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Coronary artery disease continues to be the leading cause of death globally. Identifying patients who are at risk of coronary artery disease remains a public health priority. At present, the focus of cardiovascular disease prevention relies heavily on probabilistic risk scoring despite no randomized controlled trials demonstrating their efficacy. The concept of using imaging to guide preventative therapy is not new, but has previously focused on indirect measures such as carotid intima-media thickening or coronary artery calcification. In recent trials, patients found to have coronary artery disease on computed tomography (CT) coronary angiography were more likely to be started on preventative therapy and had lower rates of cardiac events. This led to the design of the SCOT-HEART 2 (Scottish Computed Tomography of the Heart 2) trial, which aims to determine whether screening with the use of CT coronary angiography is more clinically effective than cardiovascular risk scoring to guide the use of primary preventative therapies and reduce the risk of myocardial infarction., Competing Interests: Funding Support and Author Disclosures Dr McDermott is supported by a British Heart Foundation Clinical Research Training Fellowship (FS/CRTF/23/24491). Drs Mills and Newby are supported by a Chair Award, Programme Grant, and Research Excellence Award (CH/F/21/90010, CH/09/002/26360, RG/20/10/34966, RG/F/22/110093, RE/24/130012) from the British Heart Foundation. The SCOT-HEART 2 trial is funded by the British Heart Foundation (CS/18/4/34074). Dr Williams is supported by the British Heart Foundation (FS/ICRF/20/26002); and has given talks for Canon Medical Systems, Siemens Healthineers, and Novartis. Dr Mills has received research grants, honoraria, or consultancy fees from Abbott Diagnostics, Roche Diagnostics, Siemens Healthineers, LumiraDx, and Pyros Laboratories. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Hypertrophic cardiomyopathy is a common inherited cardiac condition where the myocardium progressively thickens in the absence of abnormal loading conditions. Left ventricular hypertrophy often leads to outflow tract obstruction, and this confers significant mortality and morbidity implications. Septal reduction therapies aim to relieve the obstruction in an attempt to reduce the burden of symptoms and potentially improve prognosis. However, both surgical and catheter-based approaches to septal reduction carry risks. At present, international guidelines and expert consensus statements suggest surgical myomectomy is the gold-standard treatment. In this point-counterpoint review, we discuss why in our opinion this recommendation should be reconsidered. We hope to cover the history of catheter based septal reduction therapies and the significant advances made over the last two decades. We also hope to show why we believe the current evidence shows catheter-based alcohol septal ablation is superior to surgical myomectomy., (Copyright © 2023 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Obstructive hypertrophic cardiomyopathy is the most common genetically transmitted cardiomyopathy that is associated with significant morbidity and mortality. Despite contemporary treatments and interventions, the management of patients with obstructive hypertrophic cardiomyopathy remains poorly defined compared with other branches of cardiology. In this review, we discuss established and novel therapeutic interventions in patients with obstructive hypertrophic cardiomyopathy with a focus on percutaneous and surgical strategies including surgical myectomy, mitral valve repair or replacement, percutaneous alcohol septal ablation, pacemaker and cardioverter-defibrillator implantation, septal embolization, radiofrequency endocardial catheter ablation, and percutaneous intramyocardial septal radiofrequency ablation., (Crown Copyright © 2023. Published by Elsevier Inc. All rights reserved.)

