EACVI Research News – July 2023

How safe is transoesophageal echocardiography in structural heart disease intervention?

Shazia Afzal, Tobias Zeus, Timo Hofsähs, et al. Safety of transoesophageal echocardiography during structural heart disease interventions under procedural sedation: a single-centre study.

Eur Heart J Cardiovasc Imaging 2022; 24:68-77; https://doi.org/10.1093/ehjci/jeab280

The aim of this study was to determine the incidence of transoesophageal echocardiography (TOE)-related adverse events (AEs) during structural heart disease (SHD) interventions up to 3 months after intervention and to identify potential risk factors. Retrospective study of 898 consecutive patients undergoing TOE-guided SHD interventions under procedural sedation. TOE-related AEs were classified as bleeding complications, mechanical lesions, conversion to general anaesthesia with intubation, and the occurrence of pneumonia. TOE-related AEs were observed in 5.3% of the patients, being 8.2% in the group submitted to percutaneous mitral valve repair, 4.8% in the left atrial appendage closure group and 1.8% in the patent foramen ovale/atrial septal defect group. The most frequent AE was pneumonia with an incidence of 2.6% in the total cohort. Bleeding events occurred in 1.8% of the patients. A lower baseline haemoglobin level and an obstructive sleep apnoea were found to be associated with the occurrence of a TOE-related AE. Therefore, TOE-related AEs during SHD interventions are clinically relevant, particularly in patients undergoing mitral valve procedures.

ECHO

Transoesophageal echocardiography

Valvular heart disease

Structural heart diseases

Measurement of left atrial volumes by cardiovascular magnetic resonance is more accurate when using dedicated off-axis planes

 Tondi, L., Badano, L.P., Figliozzi, S. et al

The use of dedicated long-axis views focused on the left atrium improves the accuracy of left atrial volumes and emptying fraction measured by cardiovascular magnetic resonance

J Cardiovasc Magn Reson 2023; 25:10; https://doi.org/10.1186/s12968-022-00905-w

Left atrial (LA) volumes, emptying fraction and strain were measured in 108 consecutive patients by applying the biplane area-length algorithm to both standard and LA-focused 2- and 4-chamber cine images. Manual segmentation of a short-axis cine stack covering the LA was used as the reference method. Compared to the reference method, the standard approach significantly underestimated LA volumes and overestimated LA emptying fraction and strain; measurements from LA-focused cine images were similar to the reference method. CMR assessment of the LA using LA-focused long-axis cine imaging is quick, feasible and more accurate than standard long-axis cine imaging.

CMR

Atrial volume; atrial strain; off-axis imaging

Normal/healthy people

Normal; healthy; volunteers

What is the impact of secondary mitral regurgitation in CRT patients on left atrial function?

Jan Stassen, Xavier Galloo, Kensuke Hirasawa, et al. Interaction between secondary mitral regurgitation and left atrial function and their prognostic implications after cardiac resynchronization therapy

Eur Heart J Cardiovasc Imaging 2023; 24:532-541; https://doi.org/10.1093/ehjci/jeac149

The study's aim was to assess the interaction between a reduction in mitral regurgitation severity and an increase in left atrial function in patients with heart failure submitted to cardiac resynchronisation therapy. The authors included 340 patients, of whom 59% showed improvement in mitral regurgitation at 6 months. This improvement was independently associated with an increase in left atrial reservoir strain. Moreover, an increase in left atrial reservoir strain was significantly associated with lower all-cause mortality and this, associated with mitral regurgitation improvement, had the best outcome.

ECHO

Left atrial function; strain

Heart failure

Mitral regurgitation; cardiac resynchronisation therapy

What are the echocardiographic predictors for early intervention in asymptomatic tricuspid regurgitation?

