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The purpose of this review is to highlight the most impactful, educational, and frequently downloaded articles published in the Journal of Cardiovascular Computed Tomography (JCCT) for the year 2020. The JCCT reached new records in 2020 for the number of research submissions, published manuscripts, article downloads and social media impressions. The articles in this review were selected by the Editorial Board of the JCCT and are comprised predominately of original research publications in the following categories: Coronavirus disease 2019 (COVID-19), coronary artery disease, coronary physiology, structural heart disease, and technical advances. The Editorial Board would like to thank each of the authors, peer-reviewers and the readers of JCCT for making 2020 one of the most successful years in its history, despite the challenging circumstances of the global COVID-19 pandemic.

In this clinical practice statement, we represent a summary of the current evidence and clinical applications of cardiac computed tomography (CT) in evaluation of coronary artery disease (CAD), from an expert panel organized by the American Society for Preventive Cardiology (ASPC), and appraises the current use and indications of cardiac CT in clinical practice. Cardiac CT is emerging as a front line non-invasive diagnostic test for CAD, with evidence supporting the clinical utility of cardiac CT in diagnosis and prevention. CCTA offers several advantages beyond other testing modalities, due to its ability to identify and characterize coronary stenosis severity and pathophysiological changes in coronary atherosclerosis and stenosis, aiding in early diagnosis, prognosis and management of CAD. This document further explores the emerging applications of CCTA based on functional assessment using CT derived fractional flow reserve, peri‑coronary inflammation and artificial intelligence (AI) that can provide personalized risk assessment and guide targeted treatment. We sought to provide an expert consensus based on the latest evidence and best available clinical practice guidelines regarding the role of CCTA as an essential tool in cardiovascular prevention – applicable to risk assessment and early diagnosis and management, noting potential areas for future investigation.

Although the dose-response relationship between increasing coronary artery calcium (CAC) score and increasing risk in the asymptomatic population would be expected to persist into the upper ranges of CAC (>1,000), surprisingly, it has not been previously demonstrated. In fact, in the MESA (Multi

The 2016 National Institute of Health and Care Excellence clinical guideline for the assessment and diagnosis of chest pain positions coronary computed tomography angiography as the first test for all stable chest pain patients without confirmed coronary artery disease and discards the previous emphasis on calculation of pre-test likelihood recommended in their 2012 edition of the guidelines. On the other hand, the American College of Cardiology Foundation/American Heart Association and the European Society of Cardiology guidelines continue to present the stress testing functional modalities as the tests of choice. The aim of this review is to present, in the form of a debate, the pros and cons of these paradigm changing recommendations, with an emphasis on literature review and projection of future needs, with conclusions to be drawn by the reader.

The purpose of this study was to determine patient attitudes about mammographic reporting of breast arterial calcification (BAC), result communication, and action.A self-administered survey was created for this project and was offered to mammography patients presenting for screening or diagnostic mammography over a 1-month period.Among those who accepted questionnaires, 61.8% (419/678) responded with varying response rates to specific questions. A large percentage (95.8% [363/379]) preferred to have BAC reported. All 107 patients who were unaware of a personal history of heart disease wanted notification about BAC. There were 552 communication responses from 354 women. Among these responses, 62.5% (345/552) indicated a preference for notification from the radiology department by letter or telephone call. Among those who had a single preference, 76.6% (180/235) preferred notification by the radiology department in the patient results letter or by telephone call. Of those who chose one action option, 87.4% (181/207) indicated that they would undergo coronary artery CT before making a decision. Among those who selected multiple options, 53.2% (272/511) expressed a desire for coronary artery CT before making a decision. Age, level of education, and race were not associated with patients' attitudes toward BAC.Patients had an overwhelming preference to be informed about BAC found at mammography. Given the ease of reporting BAC and the calls by preventive cardiologists to have the information, the widespread adoption of BAC reporting on mammography reports can promote prevention, diagnosis, and if needed, treatment of cardiovascular disease.

