Search Results (187)

Cardiac computed tomography (CT) has evolved into a pivotal tool in precision cardiology, enabling comprehensive, non-invasive evaluation of coronary anatomy, plaque composition, vascular function, and inflammation. From calcium scoring to advanced physiological imaging, CT now integrates multiple layers of cardiovascular information within a unified diagnostic framework. Coronary artery calcium (CAC) quantification provides a robust, reproducible measure of atherosclerotic burden and refines risk estimation beyond traditional algorithms, particularly in asymptomatic individuals with an intermediate likelihood. Building upon this anatomical foundation, coronary CT angiography (CCTA) extends evaluation to the anatomical and morphological characterization of coronary artery disease (CAD), identifying both obstructive and non-obstructive plaques with high prognostic accuracy. The addition of CT-derived fractional flow reserve (FFR-CT) and stress perfusion CT (CTP) bridges anatomy and physiology, improving identification of flow-limiting stenoses and guiding revascularization decisions while reducing unnecessary invasive procedures. Beyond luminal assessment, CT-derived biomarkers such as the perivascular fat attenuation index (pFAI) have introduced a new dimension of vascular inflammation imaging, revealing residual risk even in patients without significant stenosis and suggesting novel pathways for individualized therapeutic targeting. Driven by advances in artificial intelligence and photon-counting detector technology, cardiac CT is transitioning from a purely diagnostic modality to an integrative platform for cardiovascular phenotyping. Taken as a whole, this integration of structural, functional, and biological data provides a genuinely holistic view of coronary health. In practical terms, it shifts clinical decision-making from population-based risk models toward precision-guided patient-specific strategies. Full article

The evaluation of stents in coronary computed tomography angiography (CCTA) is still a major topic in cardiovascular imaging. Using Photon-Counting Detector CT (PCCT) may improve the assessment of coronary stents and make on-site CT-FFR analysis feasible for ruling out in-stent restenosis (ISR). In this study, patients with previous coronary stent implantation who underwent CCTA using PCCT and subsequent invasive catheter angiography (ICA) were included. Stent characteristics such as location and length were reported. CT-FFR measurements were taken 1.8 cm before and after the stent, with a value of ≤0.80 defined as hemodynamically significant under respecting the diagnostic accuracy drop in the gray zone between 0.76 and 0.80. Delta CT-FFR with a cut-off value of ≥0.06, indicating hemodynamic significance, was determined. Any ISR and interventional treatment during the following ICA was recorded. Diagnostic performance metrics, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated for post-stent CT-FFR and Delta CT-FFR in detecting ISR. Patients were followed up to evaluate the rate of major adverse cardiovascular events (MACE) 6 months after CCTA. A total of 19 patients (5 female, 14 male, median age 69 years) were enrolled in this study. In most cases, coronary stents were located in the proximal LAD with a median stent length of 70.2 mm. Pathological CT-FFR < 0.76 distal to the stent was detected in 6 cases (31.6%), while pathological Delta CT-FFR ≥ 0.06 occurred in 14 cases (73.7%). ICA was performed in three of these patients, with ISR confirmed in two cases. These findings yield sensitivity and NPV of 100% for both post-stent CT-FFR and Delta CT-FFR for excluding ISR with a superior specificity (76.5% vs. 29.4%) and overall diagnostic accuracy (78.9% vs. 36.8%) for post-stent CT-FFR. Two patients reported a myocardial infarction in follow-up; however, neither of them was located in the territory of the stented coronary artery. This study outlines the feasibility of on-site CT-FFR analysis using PCCT in excluding ISR in coronary stents with a high diagnostic accuracy. These findings highlight the need to extend the benefits of CT-FFR analysis for non-invasive assessment of possible ISR regarding personalized risk stratification and therapy planning. Full article