Emmanuel Akintoye, Tom Kai Ming Wang, Michael Nakhla, et al. Quantitative Echocardiographic Assessment and Optimal Criteria for Early Intervention in Asymptomatic Tricuspid Regurgitation

JACC Cardiovasc Imaging 2023; 16:13-24; https://doi.org/10.1016/j.jcmg.2022.08.004

The aim of the study was to evaluate the prognostic value of echocardiographic parameters to support early intervention in asymptomatic patients with tricuspid regurgitation (TR). The Authors searched the Cleveland Clinic echocardiography database from 2004 to 2018, and identified 325 asymptomatic patients, 79.4% female, with at least 3+ TR. There were 132 deaths (40.6%), with a median survival time of 9.9 years (95% CI: 7.9-12.7 years). The median survival time in an age- and sex-matched cohort of symptomatic TR patients was 4.4 years (95% CI: 2.8-5.9 years). The echocardiographic parameters that were found to be the strongest predictors of all-cause mortality were right ventricle free wall strain and tricuspid regurgitant volume, with a cut-off of <−19% and >45 mL, respectively. Therefore, the authors concluded that both are key prognostic markers that can be serially monitored to inform optimal timing of intervention for severe asymptomatic TR.

ECHO

Right ventricular strain; tricuspid regurgitation

Valvular heart disease

Tricuspid regurgitation

Machine learning and peak atrial longitudinal strain in diastolic dysfunction assessment

Erberto Carluccio, Matteo Cameli, Andrea Rossi, et al. Left Atrial Strain in the Assessment of Diastolic Function in Heart Failure: A Machine Learning Approach

Circ Cardiovasc Imaging 2023; 16:e014605; https://doi.org/10.1161/CIRCIMAGING.122.014605

The Authors aimed to test the hypothesis that a machine learning approach would be useful to include Peak atrial longitudinal strain (PALS) in diastolic dysfunction classification and refine prognostic stratification. They used a derivation cohort of 864 heart failure patients in sinus rhythm (heart failure with reduced ejection fraction, n=541; heart failure with mildly reduced ejection fraction, n=129; heart failure with preserved ejection fraction, n=194), and machine learning techniques were retrospectively applied to PALS and guideline-recommended diastolic variables. They analysed the outcome (death/heart failure rehospitalisation) of the identified diastolic dysfunction-clusters and compared them with that by guidelines-based classification. The algorithm was subsequently validated in a prospective cohort of 189 heart failure outpatients. Three distinct echocardiographic diastolic dysfunction-clusters were identified (cluster-1, n=212; cluster-2, n=376; cluster-3 DD, n=276), with modest agreement with guidelines-recommended classification (kappa=0.40; P<0.001). They were predicted by a simple algorithm including E/A ratio, left atrial volume index, E/e′ ratio, and PALS. After 36.5±29.4 months follow-up, 318 events occurred. Compared to guideline-based classification, DD-clusters showed a better association with events in multivariable models, without interaction with ejection fraction category. In the validation cohort, cluster-based classification better predicted outcome than guideline-based classification. Therefore, integration of PALS in this algorithm improves risk stratification.

ECHO

Left atrial function; strain

Heart failure

Diastolic dysfunction

New normative values of the aortic valve

Juan I Cotella, Tatsuya Miyoshi, Victor Mor-Avi, et al. Normative values of the aortic valve area and Doppler measurements using two-dimensional transthoracic echocardiography: results from the Multicentre World Alliance of Societies of Echocardiography Study

Eur Heart J Cardiovasc Imaging 2023; 24:415-423; https://doi.org/10.1093/ehjci/jeac220

The authors evaluated sex-, age- and race-specific normative values for aortic valve area (AVA) and Doppler parameters in 1903 healthy adult subjects (48% women) from the World Alliance Societies of Echocardiography Study. Compared with men, women had smaller left ventricular outflow tract (LVOT) diameters and AVA values, and higher peak velocities and mean gradients. LVOT and aortic VTI were significantly higher in women, and it increased with age in both sexes. AVA differences persisted after indexing to body surface area. According to the current diagnostic criteria, 13.5% of women would have been considered to have mild aortic stenosis and 1.4% moderate aortic stenosis. LVOT diameter and AVA were lower in older subjects, both men and women, and were lower in Asians, compared with whites and blacks. Besides providing normative values of aortic valve parameters according to sex, age, and race, this study highlights the need for updating current guidelines for the management of aortic stenosis.

