Search Results (201)

Background/Objectives: Coronary CT angiography (CCTA) is a cornerstone in evaluating stable coronary artery disease (CAD), but conventional energy-integrating detector CT (EID-CT) has limitations, including calcium blooming and limited spatial resolution. Photon-counting detector CT (PCD-CT) may overcome these drawbacks through enhanced spatial resolution and improved tissue characterization. Methods: In this retrospective, propensity score–matched study, we compared CCTA findings from 820 patients (410 per group) who underwent either EID-CT or PCD-CT for suspected stable CAD. Primary outcomes included stenosis severity, high-risk plaque features, and downstream invasive coronary angiography (ICA) referral and yield. Results: The matched cohorts were balanced in demographics and cardiovascular risk factors (mean age 67 years, 63% male). PCD-CT showed a favorable shift in stenosis severity distribution (p = 0.03). High-risk plaques were detected less frequently with PCD-CT (22.7% vs. 30.5%, p = 0.01). Median coronary calcium scores did not differ (p = 0.60). Among patients referred for ICA, those initially evaluated with PCD-CT were more likely to undergo revascularization (62.5% vs. 44.1%), and fewer underwent potentially unnecessary ICA without revascularization (3.7% vs. 8.0%, p = 0.001). The specificity in diagnosing significant stenosis requiring revascularization was 0.74 with EID-CT and 0.81 with PCD-CT (p = 0.04). Conclusions: PCD-CT improved diagnostic specificity for CAD, reducing unnecessary ICA referrals while maintaining detection of clinically significant disease. This advanced CT technology holds promise for more accurate, efficient, and patient-centered CAD evaluation. Full article

Background: Coronary artery calcium (CAC) scores are a widely used surrogate marker for atherosclerotic burden, but they do not fully reflect plaque vulnerability or coronary inflammation. This study aimed to evaluate the relationship between CACs, coronary plaque characteristics, and perivascular inflammatory activity using advanced CCTA and CaRi-Heart^® analysis. Methods: A total of 250 patients with no prior cardiovascular disease were retrospectively evaluated and stratified by CACs into three groups: 0 (n = 28), 1–100 (n = 121), and >100 (n = 101). Coronary plaque morphology, high-risk plaque (HRP) features, CAD-RADS scores, and AI-derived fat attenuation index (FAI) centiles were assessed. Results: Significant differences across CAC categories were observed for several key parameters. The number of diseased coronary segments increased markedly (from 1.39 ± 1.10 vs. 2.97 ± 1.57 vs. 3.94 ± 2.10; p < 0.0001, one-way ANOVA). A similar upward trend was seen for segment involvement scores, HRP prevalence, and the proportions of mixed and calcified plaque components. Regression analysis demonstrated that CACs correlated significantly with segment burden (r² = 0.2520), CAD-RADS (r² = 0.1352), and the FAI score centile (r² = 0.0568). Conclusions: This study highlights the limitations of CACs as a standalone risk stratification tool. Vulnerable and inflamed plaques may already be present in patients with low or zero CACs. Integrating CCTA with perivascular FAI mapping enables earlier detection of biologically active atherosclerosis and supports more precise clinical decision-making. Full article

A revolutionary non-invasive method for the thorough evaluation of coronary artery disease (CAD) is fractional flow reserve (FFR) obtained from coronary computed tomography angiography (CCTA). Computed tomography-derived FFR (FFR_CT) assesses both the anatomical and functional significance of coronary lesions simultaneously by utilizing sophisticated computational models, including computational fluid dynamics, machine learning (ML), and Artificial Intelligence (AI) methods. The technological development, validation research, clinical uses, and real-world constraints of FFR_CT are compiled in this review. Large multicenter trials and registries consistently show that FFR_CT is a reliable gatekeeper to invasive coronary angiography (ICA) and increases diagnostic accuracy significantly when compared to coronary Computed Tomography Angiography (CTA) alone, especially in patients with intermediate-risk anatomy. Additionally, FFR_CT has demonstrated benefits in populations with in-stent restenosis (ISR) and in virtual procedural planning. Notwithstanding its advantages, the technique still requires high-quality imaging, and its practical application is constrained by expenses, processing requirements, and image distortions. Continuous developments in automation and deep learning should improve accessibility, effectiveness, and workflow integration in clinical settings. FFR_CT is expected to become more and more important in the individualized treatment of CAD by minimizing unnecessary invasive procedures and improving patient selection for revascularization. Full article