Myocardial infarction with non-obstructive coronary arteries (MINOCA) accounts for approximately 5–15% of all myocardial infarctions and disproportionately affects women. Once treated as a diagnosis of exclusion, MINOCA is now recognised as a heterogeneous, mechanism-based syndrome encompassing atherosclerotic plaque disruption, epicardial and microvascular vasospasm, microvascular dysfunction, coronary thromboembolism, and spontaneous coronary artery dissection (SCAD). Despite the absence of obstructive disease, it carries substantial morbidity and mortality, underscoring the need for accurate aetiological characterisation and tailored therapy. Our aim is to review the contemporary evidence of the role of advanced imaging modalities—cardiac magnetic resonance imaging (CMR), optical coherence tomography (OCT), intravascular ultrasound (IVUS) and invasive functional testing—in the diagnosis, prognostic stratification, and therapeutic guidance of patients with MINOCA. CMR is the non-invasive reference standard for differentiating true ischaemic MINOCA from non-ischaemic mimics such as myocarditis and Takotsubo syndrome, reclassifying the working diagnosis in up to two-thirds of cases. OCT and IVUS provide intracoronary characterisation of culprit substrates that are invisible via angiography, particularly plaque rupture, erosion, intramural haematoma and SCAD, while acetylcholine and adenosine testing identify endothelium-dependent vasospasm and endothelium-independent microvascular dysfunction respectively. Coronary Computed Tomography Angiography (CCTA) could also play an additional role in the diagnosis of epicardial CAD. Each modality additionally carries independent prognostic value, with abnormal findings consistently linked to higher rates of major adverse cardiovascular events. The recently completed PROMISE trial provided the first randomised evidence that stratified, imaging-guided treatment might have some positive impact on angina status and quality of life compared with empirical standard care. In conclusion, advanced imaging has transformed MINOCA from a diagnosis of exclusion into a mechanism-based syndrome amenable to personalised therapy. Broader integration of these modalities into routine practice, supported by further randomised trials, is needed to optimise outcomes. Full article

Aim: The aim of this observational cross-sectional study was to evaluate whether blood renalase concentration, total antioxidant status (TAS), main cardiovascular risk factors, and obstructive sleep apnea severity are associated with the anatomical severity of coronary artery disease assessed by CCTA in patients with suspected OSA. Materials and methods: The study included 93 patients with suspected OSA. All patients were assessed for main risk factors for cardiovascular disease. Polysomnography was performed to verify the suspicion of OSA, as well as coronary computed tomography angiography (CCTA) with a systematic assessment of the severity of coronary artery disease using the CAD-RADS classification. Blood renalase concentration and total antioxidant status (TAS) were determined. Results: The apnea–hypopnea index (AHI) in the study group was 16.57 ± 17.17 /h. OSA was diagnosed in 73.1% of the study group. In CCTA examinations, significant coronary artery disease (CAD-RADS ≥ 3) was suspected in 22.6% of the subjects, including 16.1% classified as CAD-RADS 3, 4.3% as CAD-RADS 4, and 2.1% as CAD-RADS 5. Patients with AHI ≥ median were significantly more often classified as CAD-RADS ≥ 3 than patients with AHI < median. Patients with blood renalase concentration ≥ median were significantly less often classified as CAD-RADS ≥ 3 than patients with blood renalase concentration < median. Similarly, patients with TAS ≥ median were significantly less often classified as CAD-RADS ≥ 3 than those with TAS < median. Older age, higher systolic blood pressure, higher blood cholesterol levels, and lower TAS were independently associated with CAD-RADS ≥ 3 in logistic regression analysis. In multivariable regression analysis, higher pack-years of smoking, higher AHI, and lower blood renalase concentration were independently associated with lower TAS. Conclusions: Higher pack-years of smoking, higher AHI values, and lower blood renalase concentration were associated with lower total antioxidant status, which, along with older age, higher systolic blood pressure, and higher total cholesterol concentration, was independently associated with suspected anatomically significant coronary artery disease on CCTA. Full article

Coronary anomalies in the form of anomalous aortic origin of the coronary arteries (AAOCA) are rare, but they may cause sudden cardiac death during physical activity in individuals under 35 years of age. We present the case of a 51-year-old man diagnosed with a coronary artery anomaly—anomalous origin of the right coronary artery (RCA) from the left coronary sinus (AAORCA). The patient complained of palpitations during exercise, and ventricular arrhythmia was detected during an exercise electrocardiographic stress test. During coronary angiography, selective cannulation of the RCA was unsuccessful despite the use of multiple catheters. Therefore, coronary computed tomography angiography (CCTA) was performed, which revealed a high-risk anatomical variant of AAORCA. Full article