ECHO

Doppler; VTI; LVOT

Valvular heart disease

Aortic valve

Prevalence of coronary microcirculatory dysfunction and cerebral small vessel disease in patients with coronary artery disease

Mejia-Renteria H, Travieso A, Matías-Guiu JA, et al. Coronary microvascular dysfunction is associated with impaired cognitive function: the Cerebral-Coronary Connection study (C3 study).

Eur Heart J 2023; 44:113-125; https://doi.org/10.1093/eurheartj/ehac521

In 67 patients with coronary artery disease (CAD), patients with impaired coronary flow reserve (<2.0) showed higher burden of white-matter abnormalities, lower grey matter volume, higher resistive and pulsatility in transcranial Doppler and worse neurocognitive test scores. These findings support the hypothesis that microvascular dysfunction in the heart and the brain are part of a single pathological process affecting microcirculation in patients with CAD.

MULTIMODAL

Intracoronary doppler, brain MR, transcranial doppler

Vascular diseases

Coronary microvascular dysfunction; brain microvascular dysfunction

Adherence to the 2019 guidelines on chronic coronary syndromes is associated with fewer, more appropriate invasive procedures

EURECA Investigators. Use of cardiac imaging in chronic coronary syndromes: the EURECA Imaging registry.

Eur Heart J 2023; 44:142-158; https://doi.org/10.1093/eurheartj/ehac640

The EURECA registry included 5156 patients with known or suspected chronic coronary syndromes recruited in 73 European centres between 2019 and 2020. A lower proportion of invasive coronary angiographies (ICA) (15% vs. 48%) and of revascularisations (8% vs. 19%) were performed in the 56% of patients in whom guidelines recommendations were adopted as compared to the remaining 44%. In patients managed according to guidelines, ICA more frequently documented obstructive coronary artery disease (60% vs. 39%) leading to revascularisation (54% vs. 37%); they also experienced higher quality of life, fewer additional testing, and longer times to late revascularisation.

MULTIMODAL

CTCA, nuclear stress perfusion Imaging, stress echocardiography, stress CMR, invasive coronary angiography

Chronic ischaemic heart disease

Chronic coronary syndromes

Low-density lipoprotein cholesterol is associated with atherosclerotic events only in patients with evidence of coronary atherosclerosis

Martin Bødtker Mortensen, Omar Dzaye, Hans Erik Bøtker, et al. Low-Density Lipoprotein Cholesterol Is Predominantly Associated With Atherosclerotic Cardiovascular Disease Events in Patients With Evidence of Coronary Atherosclerosis: The Western Denmark Heart Registry

Circulation 2023; 147:1053-1063; https://doi.org/10.1161/CIRCULATIONAHA.122.061010

The study included 23,132 patients from the Western Denmark Heart Registry referred to coronary computed tomography angiography (CTA). During a median follow-up of 4.3 years, myocardial infarction and ischaemic stroke occurred in 552 patients and were associated with LDL-cholesterol in the 10,792/23,132 patients (47%) with calcium score >0 (aHR, 1.18 [95% CI, 1.06–1.31]), while no association was observed among the 12,340 patients (53%) with calcium score=0 (aHR, 1.02 [95% CI, 0.87–1.18]), in whom diabetes, current smoking, and low high-density lipoprotein cholesterol levels were associated with future cardiovascular events.

CT

CTA and Calcium Score

Chronic ischaemic heart disease

Atherosclerotic cardiovascular disease (ASCVD); low-density lipoprotein cholesterol

Coronary inflammation assessed by peri-coronary adipose tissue attenuation on computed tomography angiography is associated with plaque vulnerability

Haruhito Yuki, MD; Tomoyo Sugiyama, MD, PhD; Keishi Suzuki, et al. Coronary Inflammation and Plaque Vulnerability: A Coronary Computed Tomography and Optical Coherence Tomography Study

Circ Cardiovasc Imaging 2023; 16:e014959; https://doi.org/10.1161/CIRCIMAGING.122.014959

