Left atrioventricular coupling index is associated with diastolic dysfunction severity and poor prognosis in heart failure patients

Fortuni F, Biagioli P, Myagmardorj R, et al.

Left Atrioventricular Coupling Index: A Novel Diastolic Parameter to Refine Prognosis in Heart Failure.

J Am Soc Echocardiogr 2024; 37:1038-1046; https://doi.org/10.1016/j.echo.2024.06.013

This study aimed to investigate the association between left atrioventricular coupling index (LACI) and left ventricular diastolic dysfunction in patients with heart failure (HF) and to assess its prognostic value. The retrospective study included 1,158 patients with chronic HF on optimal medical therapy who had undergone comprehensive standardized echocardiography as part of their routine clinical evaluation.  LACI, an index that couples left atrial to left ventricular volume at end-diastole (LAVImin/LVEDV), and assessment of diastolic function graded according to the latest guidelines were measured in all patients. Patients were followed up for a median time of 28 months (interquartile range:11-53 months) for assessing composite endpoint (HF hospitalisation all-cause death). Results indicated that LACI ≥0.26 identified moderate to severe diastolic dysfunction (area under the curve of 0.75) and was independently associated with composite end point (hazard ratio: 1.16; 95% CI,1.06-1.28; P =.002) after adjustment to clinical and echocardiographic parameters. LACI also showed incremental predictive value over the diastolic dysfunction grading system. The results were also validated in an external cohort of 242 patients with HF and were consistent with derivation cohort. The study concluded that LACI is associated with diastolic dysfunction severity and is an independent predictor of outcomes in patients with HF.

Keywords: echocardiography, diastolic function, heart failure, left atrial volume, left ventricular volume; left ventricular coupling index (LACI)

Lay summary: The study tested a new echocardiographic index called the left atrioventricular coupling index to see if it could be used to assess the diastolic function of the heart and if it is associated with clinical outcome in patients with heart failure. The new index could identify patients who had moderate to severe diastolic dysfunction. This index was better at finding patients with heart failure who have high risk of heart failure hospitalisation or death compared to clinical parameters and conventional echocardiographic parameters. This means doctors can more confidently identify heart failure patients who had diastolic dysfunction and are at increased risk for worse clinical outcome.

Pieszko K, Hiczkiewicz J, Łojewska K, et al.

Artificial intelligence in detecting left atrial appendage thrombus by transthoracic echocardiography and clinical features: the Left Atrial Thrombus on Transoesophageal Echocardiography (LATTEE) registry.

Eur Heart J 2024; 45:32-41; https://doi.org/10.1093/eurheartj/ehad431

The study aimed to develop a machine learning model to predict the presence of left atrial appendage thrombus (LAT) based on clinical and transthoracic echocardiographic (TTE) features in patients on chronic oral anticoagulation who undergoing transesophageal echocardiography (TOE) before cardioversion or catheter ablation. The study based on data from a 13-site prospective registry. Model was trained to predict LAT using data of 2827 patients, while external validation was performed on a study cohort of 1284 patients. Results showed that the model integrated clinical and TTE features (AUC 0.85, 95% CI: 0.82–0.89) performed better than the standard predictor of LAT, such as CHA2DS2-VASc score (AUC 0.69, 95% CI: 0.63-0.7) or left ventricular ejection fraction (AUC 0.81, 95% CI 0.76-0.86). Based on the proposed model, 40% of patients on chronic oral anticoagulation from the external cohort would safely avoid TOE. The study concludes that this machine learning model allows accurate prediction of LAT and might be used to guide the decision to perform transesophageal echocardiography despite chronic oral anticoagulation.

Keywords: echocardiography, artificial intelligence, machine learning, atrial fibrillation, left atrial appendage thrombus

Lay summary: This study tested the new model of artificial intelligence for prediction of left atrial appendage thrombus in patients with atrial fibrillation or atrial flutter. The new model used different personal health information, like clinical risk factors for thromboembolic events and echocardiographic parameters such as cardiac function, to estimate the chance of left atrial appendage thrombus. This model was better at finding people who have a high risk for left atrial appendage thrombus compared to other markers for thrombo-embolic risk. This means that physicians can more confidently select patients who require transoesophageal echocardiography before cardioversion or catheter ablation and those who can safely avoid it, helping to avoid the potential risks and costs associated with an additional procedure.

Takeuchi M, Utsunomiya H, Tohgi K, et al.

Prediction of tricuspid regurgitation regression after mitral valve transcatheter edge-to-edge repair using three-dimensional transoesophageal echocardiography.

Eur Heart J - Imaging Methods and Practice 2025; 3:qyaf016; https://doi.org/10.1093/ehjimp/qyaf016

This retrospective study analysed 61 patients (mean age 81.3 ± 7.6 years; 55.7% males) who underwent mitral valve transcatheter edge-to-edge repair. Two-dimensional transthoracic echocardiography was performed pre- and 1-month post-procedurally, while three-dimensional transoesophageal echocardiography was performed pre-procedurally. Tricuspid regurgitation severity was semiquantitatively assessed and categorized. At the 1-month follow-up, TR severity had regressed in 43% of patients. A lower prevalence of atrial fibrillation, smaller left atrial volume index, and smaller right atrial area were significantly associated with TR regression. Multivariate analysis revealed the tricuspid valve annulus perimeter, area, and area change as significant predictors of post-procedure TR regression. Tricuspid valve annulus perimeter was the strongest predictor among the three indicators [area under the receiver operating characteristic curve, 0.84 (95% confidence interval: 0.75–0.94), P < 0.001], with a perimeter cut-off ≤13.75 cm as the best predictor of post-procedure TR regression. Additionally, tricuspid valve annulus area ≤13.55 cm² and annulus area change ≥17.5% were predictors of post-procedure TR regression. As a conclusion, in patients with relatively severe mitral regurgitation with a non-dilated tricuspid annulus and significant change in tricuspid valve annulus area, mitral valve transcatheter edge-to-edge repair may lead to TR regression.