Background: Optimal phase selection in coronary computed tomography angiography (CCTA) is crucial. While the mid-diastolic slow-filling (SF) phase is typically predicted using a conventional formula based on heart rate and atrioventricular conduction time, its validity in complete left bundle branch block (CLBBB)—where pronounced QRS prolongation induces severe mechanical dyssynchrony—remains unclear. We evaluated the impact of bundle branch block on cardiac-phase selection and validated a QRS-corrected predictive model. Methods: We retrospectively analyzed 94 patients (sinus rhythm, n = 40; complete right bundle branch block [CRBBB], n = 36; CLBBB, n = 18). Measured SF at the proximal right coronary artery was compared against predictions from the conventional formula (SF = −362 + 0.742 × [RR − PQ]) and a proposed QRS-corrected formula incorporating a “−(QRS − 100)” subtraction. To test the necessity of a novel model, regression analyses were reconstructed exclusively for the CLBBB cohort. Results: In CLBBB patients, the conventional formula critically overestimated SF by an average of 37.9 ms (RMSE 42.5 ms). Reconstructing simple and multivariate regression models exclusively for the CLBBB group yielded coefficients remarkably similar to the conventional formula, indicating that the fundamental physiological dependency on RR and PQ intervals remains intact despite the bundle branch block. Crucially, the simple proposed QRS-corrected formula successfully eliminated the overestimation bias (mean error −6.9 ms; p = 0.176) and demonstrated the highest predictive accuracy (RMSE 21.2 ms). Conclusions: A completely new predictive regression model is unnecessary for CLBBB patients. Simply incorporating a theoretical subtraction of pathological QRS prolongation optimally corrects the diastolic resting phase. Full article

Anomalous left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital anomaly with exceptional survival into adulthood. We present a 66-year-old woman with chest and back pain in whom ALCAPA was diagnosed using coronary computed tomography angiography (CCTA) with curved planar reformation and cinematic volume rendering technique (cVRT). Photorealistic three-dimensional reconstruction provided complementary three-dimensional visualization that may facilitate anatomic understanding and communication of the anomalous origin. Conservative management was adopted given the patient’s age and well-developed collateral circulation. This case underscores the value of advanced CCTA visualization in diagnosing rare coronary anomalies in elderly patients. Full article

Background: Coronary bifurcation lesions represent one of the most technically demanding scenarios in coronary artery disease (CAD), associated with higher procedural complexity, restenosis, and periprocedural complications. Recent advances in coronary computed tomography angiography (CCTA) have markedly improved its ability to visualize complex coronary anatomy, assess plaque morphology, and guide revascularization. Objectives: This review summarizes (1) technological advances in CCTA over the last decade, (2) its role in evaluating bifurcation stenosis, (3) assessment of plaque morphology and distribution, (4) quantification of bifurcation geometry, and (5) emerging evidence supporting its application in revascularization planning and guidance. Findings: Modern wide-detector and dual-source CT systems, iterative and deep-learning reconstruction algorithms, and photon-counting CT (PCCT) have significantly improved temporal and spatial resolution, reduced blooming artifacts, and lowered radiation dose. CCTA now reliably quantifies bifurcation stenosis and plaque distribution, characterizes high-risk plaque features, and accurately measures bifurcation angles. The integration of CT-derived fractional flow reserve (FFR-CT) and artificial intelligence (AI)-based plaque quantification further strengthens its diagnostic and prognostic performance. CCTA-derived bifurcation scores and 3D modelling support procedural strategy selection, stent sizing, and side-branch (SB) protection. Conclusions: CCTA has evolved into a comprehensive tool for non-invasive diagnosis, physiological assessment, and pre-procedural planning of bifurcation disease. With the advent of PCCT and AI-enhanced quantitative tools, CCTA is poised to become a central component of revascularization decision-making in complex coronary bifurcations. Full article