The study included 474 patients (198 acute coronary syndromes and 276 stable angina pectoris) who underwent preintervention coronary computed tomography angiography and optical coherence tomography. Patients with higher peri-coronary adipose tissue attenuation (an index of coronary inflammation) had a higher prevalence of plaque vulnerability features on optical coherence tomography, including lipid-rich plaque (87.3% versus 77.8%; P=0.006), macrophage (76.2% versus 67.8%; P=0.041), microchannels (61.9% versus 48.3%; P=0.003), plaque rupture (38.1% versus 23.9%; P<0.001), and layered plaque (60.2% versus 50.0%; P=0.025). Vascular inflammation and plaque vulnerability are intimately related in patients with coronary artery disease.

CT

CTA; PCA; invasive OCT

Vascular diseases

Coronary plaques inflammation; vulnerability

Treating heart failure patients with empagliflozin for 12 weeks did not improve cardiac energetics: evidence from magnetic resonance spectroscopy

Moritz J. Hundertmark, Amanda Adler, Charalambos Antoniades, et al. Assessment of Cardiac Energy Metabolism, Function, and Physiology in Patients With Heart Failure Taking Empagliflozin: The Randomized, Controlled EMPA-VISION Trial

Circulation 2023; 147:1654-1669; https://doi.org/10.1161/CIRCULATIONAHA.122.062021

The EMPA-VISION (Assessment of Cardiac Energy Metabolism, Function and Physiology in Patients With Heart Failure Taking Empagliflozin) is a prospective, randomised, double-blind, placebo-controlled trial that enrolled 72 patients with symptomatic, nonischaemic heart failure (36 with with reduced ejection fraction, 36 with reserved ejection fraction). Compared with placebo, empaglifozin treatment for 12 weeks did not enhance the phosphocreatine:ATP ratio assessed by phosphorus magnetic resonance spectroscopy performed at rest and during peak dobutamine stress, nor serum metabolites assessed by mass spectrometry. The study suggests that the favourable effects of empagliflozin observed in patients with heart failure cannot be explained by the proposed “thrifty fuel hypothesis,”  but by other unknown mechanisms.

CMR

CMR spectroscopy

Heart failure

Metabolism; cardiac energetics

Plaque composition with compute tomography angiography provides incremental value for the prediction of ischaemia

Xu Wang, Inge J van den Hoogen, Steele C Butcher, et al. Importance of plaque volume and composition for the prediction of myocardial ischaemia using sequential coronary computed tomography angiography/positron emission tomography imaging.

Eur Heart J Cardiovasc Imaging 2023; 24:776-784; https://doi.org/10.1093/ehjci/jeac130

In 493 symptomatic patients with suspected coronary artery disease undergoing coronary computed tomography angiography (CCTA) and [15O]H2O positron emission tomography (PET), myocardial ischaemia on PET (defined as an absolute stress myocardial blood flow ≤2.4 mL/g/min in ≥1 segment) was detected in 153 (31%). Among CCTA parameters, diameter stenosis ≥50% and necrotic core volume were independently associated with myocardial ischaemia, while total plaque volume showed borderline significance. Assessing plaque composition with CCTA provides incremental value for the prediction of ischaemia when compared with stenosis alone.

NUCLEAR

CTA; PET

Chronic ischaemic heart disease

Coronary plaque; ischaemia

Additional value of cardiovascular magnetic resonance to stratify the risk for major arrhythmic events in ischaemic cardiomyopathy

 Pontone G, Guaricci AI, Fusini L et al. Cardiac Magnetic Resonance for Prophylactic Implantable-Cardioverter Defibrillator Therapy in Ischemic Cardiomyopathy

JACC Cardiovasc Imaging 2023; S1936-878X(23)00181-X; https://doi.org/10.1016/j.jcmg.2023.03.015

The DERIVATE (CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DebrillAtor ThErapy)-ICM registry is an international, multicenter study that assessed the additional value of cardiovascular magnetic resonance (CMR) to stratify the risk for major arrhythmic events in 861 patients with ischaemic cardiomyopathy and left ventricular ejection fraction <50%. During a median 3-year follow-up, left ventricular end-diastolic volume, ejection fraction and late gadolinium enhancement (LGE) mass were independent predictors.  A multiparametric CMR-guided approach identifies subjects at high risk for major arrhythmias, compared with the echocardiographic-based cutoff of 35%.