Background: In patients with stable chest pain, computed tomography (CT) plaque burden is an independent predictor of future coronary events., Objectives: The purpose of this study was to determine whether plaque burden and characteristics can predict subsequent death or myocardial infarction in patients with acute chest pain., Methods: In a post hoc analysis of a multicenter trial of early coronary CT angiography, the authors performed quantitative plaque analysis to assess the association between primary endpoint of 1-year all-cause death or nonfatal myocardial infarction and the GRACE (Global Registry of Acute Coronary Events) score, presence of obstructive coronary artery disease, and plaque burden in 404 patients with suspected acute coronary syndrome., Results: Following the index event, 25 patients had a primary event that was associated with a higher GRACE score (134 ± 44 vs 113 ± 35; P = 0.012), larger burdens of total (46% [IQR: 43%-50%] vs 36% [IQR: 21%-46%]; P < 0.001), noncalcified (41% [IQR: 37%-%47] vs 33% [IQR: 20%-41%]; P < 0.001), and low-attenuation plaque (4.22% [IQR: 3.3%-5.68%] vs 2.14% [IQR: 0.5%-4.88%]; P < 0.001), but not obstructive coronary artery disease (P = 0.065). Total, noncalcified, and low-attenuation plaque burden were the strongest predictors of future events independent of GRACE score and obstructive coronary artery disease (P ≤ 0.002 for all). Patients with a low-attenuation burden above the median had nearly an 8-fold increased risk of the primary endpoint (HR: 7.80 [95% CI: 2.33-26.0]; P < 0.001), outperforming either a GRACE score of >140 (HR: 3.80 [95% CI :1.45-6.98]; P = 0.004) or obstructive coronary artery disease (HR: 2.07 [95% CI: 0.94-4.53]; P = 0.07)., Conclusions: In patients with suspected acute coronary syndrome, low-attenuation plaque burden is a major predictor of 1-year death or recurrent myocardial infarction. (Rapid Assessment of Potential Ischaemic Heart Disease With CTCA [RAPID-CTCA]; NCT02284191)., Competing Interests: Funding Support and Author Disclosures The National Institute for Health Research HTA Programme funded the RAPID-CTCA trial study (13/04/108). Dr Meah is supported by the British Heart Foundation (FS/19/46/34445). Dr Tzolos is supported by a British Heart Foundation grant (FS/CRTF/20/24086). Dr Bularga is supported by a clinical research training fellowship (MR/V007254/1). Dr Curzen has received unrestricted research grants from Boston Scientific, HeartFlow, and Beckmann Coulter. Drs Mills, Newby, and Williams are supported by the British Heart Foundation (FS/ICRF/20/26002, CH/09/002, RG/20/10/34966, RE/18/5/34216, CH/F/21/90010). Drs Slomka and Dey have received software royalties from Cedars-Sinai Medical Center and have a patent, outside of the current study. Dr Dey is supported by National Institute of Health/National Heart, Lung, and Blood Institute grant 1R01HL148787-01A1 and 1R01HL151266. Dr Newby is the recipient of a Wellcome Trust Senior Investigator Award (WT103782AIA). All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Cardiovascular disease remains a major cause of mortality, accounting for a third of all global deaths annually. Although there have been major improvements in our ability to detect and to treat patients with coronary heart disease, most myocardial infarctions occur in previously asymptomatic individuals. Identification of individuals at risk of myocardial infarction remains challenging and primary prevention guidelines rely on the use of cardiovascular risk scores that can be supplemented by coronary artery calcium scores. Coronary artery calcium scores provide a simple surrogate late marker of atherosclerosis but is unable to identify the early high risk non-calcified plaque which can be particularly problematic in younger individuals. Coronary computed tomography angiography is increasingly being used as the imaging strategy of choice in patients with symptoms of coronary heart disease. As an anatomical test, it can non-invasively detect the presence of coronary atherosclerosis, providing clinicians with a strong mandate to commence symptom relieving and preventative therapies. For asymptomatic individuals, it allows precise targeting of therapies to those with coronary heart disease rather than those "at risk" of disease. Moreover, our ability to calculate risk using coronary computed tomography angiography is rapidly improving with the use of techniques, such as plaque quantification and characterisation. These techniques have the potential to provide clinicians with tools to target cardiovascular disease prevention in a precision medicine approach. We here debate the ways in which coronary computed tomography angiography could improve the selection of asymptomatic individuals for preventative therapies