Keywords: echocardiography, tricuspid valve, mitral valve, edge to edge repair, tricuspid regurgitation regression

Lay summary: It is still unknown to us if a patient with significant mitral and tricuspid regurgitation, will achieve regression of tricuspid regurgitation following mitral edge-to-edge repair. This retrospective study sheds light to the echocardiographic parameters which “facilitate” the regression of tricuspid regurgitation. A small tricuspid annular area as well as right atrial size as well as the lower prevalence of atrial fibrillation, facilitate the regression. This is very important for the risk stratification of these patients and staged management approach.

Myagmardorj R, Fortuni F, Généreux P, et al.

The reversibility of cardiac damage after transcatheter aortic valve implantation and short-term outcomes in a real-world setting.

Eur Heart J Cardiovasc Imaging 2025; jeaf045; https://doi.org/10.1093/ehjci/jeaf045

The study evaluates changes in cardiac damage stages in a real-world cohort of patients undergoing transcatheter aortic valve implantation (TAVI) and assesses the prognostic value of cardiac damage stage evolution. In total, 734 patients with severe aortic stenosis (AS) were analyzed, categorizing cardiac damage into five stages before and six months after TAVI. Before undergoing TAVI, 32 patients (4%) exhibited no signs of extra-valvular cardiac damage (Stage 0), while 85 (12%) had left ventricular damage (Stage 1). Cardiac damage extended to the left atrium and/or mitral valve in 220 patients (30%) (Stage 2), the pulmonary vasculature and/or tricuspid valve in 227 patients (31%) (Stage 3), and the right ventricle in 170 patients (23%) (Stage 4). Six months after TAVI, 39% of patients showed improvement by at least one stage. Cardiac damage staging at six months post-TAVI (HR per 1-stage increase 1.391; P = 0.035) and worsening of cardiac damage stage (HR 3.729; P = 0.005) were both independently linked to higher two-year all-cause mortality. In conclusion, over one-third of patients with severe aortic stenosis showed improvement in cardiac damage six months after TAVI. The Authors concluded, that assessing cardiac damage both before and after the procedure can provide valuable insights for better risk stratification.

Keywords: Aortic stenosis, echocardiography, prognosis, transcatheter aortic valve implantation

Lay summary: This study looked at heart damage in patients with severe aortic stenosis before and after TAVI, a procedure to replace the aortic valve. It found that 39% of patients improved in heart damage within six months. However, worsening damage was linked to a higher risk of death in the next two years. The study concluded that evaluation of heart damage before and after TAVI can help doctors assess patient risk more accurately.

Attar R, Malahfji M, Angulo C, et al.

Echocardiographic Evaluation of Chronic Aortic Regurgitation: Comparison With Cardiac Magnetic Resonance and Implications for Guideline Recommendations.

JACC Cardiovasc Imaging 2024; 30:S1936-878X(24)00390-5; https://doi.org/10.1016/j.jcmg.2024.08.013

This study aimed to evaluate the accuracy of the American Society of Echocardiography (ASE) guidelines for aortic regurgitation (AR) against cardiac magnetic resonance (CMR) and to develop simplified methods for detecting significant AR. A total of 81 patients with AR were studied, with median age 52 years and 58% having a bicuspid aortic valve. AR severity was graded according to ASE guidelines, and regurgitant volume was measured using various echocardiographic methods. The study found that ASE grading had a high accuracy for detecting severe AR, with an area under the curve (AUC) of 0.9 (82.4% sensitivity and 96.9% specificity). The feasibility of regurgitant volume (RegV) quantification was over 88% using either echocardiographic volumetric method, while it was lower for proximal isovelocity surface area (37%). The highest accuracy for echocardiographic parameters in comparison to CMR was observed with vena contracta width, jet width, and left ventricular end-diastolic volume index (AUC: 0.86-0.89), while pressure half-time showed the lowest accuracy. Without RegV quantification, a vena contracta width ≥0.5 cm and indexed left ventricular end-diastolic volume ≥82 mL/m² demonstrated a 95.5% positive predictive value and 87.5% negative predictive value for identifying moderate to severe AR by CMR (AUC: 0.89). These findings suggest that the ASE guidelines perform well in identifying significant AR, and a simplified approach could be used for clinical practice, though further validation in larger cohorts and against clinical outcomes is needed.

Keywords: aortic regurgitation; echocardiography; cardiovascular magnetic resonance; guidelines; vena contracta

Lay summary: This study tested how well echocardiogram guidelines (ASE) detect aortic regurgitation (AR) compared to cardiac magnetic resonance (CMR). It found that the ASE guidelines were highly accurate for detecting severe AR. Simple measurements, like the width of the heart valve regurgitant jet and the size of the left ventricle, were also effective in identifying moderate to severe AR. These results suggest that simplified methods could be used in clinical practice, though further research is needed.

Alonso A, Sambola A, Valente F, et al.

Sex-based differences in adverse left ventricular remodeling and clinical outcomes after ST-segment elevation myocardial infarction.