The purpose of this review is to summarize the work published by the Journal of Cardiovascular Computed Tomography (JCCT) for the year 2019, highlighting original research and new guidelines.

The goal of CAC-DRS: Coronary Artery Calcium Data and Reporting System is to create a standardized method to communicate findings of CAC scanning on all noncontrast CT scans, irrespective of the indication, in order to facilitate clinical decision-making, with recommendations for subsequent patient management. The CAC-DRS classification is applied on a per-patient basis and represents the total calcium score and the number of involved arteries. General recommendations are provided for further management of patients with different degrees of calcified plaque burden based on CAC-DRS classification. In addition, CAC-DRS will provide a framework of standardization that may benefit quality assurance and tracking patient outcomes with the potential to ultimately result in improved quality of care.

Evaluation of the left atrium and left atrial appendage for the presence of thrombus prior to cardioversion and pulmonary vein isolation, and of the entire heart for embolic sources in the setting of cryptogenic stroke, has long been standard medical care. Guidelines have uniformly recommended transesophageal echocardiography (TEE) to accomplish these goals. In recent years, computed tomographic angiography has demonstrated diagnostic accuracy similar to that of TEE for the detection of thrombus. Analysis of the pertinent data and relative merits of the 2 technologies leads to the conclusions that: 1) both modalities have some unique, nonoverlapping capabilities that may dictate their use in specific situations; 2) computed tomographic angiography is a reasonable alternative to TEE when the primary aim is to exclude left atrial and left atrial appendage thrombus and in patients in whom the risks associated with TEE outweigh the benefits; and 3) both options should be discussed with the patient in the setting of shared decision making.

The aim of this study was to assess the relationship of the extent of atherosclerosis on coronary computed tomographic angiography to the extent of secondhand tobacco smoke (SHTS) exposure in asymptomatic never smokers.A dose-related association between SHTS and coronary artery calcium has been reported, but the total extent of atherosclerosis has not been investigated.A total of 268 never smokers, ages 40 to 80 years, completed a questionnaire assessing risk factors and extent of lifetime SHTS exposure, providing a total SHTS exposure score. Ordinal coronary artery calcium scores were derived from low-dose nongated computed tomographic scans, followed by computed tomographic angiography. Analyses of the prevalence, extent, and plaque characteristics of atherosclerosis were performed, and the independent contribution of SHTS, adjusted for other documented risk factors, was determined.Coronary atherosclerosis was noted in 48% and was more frequent with low to moderate and high versus minimal SHTS exposure (48% and 69% vs. 25%; p 0.0001). Adjusted odds ratios for any atherosclerosis were 2.1 (95% confidence interval: 1.0 to 4.4; p = 0.05) for low to moderate and 3.5 (95% confidence interval: 1.4 to 8.5; p = 0.01) for high exposure versus minimal SHTS exposure and were not significant for standard risk factors of diabetes (p = 0.56), hyperlipidemia (p = 0.11), hypertension (p = 0.65), and renal disease (p = 0.24). With increasing SHTS exposure, the percentage of major vessel (14%, 41%, and 45%; p = 0.0013) with any plaque or stenosis increased, as did the number with 5 or more involved segments (0%, 39%, and 61%; p = 0.0001). Also the average number of involved segments increased (0.82, 1.98, and 3.49; p 0.0001), with calcified plaques alone (0.25, 0.77, and 1.52; p 0.0001), with calcified and partially calcified plaques (0.28, 0.82, and 1.58; p 0.001), but not with noncalcified plaques alone (p = 0.11).The presence and extent of atherosclerosis were associated with the extent of SHTS exposure even when adjusted for other risk factors, further demonstrating the causal relationship of SHTS exposure and coronary disease.

