Assessment of reproducibility and inter-vendor differences in 2D speckle tracking global longitudinal strain measurements following ten years of international standardization efforts 

Balinisteanu A, Duchenne J Puvrez A, et al.

Vendor differences in 2D-speckle tracking global longitudinal strain: an update on a 10-year standardization effort.
Eur Heart J Cardiovasc Imaging 2025; 26:1360-1373; https://doi.org/10.1093/ehjci/jeaf155

This multicentre study reassessed inter-vendor differences in 2D speckle-tracking global longitudinal strain (GLS) a decade after the first EACVI/ASE comparison. A total of 62 subjects with previous myocardial infarction underwent 372 echocardiograms on six ultrasound systems, with GLS analysed using vendor-specific and vendor-agnostic software, including fully automated AI-based. Variability has narrowed substantially compared with 2013, when the maximum inter-vendor bias was 3.7 strain units: with contemporary semi-automated clinically available software (GE, Philips, Canon, Fujifilm, Caas Qardia), both endocardial and mid-/full-wall GLS were highly consistent, with maximum differences <1 strain unit, though variability remains non-negligible for certain combinations of different vendors. Mid- or full-wall strain, previously unavailable in 2013, is now widely implemented across platforms, expanding the scope of standardized measurements. Test–retest reproducibility was good with semi-automated clinical software, showing relative mean errors of 5–9% and minimal detectable change values of 2–3 strain units, while switching to a different vendor’s software could increase this value. 
Overall, the study demonstrates how a decade of collaboration between societies, scientists and industries has produced tangible harmonization of GLS analysis. GLS can now be regarded as a robust, reproducible, and clinically reliable parameter, particularly valuable for longitudinal follow-up, though cautious interpretation across different software platforms remains essential.

Keywords: strain; speckle-tracking; echocardiography; inter-vendor; left ventricle; standardization. 

Lay summary: Global longitudinal strain (GLS) is a measure of how well the heart muscle shortens longitudinally. It can reveal early changes in heart function, anticipating the decline of traditional measures as left ventricular ejection fraction. In the past, results could vary depending on the ultrasound machine or the adopted software, which made it harder to compare tests and to follow patients over time. In this new study, 62 people were examined with six different ultrasound systems, and the images were analysed using both company-specific and independent software. The results are convincing: modern systems now provide very similar GLS values, with only small differences between companies. Repeated scans in the same subject also gave consistent results. These findings strengthen the role of GLS as a reliable tool for monitoring heart function. Clinicians can be more confident in its accuracy, particularly when the same system is used for follow-up care.

In moderate aortic stenosis, a transaortic flow rate <218 mL/sec, calculated with the derivation method, is associated with increased all-cause mortality and heart failure

Springhetti P, Tomaselli M, Portolan L, et al. 

Transaortic Flow Rate and Risk Stratification in Moderate Aortic Stenosis

J Am Soc Echocardiogr 2025; 38:643-654; http://doi.org/10.1016/j.echo.2025.02.017
 
This study aimed to validate the prognostic utility of transaortic flow rate in patients with moderate aortic stenosis. The study included 292 consecutive patients with moderate aortic stenosis from outpatient clinic who underwent clinically indicated echocardiography. Patients were followed up for almost 20 months to assess the composite clinical outcome of all-cause mortality and hospitalisation for heart failure. 
Results indicated that the excess risk of adverse events began to rise at the value of transaortic flow rate below 218 ml/sec. A transaortic flow rate <218 mL/sec was an independent predictor for composite clinical outcome (hazard ratio [HR] = 2.17; 95% CI, 1.14-4.12; P = 0.018) in multivariable model incorporating other significant clinical and echocardiographic predictors. Additionally, this parameter offered incremental prognostic value beyond traditional clinical and echocardiographic parameters of aortic severity. The study concluded that the transaortic flow rate <218 mL/sec was strongly associated with increased risk of all-cause mortality and heart failure hospitalisation in patients with moderate aortic stenosis. The authors wrapped up that further studies are needed to evaluate whether patients with moderate aortic stenosis and flow rate <218 mL/sec would benefit from closer follow-up or earlier interventions. 

Keywords: echocardiography, moderate aortic stenosis, flow rate, outcome, risk factor  

Lay summary: This study tested whether the specific echocardiographic parameter, called transaortic flow rate, which describes the average volume of blood that passes through a narrowed aortic valve during cardiac contraction, could identify the patients with moderate aortic stenosis with worse clinical outcome. The authors analysed almost 300 patients with moderate aortic stenosis who had echocardiography and were followed up for almost 2 years. The results of this study demonstrated that patients with a reduced transaortic flow rate were more likely to be hospitalised due to heart failure or to die during follow-up. This parameter was better at finding people who are at increased risk for adverse outcome compared with traditional echocardiographic parameters. This means that doctors might more easily identify who needs more frequent check-ups and who can safely avoid them. 

Left bundle branch block strain patterns independently predict cardiac resynchronization therapy outcome

Duchenne J, Calle S, Stankovic I, et al. 

Strain-based staging as a unifying concept in cardiac resynchronization therapy

Eur Heart J Cardiovasc Imaging 2025; 26:1389-1399; http://doi.org/10.1093/ehjci/jeaf162
 
This multicentric prospective study aimed to evaluate the association between the strain-based left bundle branch block (LBBB) classification and clinical outcomes in cardiac resynchronisation (CRT). Authors included 267 patients who underwent CRT implantation and 116 patients who were eligible for CRT but were treated only with medical therapy. Patients were followed up for almost 50 months to assess the composite clinical outcome of all-cause mortality and heart transplant. Results indicated that each successive LBBB stage resulted in significant improvement in volumetric response as well as survival. Compared to strain stage LBBB-0, strain stage LBBB-4 showed a four-fold decrease in adverse outcomes. LBBB stage classification was independently associated with a decreased risk of all-cause mortality or heart transplantation [HR 0.65 (0.49–0.85, P = 0.002)] after multivariable adjustment for several risk factors, baseline echocardiographic features and scar burden. The study concluded that strain-based LBBB classification was strongly related with the extent of reverse volumetric remodelling and survival benefit in patients underwent CRT. The authors speculated that the proposed strain-based LBBB classification might be used for risk stratification and for selection criteria  for CRT.

Keywords: echocardiography, cardiac resynchronisation therapy, strain pattern, outcome, dyssynchrony  

Lay summary: This study tested whether specific strain patterns could identify heart failure patients who will benefit from cardio resynchronisation therapy (CRT). The authors included almost 270 heart failure patients who were treated with CRT and 120 heart failure patients who were treated only with heart failure medications. The results of this study showed that patients with specific strain patterns were more likely to experience improvement in heart function, and had a better outcome with fewer heart transplants or deaths during the 50-month follow-up period. These strain patterns were also more effective at predicting who would benefit most from CRT than traditional clinical or echocardiographic parameters. This means that heart failure specialists can now better understand how effective will be the treatment in an individual heart failure patients receiving CR and they can also more confidently identify heart patients who are the best candidate for CRT.