CMR

CMR; Echo

Chronic ischaemic heart disease

Ischemic heart disease; cardiac arrhythmias

Differentiation of physiological from pathological remodelling

 Letnes JM, Nes BM, Langlo KAR et al. Indexing cardiac volumes for peak oxygen uptake to improve differentiation of physiological and pathological remodelling: from elite athletes to heart failure patients

Eur Heart J Cardiovasc Imaging 2023; 24:721-729; http://dx.doi.org/10.1093/ehjci/jead034

Cardiovascular structures adapt to meet metabolic demands; these demands are related to body size and therefore commonly indexed to body surface area (BSA). However, the confounding effects of body size are not taken into consideration. In this study, other indexing measures, such as absolute peak oxygen uptake (VO2peak) and fat-free mass (FFM) were compared to BSA with the aim to discriminate pathological from physiological remodelling. Indexing LVEDV for VO2peak compared to BSA significantly improved the differentiation of physiological from pathological adaptations (P<0.001).

ECHO

Echo

Cardiomyopathies

Pathological remodelling; physiological remodelling

Novel wearable cardiac ultrasound

Hu H, Huang H, Li M et al. A wearable cardiac ultrasound imager

Nature 2023; 613:667-675; https://doi.org/10.1038/s41586-022-05498-z

In this study, a wearable ultrasonic device for continuous, real-time and direct cardiac function assessment was presented. Innovations in device design and material fabrication that improve the mechanical coupling between the device and human skin, allowing the left ventricle to be examined from different views during motion, were introduced.

ECHO

Wearable device; Continuous monitoring; real-time

Normal/healthy people

Normal; healthy; volunteers

Prognostic differences between functional atrial versus ventricular regurgitation

 Galloo X, Dietz M, Fortuni F et al. Prognostic implications of atrial vs. ventricular functional tricuspid regurgitation

Eur Heart J Cardiovasc Imaging 2023; 24:733-741; https://doi.org/10.1093/ehjci/jead016

This study shows that patients with atrial functional tricuspid regurgitation have significantly better survival compared with patients with ventricular functional tricuspid regurgitation independently of other clinical and echocardiographic characteristics. In particular, among 554 patients with severe functional tricuspid regurgitation, cumulative 10-year survival rates was 78% for the 129 patients with atrial functional tricuspid regurgitation  compared to 46% for the 425 patients with ventricular functional tricuspid regurgitation (log-rank P < 0.001).

ECHO

Echo

Valvular heart disease

Tricuspid regurgitation; valvular interventions

Prognostic impact of left ventricular global longitudinal strain in atrial mitral regurgitation

Meucci MC, Stassen J, Tomsic A et al. Prognostic impact of left ventricular global longitudinal strain in atrial mitral regurgitation

Heart 2023; 109:478-484; http://dx.doi.org/10.1136/heartjnl-2022-321698

In this study, the association of left atrial reservoir strain and left ventricular global longitudinal strain (LV GLS) with clinical outcomes in patients with atrial functional mitral regurgitation was investigated. Impairment of LV GLS was independently associated with worse outcomes. In particular, in 197 patients with at least moderate atrial functional mitral regurgitation, patients with impaired LV GLS (≤16.3%) had a significantly lower cumulative survival rate at 5 years, as compared with patients with LV GLS (>16.3%) (74% vs 93%, p<0.001). Conversely, left atrial reservoir strain was not significantly associated with patients’ outcome.

ECHO

Strain; atrial strain;

Valvular heart disease

Mitral valve regurgitation; global longitudinal strain

Noninvasive imaging of coronary artery thrombus using a novel glycoprotein IIb/IIIa receptor antagonist-based radiotracer

Tzolos E, Bing R, Andrews J, et al. Noninvasive In Vivo Coronary Artery Thrombus Imaging.