Eur Heart J - Cardiovascular Imaging 2025; jeaf048; https://doi.org/10.1093/ehjci/jeaf048

The study included patients with a first STEMI who underwent primary percutaneous coronary intervention (PCI). CMR was performed at 6 days (Interquartile range [IQR]: 4-9 days) and after 6 months (6.42 months; IQR: 5.98-7.47 months). Follow-up was 6.94 years (IQR: 4.48-9.32 years). The primary endpoint was the presence of adverse LV remodelling (>15% of LV end-diastolic volume and a decrease of >3% in LV ejection fraction) at 6 months. The secondary endpoint was major adverse cardiac events (MACE), defined as a combined variable: cardiovascular death, heart failure admission, or ventricular arrhythmias. One thousand sixty-seven patients were included (17.5% women; mean age: 58.71±11.85 years). Women were older and had more cardiovascular risk factors. There was no association between sex and adverse LV remodelling (OR 0.80; 95%CI 0.39-1.64, P=0.536). MACE occurred in 177 patients (16.7%) and was more frequent in women (22.6% vs. 15.4%, P=0.017). However, after adjusting for baseline differences and cardiovascular risk factors, the female sex was not associated with MACE (HR: 1.21 95% CI, 0.81-1.81, P=0.343). As conclusion, the higher rate of MACE after STEMI in women compared to men appears to be associated with a higher prevalence of cardiovascular risk factors and comorbidities rather than a more significant occurrence of adverse LV remodelling.

Keywords: echocardiography; cardiovascular magnetic resonance; remodelling; myocardial infarction; ischemia; left ventricle

Lay summary: Sex based differences in myocardial ischemia are of paramount importance for the early diagnosis and management. This studied demonstrated that the higher rate of major adverse events after ST myocardial infarction in women, is associated with more cardiac risk factors, greater age at presentation and greater prevalence of comorbidities. These findings have important clinical implementations.

Demirel OB, Ghanbari F, Hoeger CW, et al.

Late gadolinium enhancement cardiovascular magnetic resonance with generative artificial intelligence.

J Cardiovasc Magn Reson 2024; 27:101127; https://doi.org/10.1016/j.jocmr.2024.101127

Image acceleration in late gadolinium enhancement (LGE) remains challenging due to its limited signal-to-noise ratio. In this study, a rapid two-dimensional (2D) LGE imaging protocol using a generative artificial intelligence (AI) algorithm was used to improve the sharpness of 2D LGE images acquired with low spatial resolution in the phase-encode direction. In 100 patients, three sets of LGE images were acquired, with in-plane spatial resolutions of 1.5 × 1.5-3-6 mm2. The generative AI model enhanced in-plane resolution to 1.5 × 1.5 mm2 from the low-resolution counterparts. The scan times for the three imaging sets were 15 ± 3, 9 ± 2, and 6 ± 1 s, respectively. Inline generative AI-based image reconstruction took ∼37 ms. The generative AI-based model improved visual image sharpness, resulting in lower blur metric compared to low-resolution counterparts (AI-enhanced from 1.5 × 3 mm2 resolution: 0.3 ± 0.03 vs 0.35 ± 0.03, P < 0.01). Meanwhile, AI-enhanced images from 1.5 × 3 mm2 resolution and original LGE images showed similar blur metric (0.30 ± 0.03 vs 0.31 ± 0.03, P = 1.0) Additionally, there was an overall 18% improvement in image sharpness between AI-enhanced images from 1.5 × 3 mm2 resolution and original LGE images in the subjective blurriness score (P < 0.01). The Authors concluded that generative AI enhances the image quality of 2D LGE images while reducing the scan time and preserving imaging sharpness.

Keywords: CMR; MRI; late enhancement; deep leaning; artificial intelligence; image reconstruction

Lay summary: This study explored using artificial intelligence (AI) to speed up and improve a common type of heart MRI called late gadolinium enhancement (LGE), which helps visualize scar tissue. Researchers developed an AI program that enhances LGE images taken at lower resolutions. They tested this AI on 100 patients, comparing regular LGE images to faster, lower-resolution images both before and after AI enhancement. The AI significantly improved the sharpness of the faster images, making them comparable to the standard images, and dramatically reducing scan time. Essentially, the AI allowed for quicker scans without sacrificing image quality. While promising, this was a small initial study, and more research is needed to confirm if this AI-enhanced LGE imaging ultimately improves patient care.

Masri A, Rhanderson NC, Abraham T, et al.

Effect of Aficamten on Cardiac Structure and Function in Obstructive Hypertrophic Cardiomyopathy: SEQUOIA-HCM CMR Substudy.

J Am Coll Cardiol 2024; 84:1806-1817; https://doi.org/10.1016/j.jacc.2024.08.015

Obstructive hypertrophic cardiomyopathy (HOCM) is characterized by various structural changes such as left ventricular outflow tract obstruction. Aficamten is a next-in-class cardiac myosin inhibitor that reduces outflow tract obstruction by modulating cardiac contractility, with the potential to reverse pathological remodeling. SEQUOIA-HCM was a phase 3 double-blind, placebo-controlled trial for adults with symptomatic HOCM who were randomized 1:1 to 24 weeks of aficamten or placebo. Eligible participants were offered enrollment in the CMR substudy with studies performed at baseline and week 24. 57 (20%) participated in the substudy, and of those, 50 (88%) completed both baseline and week 24 CMR. Of these 50 patients, 21 received aficamten and 29 received placebo. Relative to placebo, patients receiving aficamten demonstrated significant reductions in LV mass index, maximal LV wall thickness, left atrial volume, native T1 relaxation time, indexed extracellular volume fraction, and indexed myocyte mass, while there were no significant changes in LV chamber volumes, LV replacement fibrosis, or extracellular volume. This study demonstrated that treatment with aficamten relative to placebo for 24 weeks resulted in favorable cardiac remodeling which could potentially lead to reduced cardiovascular events with longer follow-up.

Keywords: CMR, Obstructive hypertrophic cardiomyopathy, aficamten, myocardial fibrosis

Lay summary: This study used special heart scans to look at the heart muscle structure in people with an inherited condition called hypertrophic cardiomyopathy (HCM), treated both with a newer agent called Aficamten or placebo (no real drug). The heart scans were performed at baseline and 6 months in 50 patients, 21 of whom received aficamten. Relative to placebo, patients receiving the drug demonstrated significant reductions in the mass of the left heart chamber, its thickening, left atrial volume, and other favorable effects on indexes of heart muscle composition. In contrast, there were no significant changes in the left heart volumes, exctracellular volume and fibrosis (scarring). This study showed that this drug may help patients to avoid cardiovascular events including heart failure and atrial fibrillation in the long run, based on more favorable heart remodeling.