Background/Objectives: Invasive coronary angiography (ICA) is the gold standard for the diagnosis of coronary artery disease (CAD), with various non-invasive imaging modalities also available. Machine learning (ML) methods are increasingly applied to overcome the limitations of diagnostic imaging by improving accuracy and observer independent performance. Methods: This meta-analysis (PRISMA method) summarizes the evidence for ML-based analyses of coronary imaging data from ICA, coronary computed tomography angiography (CT), and nuclear stress perfusion imaging (SPECT) to predict clinical outcomes and performance for precise diagnosis. We searched for studies from Jan 2012–March 2023. Study-reported c index values and 95% confidence intervals were used. Subgroup analyses separated models by outcome. Combined effect sizes using a random-effects model, test for heterogeneity, and Egger’s test to assess publication bias were considered. Results: In total, 46 studies were included (total subjects = 192,561; events = 31,353), of which 27 had sufficient data. Imaging modalities used were CT (n = 34), ICA (n = 7) and SPECT (n = 5). The most frequent study outcome was detection of stenosis (n = 11). Classic deep neural networks (n = 12) and convolutional neural networks (n = 7) were the most used ML models. Studies aiming to diagnose CAD performed best (0.85; 95% CI: 82, 89); models aiming to predict clinical outcomes performed slightly lower (0.81; 95% CI: 78, 84). The combined c-index was 0.84 (95% CI: 0.81–0.86). Test of heterogeneity showed a high variation among studies (I² = 97.2%). Egger’s test did not indicate publication bias (p = 0.485). Conclusions: The application of ML methods to diagnose CAD and predict clinical outcomes appears promising, although there is lack of standardization across studies. Full article

In the original randomised Dietary Intervention to Stop Coronary Atherosclerosis (DISCO-CT) trial, a 12-month Dietary Approaches to Stop Hypertension (DASH) project led by dietitians improved cardiovascular and metabolic risk factors and reduced platelet chemokine levels in patients with coronary artery disease (CAD). It is unclear whether these benefits are sustained. Objective: To determine whether the metabolic, inflammatory, and clinical benefits achieved during the DISCO-CT trial are sustained six years after the structured intervention ended. Methods: Ninety-seven adults with non-obstructive CAD confirmed in coronary computed tomography angiography were randomly assigned to receive optimal medical therapy (control group, n = 41) or the same therapy combined with intensive DASH counselling (DASH group, n = 43). After 301 ± 22 weeks, 84 individuals (87%) who had given consent underwent reassessment of body composition, meal frequency assessment, and biochemical testing (lipids, hs-CRP, CXCL4, RANTES and homocysteine). Major adverse cardiovascular events (MACE) were assessed. Results: During the intervention, the DASH group lost an average of 3.6 ± 4.2 kg and reduced their total body fat by an average of 4.2 ± 4.8 kg, compared to an average loss of 1.1 ± 2.9 kg and a reduction in total body fat of 0.3 ± 4.1 kg in the control group (both p < 0.01). Six years later, most of the lost body weight and fat tissue had been regained, and there was a sharp increase in visceral fat area in both groups (p < 0.0001). CXCL4 decreased by 4.3 ± 3.0 ng/mL during the intervention and remained lower than baseline values; in contrast, in the control group, it initially increased and then decreased (p < 0.001 between groups). LDL cholesterol and hs-CRP levels returned to baseline in both groups but remained below baseline in the DASH group. There was one case of MACE in the DASH group, compared with four cases (including one fatal myocardial infarction) in the control group (p = 0.575). Overall adherence to the DASH project increased by 26 points during counselling and then decreased by only four points, remaining higher than in the control group. Conclusions: A one-year DASH project supported by a physician and dietitian resulted in long-term suppression of the proatherogenic chemokine CXCL4 and fewer MACE over six years, despite a decline in adherence and loss of most anthropometric and lipid benefits. It appears that sustained systemic reinforcement of behaviours is necessary to maintain the benefits of lifestyle intervention in CAD. Full article