Evaluation of cardiac damage stage before and after TAVI and its prognostic implications 

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; 26:918-927; https://doi.org/10.1093/ehjci/jeaf045

In this retrospective, single-centre analysis of 734 patients with severe aortic stenosis undergoing TAVI, investigators assessed the prevalence, reversibility, and prognostic significance of extra-valvular cardiac damage. Damage was staged from 0 (none) to 4 (right ventricular dysfunction) using echocardiographic criteria, both before and six months after intervention. At baseline, 96% of patients demonstrated some degree of cardiac damage. At six months, 39% of patients improved by at least one stage, 38% remained unchanged, and 13% worsened. Landmark analysis showed that both the six-month stage and the evolution of cardiac damage independently predicted two-year all-cause mortality, even after adjustment for EuroSCORE II and baseline characteristics. Each one-stage increase in damage was associated with a ~37% higher mortality risk, and patients with worsening stages had over a threefold higher risk of death compared to those who improved. These results underscore the partial reversibility of extravalvular damage following TAVI and emphasize the prognostic implications of persistent or progressive involvement, particularly at the right ventricular level. Cardiac damage staging both before and after TAVI adds incremental prognostic information and could be incorporated into routine clinical assessment and risk stratification.

Keywords: aortic stenosis; echocardiography; extravalvular cardiac damage; prognosis; transcatheter aortic valve implantation. 

Lay summary: Severe aortic stenosis not only affects the aortic valve but also places strain on the heart muscle and other chambers, leading to progressive damage. Transcatheter aortic valve implantation (TAVI) offers a minimally invasive way to replace the diseased valve and relieve the obstruction. In this study of more than 700 patients, echocardiograms were performed before TAVI and again six months later. Nearly all patients showed signs of extravalvular damage at baseline. After the procedure, about 40% demonstrated an improvement in heart structure, while a smaller group worsened despite treatment. Survival over the following two years was strongly related to these changes: patients whose heart damage improved did better, while those with worsening findings were at increased risk. These results show that TAVI can promote recovery of heart function in a substantial proportion of patients, but careful follow-up imaging remains essential to identify those at risk of ongoing progression.

Prognostic Significance of Mitral Annular Calcification and Mitral Valve Dysfunction in Severe Aortic Stenosis

Vanhaecke P, Bohbot Y, Hucleux E, et al. 

Mitral Annular Calcification in Severe Aortic Stenosis: Prognostic Value of Calcification Severity and Mitral Valve Dysfunction.

Eur Heart J Cardiovasc Imaging 2025; jeaf214; https://doi.org/10.1093/ehjci/jeaf214

 
This study evaluated the prognostic impact of mitral annular calcification (MAC) and associated mitral valve dysfunction (MVD) in patients with severe aortic stenosis (AS). A total of 613 patients were retrospectively analysed and classified according to MAC severity and the presence of MVD, defined as a mean transmitral gradient ≥5 mmHg. MAC was present in 50.4% of the patients, with 16% showing severe involvement, and 21% also having MVD. Patients with MAC had significantly worse six-year survival compared with those without (47 ± 3% vs. 64 ± 3%, log-rank P < 0.001) even after adjustment for covariates with prognostic impact {hazard ratio [HR] [95% confidence interval (CI)] = 1.24 [1.03–1.67]}. Severe MAC was linked to older age, female sex, higher comorbidity burden, elevated pulmonary pressures (all P < 0.05), and markedly reduced 6-year survival (23 ± 7% vs. 55 ± 5% in mild and 50 ± 5% in moderate MAC). The coexistence of MAC and MVD was associated with a markedly reduced 6-year survival (28 ± 7%) compared with patients who had MAC alone (53 ± 4%). In multivariable analysis, severe MAC and MVD emerged as independent predictors of death, with HR of 2.63 (95% CI 1.51–4.60) and 1.86 (95% CI 1.24–2.77), respectively. These findings indicate that MAC is not only common in severe AS but also carries important prognostic implications, underscoring the need for assessment of MAC severity and transmitral gradients in clinical management of patients with severe AS.

Keywords: aortic stenosis; mitral annular calcification; mitral valve dysfunction; prognosis; survival; echocardiography

Lay summary: This study looked at patients with severe aortic valve narrowing (aortic stenosis) and a condition called mitral annular calcification (MAC), where calcium builds up around the heart’s mitral valve. More than half of the 600 patients studied had MAC, and about one in five also had problems with function of the mitral valve (mitral valve dysfunction, MVD). The results showed that people with MAC lived for a shorter time than those without it, and survival was especially poor when the calcification was severe or when it was combined with MVD. Even after taking other health problems into account, severe MAC and MVD were strong predictors of worse outcomes. This means that checking for calcium around the mitral valve and measuring how well the valve works are important steps in patients with aortic stenosis, helping doctors better understand risk and guide treatment decisions.

Sex-Based Differences in Tricuspid Regurgitation Severity, Right Ventricular Remodeling, and Patient Prognosis 

Tomaselli M, Penso M, Badano LP, et al. 

Sex-Specific Differences in Right Heart Remodeling and Patient Outcomes in Secondary Tricuspid Regurgitation.

Eur Heart J Cardiovasc Imaging 2025; jeaf215; https://doi.org/10.1093/ehjci/jeaf215
 
This study investigated whether risk-based thresholds for secondary tricuspid regurgitation (STR) severity, right ventricular (RV), and tricuspid annulus (TA) remodeling differ between men and women. A total of 554 patients with moderate or severe STR (mean age 74 ± 13 years, 51% women) were included, and the primary endpoint was all-cause mortality or heart failure hospitalization. Women were older and more frequently presented with atrial fibrillation and atrial STR, while men more often had coronary artery disease, chronic kidney disease, and mitral regurgitation. Compared with men, women demonstrated smaller RV and TA dimensions as well as higher RV ejection fraction. During a median follow-up of 19 (8-27) months, 230 patients reached the composite endpoint, with no significant differences in 2-year event-free survival between sexes, even after adjustment. Sex-specific thresholds for STR severity were lower in women for effective regurgitant orifice area (0.36 cm² vs. 0.43 cm²) and regurgitant volume (31 mL vs. 35 mL) but higher for regurgitant fraction (46% vs. 39%). Similarly, women experienced comparable risk at lower RV end-diastolic (81 mL/m² vs. 96 mL/m²) and end-systolic volumes (37 mL/m² vs. 49 mL/m²), higher RVEF (49% vs. 41%), and smaller TA diameter (19 mm/m² vs. 22 mm/m²). These findings reveal that women with STR reach similar risk levels at lower EROA and RegVol, with smaller RV volumes, higher RVEF, and smaller TA dimensions, what underscores the importance of applying sex-specific thresholds when evaluating STR severity and right heart remodeling in clinical practice.

Keywords: Secondary tricuspid regurgitation; right ventricular remodeling; tricuspid annulus; sex differences; risk stratification; echocardiography

Lay summary: This study looked at differences between men and women with a heart valve problem called secondary tricuspid regurgitation (STR), where the valve between the right-sided heart chambers does not close properly and causes blood to leak backwards. Researchers followed 554 patients to see who developed complications such as heart failure hospitalization or death. They found that women tended to have smaller right heart chambers dimensions and better right ventricular pumping function than men. Importantly, women showed the same risk of complications as men even when their valve leak and heart changes were less severe. This means that women may develop problems earlier, at lower levels of valve leakage and heart enlargement. The findings suggest doctors should use different thresholds for men and women when judging the severity of this condition, so that treatment decisions can be better tailored to each patient.