Several questions of great importance to the cardiovascular community loom large in chest CT imaging: 1. Is the imager responsible for reporting all relevant cardiovascular findings in the field of view? 2. If imaging of the requested organs (aorta and pulmonary arteries) on computed tomographic angiography is enhanced by simple techniques that enable analysis of the coronary arteries, should the acquisition standard of care be changed to permit coronary analysis and reporting? The Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology have answered the first question in the 2016 SCCT/STR Guidelines for Coronary Artery Calcium Scoring of noncontrast noncardiac chest CT scans.1 Because Coronary Artery Calcium Scoring analysis is always feasible and the information provides robust prediction of cardiovascular events in asymptomatic patients, the guideline states that Coronary Artery Calcium Scoring by quantitative or semiquantitative analysis should be part of every noncontract chest CT analysis and report, whether gated or nongated, even though it has not been requested by the referring physician. The second question, which has not been addressed by any guideline, relates to coronary artery analysis and reporting on contrast CT scans ordered for the acute scenarios of aortic dissection (AD) and pulmonary embolus (PE) and for the chronic surveillance of thoracic aortic aneurysms, both before and after repair. This should be differentiated from the triple rule out in ED chest pain patients with clinical presentations consistent with coronary artery disease (CAD) in which AD and PE are also of concern. In this ED setting, in 1555 patients, 15.5% had >50% coronary diameter stenosis, 1.1% had PE and 0.4% had AD.2 In a second series of 1192 patients, significant CAD was found in 11.7%, PE in 2.3%, and AD in 0.3%.3 As with all imaging paradigm changes, technical feasibility and a favorable benefit to risk …

Coronary artery calcium (CAC), a marker of subclinical atherosclerosis, has emerged as the most robust predictor of adverse cardiovascular events in the asymptomatic population; it is superior to all risk factor-based scores including the Pooled Cohort Equation in the 2013 ACC/AHA Cholesterol Guidelines. It is most useful in reclassifying patients in the intermediate risk group to lower or higher risk categories and has been incorporated into guidelines as part of the decision-making process in selected circumstances. Progression of CAC on serial scanning is indicative of poorer outcomes.

Coronary computed tomographic angiography (CTA) use is growing rapidly, and multiple studies have shown its value in improving patient care. However, CTA providers range across the cardiology and radiology specialties and have developed their own styles of reporting. This can bring some variability

This study sought to determine if breast arterial calcification (BAC) on digital mammography predicts coronary artery calcification (CAC).BAC is frequently noted but the quantitative relationships to CAC and risk factors are unknown.A total of 292 women with digital mammography and nongated computed tomography was evaluated. BAC was quantitatively evaluated (0 to 12) and CAC was measured on computed tomography using a 0 to 12 score; they were correlated with each other and the Framingham Risk Score (FRS) and the 2013 Cholesterol Guidelines Pooled Cohort Equations (PCE).BAC was noted in 42.5% and was associated with increasing age (p0.0001), hypertension (p = 0.0007), and chronic kidney disease (p0.0001). The sensitivity, specificity, positive and negative predictive values, and accuracy of BAC0 for CAC0 were 63%, 76%, 70%, 69%, and 70%, respectively. All BAC variables were predictive of the CAC score (p0.0001). The multivariable odds ratio for CAC0 was 3.2 for BAC 4 to 12, 2.0 for age, and 2.2 for hypertension. The agreements of FRS risk categories with CAC and BAC risk categories were 57% for CAC and 55% for BAC; the agreement was 47% for PCE risk categories for CAC and 54% by BAC. BAC0 had area under the curve of 0.73 for identification of women with CAC0, equivalent to both FRS (0.72) and PCE (0.71). BAC0 increased the area under the curve curves for FRS (0.72 to 0.77; p = 0.15) and PCE (0.71 to 0.76; p = 0.11) for the identification of high-risk (4 to 12) CAC. With the inclusion of 33 women with established CAD, BAC0 was significantly additive to both FRS (p = 0.02) and PCE (p = 0.04) for high-risk CAC.There is a strong quantitative association of BAC with CAC. BAC is superior to standard cardiovascular risk factors. BAC is equivalent to both the FRS and PCE for the identification of high-risk women and is additive when women with established CAD are included.