Coronary computed tomography angiography (CCTA) has emerged as the leading noninvasive imaging modality for the assessment of coronary artery disease (CAD), offering high-resolution visualization of the coronary anatomy and plaque characterization. The development of fractional flow reserve derived from CCTA (FFR-CT) has further transformed the diagnostic landscape by enabling the simultaneous evaluation of both anatomical stenosis and lesion-specific ischemia. FFR-CT has demonstrated diagnostic accuracy comparable to invasive FFR. The combined use of CCTA and FFR-CT is now pivotal in a broad range of clinical scenarios, including the evaluation of stable and acute chest pain, assessment of high-risk and complex plaque features, and preoperative planning. As evidence continues to mount, CCTA and FFR-CT are positioned to become the primary gatekeepers to the cardiac catheterization laboratory, potentially reducing the number of unnecessary invasive procedures. This review highlights the growing clinical utility of FFR-CT, its integration with advanced plaque imaging, and the future potential of these technologies in redefining the management of CAD, while also acknowledging current limitations, including image quality requirements, cost, and access. Full article

Background: Kawasaki disease (KD) is a systemic vasculitis and the leading cause of acquired heart disease in children. Early identification of coronary artery abnormalities (CAAs) is crucial to guide treatment and improve outcomes. While transthoracic 2D echocardiography (TTE) remains the first-line imaging modality, it has limitations, particularly in visualizing distal coronary artery segments and detecting thrombi. Computed tomography coronary angiography (CTCA) offers enhanced visualization, but its role at initial presentation of KD remains underexplored. Methods: We reviewed the records of 71 children with KD who underwent CTCA at their initial presentation at a tertiary center between November 2013 and December 2024. The CTCA findings were compared with those of TTE. CTCA was performed after stabilization using radiation-minimized protocols. Results: Of 71 patients, 62 had CAAs on baseline TTE. CTCA confirmed CAAs in 39 patients, identified additional lesions in 23, and detected distal aneurysms and coronary branch involvement missed by TTE. In 20 patients with initially abnormal TTE, CTCA demonstrated normal coronaries, facilitating treatment de-escalation. CTCA identified coronary thrombi missed on TTE in two patients and congenital coronary anomalies in three patients. CTCA findings led to modification of therapy in multiple cases. Conclusions: CTCA is a valuable adjunct to TTE in evaluating coronary artery involvement at the time of initial presentation of children with KD. Given its superior visualization of the entire length of coronary arteries, CTCA has a vital role in therapeutic decision-making in KD. Full article

(1) Background: Our aim was to evaluate the diagnostic performance of combined coronary computed tomography angiography (CCTA) and dynamic CT myocardial perfusion imaging (CT-MPI) for detecting hemodynamically significant coronary artery disease (CAD) in patients with intermediate pretest probability. (2) Methods: Patients with an intermediate pretest probability of CAD were retrospectively enrolled. All patients underwent CCTA and dynamic CT-MPI using a third-generation dual-source CT scanner prior to invasive coronary angiography (ICA). Anatomically significant stenosis was defined as ≥50% luminal narrowing on both CCTA and ICA. Fractional flow reserve (FFR) was performed during ICA in selected cases. Hemodynamically significant CAD was defined per vessel as FFR ≤ 0.80, angiographic stenosis ≥70%, or having undergone revascularization. The diagnostic performance of CCTA alone and CCTA combined with CT-MPI was compared against this reference standard. (3) Results: Seventy-four patients (mean age, 66.8 ± 11.1 years; 59 men) were included. The median coronary calcium score was 508.5 Agatston units (interquartile range: 147–1173). ICA and CCTA detected anatomically significant stenoses in 137 (61.7%) and 146 (65.8%) coronary vessels, respectively, and in 62 (83.8%) and 71 (95.9%) patients, respectively. Hemodynamically significant stenosis was present in 56 patients (76%) and 99 vessels (45%). On a per-vessel basis, CCTA alone yielded a sensitivity of 96.7%, specificity of 60.3%, positive predictive value (PPV) of 64.4%, and negative predictive value (NPV) of 96.1%. Combined CCTA and CT-MPI demonstrated a sensitivity of 90.1%, specificity of 84.3%, PPV of 82.7%, and NPV of 91.1%. The area under the receiver operating characteristic curve improved from 0.787 (95% confidence interval: 0.73–0.84) for CCTA to 0.872 (95% confidence interval: 0.82–0.91) for the combined approach (p < 0.05). The median total radiation dose for both CCTA and CT-MPI was 8.05 mSv (interquartile range: 6.71–11.0). (4) Conclusions: In patients with intermediate pretest probability of CAD, combining CCTA with dynamic CT-MPI significantly enhances the diagnostic performance for identifying hemodynamically significant coronary stenosis compared to CCTA alone. Full article