Myocyte volume, scar and extracellular volume by CMR progressively increase with higher grades of diastolic dysfunction in patients with aortic regurgitation 

Lababidi H, Malahfji M, Saeed M, et al.

Relation of left ventricular diastolic function to LV structure and outcomes in patients with aortic regurgitation.

Eur Heart J Cardiovasc Imaging 2025; 26:1560–1569; https://doi.org/10.1093/ehjci/jeaf168

 
In the complex landscape of chronic aortic regurgitation (AR), left ventricular (LV) ejection fraction and end-systolic dimension have determined the surgical decision-making. This study evaluated 323 patients with at least moderate aortic regurgitation (AR) confirmed by both echocardiography and CMR to determine how left ventricular diastolic dysfunction (DD) relates to myocardial structure, specifically to extracellular volume (ECV), scar burden, and myocyte volume, as well as clinical outcomes. The echocardiographic and CMR findings revealed that patients with higher grades of DD had progressively increased both extracellular and cellular volumes, and greater scar burden—all markers of pathological myocardial remodeling. Over a median 3.8-year follow-up, Grades II and III DD were strong independent predictors of mortality (HR 1.49, 95% CI 1.1–1.98, P=0.009), even after adjusting for LV ejection fraction, AR severity, comorbidities, and valve replacement.  Among asymptomatic patients with preserved LV ejection fraction, presence of DD improved risk prediction beyond traditional parameters. The findings support the incremental clinical value of comprehensive diastolic function grading for identifying high-risk AR patients beyond traditional criteria as it precedes the fall in LV ejection fraction.

Keywords: aortic regurgitation; cardiovascular magnetic resonance; tissue characterization; extracellular volume; diastolic dysfunction; LV remodelling; prognosis.

Lay summary: This study evaluated 323 patients moderate or severe aortic valve leakage and analysed heart structure and function as well as relaxation features, using both CMR and ultrasound respectively. They found that more severe heart relaxation (diastolic dysfunction) goes hand-in-hand with more scar tissue and swelling in the cardiac muscle, seen on CMR. Worse relaxation also predicted a greater risk of death and heart failure, including for patients who had no symptoms and normal heart function. This means measuring diastolic dysfunction closely may help detect those with early disease progression.

 
Prevalence of Diastolic (True-MAD) and Systolic (Pseudo-MAD) Mitral Annular Disjunction in Patients With Mitral Valve Prolapse 

Fiore G, Rizza V, Ingallina G, et al.

Prevalence of Diastolic and Systolic Mitral Annular Disjunction in Patients With Mitral Valve Prolapse.

J Am Soc Echocardiogr 2025; 38:1-11; https://doi.org/10.1016/j.echo.2024.10.004
 
Mitral annular disjunction (MAD) can be divided into 2 distinct phenotypes: True-MAD (atrial displacement of the posterior leaflet in diastole and systole) and Pseudo-MAD (apparent displacement in systole only). The aim of this study was to assess the prevalence of True-MAD and Pseudo-MAD in myxomatous MVP patients by transthoracic echocardiography (TTE) and to validate TTE compared to cardiac magnetic resonance in 603 patients. The prevalence of True-MAD and Pseudo-MAD was 7% (42) and 37% (221), respectively. Accordingly, 221 of 263 (84%) patients classically classified as "MAD" would have been reclassified as Pseudo-MAD. Pseudo-MAD prevalence and systolic length increased with higher mitral regurgitation (MR) severity, while True-MAD prevalence was consistent across MR grades. Pseudo-MAD was linked to systolic curling and the "Pickelhaube" sign at tissue Doppler imaging. Transthoracic echocardiography showed an overall accuracy of 0.89, and an almost perfect intra-rater agreement. True-MAD, unlike Pseudo-MAD, is rare in patients with MVP. Pseudo-MAD is associated with the grade of MR. Transthoracic echocardiography is an accurate and reliable first-line method to assess this pathology.

Keywords: CMR; echocardiography; arrhythmic mitral valve prolapse; MAD; Mitral annulus; Mitral regurgitation; Pseudo-MAD; Ventricular arrhythmias.

Lay summary: The aim of this study was to assess the prevalence of True-MAD and Pseudo-MAD in 603 patients by an ultrasound-based heart scan (TTE) and to validate this with MRI heart scans which is the gold standard. MAD is a displacement of the mitral valve leaflet hinge point away from the ventricular myocardium, causing the mitral valve to attach higher up in the left atrium than normal, and this can be in systole (Pseudo-MAD), or diastole (True-MAD). The prevalence of True-MAD and Pseudo-MAD was 7% and 37%, respectively. Impressively, 84% of the patients classified as "MAD" would have been reclassified as Pseudo-MAD based on this definition. Transthoracic echocardiography is an accurate and reliable first-line method to assess this pathology.

A novel risk score to predict major ventricular arrhythmias in non-dilated left ventricular cardiomyopathy 

Peretto G, Merlo M, Ambrosi A, et al.

Major arrhythmias in non-dilated left ventricular cardiomyopathy: a novel prediction score.

Eur Heart J 2025; 00:1–13; https://doi.org/10.1093/eurheartj/ehaf477

 
This multicentre European study retrospectively analyzed 337 patients with non-dilated left ventricular cardiomyopathy (NDLVC) to identify risk factors predicting major arrhythmic events (MAEs) over 5 years. Patients without prior MAEs underwent baseline workup including cardiac magnetic resonance imaging (CMR), endomyocardial biopsy (EMB), and genetic testing. Young adult cohort, mean age 37 ± 15 years, 62% male, where CMR was completed in 89%, serving as the main modality both for identifying late gadolinium enhancement (LGE) and for detecting myocardial inflammation via T2-weighted imaging and mapping. EMB was performed in 37%, predominantly for diagnostic clarification when symptoms persisted or when arrhythmic burden was high and CMR was inconclusive. Genetic testing was performed in 62%.
The primary endpoint was the first occurrence of sustained ventricular tachycardia, ventricular fibrillation, or appropriate ICD intervention over 60 months. Seven key predictors emerged: male sex, non-sustained VT, left ventricular ejection fraction <45%, septal and ring-like LGE on CMR, pathogenic/likely pathogenic variants in high-risk genes (LMNA, FLNC, TMEM43, PLN, DSP, RBM20), and myocardial inflammation proven by CMR or EMB. These factors formed the NDLVC-5y risk score, which performed well in a validation cohort (Uno’s C-index 0.81). This is a useful multi-parametric, evidence-based approach for arrhythmic risk stratification in NDLVC and helping select candidates for ICD therapy. Specially, CMR is the primary, most widely available tool for multimodal risk stratification and influences model applicability to real-world NDLVC populations.