Quality control is pervasive in most modern business, but, surprisingly, is in its infancy in medicine in general-and cardiovascular imaging in particular. The increasing awareness of the cost of cardiovascular imaging, matched by a desire to show benefits from imaging to patient outcome, suggests that this deficiency should be reassessed. Demonstration of improved quality has been proposed to require a focus on several domains: laboratory organization, patient selection, image acquisition, image interpretation, and results communication. Improvement in these steps will require adoption of a variety of interventions, including laboratory accreditation, appropriate use criteria, and continuous quality control and enhancements in reporting, but the evidence base for the benefit of interventions on these steps has been sparse. The purpose of this review is to evaluate the current status and future goals of developing the evidence base for these processes in cardiovascular imaging.

Aims We sought to present a series of 13 pregnancy-associated spontaneous coronary artery dissection (P-SCAD), their angiographic and multimodal imaging findings, acute phase treatment, and outcomes. Methods and results Between 2005 and 2015, 13 cases of P-SCAD were collected from a database of 11 tertiary hospitals. The mean age was 33.8 ± 3.7 years; most patients had no risk factors for coronary artery disease, and the majority were multiparous. P-SCAD occurred during the puerperium in 12 patients with a median time of 10 days. Only one patient presented with P-SCAD in the 37th week of pregnancy, and she was the only patient who died in this series. Six patients (46%) presented with ST-segment elevation acute myocardial infarction (STEMI), six (46%) presented with non-STEMI, and one presented with unstable angina; one-third of women had cardiogenic shock. In 12 patients, the dissection involved the left anterior descending or circumflex artery, and it extended to the left main coronary artery in 6 patients. Intravascular ultrasound or optical coherence tomography helped to confirm diagnosis and guide treatment in 46% of cases. Seven women were managed clinically; percutaneous coronary intervention was performed in five cases, and coronary artery bypass grafting was performed in one patient. Conclusion In these 13 cases of P-SCAD, clinical presentation commonly included acute myocardial infarction and cardiogenic shock. Multivessel dissections and involvement of the left coronary artery and left main coronary artery were highly prevalent. Clinicians must be aware of angiographic appearances of P-SCAD for prompt diagnosis and management in these high-risk patients.

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.

Coronary computed tomographic angiography (CTA) has become an accepted tool for the evaluation of obstructive coronary artery disease, with high accuracy and proven prognostic implications. Although detailed information regarding plaque characteristics is available in coronary CTA datasets of

BackgroundCoronary computed tomography angiography (CTA)-verified positive remodeling and low attenuation plaques are considered morphological characteristics of high-risk plaque (HRP) and predict short-term risk of acute coronary syndrome (ACS).ObjectivesThis study evaluated whether plaque characteristics by CTA predict mid-term likelihood of ACS.MethodsThe presence of HRP and significant stenosis (SS) of ≥70% were evaluated in 3,158 patients undergoing CTA. Serial CTA was performed in 449 patients, and plaque progression (PP) was evaluated. Outcomes (fatal and nonfatal ACS) were recorded during follow-up (mean 3.9 ± 2.4 years).ResultsACS occurred in 88 (2.8%) patients: 48 (16.3%) of 294 HRP(+) and 40 (1.4%) of 2,864 HRP(−) patients. ACS was also significantly more frequent in SS(+) (36 of 659; 5.5%) than SS(−) patients (52 of 2,499; 2.1%). HRP(+)/SS(+) (19%) and HRP(+)/SS(−) (15%) had higher rates of ACS compared with no-plaque patients (0.6%). Although ACS incidence was relatively low in HRP(−) patients, the cumulative number of patients with ACS developing from HRP(−) lesions (n = 43) was similar to ACS patients with HRP(+) lesions (n = 45). In patients with serial CTA, PP also was an independent predictor of ACS, with HRP (27%; p < 0.0001) and without HRP (10%) compared with HRP(−)/PP(−) patients (0.3%).ConclusionsCTA-verified HRP was an independent predictor of ACS. However, the cumulative number of ACS patients with HRP(−) was similar to patients with HRP(+). Additionally, plaque progression detected by serial CTA was an independent predictor of ACS.