Chronic total occlusions (CTOs), defined as complete coronary artery blockages persisting for over three months, are frequently encountered in up to 25% of coronary angiograms. Although percutaneous coronary intervention (PCI) for CTO remains technically challenging, advancements in guidewires, microcatheters, re-entry devices, and intravascular imaging, along with the expertise of specialized operators, have significantly improved procedural success rates, now exceeding 90% in expert centers. While recent evidence, such as the SYNTAX II study, emphasizes the importance of complete revascularization, over half of CTO cases continue to be managed conservatively with optimal medical therapy (OMT), partly due to the limited high-quality randomized evidence supporting revascularization. Observational studies have demonstrated that successful CTO-PCI is associated with improved angina relief, quality of life, left ventricular function, and possibly long-term survival. Extended observational follow-up, such as the Korean and Canadian registries, suggests long-term reductions in cardiac and all-cause mortality with CTO revascularization. However, randomized controlled trials (RCTs) have primarily shown symptomatic benefit, with no consistent reduction in major adverse cardiac events (MACE) or mortality, likely due to limited sample sizes, short follow-up, and treatment crossovers. Various strategies, including the hybrid algorithm, guide CTO interventions by balancing antegrade and retrograde techniques based on lesion complexity. Imaging modalities such as coronary CT angiography and intravascular ultrasound play a pivotal role in planning and optimizing these procedures. Future innovations, such as real-time fusion imaging of CCTA with coronary angiography, may enhance lesion visualization and guidewire navigation. While current guidelines recommend CTO-PCI in selected symptomatic patients with demonstrable ischemia or viable myocardium, the decision should be individualized, incorporating anatomical feasibility, comorbidities, patient preferences, and input from a multidisciplinary Heart Team. Looking ahead, adequately powered RCTs with extended follow-up are essential to determine the long-term clinical impact of CTO-PCI on hard outcomes such as mortality and myocardial infarction. Full article

Objective: We aimed to evaluate the feasibility, added value, and radiation dose of coronary computed tomography angiography (CCTA) and stress dynamic CT myocardial perfusion imaging (MPI) in patients with coronary artery disease (CAD) in a real-world setting. Materials and Methods: This retrospective study included 65 patients (mean age: 51.2 ± 11.5 years; 21 female) with moderate CAD, selected from the Radiological Database of our hospital between May 2022 and December 2024. All patients underwent CCTA and stress dynamic CT-MPI using a third-generation dual-source CT scanner. The shuttle-mode acquisition technique was used for CT-MPI with 60 mL of contrast (iopamidol, 370 mg iodine/mL) administered at a flow rate of 6 mL/s. The mean myocardial blood flow (MBF) and other quantitative parameters were measured for both CAD and reference segments (RSs). A 17-segment-based analysis was employed (excluding the apex). The MBF ratio, defined as the mean MBF value of CAD segments divided by that of RS, was used with a cut-off value of 0.85 to distinguish hypoperfused from non-hypoperfused segments within CAD territories. Non-parametric statistical tests were applied. Results: A total of 1040 segments were evaluated. In 62 segments, the mean MBF of CAD territories was found to have decreased. The mean MBF and myocardial blood volume (MBV) in hypoperfused CAD segments were 65.1 ± 19.8 mL/100 mL/min and 14.5 ± 2.7 mL/100 mL, respectively, both significantly lower compared to non-hypoperfused CAD segments and RSs (p < 0.001). The mean effective dose of the protocol was 6.3 ± 1.4 mSv, corresponding to an estimated individual lifetime cancer risk of approximately 0.06% per test, based on BEIR VII Phase 2 modeling. This risk is cumulative, with repeat testing over a 10-year period potentially increasing lifetime cancer risk in proportion to total radiation exposure. The mean total examination time was 26 ± 4 min. Conclusion: The combined CCTA and dynamic CT-MPI protocol is feasible in real-world clinical practice and offers a comprehensive morphological and functional assessment of moderate CAD, with a manageable radiation dose and examination time. Full article