Clerc OF, Cuddy S, Jerosch-Herold M, et al.

Myocardial Characteristics, Cardiac Structure, and Cardiac Function in Systemic Light-Chain Amyloidosis.

JACC Cardiovasc Imaging 2024; 17:1271-1286; https://doi.org/10.1016/j.jcmg.2024.05.004

Systemic light-chain (AL) amyloidosis, is associated with cardiac involvement and poor outcomes. This study was designed to detect early myocardial alterations, to analyze longitudinal changes with therapy, and to predict major adverse cardiac events (MACE) in participants with AL amyloidosis using cardiac magnetic resonance imaging (CMR). AL amyloidosis with and without cardiomyopathy (AL-CMP, AL-non-CMP) were defined based on abnormal cardiac biomarkers and wall thickness. MRI was performed at baseline, 6 months in all participants, and 12 months in participants with AL-CMP. It included 80 participants. Extracellular volume (ECV) was abnormal (>32%) in all participants with AL-CMP and in 47% of those with AL-non-CMP. With therapy ECV tended to increase at 6 and returned to baseline values at 12 months in participants with AL-CMP. Global longitudinal strain (GLS) improved at 6 months and 12 months  in participants with AL-CMP. ECV and GLS were strongly associated with MACE and improved the prognostic value when added to Mayo stage. No participant with ECV ≤32% had MACE, while 74% of those with ECV >48% had MACE. It seems ECV and GLS offer additional prognostic performance over Mayo stage.

Keywords: T1 mapping; cardiac magnetic resonance imaging; extracellular volume; global longitudinal strain; light-chain (AL) amyloidosis; myocardial characterization

Lay summary: This study used special heart MRI scans to look into a rare disease called AL amyloid with known significant involvement from the heart due to deposition of pathological proteins in the heart muscle cells. MRI was performed at baseline, 6 months in all participants, and 12 months in participants with evidence of heart involvement. It included 80 participants in total. With ongoing treatment a heart muscle composition marker called ECV and left ventricular heart function in the longitudinal axis (GLS) were not only improved but also correlated with more favorable outcome, evident by less cardiovascular events, death, heart failure hospitalization, and cardiac transplantation.

Prosperi S, Monosilio S, Lemme E, et al.

T1 and T2 mapping in Olympic athletes: the influence of sports discipline and sex.

Eur Heart J Cardiovasc Imaging 2024; 26:89-95; https://doi.org/10.1093/ehjci/jeae247

Cardiac magnetic resonance (CMR) has a growing role in evaluating athletes' hearts particularly with mapping techniques. A group of 300 Olympic athletes with unremarkable cardiovascular screening and a control group of 42 sedentary subjects underwent CMR without contrast. Athletes were divided based on sex and sports categories according to the ESC classification. Among athletes of different sports categories and controls, endurance exercise presented the lowest value of T1 mapping but same T2 values. Female athletes had higher values of T1 native mapping compared with males. Male athletes with higher left ventricular mass indexed (LV-Massi) had lower values of T1 mapping. Female athletes with higher LV-Massi did not show significant differences in T1 and T2 mapping. In conclusion, T1 native myocardial mapping showed significant differences related to sports disciplines and gender. Athletes with the largest LV remodelling, mostly endurance and mixed, showed the lowest values of T1 mapping.

Keywords: CMR; MRI; T1 mapping; T2 mapping; athlete’s heart; sex; sports disciplines

Lay summary: This study used special heart MRI scans to look into the heart muscle composition at a molecular level of 300 Olympic athletes and 42 sedentary individuals, using special sequences called native T1 and T2, without the need to administer contrast. Athletes were divided based on sex and sports categories. T1 values showed significant differences related to sports disciplines and sex. Athletes with the largest heart exercise adaptation, mostly doing endurance exercise and mixed, showed the lowest values of T1.

Lim DJ, Varadarajan V, Quinaglia T, et al.

Change in left atrial function and volume predicts incident heart failure with preserved and reduced ejection fraction: Multi-Ethnic Study of Atherosclerosis.

Eur Heart J Cardiovasc Imaging 2024; 25:1712-1720; https://doi.org/10.1093/ehjci/jeae138

The Multi-Ethnic Study of Atherosclerosis (MESA) prospective, community-based multi-ethnic cohort study evaluated the relationship between longitudinal changes in left atrial (LA) parameters and incident heart failure (HF) in individuals with subclinical cardiovascular disease (CVD). The study population comprised 2470 participants (47% male, mean age 60 ± 9 years) with CMR performed at baseline and after 9.4 ± 0.6 years. Over a mean follow-up of 7.1 ± 2.1 years after the second CMR, 3% developed incident HF: 39 with preserved ejection fraction (HFpEF) ≥50% and 34 with reduced ejection fraction (HFrEF) <50%. Individuals who developed incident HF were significantly older and were on anti-hypertensive medications (77% vs.53%) at the second study compared to those who did not (68.9 ± 9.12 years) (p<0.001). An annual decrease in peak LA strain (ΔLASmax) was significantly associated with HFpEF (HR 2.56, 95% CI 1.34–4.90). Further ΔLASmax improved the HFpEF prediction model ( c-statistic 0.84, 95% CI 0.79–0.90). On the other hand, a yearly decrease in preatrial indexed LA volume (ΔLAVipreA) was strongly associated with HFrEF (HR 1.88, 95% CI 1.44–2.45) and also improved the prediction model for HFrEF (c-statistic 0.81, 95% CI 0.72–0.90). More importantly, these associations remained significant after adjusting for cardiovascular risk factors and baseline LA measures. The study highlights the incremental predictive value of longitudinal changes in LA function and volume, to improve HF risk stratification in patients with subclinical CVD.