Keywords: non-dilated left ventricular cardiomyopathy, cardiovascular magnetic resonance, tissue characterization, inflammatory cardiomyopathy, sudden cardiac death.

Lay summary: Researchers followed 337 patients with a recently defined heart muscle condition where the left ventricle has a scar or a depressed ejection fraction but is not enlarged. They wanted to evaluate which patient features determine a higher risk of dangerous heart rhythm problems. The team found that being male, having lower pumping function, a personal history of transient fast heartbeats, specific patterns of heart scarring on CMR, inflammation shown by CMR or biopsy, and certain genetic mutations, greatly increased the likelihood of a serious arrhythmia over five years. By combining these risk factors, they built a new scoring system that helps decide who may need a preventive defibrillator and who can be safely monitored, aiming to better target care and reassure low-risk patients.

CMR-based LGE extent and impaired myocardial dynamics are prognostic of major ventricular arrhythmias in lamin heart disease 

Topriceanu CC, Al-Farih M, Joy G, et al.

The Cardiovascular Magnetic Resonance Phenotype of Lamin Heart Disease.

JACC Cardiovasc Imaging 2025; 18:644-660; https://doi.org/10.1016/j.jcmg.2025.01.004

 
This prospective multicenter study aimed to perform deep phenotyping among LMNA variant carriers through advanced cardiovascular magnetic resonance (CMR) to identify whether myocardial tissue properties (Strain, T1/T2 mapping, extracellular volume [ECV], late gadolinium enhancement [LGE]) may be associated with major adverse cardiovascular events. 187 individuals were categorized into four groups: LMNA carriers with preserved left ventricular ejection fraction (LVEF≥55%; Lamin+EF), LMNA carriers with LVEF<55% (Lamin–EF), dilated cardiomyopathy patients without LMNA variants (DCMwt), and healthy volunteers (HVs). Key findings revealed that LMNA+LVEF patients showed already subclinical abnormalities: prolonged T2 relaxation times (10 ms longer than HVs; 95%CI: 2–20), elevated ECV (3% higher; 95%CI:1%–6%), impaired myocardial strain, and higher troponin levels (27 ng/L vs. 5 ng/L in DCMwt). Those with reduced LVEF showed further deterioration, including higher ECV (5% increase vs. DCMwt; 95%CI:1%–9%) and elevated NT-proBNP levels. Over a 4-year follow-up, 21% of LMNA carriers experienced MACE, significantly higher than DCMwt (6%;p<0.001). LGE and reduced strain independently predicted MACE (HR1.15 (95%CI:1.02–1.30) and HR 1.01 (95%CI:1.01–1.02) per 1% change, respectively). The study concludes that CMR detects early myocardial changes in LMNA carriers before systolic dysfunction manifests. CMR may be used for early screening and risk stratification in LMNA carriers.

Keywords: cardiovascular magnetic resonance; strain; cardiomyopathy; lamin heart disease; LMNA variant carrier.

Lay summary: This study used CMR to deeply understand how Lamin heart disease affects patients. 187 patients were studied, including those with the LMNA gene (with and without reduced heart function), others with heart muscle disease without the gene mutation, and healthy volunteers. The authors found that even when the heart function is normal, patients with the LMNA gene show subtle signs of changes, such as increased heart muscle inflammation (seen on CMR scans) and higher levels of a biomarker (troponin) linked to heart damage. Over four years, those with the gene mutation were more likely to experience serious outcomes, like life-threatening arrhythmias or heart failure. CMR also identified specific patterns (like scar tissue or reduced heart muscle flexibility) that helped identify those at a higher risk. This means CMR scans can detect early warning signs in LMNA carriers before symptoms or heart dysfunction develops.

Elite athletes have lower native myocardial T1 

Daems JJN, Verwijs SM, van Diepen MA, et al.

Native T1 mapping times are strongly influenced by elite athlete status.

Eur Heart J Cardiovasc Imaging 2025; 26:1208–1216; https://doi.org/10.1093/ehjci/jeaf123
 
Among athletes, differentiating between early-onset cardiomyopathy and exercise-induced cardiac remodeling can be challenging, with the risk of both misdiagnosis and unnecessary restriction from competitive sports. This cross-sectional study evaluated 240 elite athletes (50% female; median age 28 years (25–32); ≥10 hours of exercise/week) from the ELITE study, in comparison to 80 age- and sex-matched healthy non-athletic controls and performed cardiovascular magnetic resonance (CMR) to evaluate T1 mapping and extracellular volume fraction (ECV). The results demonstrated that elite athletes had significantly lower native T1 values than controls (960 ± 21 ms vs. 983 ± 26 ms, P < 0.001). When analysed by sex, female athletes exhibited higher T1 values than male athletes (968 ± 20 ms vs. 953 ± 19 ms), yet the reduction in T1 compared to non-athletic controls was evident in both sexes. Multivariate analysis identified elite athlete status, heart rate, left ventricular wall thickness, and native blood pool T1 as independent predictors of native T1 (adjusted R² = 51.4%). The authors conclude that elite athletes, regardless of sex, have lower native T1 values compared to non-athletes, likely reflecting physiological cardiac remodeling rather than disease. These findings emphasize the need for athlete- and sex-specific reference ranges when interpreting T1 mapping in athletic populations to avoid misdiagnosis of cardiac pathology.

Keywords: cardiovascular magnetic resonance; T1 mapping; tissue characterization; exercise-induced cardiac remodeling; elite athletes; sports cardiology.

Lay summary: This study used CMR to understand whether the heart of elite athletes in comparison to non-athletes shows different results, regarding T1 mapping. The researchers scanned 240 elite athletes and 80 healthy non-athletes and found that athletes had lower T1 values, which is a normal sign of how their hearts adapt to regular intense exercise. This was true for both men and women. Endurance athletes show more pronounced myocardial adaptations, reflected in lower T1 values. The results mean that doctors should use different “normal” ranges for these scans when checking athletes’ hearts, so they don’t mistake healthy athletic changes for heart disease, especially in female athletes.

LGE features predict the risk of life-threatening ventricular arrhythmias in patients with biopsy-proven sarcoidosis 

Azzu A, Antonopoulos AS, Okafor J, et al.

Extent and Features of Late Gadolinium Enhancement Stratify Arrhythmic Risk in Patients With Biopsy-Proven Sarcoidosis.

JACC Cardiovasc Imaging 2025; 18:768-780; https://doi.org/10.1016/j.jcmg.2025.02.012

 
The study cohort included 324 patients with biopsy-proven sarcoidosis, representing one of the largest available cohorts. LGE extent, pattern, and location were analysed. The primary endpoint was ventricular tachycardia (VT) or ventricular fibrillation (VF) or appropriate device therapy. Secondary endpoints were hospitalization for heart failure (HF) or heart transplantation (HTx) and all-cause mortality. Over a 4.6-year follow-up, 30 patients (9.3%) reached the primary endpoint. HF/HTx occurred in 15 patients (4.6%) and all-cause mortality in 41 (12.7%). LGE extent was independently predictive of the primary endpoint (per SD change: HR: 1.03), but not of HF/HTx or all-cause mortality. Further to LGE extent, LGE on the right ventricular (RV) septum (HR: 5.43, P < 0.001), RV free wall (HR: 4.30, P < 0.001), and multifocal LGE (HR: 4.62, P < 0.001) were strongly predictive of the arrhythmia endpoint. Based on these findings, the authors proposed an algorithm that identifies 4 patient subgroups and stratifies well the arrhythmia risk in biopsy-proven sarcoidosis patients. Compared with the Heart Rhythm Society classification system, this approach significantly enhanced model performance and risk discrimination, and reclassified 43% of the population (9% to higher and 34% to lower risk categories).