Background: In patients with type 2 diabetes mellitus (T2DM), angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) are first-line antihypertensive treatments with important cardiovascular benefits, but their impacts on coronary-specific inflammation are unknown. Pericoronary adipose tissue (PCAT) attenuation, as assessed by coronary computed tomography angiography (CCTA), serves as a specific biomarker for coronary inflammation. Here, we aim to assess whether treatment with ACE-I or ARB is correlated with lower PCAT attenuation. Methods: In this retrospective observational study, we analyzed 223 patients with T2DM and coronary atherosclerosis who underwent CCTA from 1 January 2017 to 1 September 2024 at our institution. PCAT attenuation was measured in the proximal right coronary artery. Propensity score matching and multivariate linear regression analyses were performed for comparisons. Results: Of the 223 patients (mean age of 64.9 ± 8.8 years, 69.1% male), 122 patients were on ACE-I or ARB (ACE-I/ARB). ACE-I/ARB users had similar PCAT attenuation as their counterparts after propensity score matching (−72.1 ± 7.5 and −71.7 ± 8.1 HU, respectively; p = 0.722). Subgroup analysis in patients with glomerular filtration rate (GFR) < 90 mL/min revealed lower PCAT attenuation in ACE-I/ARB users (−74.8 ± 6.6 vs. −71.4 ± 7.1 HU; p = 0.038), with a significant interaction between these two factors in the multivariate analysis (p = 0.047). Other antihypertensive treatments (beta blockers, dihydropyridine calcium channel blockers, and thiazides) were not linked with lower coronary inflammation. Conclusions: In T2DM patients with coronary atherosclerosis, we did not find an association between ACE-I/ARB treatment and lower coronary inflammation as defined by PCAT attenuation, although such a relationship may exist in those with reduced GFRs. Full article

A substantial proportion of cardiovascular (CV) events occurs in individuals without previously diagnosed CV disease, underscoring the need for improved primary prevention strategies. Traditional risk scores provide probabilistic estimates but fail to directly identify the presence and heterogeneity of subclinical atherosclerosis. This review summarizes current evidence on advanced multimodality imaging approaches for identifying high-risk individuals without prior CV events. Evidence from cohort studies, randomized trials, and meta-analyses was examined to evaluate the role of coronary artery calcium (CAC) scoring, coronary computed tomography angiography (CCTA), perivascular fat attenuation index (FAI), and vascular ultrasound in risk stratification. CAC scoring remains the most validated and widely recommended tool, offering robust prognostic value and significant risk reclassification, particularly in intermediate-risk individuals. CCTA provides additional insights into plaque burden and high-risk phenotypes, while FAI enables noninvasive assessment of coronary inflammation, improving risk prediction beyond anatomical measures. Vascular ultrasound offers a radiation-free, accessible method for detecting systemic plaque burden and refining risk estimation. Overall, multimodality imaging enhances the identification of subclinical disease and supports more individualized, disease-based risk assessment. Future research should clarify cost effectiveness, optimize patient selection, and determine whether imaging-guided strategies improve long-term clinical outcomes. Full article