Keywords: CMR; MRI; heart failure; HFpEF; HFrEF; cardiovascular disease; prognosis; left atrial strain; left atrial volume

Lay summary: This study used CMR in a multi-ethnic cohort with subclinical cardiovascular disease (CVD) to investigate the role whether left atrial (LA) function may be linked to linked to the future development of heart failure (HF). Over a mean follow-up of 16.5 years, changes in LA parameters were analysed in relation to the development of either HF with preserved (HFpEF) and reduced ejection fraction (HFrEF). The key finding was that an annual decline in the LA stretch improved prediction of HFpEF and a decrease in LA volume was independently associated with HFrEF and improved prediction models. These results suggest that monitoring LA function and size with CMR may help predict and potentially prevent HF in people with early signs of heart disease.

Williams MC, Wereski R, Tuck C, et al.

Coronary CT Angiography-Guided Management of Patients with Stable Chest Pain: 10-Year Outcomes from the SCOT-HEART Randomised Controlled Trial.

Lancet 2025; 405: 329–37; https://doi.org/10.1016/S0140-6736(24)02679-5

The Scottish Computed Tomography of the Heart (SCOT-HEART) trial previously showed that coronary CT angiography (CCTA) improves diagnosis, management, and outcomes in stable chest pain. This 10-year follow-up assessed its long-term impact on coronary heart disease (CHD) mortality and non-fatal myocardial infarction (MI). A total of 4,146 patients (ages 18–75) with suspected stable angina were randomized to CCTA + standard care (n=2,073) or standard care alone (n=2,073) across 12 cardiology clinics in Scotland. The primary outcome was CHD death or non-fatal MI at 10 years. CCTA reduced CHD death or non-fatal MI (6.6% vs. 8.2%, HR 0.79, p=0.044) and non-fatal MI (4.3% vs. 6.0%, HR 0.72, p=0.017), with a lower MACE rate (8.3% vs. 10.3%, HR 0.80, p=0.026). Revascularization rates were similar (15.2% vs. 15.3%, p=0.99), while preventive therapy use was higher with CCTA (55.9% vs. 49.0%, p=0.034). CCTA-guided management sustains long-term reductions in CHD death and non-fatal MI, primarily by preventing MI. No observed excess in revascularisation suggests CCTA helps optimize patient selection for interventions. Preventive therapy adherence remained higher in the CCTA group at 10 years, likely contributing to improved outcomes.

Keywords: coronary CT angiography (CCTA), coronary heart disease (CHD), randomised controlled trial (RCT)

Lay summary: This 10-year follow-up of the SCOT-HEART trial examined how coronary CT angiography (CCTA) impacts long-term heart health in patients with chest pain. CCTA helped reduce heart disease-related deaths and heart attacks by improving early detection and guiding better treatment decisions. Patients who had CCTA were more likely to stay on preventive medications, which may have contributed to their improved outcomes. Importantly, the need for stents or surgery did not increase, highlighting CCTA as a valuable tool for managing heart disease.

Kelham M, Beirne AM, Rathod KS, et al.

CTCA Prior to Invasive Coronary Angiography in Patients With Previous Bypass Surgery: 3-Year Outcomes from the BYPASS-CTCA Trial.

Circ Cardiovasc Interv 2024;17:e014142; https://doi.org/10.1161/CIRCINTERVENTIONS.124.014142

The BYPASS-CTCA Trial previously showed that CT coronary angiography (CCTA) before invasive coronary angiography (ICA) reduces procedure time, contrast use, and patient discomfort in post-CABG patients. This three-year follow-up assessed its impact on patient outcomes, imaging utilization, and major adverse cardiac events (MACE).A total of 688 patients (mean age 69.8 years) with prior CABG were randomized to CCTA + ICA (n=344) or ICA alone (n=344) for suspected ischemia (55% stable angina, 45% acute coronary syndrome). Median follow-up was 3 years (2.2–3.4 years). At 3 months, the CCTA+ICA group had more angina-free patients (51.7% vs. 43.2%, p=0.03) and higher quality-of-life scores (81.6 vs. 74.4, p=0.001), though these benefits did not persist at 12 months or 3 years. CCTA reduced the need for additional cardiac imaging (35.8% vs. 45.1%, OR 0.68, p=0.013) and lowered MACE rates at 3 years (35.8% vs. 43.6%, HR 0.73, p=0.010). Myocardial infarction (MI) rates were lower with CCTA (16.6% vs. 25.9%, HR 0.59, p=0.002), but all-cause and cardiovascular mortality were similar. The CCTA+ICA group had a higher rate of targeted PCI, likely due to better lesion visualization. CCTA before ICA reduced additional imaging needs and MI rates, supporting its routine use in post-CABG patients to improve diagnostic efficiency and reduce cardiac events.

Keywords: CT coronary angiography (CCTA), coronary artery bypass grafting (CABG), adverse cardiac events (MACE)

Lay summary: This three-year follow-up of the BYPASS-CTCA trial evaluated the long-term impact of performing CCTA before invasive coronary angiography in post-CABG patients. CCTA reduced the need for additional cardiac imaging and was associated with lower myocardial infarction rates without affecting overall mortality. While early improvements in angina relief and quality of life did not persist, CCTA improved diagnostic efficiency and may help reduce adverse cardiac events.

Sakai K, Shin D, Singh M, et al.

Diagnostic Performance and Clinical Impact of Photon-Counting Detector Computed Tomography in Coronary Artery Disease.