Keywords: cardiac sarcoidosis; cardiovascular magnetic resonance; tissue characterization; fibrosis; late enhancement; arrhythmias; sudden death; heart failure; prognosis.

Lay summary: This study is based in one of the largest available cohorts of patients with biopsy-proven sarcoidosis and myocardial scarring. The Authors proposed an algorithm for arrhythmic risk stratification based on systolic function and scaring extent, as well as the presence of high-risk scarring features. Patients with biopsy-proven sarcoidosis who show left ventricular systolic function (LVEF) >50% and scarring extent <7.4% in the absence of high-risk features have a low risk of developing life-threatening ventricular arrhythmias. All patients with LVEF >50% and high-risk features have a high arrhythmic risk independently from extent and should be considered for defibrillator implantation for primary prevention of sudden cardiac death.

Margonato D, Koike H, Fukui M, et al.

Severe Aortic Stenosis With High Noncalcific Aortic Valve Volume: A Novel Marker of Myocardial Fibrosis.

JACC Cardiovasc Imaging 2025; 18:928 – 930; https://doi.org/10.1016/j.jcmg.2025.03.012

The study aimed to assess with cardiac computed tomography angiography (CCTA), the calcific and non-calcific fibrotic remodeling of the aortic valve (AV) in patients with severe aortic stenosis and to evaluate whether the type of AV remodeling is associated with myocardial fibrosis assessed by left ventricular (LV) myocardial extracellular volume (m-ECV). Out of the 280 AS patients who had a CCTA (3rd generation, dual-source Somaton Force, Siemens) and echocardiography from 2020 till 2022, 91 (83 years old, 48% female, 55% atrial fibrillation, 37% low-flow low-gradient AS) were randomly included in the current analysis. For the AV calcific and fibrotic burden and the m-ECV a dedicated software by 3MensioStructural Heart v10.4 was applied. The ratio of AV non-calcific to calcific volume (NC/C) was evaluated and the cohort was divided in 2 groups according to the median value of this ratio. The patients with high NC/C ratio had significantly smaller AV area, higher E/E’ ratio, increased LV relative wall thickness, larger left atrial volume index, worse LV longitudinal strain and higher LV m-ECV. In multivariable analysis, NC/C ratio > median was independently associated with elevated m-ECV, even after adjustment for age, gender, and AV area (OR: 3.69 [95% CI: 1.47-9.28]; P= 0.005). In conclusion, the NC type of AV remodeling in aortic stenosis presented with worse LV structural and functional abnormalities; increased myocardial fibrosis and elevated filling pressures.

Keywords: cardiac CT; CCTA; aortic stenosis; aortic valve calcification; non-calcified aortic stenosis; myocardial fibrosis.

Lay summary: In patients with aortic stenosis, the AV remodeling can be either due to calcific deposition or due to leaflet fibrosis. The current study highlights that the ratio of NC/C volume has to be evaluated and if it is > 0.96, the LV myocardial structure and function will be more impaired maybe due to co-existing myocardial or systemic pathologies beyond the calcification and atherosclerosis process. The more fibrotic and less calcific AV remodeling in aortic stenosis, is associated with LV eccentric remodeling, higher LV myocardial fibrosis, assessed by m-ECV, and elevated LV filling pressures indicating that there may be further therapeutic targets beyond the AV replacement. The current study is a proof of concept that both the valve, AV morphology and structure, and the ventricle, LV myocardial fibrosis and function, should be evaluated in AS, to raise awareness of the underlying pathophysiology and drive the therapeutic strategy.

Albertini T, Dörner M, Giannopoulos AA, et al.

Association between inflammatory biomarkers, chronic stress, and pericoronary adipose tissue attenuation obtained with coronary CT.

Eur Heart J - Cardiovascular Imaging 2025; jeaf217; https://doi.org/10.1093/ehjci/jeaf217

Pericoronary adipose tissue (PCAT) attenuation is a novel imaging biomarker of coronary inflammation associated with an increased risk of coronary artery disease (CAD). The current analysis studied the association of PCAT attenuation of the right coronary artery, with inflammatory biomarkers including interleukin-6 (IL-6) and tumour necrosis factor-a (TNF- α), chronic stress measured by hair cortisol concentration (HCC), coronary total plaque volume (TPV), artery stenosis and high-risk features. A total of 98 participants without known CAD were included. IL-6, TNF-α, and a greater TPV were significantly associated with PCAT attenuation, while the vulnerable plaque features or the coronary stenosis were not. HCC moderated the relationship between IL-6, but not TNF-α, and PCAT attenuation. In conclusion, increased PCAT attenuation was indicative of high TPV but not stenosis severity. IL-6 and TNF-α were significantly and independently associated with elevated PCAT attenuation with the effect of IL-6 being moderated by chronic stress.

Keywords: CT; CCTA; pericoronary adipose tissue attenuation; coronary artery disease; total plaque burden; inflammation; chronic stress; IL-6; TNF- α.

Lay summary: In patients without known CAD, PCAT attenuation evaluated by CCTA at the proximal right coronary artery is indicative of coronary inflammation since well-known inflammatory biomarkers such as IL-6 and TNF-α are associated with it. Additionally, high PCAT attenuation was associated with greater TPV but not with coronary stenosis severity and vulnerable plaque features. These findings suggest that high PCAT attenuation is an early sign of atherosclerosis, that precedes obstructive CAD, identifying the early stages of the CAD disease and highlighting the potential role of inflammation in the disease progression. Another important finding of the study is that chronic stress, expressed by the elevated cortisol, has moderating effects on PCAT attenuation and inflammatory biomarkers, raising the question whether cortisol accelerates the advancement of atherosclerosis. Thus, coronary inflammation could be a therapeutic target in the early stages of CAD and PCAT attenuation could be used as a specific marker of vascular inflammation to test the effects of novel therapeutics and psychosocial interventions, enhancing the prevention of atherosclerosis and overt CAD.

Kwan AC, Tzolos E, Klein E, et al.

Pericoronary Adipose Tissue Attenuation in Patients with Future Acute Coronary Syndromes: The ICONIC Study.