Background: Coronary computed tomography angiography (cCTA) is now indicated as a non-invasive tool for ruling out obstructive coronary artery disease (O-CAD) in patients who are candidates for transcatheter aortic valve implantation (TAVI) showing low-intermediate pre-test probability of O-CAD. In elderly and comorbid TAVI candidates, the safety and accuracy of cCTA as an alternative to invasive coronary angiography (ICA) for ruling out O-CAD remain to be established. Aim: To assess the feasibility, diagnostic accuracy, and clinical safety of cCTA for ruling out proximal O-CAD in elderly, comorbid, high-risk patients undergoing TAVI. Methods: We conducted a retrospective, single-center study including all consecutive patients with severe symptomatic aortic stenosis who underwent TAVI between January 2019 and December 2020. All patients underwent pre-TAVI cCTA. Patients with positive or non-diagnostic cCTA underwent ICA selectively (ICA group). In patients with no-O-CAD, ICA was omitted and proceeded directly to TAVI (no-ICA group). Accordingly, patients were divided into two groups: no-ICA and ICA group. Clinical follow-up was extended up to 5 years, with assessment of major adverse cardiovascular events (MACEs), mortality, heart failure hospitalizations, and unplanned revascularization. Results: Among 355 patients enrolled, 210 were included in the study. Among them, 140 (66.7%) had negative cCTA for O-CAD, and ICA was safely omitted in 132 patients (62.8%). cCTA was inconclusive in 43 patients (20.5%) and positive in 27 (12.9%). ICA confirmed O-CAD in 53 of 78 patients (67.9%) and PCI was performed in 35 of 53 (66.0%). The accuracy of cCTA for ruling in O-CAD was low (66.28%). During the follow-up period (1513 ± 508 days), the no-ICA group showed comparable outcomes to the ICA group in terms of periprocedural complications and long-term results—at both 1 and 5 years—for MACEs, heart failure hospitalizations, mortality and unplanned revascularization. Outcomes remain comparable between the two groups after performing matched-pair analyses. Conclusions: Our data show that cCTA may provide a reliable, safe, and effective alternative to ICA for ruling out obstructive CAD in elderly patients undergoing TAVI when image quality is diagnostic. A cCTA-based strategy allows deferral of ICA in most cases without compromising procedural safety or long-term clinical outcomes, enabling a personalized and tailored clinical pathway. Whether advanced CT techniques, such as CT-FFR and photon-counting CT, may help refine patient selection for invasive coronary assessment remains to be demonstrated. Full article

Background: While reducing LDL cholesterol (LDL-C) remains central focuses of conventional preventive cardiology, substantial heterogeneity exists in the cardiovascular risk associated with even extreme LDL-C elevations, likely depending heavily on the broader metabolic context. Specifically, the lean mass hyper-responder (LMHR) phenotype—characterized by markedly elevated LDL-C with elevated high-density lipoprotein cholesterol (HDL-C) and low triglycerides in the setting of a ketogenic diet—has recently been described, though its long-term risk profile remains poorly defined. Case Presentation: We describe a male in his 30s without any congenital dyslipidemia who adopted a ketogenic diet for the management of ulcerative colitis and who subsequently exhibited a sixfold increase in LDL-C from a baseline of 95 mg/dL to 574 mg/dL, with total cholesterol of up to 705 mg/dL, HDL-C at 124 mg/dL, and triglycerides at 34 mg/dL. Despite maintaining these extreme lipid levels for nearly seven years, he demonstrated no coronary plaque or stenosis on coronary computed tomography angiography (CCTA; CAD-RADS = 0). Additionally, quantification of coronary plaque as assessed by AI-guided quantified analysis by Heartflow^® identified 0 mm³ plaque in any vessels, placing him in the lowest percentile for atherosclerotic plaque. Conclusions: This case represents an extreme and extensively characterized example of the LMHR phenotype and highlights the limitations of extrapolating cardiovascular risk from LDL-C levels alone without consideration of broader patient context and the etiology of hypercholesterolemia. While a single case cannot redefine clinical practice, this well-characterized case is consistent with emergent literature on LMHR, and careful study of such individuals may provide valuable insights into lipid metabolism, atherosclerosis biology, and precision cardiovascular risk assessment. Full article

Giant coronary artery aneurysms, defined as those with a diameter exceeding 8 mm or a four-fold increase relative to the reference vessel segment, are incredibly rare, with an estimated prevalence of approximately 0.02% in the general population. We present computed tomography angiography images of a thrombotic occlusion of a giant right coronary artery (RCA) aneurysm. An 80-year-old Caucasian man with chronic coronary artery disease, who had undergone percutaneous coronary intervention of the middle segment of the left circumflex artery (LCx) with drug-eluting stent implantation, was referred to the computed tomography department for coronary computed tomography angiography (CCTA) due to difficulty visualizing RCA during invasive coronary angiography. In CCTA, a giant aneurysm in the proximal segment of the RCA, with a massive thrombus, communicating with the typical origin of the RCA from the right aortic bulb sinus, then extending into the occluded part of the proximal segment of the RCA, was visualised. The maximum long dimension of the RCA aneurysm was 5.3 cm, and the maximum short dimension of the RCA aneurysm was 4.4 cm. The maximum thrombus thickness in the RCA aneurysm was 2.2 cm. The middle and distal segments of the RCA, presumably filled with collateral circulation, have significantly weaker contrast, and contain numerous predominantly calcified atherosclerotic plaques. In summary, the presented CCTA images confirm the clinical importance of this modality in diagnosing coronary artery aneurysms, even in situations where the results of invasive coronary angiography remain equivocal. Due to higher spatial resolution, the ability to perform image reconstruction in multiple planes, the ability to detect thrombus, and the ability to assess the vessel wall and extracoronary structures, CCTA not only enables the detection of coronary artery aneurysms but also enables risk prediction, thus enabling the planning of a more optimal treatment strategy. Full article