Coronary artery disease (CAD) is a highly prevalent cardiovascular disease and one of the leading causes of death worldwide. The accurate segmentation of coronary arteries from CT angiography (CTA) images is essential for the diagnosis and treatment of coronary artery disease. However, due to small vessel diameters, large morphological variations, low contrast, and motion artifacts, conventional segmentation methods, including classical image processing (such as region growing and level sets) and early deep learning models with limited receptive fields, are unsatisfactory. We propose SADiff, a hybrid framework that integrates a dilated attention network (DAN) for ROI extraction, a diffusion-based subnet for noise suppression in low-contrast regions, and a striped attention network (SAN) to refine tubular structures affected by morphological variations. Experiments on the public ImageCAS dataset show that it has a Dice score of 83.48% and a Hausdorff distance of 19.43 mm, which is 6.57% higher than U-Net3D in terms of Dice. The cross-dataset validation on the private ImageLaPP dataset verifies its generalizability with a Dice score of 79.42%. This comprehensive evaluation demonstrates that SADiff provides a more efficient and versatile method for coronary segmentation and shows great potential for improving the diagnosis and treatment of CAD. Full article

Background/Objectives: Estrogen deficiency is strongly related to osteoporosis, but its role in the development of atherosclerotic cardiovascular disease (CVD), particularly in postmenopausal women, is unclear. The aim of this study was to assess the relationship between osteopenia and subclinical atherosclerosis in asymptomatic non-diabetic postmenopausal women. Methods: This prospective study included 117 consecutive postmenopausal women (mean age 59 ± 7 years) referred from the outpatient Rheumatology Clinic of the University Clinical Centre of Kosovo, recruited between September 2021 and December 2022. Clinical, biochemical, bone mineral density (BMD), carotid ultrasound and coronary CT angiography data were analyzed. Subclinical atherosclerosis was diagnosed as the presence of carotid plaques and/or increased intima-media thickness (CIMT) > 1.0 mm. Results: Of the 117 studied women, 83 (71%) had osteopenia or osteoporosis (T-score < −1 SD), who had higher prevalence of carotid artery plaques (27.7 vs. 8.8%, p = 0.019), compared to those with normal BMD. They were, also, older (p < 0.001), had a longer duration of menopause (p = 0.004) and higher CAC scores (p < 0.019), compared to those without plaques. In multivariate analysis [odds ratio 95% confidence interval], age [1.244 (1.052–1.470), p = 0.001], osteoporosis [0.197 (0.048–0.806), p = 0.024] and CAC score > 10 HU [0.174 (0.058–0.806), p = 0.006] were independently associated with the presence of carotid plaques. Conclusions: Reduced BMD is highly prevalent in asymptomatic non-diabetic postmenopausal women and is associated with a high prevalence of subclinical carotid atherosclerosis. Age, osteoporosis and CAC score > 10 HU were independently associated with atherosclerotic carotid plaque formation. These findings highlight the potential pathophysiological link between osteoporosis and subclinical atherosclerosis. Full article