J Am Coll Cardiol 2024:S0735-1097(24)09956-X; https://doi.org/10.1016/j.jacc.2024.10.069

Photon-counting detector computed tomography (PCD-CT) offers enhanced spatial resolution compared to conventional energy-integrating detector CT (EID-CT). This retrospective study evaluated its clinical impact and diagnostic performance in 7,833 patients undergoing coronary CT angiography (CCTA) at a single center (PCD-CT: n=3,876; EID-CT: n=3,957). Subsequent invasive coronary angiography (ICA) and revascularization were performed as part of routine care. Patients in the PCD-CT group were less frequently referred for ICA than those in the EID-CT group (9.9% vs. 13.1%, p<0.001). Among those undergoing ICA, revascularization rates were higher with PCD-CT (43.4% vs. 35.5%, p=0.02), suggesting improved selection for intervention. Vessel-level analysis (n=1,686) showed higher specificity (98.0% vs. 93.0%, p<0.001), positive predictive value (83.3% vs. 63.0%, p=0.002), and diagnostic accuracy (97.2% vs. 92.8%, p<0.001) with PCD-CT. Sensitivity (90.9% vs. 90.7%, p=0.95) and negative predictive value (98.9% vs. 98.7%, p=0.83) remained similar between groups. These findings indicate that PCD-CT improves diagnostic accuracy and reduces unnecessary ICA referrals while maintaining high sensitivity for obstructive CAD, supporting its clinical utility in CCTA.

Keywords: computed tomography; coronary artery disease; coronary computed tomography angiography; photon counting; quantitative coronary angiography

Lay summary: This study compared a new CT technology (PCD-CT) with conventional CT scans for detecting blocked coronary arteries. Researchers found that patients scanned with PCD-CT were less likely to be sent for invasive follow-up tests, yet when such tests were performed, they were more likely to lead to treatment. Additionally, PCD-CT showed higher accuracy in correctly identifying blockages, while both methods were similarly effective at ruling out disease.

Lorenzatti D, Piña P, Huang D, et al.

Interaction between risk factors, coronary calcium, and CCTA plaque characteristics in patients aged 18–45 years.

Eur Heart J - Cardiovascular Imaging 2024; 25:1071–1082; https://doi.org/10.1093/ehjci/jeae094

This study evaluated the prevalence and predictors of coronary artery calcium (CAC), plaque subtypes, and plaque burden in symptomatic young adults under 45 years old using coronary CT angiography (CCTA). A total of 907 patients (55% female, 44% Hispanic) underwent CCTA for chest pain evaluation. Traditional risk factors (hypertension, hyperlipidemia, diabetes, smoking, and family history of premature coronary artery disease) were assessed, and plaque burden was quantified using semi-automated software. CAC=0 was present in 89% of patients, yet 15% had any plaque, and 1.8% had stenosis >50%. Non-calcified plaque (NCP) was found in 37.2%, and low-attenuation plaque in 4.24%. The likelihood of CAC >0 or any plaque increased significantly with >3 risk factors (OR 7.13, p<0.001 and OR 10.26, p<0.001, respectively). Age ≥35 years (OR 3.62) and family history (FHx) of premature CAD (OR 2.76) were the strongest independent predictors of any plaque. Notably, 31% of patients with stenosis >50% had CAC=0, and among those with CAC=0, 5% still had plaque, with FHx being the only predictor of NCP (OR 2.29, p=0.03). These findings highlight that traditional risk assessment may underestimate atherosclerosis in young adults, particularly in those with a strong family history, and suggest that CCTA may improve risk stratification in this population.

Keywords: cardiac computed tomography; cardiovascular disease risk factors; coronary artery calcium; coronary artery disease; young adults

Lay summary: This study examined young adults under 45 with chest pain to understand early signs of heart artery plaques presence using coronary CT angiography scans. Most had no coronary artery calcium (89%), but 15% had plaque buildup, including non-calcified and high-risk plaques, which traditional risk scores which cardiologists use, might miss. The strongest predictors of plaque were being over 35 or having a family history of early heart disease. These findings suggest that traditional risk assessment may underestimate heart disease in young adults, highlighting the need for improved early detection strategies.

Swahn E, Sederholm Lawesson S, Alfredsson J, et al.

Sex differences in prevalence and characteristics of imaging-detected atherosclerosis: a population-based study.

Eur Heart J - Cardiovascular Imaging 2024; 25:1663–1672; https://doi.org/10.1093/ehjci/jeae217

This population-based study analyzed sex differences in coronary and carotid atherosclerosis in 25,580 middle-aged Swedish adults (50–65 years old) from the Swedish Cardiopulmonary bioImage Study, all without known atherosclerosis. Participants underwent coronary CT angiography (CCTA) and carotid ultrasound. Men had higher rates of hypertension, hyperlipidemia, and diabetes compared to women. Coronary atherosclerosis was present in 56.2% of men and 29.5% of women, while coronary stenosis ≥50% was detected in 9.0% of men and 2.3% of women. Men also had higher segment involvement scores (SIS ≥4: 20.2% vs. 5.3%), coronary artery calcium scores (CACS >100: 18.2% vs. 5.6%), and carotid plaque (60.9% vs. 48.7%). After adjusting for age, cardiovascular risk factors, lifestyle, and socioeconomic factors, men had significantly higher odds of coronary and carotid atherosclerosis compared to women. The likelihood of coronary atherosclerosis was nearly three times higher in men (OR 2.75), while severe disease (SIS ≥4) was nearly four times more likely (OR 3.99). Men also had higher odds for coronary stenosis ≥50% (OR 2.88), CACS >100 (OR 3.29), and carotid plaque (OR 1.57). These findings confirm that men have a substantially higher burden of imaging-detected atherosclerosis than women, even after adjusting for conventional risk factors, reinforcing the need for sex-specific cardiovascular risk assessment.