There is a common misperception in the cardiology community that most acute coronary events arise from ruptures of mildly stenotic plaques. This notion has emanated from multiple studies that had measured the degree of angiographic luminal narrowing in culprit plaques months to years before myocardial infarction. However, angiographic studies within 3 months before myocardial infarction, immediately after myocardial infarction with thrombus aspiration or fibrinolytic therapy, and postmortem pathological observations have all shown that culprit plaques in acute myocardial infarction are severely stenotic. Serial angiographic studies also have demonstrated a sudden rapid lesion progression before most cases of acute coronary syndromes. The possible mechanisms for such rapid plaque progression and consequent luminal obstruction include recurrent plaque rupture and healing and intraplaque neovascularization and hemorrhage with deposition of erythrocyte-derived free cholesterol. Moreover, recent intravascular and noninvasive imaging studies have demonstrated that plaques which result in coronary events have larger plaque volume and necrotic core size with greater positive vessel remodeling compared with plaques, which remain asymptomatic during several years follow-up, although these large atheromatous vulnerable plaques may angiographically seem mild. As such, it is these vulnerable plaques which are more prone to rapid plaque progression or are those in which plaque progression is more likely to become clinically evident. Therefore, in addition to characterizing plaque morphology, inflammatory activity, and severity, detection of the rate of plaque progression might identify vulnerable plaques with an increased potential for adverse outcomes.

Coronary artery calcium scanning (CAC) has emerged as the most robust predictor of coronary events in the asymptomatic primary prevention population, particularly in the intermediate-risk cohort. Every study has demonstrated its superiority to risk factor–based paradigms, e.g., the Framingham Risk Score, with outcome-based net reclassification indexes ranging from 52.0% to 65.6% in the intermediate-risk, 34.0% to 35.8% in the high-risk, and 11.6% to 15.0% in the low-risk cohorts. CAC improves medication and lifestyle adherence and is cost-effective in specified populations, with the ability to effectively stratify the number needed to treat and scan for different therapeutic strategies and patient cohorts. Data have emerged clearly demonstrating the worse prognosis associated with increasing CAC on serial scans, suggesting a potential role for evaluating residual risk and treatment success or failure. CAC is also strongly associated with the development of stroke and congestive heart failure.

One of the important and least controversial concepts introduced by the 2013 American College of Cardiology and American Heart Association cholesterol guidelines, with a class IIa recommendation, is shared decision making (SDM) [(1)][1]: informing patients about all available options and seeking

“In the Western world both the proverb and the image are often used to refer to a lack of moral responsibility on the part of people who refuse to acknowledge impropriety, looking the other way or feigning ignorance.”—Wikipedia [(1)][1] Consider the following scenario: a 40-year-old male

Without question, CAC scanning is one of the most important diagnostic achievements in the primary prevention of coronary heart disease in the past generation. Every study, whether retrospective, self-referred, or based on a prospective population, has consistently and conclusively shown CAC to be the most powerful predictor of risk in asymptomatic patients, outperforming carotid intima media thickness, brachial artery reactivity, ankle brachial index, and serum biomarkers, including C-reactive protein. It consistently adds incremental and independent predictive value to risk calculators (ie- Framingham Risk or Pooled Risk Cohort) for future ASCVD events. CAC has a strong influence to improving adherence to statin medications, aspirin, diet, and exercise programs. This has been consistently demonstrated, with greater adherence reflecting higher CAC scores. Finally, non-coronary calcifications (ie – thoracic aorta and valve calcification) have been demonstrated to add important prognostic and diagnostic information related to the cardiac patient. Thus, coronary artery calcium is a robust, easy to perform, low radiation test, that is increasingly being used as a screening test in asymptomatic persons to identify those with advanced atherosclerosis who would benefit from preventive therapies.

The 2010 Expert Consensus Document on Coronary CT Angiography (CTA) states, “Coronary stents pose some significant technical challenges for coronary CTA, since the metal in the stents may create several types of artifacts in the images. Special algorithms are now routinely used that may reduce some of these artifacts during image reconstruction. The literature suggests that in patients who have large diameter stents, good image quality, and whose clinical presentation suggests low-to-intermediate probability for restenosis, 64-channel coronary CTA can be used to rule out severe in-stent restenosis” [1].