Computational fluid dynamics (CFD)-based simulation of coronary blood flow provides valuable hemodynamic markers, such as pressure gradients, for diagnosing coronary artery disease (CAD). However, CFD is computationally expensive, time-consuming, and difficult to integrate into large-scale clinical workflows. These limitations restrict the availability of labeled hemodynamic data for training AI models and hinder the broad adoption of non-invasive, physiology-based CAD assessment. To address these challenges, we develop an end-to-end pipeline that automates coronary geometry extraction from coronary computed tomography angiography (CCTA), streamlines simulation data generation, and enables efficient learning of coronary blood pressure distributions. The pipeline reduces the manual burden associated with traditional CFD workflows while producing consistent training data. Furthermore, we introduce a diffusion-based regression model. Specifically, the inverted conditional diffusion (ICD) model is designed to predict coronary blood pressure directly from CCTA-derived features, thereby bypassing the need for computationally intensive CFD during inference. The proposed model is trained and validated on two CCTA datasets using the Adam optimizer with a weight decay of $1\times {10}^{-3}$, a learning rate of $1\times {10}^{-5}$, a batch size of 100, and Huber loss. It is then evaluated on a test set of ten simulated coronary hemodynamic cases. Experimental results demonstrate state-of-the-art performance. Compared with Long Short-Term Memory (LSTM), the proposed model improves the $R^2$ score by 19.78%, reduces the root mean squared error (RMSE) by 19.44%, and lowers the normalized root mean squared error (NRMSE) by 18%. Compared with a multilayer perceptron (MLP), it improves the $R^2$ score by 8.38%, reduces RMSE by 4.3%, and reduces NRMSE by 5.4%. This work represents a first step toward a scalable and accessible framework for rapid, non-invasive, CFD-based blood pressure prediction, with the potential to support CAD diagnosis. Full article

Background: the pathophysiological mechanisms underlying spontaneous coronary artery dissection (SCAD) remain incompletely understood. Inflammation may play a pivotal role by promoting vascular susceptibility to SCAD. This study aimed to evaluate pericoronary adipose tissue (PCAT) attenuation, a recognized imaging marker of vascular inflammation, in patients with SCAD. Methods: patients with SCAD who underwent coronary computed tomography angiography (CCTA) within 48 h of the index event and with an identifiable trigger were included. Patients were classified according to the trigger preceding the event (emotional vs. physical). PCAT attenuation was measured in culprit and non-culprit vessels in all patients. Results: A total of 25 SCAD patients were included (mean age 55 ± 11 years, 80.0% female). Emotional triggers were reported in 17 patients (68.0%), while 8 (32.0%) experienced a physical trigger. Type 2 dissections were more common in the emotional trigger group (64.7% vs. 25.0%, p = 0.040). Patients with emotional triggers exhibited higher PCAT attenuation compared with those with physical triggers in the SCAD-related vessel (−62.35 ± 6.46 HU vs. −70.86 ± 8.45 HU; p = 0.028) and in non-culprit vessels (−61.39 ± 7.24 HU vs. −71.16 ± 5.28 HU; p = 0.001). Conclusions: patients with SCAD demonstrated elevated PCAT attenuation, particularly in those with emotional triggers, in both culprit and non-culprit vessels. These findings suggest that vascular inflammation may represent a predisposing factor for SCAD and a target for preventive and therapeutic strategies. Full article