Keywords: sex; coronary computed tomography angiography; atherosclerosis; coronary artery disease; carotid artery disease; ultrasonography

Lay summary: This study examined differences in heart artery and neck artery disease between men and women aged 50–65 using coronary CT angiography scans and ultrasound of the neck arteries. Men were significantly more likely to have coronary artery disease, with nearly twice the risk of any plaque and four times the risk of major blockages (≥50%). Carotid artery disease was also more common in men but showed a smaller difference. Notably, women at age 65 had atherosclerosis levels similar to men who were 11–13 years younger, highlighting the need for sex-specific prevention strategies.

Barton AK, Craig NJ, Loganath K, et al.

Myocardial Fibroblast Activation After Acute Myocardial Infarction: A Positron Emission Tomography and Magnetic Resonance Study.

J Am Coll Cardiol 2025; 85:578-591; https://doi.org/10.1016/j.jacc.2024.10.103

This study investigated myocardial fibroblast activation following acute myocardial infarction (MI) using [68Ga]-FAPI-46 positron emission tomography (PET) combined with cardiac magnetic resonance imaging. The Authors included 40 patients with acute MI, 19 control subjects, and 20 patients who suffered a MI >2 years. The results of the study showed that fibroblast activation was most intense in the infarct and peri-infarct regions, exceeding the area of late gadolinium enhancement. The highest uptake occurred at 1-2 weeks post-MI and gradually declined over 12 weeks. However, persistent fibroblast activity was detected even years after MI, albeit at lower intensity.

Higher [68Ga]-FAPI-46 uptake was associated with lower left ventricular ejection fraction (r = −0.606), increased left ventricular end-diastolic volume (r = 0.572), and greater scar burden (r = 0.871) at one year, suggesting a link between early fibroblast activation and adverse left ventricular remodeling.

This study highlights that fibroblast activation extends beyond the infarct region and persists long-term, indicating a potential role in left ventricular dilation and progressive dysfunction. It also demonstrates the potential of molecular hybrid PET-MRI imaging to assess fibrosis dynamics and predict long-term cardiac remodeling in MI patients.

Keywords: CMR; MRI; PET imaging, myocardial infarction, fibrosis, fibroblast activation, left ventricular remodeling

Lay summary: The heart muscle undergoes a healing process after a heart attack, which involves the activation of special cells called fibroblasts. These cells help form scar tissue, but too much activation can lead to long-term heart damage, called fibrosis. This study used an advanced hybrid imaging technique to track fibroblast activity in 40 patients who had recently suffered a heart attack. The researchers found that fibroblast activity peaked within the first two weeks and then slowly declined over time. However, some level of activity remained for years. Patients with higher rates of this early fibroblast activity were more likely to develop heart enlargement and weaker heart function over time. The findings of this study could help doctors predict which patients are at higher risk of weaker pumping function of the heart after a heart attack and allow earlier treatment to prevent long-term complications.

Hasse B, Ledergerber B, Van Hemelrijck M, et al.

18F-fluorodeoxyglucose Uptake Patterns in PET/CT Caused by Inflammation and/or Infection After Graft Surgery for Thoracic Aortic Dissection.

J Nucl Cardiol 2024; 36:101865; https://doi.org/10.1016/j.nuclcard.2024.101865

This study examined patterns of 18F-fluorodeoxyglucose (FDG) uptake in PET/CT scans following thoracic aortic graft surgery to differentiate between infection, inflammation, and normal post-surgical changes. A retrospective analysis of 60 patients (187 PET/CT scans) from a cohort of 610 thoracic aortic graft recipients was conducted. Findings showed that FDG uptake in infected grafts was higher than in non-infected ones (standardized uptake value ratio: 2.19 vs. 1.63; P < 0.001) and was predominantly focal (90%). Uptake decreased over time, but the rate of decline did not significantly differ between infected and non-infected grafts. Additionally, FDG uptake at the anastomosis was more common in non-infected grafts (66% vs. 21%; OR 11.34; P < 0.001), with potential attenuation by the use of BioGlue® surgical adhesive (OR 5.05; P = 0.19). No association was found between FDG uptake and graft coating materials (gelatin or collagen).

These findings suggest that while higher FDG uptake can indicate infection, focal uptake—especially at the anastomosis—can occur even in non-infected grafts. Awareness of these uptake patterns is crucial for differentiating true infections from post-surgical inflammatory changes.

Keywords: PET/CT, thoracic aortic graft, FDG uptake, graft infection, BioGlue®, anastomosis inflammation, vasculitis

Lay summary: Doctors often use PET/CT scans to examine for infections in patients who have had aortic graft surgery (a procedure to replace a degenerated part of the aorta, the body’s largest artery). However, sometimes the scan shows increased activity, which could be from infection or normal healing. This study examined 60 patients who had aortic graft surgery and found that higher activity on the scan was more common in infected grafts, but non-infected grafts also often showed activity—especially at the points where the graft was attached to the artery. Over time, this activity slowly decreased, but it was not always a clear sign of infection. These findings can help doctors better interpret PET/CT scans after graft surgery, reducing the risk of misdiagnosing infections and avoiding unnecessary treatments.

Prasad N, Harris E, DeFilippis EM, et al.

PET/CT with Myocardial Blood Flow Assessment Is Prognostic of Cardiac Allograft Vasculopathy Progression and Clinical Outcomes.

J Nucl Med 2025; 66:264-270; https://doi.org/10.2967/jnumed.124.268713

This study evaluates the prognostic value of quantitative 13N-ammonia positron emission tomography (PET) perfusion imaging in heart transplant recipients for cardiac allograft vasculopathy (CAV) assessment. The investigators enrolled 344 patients over a median follow-up of 5 years and compared noninvasive PET perfusion results with routine invasive coronary angiography (ICA) surveillance. They found that PET CAV grades of 0/1 had good negative predictive values of 0.93, 0.95, and 0.95 at 600, 900, and 1200 days for developing moderate to severe CAV on ICA follow-up.