The rising cost of healthcare is prompting numerous policy and advocacy discussions regarding strategies for constraining growth and creating a more efficient and effective healthcare system. Cardiovascular imaging is central to the care of patients at risk of, and living with, heart disease. Estimates are that utilization of cardiovascular imaging exceeds 20 million studies per year. The Society of Cardiovascular CT (SCCT), alongside Rush University Medical Center, and in collaboration with government agencies, regional payers, and industry healthcare experts met in November 2016 in Chicago, IL to evaluate obstacles and hurdles facing the cardiovascular imaging community and how they can contribute to efficacy while maintaining or even improving outcomes and quality. The summit incorporated inputs from payers, providers, and patients' perspectives, providing a platform for all voices to be heard, allowing for a constructive dialogue with potential solutions moving forward. This article outlines the proceedings from the summit, with a detailed review of past hurdles, current status, and potential solutions as we move forward in an ever-changing healthcare landscape.

In the January/February 2017 issue of Journal of Cardiovascular Computed Tomography, in the Guidelines article titled ‘‘2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans a report of the society of Cardiovascular Computed Tomography and Society of Thoracic Radiology’’ (2017; 11:74–84; http://dx.doi.org/10.1016/j.jcct.2016.11.003), Appendix 1 containing the disclosures was not included. The appendix has been added to the online version of the article.

This expert consensus statement summarizes the available data regarding the prognostic value of CAC in the asymptomatic population and its ability to refine individual risk prediction, addresses the limitations identified in the current traditional risk factor-based treatment strategies recommended by the 2013 ACC/AHA Prevention guidelines including use of the Pooled Cohort Equations (PCE), and the US Preventive Services Task Force (USPSTF) Recommendation Statement for Statin Use for the Primary Prevention of Cardiovascular Disease in Adults. It provides CAC based treatment recommendations both within the context of the shared decision making model espoused by the 2013 ACC/AHA Prevention guidelines and independent of these guidelines.

The Society of Cardiovascular Computed Tomography (SCCT) and the Society of Thoracic Radiology (STR) have jointly produced this document. Experts in this subject have been selected from both organizations to examine subject-speci&filig;c data and write this guideline in partnership. A formal literature review, weighing the strength of evidence has been performed. When available, information from studies on cost was considered. Computed tomography (CT) acquisition, CAC scoring methodologies and clinical outcomes are the primary basis for the recommendations in this guideline. This guideline is intended to assist healthcare providers in clinical decision making. The recommendations re&fllig;ect a consensus after a thorough review of the best available current scienti&filig;c evidence and practice patterns of experts in the &filig;eld and are intended to improve patient care while acknowledging that situations arise where additional information may be needed to better inform patient care.

Coronary artery disease (CAD) and lung cancer have several important features in common. First, their dramatic increases are in large part attributable to societal ills, including worsening dietary patterns, obesity, and tobacco use. Secondly, as these behaviours permeate the world, the diseases are disproportionately increasing in the poorer societies with limited resources for healthcare. Consequently, it is necessary to develop cost-effective strategies. Both disease states may be amenable to early detection by a single low radiation dose CT scan. ### Early detection of coronary artery disease: guidelines and general considerations Gated multidetector computed tomographic imaging of coronary artery calcium (CAC) is a robust strategy for the early detection of CAD in asymptomatic patients that has performed superior to risk factor-based paradigms such as the Framingham Risk Score (FRS) and the European Society of Cardiology Score.1 Notwithstanding these data, the US Preventive Services Task Force (USPSTF) in 2009 concluded that the current evidence was insufficient to assess the balance of benefits and harms of using non-traditional risk factors, including CAC scans, to screen asymptomatic men and women with no history of CAD to prevent coronary events.2 However, in 2010, CAC assessment was incorporated into ACC/AHA Guidelines with a Class IIa status (recommendation in favour of treatment or procedure being useful/effective). Measurement of CAC was considered reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate risk, and all diabetic patients 40 years or older.3 The ACCF/SCCT/ACR/AHA/ASE/ASNC/NASCI/SCAI/SCMR 2010 appropriate use criteria deemed CAC appropriate for intermediate-risk patients as well as for low-risk individuals with a family history of premature disease.4 In 2012, the European Society of Cardiology awarded a similar Class IIa recommendation, and suggested CAC for cardiovascular risk assessment in asymptomatic adults at moderate risk.5 In an attempt to simplify cholesterol treatment, the 2013 ACC/AHA Guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk …

The procedural success rates of percutaneous intervention for chronic total coronary occlusions (CTOs) over the past decade have been increasing, driven by the development of specialized guidewires and microcatheters and the introduction of new technical strategies, including antegrade subintimal re

The ability to monitor the success or failure of treatment is an essential component of every aspect of medicine. Tumor progression is tracked in cancer therapeutics either through imaging or biomarkers, and therapy is often titrated on the basis of changes in these markers. Similar strategies are

Objective This study was designed to evaluate the severity of subclinical atherosclerosis in patients with asymptomatic impaired fasting glucose (IFG) compared to those with diabetes mellitus (DM) and normal fasting glucose (NFG), as measured by coronary computed tomographic angiography (CCTA). Design Subjects were divided into three groups: NFG (

Two thousand sixteen marks the 400th anniversary of William Shakespeare’s death, and his legacy of famous quotations has gained relevance in almost all aspects of our lives. “A rose by any other name would smell as sweet,” from Romeo and Juliet [(1)][1], has long been used to imply that names

IMPORTANCE: Obstructive coronary lesions with reduced luminal dimensions may result in abnormal regional myocardial blood flow as assessed by stress-induced myocardial perfusion imaging or a significant fall in distal perfusion pressure with hyperemia-induced vasodilatation (fractional flow reserve [FFR] ≤0.80). An abnormal FFR has been demonstrated to identify high-risk lesions benefitting from percutaneous coronary intervention while safely allowing revascularization to be deferred in low-risk lesions, resulting in a decrease in the number of revascularization procedures as well as substantially reduced death and myocardial infarction. While FFR identifies hemodynamically significant lesions likely to produce ischemia-related symptoms, it remains less clear as to why it might predict the risk of acute coronary syndromes, which are usually due to plaque rupture and coronary thrombosis.OBSERVATIONS: Although the atherosclerotic plaques with large necrotic cores (independent of the degree of luminal stenosis) are known to be associated with vulnerability to rupture and acute coronary syndromes, emerging evidence also suggests that they may induce greater rates of ischemia and reduced FFR compared with non-lipid-rich plaques also independent of the degree of luminal narrowing. It is proposed that the presence of large necrotic cores within the neointima may be associated with the inability of the vessel to dilate and may predispose to ischemia and abnormal FFR.CONCLUSIONS AND RELEVANCE: Having a normal FFR requires unimpaired vasoregulatory ability and significant luminal stenosis. Therefore, FFR should identify lesions that are unlikely to possess large necrotic core, rendering them safe for treatment with medical therapy alone. Further studies are warranted to determine whether revascularization decisions in patients with stable coronary artery disease could be improved by assessment of both plaque composition and ischemia.

Risk stratification in patients with stable ischemic heart disease is essential to guide treatment decisions. In this regard, whether coronary anatomy, physiology, or plaque morphology is the best determinant of prognosis (and driver an effective therapeutic risk reduction) remains one of the greatest ongoing debates in cardiology. In the present report, we review the evidence for each of these characteristics and explore potential algorithms that may enable a practical diagnostic and therapeutic strategy for the management of patients with stable ischemic heart disease.