Radiol Cardiothorac Imaging 2025; 7:e240200; https://doi.org/10.1148/ryct.240200

This retrospective case–control analysis from the ICONIC study evaluated whether pericoronary adipose tissue attenuation (PCATa) measured by coronary CT angiography (CCTA) independently predicts future acute coronary syndromes (ACS). From 234 matched case–control pairs, 200 analyzable pairs (400 patients, 1,174 vessels) were included. PCATa was calculated around proximal coronary segments and adjusted for fat attenuation. While mean PCATa values did not differ significantly between ACS cases and matched controls (−72.99 ± 9.42 HU vs −73.96 ± 9.47 HU; P = 0.08), multivariable Cox models showed PCATa was modestly but significantly associated with ACS risk after adjusting for noncalcified plaque volume (HR 1.015; 95% CI 1.001–1.028), total plaque volume (HR 1.015; 95% CI 1.002–1.029), and stenosis/high-risk plaque features (HR 1.014; 95% CI 1.000–1.028). Findings suggest that while PCATa differences are quantitatively small in matched populations, elevated PCATa confers a slight independent risk of ACS beyond conventional CCTA metrics.

Keywords: CT-Angiography; Pericoronary Adipose Tissue Attenuation; Coronary Arteries; Acute Coronary Syndrome; Cardiovascular Risk; Inflammation; Noncalcified Plaque; ICONIC Study.

Lay summary: This study explored whether a CT scan measure of fat surrounding coronary arteries—called pericoronary adipose tissue attenuation (PCATa)—can predict future heart attacks. Researchers compared over 200 people who later had acute coronary syndromes with matched controls who did not. Average PCATa values were very similar between the two groups. However, after accounting for other artery findings, higher PCATa was linked to a slightly higher risk of future heart problems. This suggests PCATa might provide extra information for risk assessment, but it is not strong enough on its own to clearly identify who will have a heart attack.

Plaque Progression in Lean Individuals on a Ketogenic Diet: Findings From the KETO-CTA Study

Soto-Mota A, Norwitz NG, Manubolu VS, et al.

Longitudinal Data From the KETO-CTA Study: Plaque Predicts Plaque, ApoB Does Not..

JACC Adv 2025; 4:101686; https://doi.org/10.1016/j.jacadv.2025.101686

This prospective one-year follow-up study evaluated predictors of coronary plaque progression in 100 metabolically healthy individuals on a ketogenic diet (KD) who developed marked LDL-C elevation (≥190 mg/dL), high HDL-C (≥60 mg/dL), and low triglycerides (≤80 mg/dL). Participants underwent baseline and follow-up coronary artery calcium scoring and coronary computed tomography angiography. Despite high median ApoB (178 mg/dL) and LDL-C (237 mg/dL) levels, baseline total plaque burden was low. Over 12 months, median increases in noncalcified plaque volume (NCPV) and percent atheroma volume (PAV) were 18.9 mm³ and 0.8%, respectively. Neither baseline ApoB, change in ApoB, nor cumulative LDL-C exposure were associated with changes in plaque metrics; Bayesian analysis strongly favoured the null hypothesis of no association. In contrast, all baseline plaque measures were strongly predictive of plaque progression. These findings suggest that in this lean, low-risk KD cohort, existing plaque burden—not ApoB—drives short-term progression.

Keywords: ketogenic diet; LDL cholesterol; ApoB; coronary computed tomography angiography; plaque progression; lean mass hyper-responder; atherosclerosis.

Lay summary: This study followed 100 healthy, lean people on a ketogenic diet who developed very high LDL cholesterol but had little existing plaque in their heart arteries. Over one year, small increases in artery plaque were observed. Surprisingly, the amount of ApoB or LDL cholesterol in the blood—either at the start or over time—did not predict plaque growth. Instead, the best predictor was how much plaque a person already had at the beginning. In this group, high cholesterol alone did not appear to drive short-term plaque buildup.

Quality of Life and Angina Outcomes After CT or Invasive Coronary Angiography in Stable Chest Pain: Secondary Analysis of the DISCHARGE Trial

DISCHARGE Trial Group: Rieckmann N, Neumann K, Maurovich-Horvat P et al.

Health Status Outcomes After Computed Tomography or Invasive Coronary Angiography for Stable Chest Pain: A Prespecified Secondary Analysis of the DISCHARGE Randomized Clinical Trial.

JAMA Cardiol 2025; 10:728-739; https://doi.org/10.1001/jamacardio.2025.0992

This prespecified secondary analysis of the DISCHARGE randomized clinical trial compared long-term health status outcomes in patients with stable chest pain and intermediate pretest probability of coronary artery disease who underwent either computed tomography (CT) or invasive coronary angiography (ICA) as their initial diagnostic strategy. Conducted at 26 European centers, 3,561 patients (mean age 60 years; 56% female) were followed for a median of 3.5 years. Quality of life (QOL) was assessed using EQ-5D-3L and SF-12 physical and mental component scores; angina status was also evaluated. Both groups experienced significant improvements in most QOL measures, with no significant differences between CT and ICA, except for depression scores (HADS-D), which improved only in the CT group. Women had worse baseline and follow-up QOL than men but showed greater relative improvement in some measures. Angina prevalence at 3.5 years was similar between groups. These results suggest comparable long-term health status and symptom outcomes for CT- and ICA-first strategies, with persistent sex differences in QOL.

Keywords: stable chest pain; computed tomography; invasive coronary angiography; quality of life; angina; DISCHARGE trial; sex differences; coronary artery disease.

Lay summary: This study followed over 3,500 people with stable chest pain for more than three years to compare two diagnostic approaches: a CT scan of the heart or an invasive test called coronary angiography. Both groups reported better quality of life and fewer symptoms over time, and the results were similar between the two strategies. Women generally had worse quality of life than men at the start and after follow-up, although they tended to improve more in some areas. The choice between CT or angiography did not change these patterns, suggesting either approach can be effective for long-term health status.

Yuan J, Ding X, Yang W et al.

The impact of lipoprotein(a) level on cardiac pathologies in diabetes: a cardiac CT study.

Eur Radiol 2025; 35:220-231; https://doi.org/10.1007/s00330-024-10903-4

This prospective observational study investigated the association between lipoprotein(a) [Lp(a)] levels and multiple cardiac CT parameters in diabetic patients. Over a 20-month period, 207 participants (mean age 59.1 years; 54% male) underwent coronary CT angiography, stress CT myocardial perfusion imaging, and late iodine enhancement. Patients were classified as having elevated (≥30 mg/dL) or normal Lp(a) levels. Elevated Lp(a) was associated with higher percent atheroma volume, increased prevalence of positive remodeling, spotty calcification, and high-risk plaques (HRPs). Multivariate analysis confirmed elevated Lp(a) as an independent predictor of HRPs (OR = 2.61). No significant group differences were observed in pericoronary adipose tissue density, stress myocardial blood flow, or extracellular volume fraction. These findings suggest that in diabetes, elevated Lp(a) contributes to more extensive coronary atherosclerosis and vulnerable plaque phenotype, but is not associated with perivascular inflammation, impaired perfusion, or interstitial fibrosis.

Keywords: diabetes; lipoprotein(a); computed tomography angiography; coronary atherosclerosis; high-risk plaque; myocardial perfusion; extracellular volume.

Lay summary: This study examined whether the blood fat lipoprotein(a) is linked to heart problems in people with diabetes. Using advanced CT scans, researchers found that those with higher lipoprotein(a) had more plaque in their heart arteries and more signs of dangerous plaque types. However, higher levels were not linked to heart muscle inflammation, reduced blood flow, or scarring. Screening for lipoprotein(a) may help identify diabetic patients at greater risk for severe artery disease.