Patients with higher PET CAV grade 2/3 had a 2.9-fold risk of overall mortality. In a further sensitivity analysis of 135 patients with stable CAV, PET CAV grade 2/3 remained associated with a higher risk of death or re-transplantation.

The study concludes that noninvasive CAV assessment using PET perfusion provides prognostic information and suggests that intervals between invasive screenings could be extended for certain patients, potentially reducing the need for frequent invasive procedures.

Keywords: PET perfusion, 13N-ammonia, heart transplant, allograft vasculopathy

Lay summary: This study evaluates how well the measurement of heart blood flow using a positron emission tomography (PET) scan predicts the development of coronary artery disease in heart transplant receivers. Researchers found that the noninvasive PET scan predicted the development of coronary artery disease. They conclude that PET scan shows promise for reducing the need for invasive routine cardiac testing in heart transplant patients.

Abadie B, Elghoul Y, Prakash SS, et al.

Coronary microvascular dysfunction by positron emission tomography and outcomes in patients after cardiac transplantation without epicardial allograft vasculopathy.

Eur Heart J Cardiovasc Imaging 2025; jeaf042; https://doi.org/10.1093/ehjci/jeaf042

This study evaluates the prognostic implications of coronary microvascular dysfunction (CMD) in heart transplant patients without epicardial cardiac allograft vasculopathy (CAV). Researchers included 356 transplant patients with no prior history of CAV. They assessed coronary CMD quantitatively using the 82Rb positron emission tomography (PET) by coronary flow reserve. CMD was defined as perfusion reserve less than 2.0 and further classified into two subtypes: endogen/functional (higher stress flow) and classical/structural (lower stress flow). CMD was present in 40% of patients, with 31% having endogen/functional CMD and 8% having classical/structural CMD.

The study found that endogen/functional CMD was associated with a higher risk of adverse events, including all-cause mortality, heart failure hospitalization, acute coronary syndrome, revascularization, and re-transplantation. Specifically, patients with endogen/functional CMD had a 2.4-fold increased risk of the composite outcome and a 3.0-fold increased risk of all-cause mortality. In contrast, classical/structural CMD was not associated with an increased risk of adverse outcomes.

The findings suggest that quantitative assessment of microvascular dysfunction by PET perfusion could help identify higher-risk heart transplant patients who might benefit from closer monitoring and further interventions.

Keywords: PET perfusion, 82Rb, heart transplant, microvascular dysfunction

Lay summary: This study tried to assess whether the presence and patterns of CMD impacted prognosis in heart transplanted patients without overt CAV and without regional myocardial perfusion defects. The main findings of the study allow to conclude that, although the presence of CMD is associated with a higher rate of adverse events at follow-up, this trend was limited to patients with an endogen/functional CMD subtype. In those patients, the cause of MFR impairment can be identified in a pathologically increased resting MBF due to myocardial oxygen supply/demand mismatch (i.e., higher resting heart rate or diastolic LV pressure) and may be indicative of myocardial disease. This means that incorporating endogen/microvascular dysfunction assessment in PET/CT reporting may identify a higher risk group of transplanted patients among those that are now considered at low risk.

Barton AK, Kwiecinski J, Hashimoto H, et al.

Imaging small dynamic lesions using positron emission tomography and computed tomography: an 18F-sodium fluoride valvular phantom study.

Eur Heart J Imaging Methods Pract 2025; 3:qyaf013; https://doi.org/10.1093/ehjimp/qyaf013

The study aimed to develop a cardiac Phantom to optimize 18F-sodium fluoride (18F-NaF) positron emission tomography (PET) imaging of bioprosthetic valve microcalcifications. Indeed, measuring small areas of 18F-NaF uptake within moving structures remains technically challenging. The Authors placed a bioprosthetic valve with two pockets sutured to the leaflets mimicking valvular lesions and a subvalvular ring mimicking the valve remnant into the phantom and injected each with 18F-radionuclide (1 μCi pockets, 4 μCi ring). They analysed target-to-background ratio (TBR) and signal-to-noise ratio (SNR) and subjective measures of image quality, comparing the results with a human case of transcatheter aortic valve replacement. Initially the SNR and TBR in the phantom greatly exceeded those from human imaging. After reducing scan duration used for reconstruction to 30 and 15 s, comparable results were achieved (30 s vs. 15 s vs. patient: SNR 45.6 vs. 13.9 vs. 44.3, TBRmax 6.5 vs. 5.4 vs. 4.1, noise 10.2% vs. 8.8% vs. 12.0%). With motion correction, SNR and image quality improved in the phantom (30 s 135.8 vs. 45.6, 15 s 32.9 vs. 13.9) but remained similar in the human case (47.3 vs. 44.3). In conclusion, a cardiac phantom mimicking clinical 18F-NaF valve bioprosthesis imaging provided an opportunity to explore acquisition, reconstruction, and post-processing of 18F-NaF PET/CT for small mobile cardiac structures.

Keywords: cardiac computed tomography; nuclear; cardiac phantom; multi-modality imaging; positron emission tomography; 18F-sodium fluoride; bioprosthetic valve microcalcifications

Lay summary: This study created a model, called a "phantom," of a heart with an artificial valve to improve PET scans that detect tiny calcium deposits using a radioactive tracer called 18F-NaF. These deposits can indicate problems with artificial heart valves. The challenge is that the heart moves, making it hard to get clear images of these small areas. The researchers tested different scan settings on their phantom and compared the results to a real patient scan, who had an artificial valve implanted. Initially, the phantom images were much clearer than the patient's. By shortening the scan time and using motion correction techniques, they were able to make the phantom images more similar to the patient's. Motion correction significantly improved image clarity in the phantom, but not as much in the real patient. Essentially, the phantom allowed researchers to experiment with different scan settings to find the best way to image small, moving calcium deposits on artificial heart valves using 18F-NaF PET scans.