Invasive fractional flow reserve (FFR) is now the gold standard for intervention. Noninvasive functional imaging analyses derived from coronary computed tomographic angiography (CTA) offer alternatives for evaluating lesion-specific ischemia. CT-FFR, CT myocardial perfusion imaging, and transluminal attenuation gradient/corrected contrast opacification have been studied using invasive FFR as the gold standard. CT-FFR has demonstrated significant improvement in specificity and positive predictive value compared with CTA alone for predicting FFR of ≤0.80, as well as decreasing the frequency of nonobstructive invasive coronary angiography. High-risk plaque characteristics have also been strongly implicated in abnormal FFR. Myocardial computed tomographic perfusion is an alternative method with promising results; it involves more radiation and contrast. Transluminal attenuation gradient/corrected contrast opacification is more controversial and may be more related to vessel diameter than stenosis. Important considerations remain: (1) improvement of CTA quality to decrease unevaluable studies, (2) is the diagnostic accuracy of CT-FFR sufficient? (3) can CT-FFR guide intervention without invasive FFR confirmation? (4) what are the long-term outcomes of CT-FFR–guided treatment and how do they compare with other functional imaging-guided paradigms? (5) what degree of stenosis on CTA warrants CT-FFR? (6) how should high-risk plaque be incorporated into treatment decisions? (7) how will CT-FFR influence other functional imaging test utilization, and what will be the effect on the practice of cardiology? (8) will a workstation-based CT-FFR be mandatory? Rapid progress to date suggests that CTA-based lesion-specific ischemia will be the gatekeeper to the cardiac catheterization laboratory and will transform the world of intervention.

The quantification of coronary artery calcium (CAC) on gated noncontrast cardiac CT, as a screening test for subclinical coronary artery disease, has been consistently proven to be superior to risk factors and biomarkers for the prediction of long-term cardiovascular risk. Coronary artery calcium is also readily evaluable in every noncontrast (nongated) chest CT scan, yet there are no recommendations for reporting CAC in scans done for noncardiac indications. Lung CT scanning has been approved for lung cancer screening, and almost all the candidates are intermediate to high risk for coronary artery disease, which can be powerfully evaluated by the assessment of CAC at no additional radiation or cost. There are technical requirements for scanner detectors, slice thickness, and voltage which are easily satisfied. EKG gating provides the highest quality studies but will be more difficult to universally implement. Agatston scoring, ordinal scoring, and visual estimation of nongated scans offer alternatives and are supported by varying degrees of data. Similarly, newer reconstruction algorithms are available but are not yet widely used. Barriers to reporting include increased time and lack of increased reimbursement for CAC analysis, difficulties inherent to reporting abnormal results, and referring physician understanding and utilization of the results to alter patient education and management.

Cardiac risk assessment has traditionally been based on conventional risk factors; the shortcomings of this approach are all too often highlighted by major cardiac events occurring in presumably low-risk people. The annual presentation of 650,000 previously asymptomatic patients with an acute coronary event as the initial manifestation of coronary artery disease (CAD) [1] is a testimony to the failure of our current risk assessment model. Consequently, there has been a focus on markers of subclinical atherosclerosis that may be utilized for risk assessment of individuals, rather than extrapolating from risk factors that reflect trends in large groups of patients in epidemiologic studies. The most powerful of these subclinical markers is coronary artery calcium (CAC).

Coronary artery calcium (CAC) is the most powerful cardiac risk prognosticator in the asymptomatic population, with consistent superiority to all risk factor-based paradigms. More recently, the strong prognostic value of changes in CAC has been demonstrated. The application of CAC to asymptomatic patients with diabetes mellitus (DM), all of whom have been presumed to be of high risk, has yielded a range of risks from low to high, proportional to the amount of calcified plaque, as in patients without DM. These risks are higher than in non-diabetic patients at corresponding CAC levels, except for those without CAC who have the same low risk as non-diabetic patients. In addition, the value of serial scanning to assess plaque progression and prognosis in people with DM has been demonstrated. Therefore, we propose that: (i) DM is not a coronary artery disease equivalent; (ii) CAC can be used routinely in all asymptomatic diabetic patients >40 years of age, as proposed by American College of Cardiology/American heart Association guidelines; and (iii) serial CAC scanning be considered for evaluation of the response to therapy.