Background and Objectives: To examine individual-level sex differences in traditional and non-traditional risk factors and their potential effects on the severity of coronary artery disease (CAD). Materials and Methods: A cross-sectional analysis was performed on 208 patients with a low-to-intermediate pretest probability of CAD, referred to a Coronary CT angiography (CCTA) at the Department of Radiology, Maribor University Medical Centre, from January 2022 to January 2024. CCTA-derived EAT (epicardial adipose tissue) attenuation and CAC (coronary artery calcification) values were measured. The association between CAD, EAT, and risk factors was analyzed by sex, using correlation analysis and multivariate regression. Results: In the results obtained using the univariate logistic regression model, age (OR 1.122, p < 0.001) and hypertension (OR 4.087, p = 0.048) were significantly associated with the presence of obstructive CAD in women, while in men, age (OR 1.052, p = 0.008), hypercholesterolemia (OR 3.765, p = 0.042), and EAT attenuation (OR 1.053, p = 0.011) were significant factors. In results obtained using the multivariable logistic regression analysis model, EAT attenuation was found to be significantly associated with the presence of obstructive CAD in men (OR 1.087, p = 0.012), and age was a significant factor in women (OR =1.108, p = 0.033), while hypertension, body mass index (BMI), diabetes, hypercholesterolemia, angina pectoris, and smoking were not. Conclusions: In the sex-specific multivariable logistic regression analysis model, EAT attenuation was significantly associated with obstructive CAD in men, while in women, it was associated with age. EAT may function as a beneficial alternative indicator in identifying patients with CAD. Full article

Coronary CT angiography (CCTA) has seen steady progress since its inception, becoming a key player in the non-invasive assessment of coronary artery disease (CAD). Advancements in CT technology, including iterative and deep-learning-based reconstruction, wide-area detectors, and dual-source systems, have helped mitigate early limitations, such as high radiation doses, motion artifacts, high iodine load, and non-diagnostic image quality. However, the adjustments between ionizing radiation and iodinated contrast material (CM) volumes remain a critical concern, especially due to the increasing use of CCTA in various indications. This review explores the balance between radiation and CM volumes, emphasizing patient-specific protocol optimization to improve diagnostic accuracy while minimizing risks. Radiation dose reduction strategies, such as low tube voltage protocols, prospective ECG-gating, and modern reconstruction algorithms, have significantly decreased radiation exposure, with some studies achieving sub-millisievert doses. Similarly, CM volume optimization, including adjustments in strategies for calculating CM volume, iodine concentration, and flow protocols, plays a role in managing risks such as contrast-associated acute kidney injury, particularly in patients with renal impairment. Emerging technologies, such as photon-counting CT and deep-learning reconstruction, promise further improvements in dose efficiency and image quality. This review summarizes current evidence, highlights the benefits and limitations of dose control approaches, and provides practical recommendations for practitioners. By tailoring protocols to patient characteristics, such as age, renal function, and body habitus, clinicians can achieve an optimal trade-off between diagnostic accuracy and patient safety, ensuring optimal operation of CT systems in clinical practice. Full article

Background: Sepsis survivors are at risk of developing myocardial infarction and heart failure. It remains unclear whether coronary artery disease (CAD) is a major contributor to the development of these complications. This study sought to characterize the burden and distribution of significant CAD in sepsis survivors. Methods: Sepsis survivors who underwent computed tomography coronary angiography (CTCA) or invasive coronary angiography (ICA) in a UK tertiary cardiac center for suspected ischemic heart disease were retrospectively studied. Results: Of the 30 sepsis survivors (age 57 ± 12 years; 50% males), 21 patients underwent CTCA and 9 patients underwent ICA a median 39 days [IQR 12–152] from the sepsis episode. Eight patients (~27%) had angiographically significant CAD (n = 6 severe [>70%] stenosis; n = 2 moderate [50–70%] stenosis). The CT coronary calcium score was higher in patients with significant CAD compared to patients without significant CAD (638 [368–1015] vs. 4 [1–72]; p < 0.001). Of the 8 patients with significant CAD, 3 patients had LV systolic dysfunction (38%) on echocardiography and 8/21 (38%) patients without significant CAD had LV systolic dysfunction (p = 1.00). Long-term adverse complications (all-cause mortality and/or heart failure hospitalization) occurred 3/8 (38%) patients with significant CAD and 4/22 (18%) patients without significant CAD (p = 0.345). Conclusions: A minority of sepsis survivors have significant CAD. The presence of significant CAD cannot fully explain the occurrence of post-sepsis LV systolic dysfunction and adverse outcomes. The ischemic and non-ischemic mechanisms underlying post-sepsis cardiovascular disease require further investigation. Full article