Smiley DA, Einstein AJ, O'Gorman KJ, et al.

Early Detection of Transthyretin Cardiac Amyloidosis Using ¹²⁴I-Evuzamitide Positron Emission Tomography/Computed Tomography

JACC Cardiovasc Imaging 2025; 18:799-811; https://doi.org/10.1016/j.jcmg.2025.01.018

This study evaluates the diagnostic performance of a novel direct amyloid-binding positron emission tomography (PET) radiotracer ¹²⁴I-evuzamitide in detecting transthyretin cardiac amyloidosis (ATTR). Among 25 ATTR patients, PET detected myocardial uptake in all biopsy-confirmed cases and in several patients with extracardiac evidence of ATTR. In particular, 11 subjects with ATTR and Perugini grade 0 or 1 ^99mTc-pyrophosphate cardiac scans had cardiac uptake of 124I-evuzamitide, suggesting that 124I-evuzamitide PET/CT imaging may detect ATTR amyloid deposits earlier than ^99mTc-pyrophosphate cardiac scintigraphy. Uptake levels correlated with disease stage, echocardiographic findings, and quality-of-life scores. These results suggest that ¹²⁴I-evuzamitide PET is a promising radiotracer for early detection and monitoring of ATTR amyloid burden.

Keywords: Cardiac amyloidosis; ATTR; PET; Nuclear Imaging; evuzamitide

Lay summary: This study tested a new imaging method for detecting a heart condition called transthyretin cardiac amyloidosis (ATTR). This condition involves abnormal protein buildup in the heart. The study used a PET scan with a new tracer molecule called ¹²⁴I-evuzamitide, which binds directly to amyloid proteins like a dye used in microscopy. Radioactive labeling enables the imaging and tracking of molecules inside the patient’s body. Among 25 patients, the scan detected ATTR heart involvement, which was related to the severity of the disease and the patient's quality of life. This new method seems promising in the early diagnosis and monitoring of ATTR disease.

Scherping SC 3rd, Ahmad SM, Katz SM, et al.

The prevalence and prognostic impact of additive abnormal stress exercise markers in patients with normal stress myocardial perfusion imaging

J Nucl Cardiol 2025; 50:102267; https://doi.org/10.1016/j.nuclcard.2025.102267

This single-centre retrospective study examined 892 patients with normal SPECT perfusion (defined as normal myocardial perfusion and no ischemic electrocardiogram ST segment depression) to evaluate the prognostic value of abnormal exercise stress markers in these patients. These markers included poor functional capacity, heart rate response, heart rate recovery, hemodynamic response, and blood pressure at exercise. They found that 65% of patients had at least one abnormal marker, and 10% had three or more. Each additional abnormal marker was associated with a stepwise increase in the risk of adverse cardiac events, including death and non-fatal myocardial infarction. Patients with three or more markers had a hazard ratio of 2.4 for future events, even after adjusting for traditional risk factors. The findings suggest that exercise stress markers provide valuable additional prognostic information beyond perfusion imaging results. Incorporating these markers into routine assessment may improve risk stratification.

Keywords: SPECT; Myocardial perfusion imaging; Nuclear imaging; Exercise stress

Lay summary: Imaging of heart blood flow is a standard nuclear medicine test to detect coronary artery disease. This study evaluated the additional value of standard exercise stress test variables for better risk stratification in 892 patients with a normal heart scan. Simple exercise stress values of exercise tolerance, heart rate elevation response, and blood pressure at exercise were beneficial for risk stratification of these patients. Each abnormal exercise marker improved the prediction of death or future myocardial infarction. These findings might help doctors to better evaluate patients’ risk.

Interaction between left ventricular cavity size and transient ischaemic dilation ratio in female patients with normal dipyridamole stress single-photon emission computerized tomography myocardial perfusion imaging

Chun Hui Sharmaine Wong, Min Sen Yew.

Relationship between left ventricular cavity size and transient ischaemic dilation ratio on dipyridamole stress single-photon emission computerized tomography myocardial perfusion imaging in a female Asian population

Eur Heart J - Imaging Methods and Practice 2025; qyaf102; https://doi.org/10.1093/ehjimp/qyaf102

This study aimed to assess the factors associated with increasing transient ischemic dilations (TID) on single-photon emission computed tomography (SPECT) myocardial perfusion imaging in female Asian patients with otherwise normal left ventricular (LV) structure and function and without inducible myocardial ischemia. Accordingly, 107 female patients with clinical indication for SPECT MPI and otherwise normal scans were selected and further classified according to the presence of small LV cavity size at rest (i.e., end-diastolic volume <20th percentile of the overall study population). The TID was computed by comparing the endocardial LV volumes measured in ungated post stress and rest short axis images. The threshold for small LV cavity as defined by gated LV EDV below the lowest quintile of the overall population was calculated to be 36.6 mL. No differences in the prevalence of major cardiovascular risk factors present among patients with «normal» or «small» LV cavity size. The mean TID was significantly greater for patients with smaller LV cavity size compared to patients with non-small LV cavity size (1.33 ± 0.11 vs 1.28 ± 0.07, p=0.042). There was a significant negative correlation between rest EDV and TID (r = - 0.34, p< 0.001), which remained significant after controlling for age, BMI, resting LVEF, and major cardiovascular risk factors (r = –0.35, p < 0.001).

The study concludes that there was a significant inverse correlation between gated LV EDV and TID amongst Asian females with otherwise normal dipyridamole stress SPECT MPI, whereby females with smaller LV cavities exhibited a higher mean TID compared to those with larger ventricles.

Keywords: SPECT, MPI, transient ischemic dilation, female gender, LV volume

Lay summary: This study assessed whether patients’ demographic, clinical as well as LV functional and structural variables could predict the development and magnitude of TID in female patients with otherwise normal SPECT MPI results. The main results were that, after extensive statistical correction for possible confounders, the presence of a “smaller” resting LV cavity resulted the main determinant of TID, whereby LV with a EDV lower than ≈36 ml might develop a significantly increased TID if compared to larger ventricles.  Present findings highlight LV cavity size as a potential confounder to the interpretation of TID in females, suggesting that clinicians should interpret single TID values in context, integrating clinical presentation and other diagnostic data before reaching a final conclusion.

Sayed A, Al Rifai M, Alwan M, et al.

