5 fold. Increased heart rate and coronary artery calcium score were predictive of uninterpretable CCTA study results. Uninterpretable results were associated with 3-month outcomes in the development cohort., Conclusions: The URS can categorize patients who are likely to have at least 1 uninterpretable major coronary segment on CCTA. This may aid in appropriate patient selection for CCTA and avoiding radiation exposure in those likely to have an uninterpretable study. Clinical Trial Registration- URL: http:///www.clinicaltrials.gov. Unique identifier: NCT00640068.