JACC Cardiovasc Imaging 2023; 16:820-832; https://doi.org/10.1016/j.jcmg.2022.10.002

The present study evaluated the feasibility of 18F-GP1 PET/CT, using a novel glycoprotein IIb/IIIa receptor antagonist-based radiotracer, to detect thrombus formation in coronary arteries in 49 patients with a recent acute myocardial infarction. In these patients, coronary 18F-GP1 uptake co-localized in 39 of the 49 culprit lesions (80%) with false negative results likely related to a higher time delay to scan performance and low thrombus burden in small caliber distal arteries. Interestingly, extracoronary cardiac 18F-GP1 uptake also included infarct-related intramyocardial uptake (35%) as well as left ventricular (8%) or left atrial (2%) thrombus. Authors concluded that 18F-GP1 PET/CT could inform the diagnosis, management, and treatment of patients with acute myocardial infarction.

Nuclear

Molecular imaging, PET

Acute ischaemic heart disease

Thrombosis

Deep learning coronary calcium scores predict cardiovascular risk similarly to manual quantification by experienced operators and can be obtained almost instantly

Pieszko K, Shanbhag A, Killekar A, et al. Deep Learning of Coronary Calcium Scores From PET/CT Attenuation Maps Accurately Predicts Adverse Cardiovascular Events

JACC Cardiovasc Imaging 2023; 16:675-687; https://doi.org/10.1016/j.jcmg.2022.06.006

This study evaluated the accuracy and prognostic abilities of a deep-learning (DL) model capable of fully automated coronary artery calcium (CAC) definition from PET CT attenuation correction (AC) scans. The model was trained in >9k expert-annotated CT scans and was tested in>4k patients from an external cohort with the occurrence of MACE at a mean follow-up of 4.3 years).  Automatic DL scoring required <6 seconds per scan, predicting cardiovascular risk similarly to standard CAC scores quantified manually by experienced operators. Specifically, the negative predictive values for MACE of zero CAC with standard (85%) and DL-derived (83%) CAC scores were similar (P = 0.19). Authors concluded that DL CAC scores derived from CTAC maps can be computed almost instantly, with no changes to PET/CT scanning protocol.

CT

Calcium Score; AI

Chronic ischaemic heart disease

Coronary atherosclerosis

Aortic valve calcium is associated with larger left ventricular mass, larger left atrial size and incident heart failure

Zhu F, Kaiser Y, Boersma E, et al. Aortic Valve Calcium in Relation to Subclinical Cardiac Dysfunction and Risk of Heart Failure.

Circ Cardiovasc Imaging 2023; 16:e014323; https://doi.org/10.1161/CIRCIMAGING.122.014323

This present study investigated the association between CT-assessed aortic valve calcium (AVC) with the presence of subclinical cardiac dysfunction, and with the development of heart failure (HF) at follow-up in a population of 2348 patients. Greater AVC (i.e. >800) associated with measure of adverse cardiac remodelling, such as larger LV mass and LA size. After 9.8 years of follow-up, compared to patients with AVC=0, those with AVC between 300 and 799 (subdistribution hazard ratio, 2.36 [95% CI, 1.32-4.19]) and AVC ≥800 (subdistribution hazard ratio, 2.54 [95% CI, 1.31-4.90]) were associated with a high risk of HF. Authors concluded that larger CT-assessed AVC is associated with adverse cardiac remodelling and predicts the development of HF.