The prognostic interplay between PET-derived resting myocardial blood flow and left ventricular ejection fraction

Eur Heart J - Cardiovascular Imaging 2025; 26:1333–1342; https://doi.org/10.1093/ehjci/jeaf132

This study aimed to assess whether the prognostic value of either resting myocardial blood flow (MBF) and flow reserve (MFR), assessed at stress/rest myocardial perfusion imaging (MPI) using Rb82 positron emission tomography (PET) were influenced by left ventricular (LV) systolic function. To this purpose, 8089 consecutive patients with a clinical indication for Regadenoson stress Rb82 PET were followed-up for the occurrence of a composite of death and heart failure (HF) hospitalizations for a median of 519 days (IQR: 186–916 days). At follow-up, 466 deaths and 819 HF hospitalizations occurred. The 50th percentile of MBFrest/MFR served as the reference (0.88 ml/min/g and 2.05, respectively). After adjusting for traditional risk factors and other PET parameters, both high MBFrest and low MFR were associated with an increased risk of the primary outcome (HRs of 1.39 and 1.70, respectively). Interestingly, a significant prognostic interaction with EF for both MBFrest and MFR existed, with greater prognostic value at higher LV ejection fraction (EF) values. In particular, at EFs of 40%, 50%, 60%, 70% the HRs for high vs. low MBFrest were 1.24, 1.61, 1.97, and 2.46, respectively and for low vs. high MFR were 1.57, 2.06, 2.59, and 3.13, respectively. The Authors concluded that, the prognostic value of MBFrest and MFR is more evident at higher EF values, with a higher MBFrest carrying a greater risk of death or HF hospitalization at constant MFR values.

Keywords: PET, MPI, rubidium, myocardial blood flow at rest, myocardial flow reserve, LV ejection fraction, prognosis

Lay summary: This study assessed whether the prognostic value of MBFrest - surrogate for myocardial oxygen demand - and MFR vary across the spectrum of LV EF values. Accordingly, it was demonstrated that LVEF modifies the prognostic impact of absolute myocardial perfusion parameters at Rb82 PET, demonstrating that both higher MBFrest and lower MFR values had a more pronounced association with future events (death or HF hospitalization) at higher EFs. Interestingly, even in patients with a preserved LV EF, the presence of an elevated MBFrest or an impaired MFR, harbours a similar risk to overt systolic dysfunction. Furthermore, a relatively elevated MBFrest carries an elevated risk for future events, even when microvascular function is normal (i.e., in the presence of normal MFR values). In conclusion, impaired MBFrest and MFR values, even in the presence of a preserved LV systolic function, identify patients at a substantially higher risk of poor outcome.

Thommen K, Frey SM, Kammerer D, et al. on behalf of, the BARDOT investigators.

Prognostic value of myocardial perfusion imaging in asymptomatic high-risk diabetic patients: 10-year follow-up of the prospective multicentre BARDOT trial

Eur Heart J - Cardiovascular Imaging 2025; 26:1130–1139; https://doi.org/10.1093/ehjci/jeaf126

In order to ascertain the usefulness of screening asymptomatic patients with type 2 diabetes mellitus (T2DM) for myocardial ischaemia, this study enrolled 400 asymptomatic high-risk T2DM patients without history of CAD (mean age 63 ± 8 years; 69% male), who underwent screening with Single Photon Emission Computed Tomography (SPECT). Abnormal SPECT was defined as Summed Stress Score ≥ 4 or Summed Difference Score ≥ 2. Patients were followed for all-cause mortality and major adverse cardiovascular events (MACE, cardiovascular mortality + myocardial infarction). Baseline SPECT was abnormal in 22% of patients. During 11.1-year (8.8-12,8) follow-up, abnormal SPECT was associated with higher all-cause mortality [hazard ratio (HR) 1.614, P = 0.029] and MACE (HR 2.024, P = 0.009). A normal SPECT was associated with a significantly better prognosis (all-cause mortality 1.9 vs. 3.1%/year, P = 0.016; MACE 1.2 vs. 2.3%/year, P = 0.010). In the small subgroup of patients with abnormal SPECT, the treatment strategy (revascularization vs. conservative) had no effect on event-free survival. SPECT perfusion imaging represents a valuable tool for advanced risk stratification in asymptomatic high-risk T2DM patients, but definite evidence on the benefit of revascularization is still lacking.

Keywords: SPECT; myocardial perfusion; ischaemia; diabetes; prognosis; revascularization

Lay summary: Cardiovascular disease is a major issue for people with type 2 diabetes (T2DM), but it's not clear whether screening those without symptoms is helpful. This study followed 400 high-risk, asymptomatic T2DM patients for over 11 years to see if a cardiac imaging test called SPECT could predict their long-term health.

The results showed that patients with an abnormal SPECT scan were at a higher risk of death and major cardiovascular events (like heart attacks) compared to those with a normal scan. This suggests that SPECT is a useful tool for identifying T2DM patients who are at higher risk. Interestingly, for those with an abnormal scan, there was no clear benefit to undergoing a procedure to open up their arteries (revascularization) compared to just managing their condition with medication.

Souza ACDAH, Troschel AS, Marquardt JP, et al.

Skeletal muscle adiposity, coronary microvascular dysfunction, and adverse cardiovascular outcomes

Eur Heart J 2025; 46:1112–1123; https://doi.org/10.1093/eurheartj/ehae827

Skeletal muscle (SM) fat infiltration, or intermuscular adipose tissue (IMAT), reflects muscle quality and is associated with inflammation, a key determinant in cardiometabolic disease. Coronary flow reserve (CFR), a marker of coronary microvascular dysfunction (CMD), is independently associated with body mass index (BMI), inflammation, and risk of heart failure, myocardial infarction, and death. In this study, 699 consecutive patients undergoing evaluation for coronary artery disease with cardiac stress positron emission tomography demonstrating normal perfusion and preserved left ventricular ejection fraction were followed over a median of 6 years for major adverse cardiovascular events (MACE), including death and hospitalization for myocardial infarction or heart failure. Subcutaneous adipose tissue (SAT), SM, and IMAT areas (cm2) were obtained from simultaneous PET attenuation correction computed tomography using semi-automated segmentation at the 12th thoracic vertebra level. Nearly half of patients were obese, and BMI correlated highly with SAT and IMAT, and moderately with SM. Decreased SM and increased IMAT, but not BMI or SAT, remained independently associated with decreased CFR. In adjusted analyses, both lower CFR and higher IMAT were associated with increased MACE (HR 1.78 and 1.53, adjusted P =0.002 and P <0.0001, respectively), while higher SM and SAT were protective (HR 0.89 and 0.94, adjusted P =0.01 and P =0.003, respectively). Every 1% increase in fatty muscle fraction (IMAT/[SM + IMAT]) conferred an independent 2% increased odds of CMD and a 7% increased risk of MACE.

The Authors conclude that increased IMAT is associated with CMD and MACE independently of BMI and conventional risk factors. The presence of CMD and SM fat infiltration identifies a novel at-risk cardiometabolic phenotype.

Keywords: Adiposity; obesity; PET; Nuclear Imaging; microvascular dysfunction; prognosis.

Lay summary: This study demonstrated that having more fat woven into the skeletal muscles, a condition called intermuscular adipose tissue (IMAT), is a significant cardiovascular risk marker. Indeed, an increased amount of IMAT was associated with an impaired coronary microvascular function, but also with a higher risk for serious heart-related events, including death and heart attacks. Interestingly, this link was independent of body mass index (BMI), suggesting that body composition is a more accurate predictor of heart disease risk than simply the overall amount of fat. In fact, the study showed that for every 1% increase in IMAT, the risk of a major heart event went up by 7%. This finding points to a new way of identifying people at high risk for heart disease, highlighting that fatty muscles combined with poor heart microvascular function creates a unique and dangerous health profile.