CT

Aortic calcium

Heart failure

Aortic calcifications; incident HF

Current cardiovascular risk scores present limited accuracy in identifying people with increased coronary artery calcium score

Ties D, van der Ende YM, Pundziute G, et al. Pre-screening to guide coronary artery calcium scoring for early identification of high-risk individuals in the general population

Eur Heart J Cardiovasc Imaging 2022; 24:27-35; https://doi.org/10.1093/ehjci/jeac137

This present study evaluated the different cardiovascular risk estimators, including the “Systematic COronary Risk Estimation 2 (SCORE2)” to identify individuals with high coronary artery calcium score (CACS) – defined as either ≥100 or ≥ 300 – in the general population. Out of 6530 subjects, miss rate was 32 and 41% for pre-screening by moderate (≥5%) SCORE2 risk and 81 and 87% for high (≥10%) SCORE2 risk, for CACS ≥300 and CACS ≥100 respectively. Conversely, miss rate was only 8 and 11% for pre-screening by at least one CAD risk factor (obesity, hypercholesterolaemia, hypertension, diabetes, smoking, and family history of CAD), for CACS ≥300 and CACS ≥100 respectively. Authors concluded that the diagnostic yield of SCORE2 for identifying subjects with high CACS is modest.

CT

Calcium Score

Chronic ischaemic heart disease

Screening; CV risk

Warranty period for normal coronary computed tomography angiography is ≥10 years, while for non-obstructive coronary artery disease is 5 years

Jukema R, Maaniitty T, van Diemen P, et al. Warranty period of coronary computed tomography angiography and [15O]H2O positron emission tomography in symptomatic patients

Eur Heart J Cardiovasc Imaging 2023; 24:304-311; https://doi.org/10.1093/ehjci/jeac258

This present study assessed the event-free (warranty) period – defined as the time for which the cumulative event rate of death and non-fatal MI was below 5% – after a coronary CTA and the potential additional value of ischemia imaging with PET. Out of 2575 subjects with suspected CAD submitted to either CTA (N=2268) and and/or PET (N=1208), 1237 underwent combined CTA/PET assessment. The warranty period for patients with no CAD on coronary CTA was ≥10 years, whereas patients with non-obstructive CAD had a 5-year warranty period. Patients with obstructive CAD and no inducible ischemia had a 2-year longer warranty period than those with obstructive CAD and abnormal MBF (3 years vs. 1 year). Data show that the prognosis of patients with no CAD is excellent. However, even in those with obstructive disease the absence of ischemia identifies a lower risk category.

CT

CCTA; PET

Chronic ischaemic heart disease

ACS; CCS; warranty period; prognosis

Myocardial oedema measured by T2 mapping is an independent prognostic predictor in hypertrophic cardiomyopathy

Xu Z, Wang J, Cheng W, et al. Incremental significance of myocardial oedema for prognosis in hypertrophic cardiomyopathy

Eur Heart J Cardiovasc Imaging 2023; 24:876-884; https://doi.org/10.1093/ehjci/jead065

In 674 patients with hypertrophic cardiomyopathy (HCM), myocardial oedema (quantitatively measured by T2 mapping) was an independent predictor of cardiovascular death and appropriate implantable cardioverter defibrillator discharge during a median follow-up of 36 months, on top of established risk factors, including extensive LGE. Patients with late gadolinium enhancement and T2 max ≥44.9ms had a higher risk of developing cardiovascular events.

CMR

Oedema; T2

Cardiomyopathies

HCM

Left atrial fibrosis late enhancement is more frequent in patients with stroke than in controls independent of aetiological classification

Larsen BS, Bertelsen L, Christensen H, et al. Left atrial late gadolinium enhancement in patients with ischaemic stroke

Eur Heart J Cardiovasc Imaging 2023; 24:625-634; https://doi.org/10.1093/ehjci/jead008

The study assessed left atrial fibrosis in 78 patients free of atrial fibrillation with recent ischaemic stroke (<30 days) and 45 age- and sex-matched controls. Left atrial fibrosis was quantified from 3D late enhancement images, by including atrial wall voxels with a signal intensity > 1.2 times the mean bloodpool intensity. Patients with stroke had a larger extent of left atrial fibrosis [6.9%, interquartile range (IQR) 3.6–15.4%] than matched controls (4.2%, IQR 2.3–7.5%; P = 0.007). A similar extent of left atrial fibrosis was observed in patients with stroke of undetermined aetiology and stroke classified as attributable to large- or small-vessel disease. These findings suggest that left atrial structural abnormality is more frequent in patients with stroke.

CMR

Atrial fibrosis; atrial LGE

Other

stroke