over and above risk calculators and calcium scoring., Competing Interests: Declaration of competing interest None., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to describe the potential of 18 F-sodium fluoride ( 18 F-NaF) positron emission tomography (PET) to identify graft vasculopathy and to investigate the influence of coronary artery bypass graft (CABG) surgery on native coronary artery disease activity and progression., Background: As well as developing graft vasculopathy, CABGs have been proposed to accelerate native coronary atherosclerosis., Methods: Patients with established coronary artery disease underwent baseline 18 F-NaF PET, coronary artery calcium scoring, coronary computed tomographic angiography, and 1-year repeat coronary artery calcium scoring. Whole-vessel coronary microcalcification activity (CMA) on 18 F-NaF PET and change in calcium scores were quantified in patients with and without CABG surgery., Results: Among 293 participants (mean age 65 ± 9 years, 84% men), 48 (16%) underwent CABG surgery 2.7 years [IQR: 1.4-10.4 years] previously. Although all arterial and the majority (120 of 128 [94%]) of vein grafts showed no 18 F-NaF uptake, 8 saphenous vein grafts in 7 subjects had detectable CMA. Bypassed native coronary arteries had 3 times higher CMA values (2.1 [IQR: 0.4-7.5] vs 0.6 [IQR: 0-2.7]; P < 0.001) and greater progression of 1-year calcium scores (118 Agatston unit [IQR: 48-194 Agatston unit] vs 69 [IQR: 21-142 Agatston unit]; P = 0.01) compared with patients who had not undergone CABG, an effect confined largely to native coronary plaques proximal to the graft anastomosis. In sensitivity analysis, bypassed native coronary arteries had higher CMA (2.0 [IQR: 0.4-7.5] vs 0.8 [IQR: 0.3-3.2]; P < 0.001) and faster disease progression (24% [IQR: 16%-43%] vs 8% [IQR: 0%-24%]; P = 0.002) than matched patients (n = 48) with comparable burdens of coronary artery disease and cardiovascular comorbidities in the absence of bypass grafting., Conclusions: Native coronary arteries that have been bypassed demonstrate increased disease activity and more rapid disease progression than nonbypassed arteries, an observation that appears independent of baseline atherosclerotic plaque burden. Microcalcification activity is not a dominant feature of graft vasculopathy., Competing Interests: Funding Support and Author Disclosures This research was supported in part by grant R01HL135557 from the National Heart, Lung, and Blood Institute. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. Dr Newby (CH/09/002, RE/18/5/34216, RG/16/10/32375), Dr Tzolos (FS/CRTF/20/24086), Dr Fletcher (FS/19/15/34155), Dr Baker (RG/20/5/34796), Dr Dweck (FS/14/78/31020), and Dr Williams (FS/ICRF/20/26002) are supported by the British Heart Foundation. Dr Adamson is supported by a Heart Foundation of New Zealand Senior Fellowship (1844). Dr van Beek is supported by the Scottish Imaging Network. Dr Tzolos was supported by a grant from the Dr Miriam and Sheldon G. Adelson Medical Research Foundation. Dr Newby is a recipient of a Wellcome Trust Senior Investigator Award (WT103782AIA). Dr Dweck is a recipient of the Sir Jules Thorn Award for Biomedical Research Award (2015). Dr Sellers is supported by fellowships from the Canadian Institutes of Health Research and the Michael Smith Foundation for Health Research. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2022 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: The ability to characterize and to quantify the extent of coronary artery disease has the potential to improve the prognostic capability of coronary computed tomography angiography. Although reproducible techniques have been described in those with mild coronary disease, this has yet to be assessed in patients with advanced disease., Methods: Twenty patients with known multivessel disease underwent repeated computed tomography coronary angiography, 2 weeks apart. Coronary artery segments were analysed using semi-automated software by two trained observers to determine intraobserver, interobserver and interscan reproducibility., Results: Overall, 149 coronary arterial segments were analysed. There was excellent intraobserver and interobserver agreement for all plaque volume measurements (Lin's coefficient 0.95 to 1.0). There were no substantial interscan differences (P ​> ​0.05 for all) for total (2063 ​± ​1246 ​mm 3 , mean of differences -35.6 ​mm 3 ), non-calcified (1795 ​± ​910 ​mm 3 , mean of differences -4.3 ​mm 3 ), calcified (298 ​± ​425 ​mm 3 , mean of differences -31.3 ​mm 3 ) and low-attenuation (13 ​± ​13 ​mm 3 , mean of differences -2.6 ​mm 3 ) plaque volumes. Interscan agreement was highest for total and noncalcified plaque volumes. Calcified and low-attenuation plaque (-236.6 to 174 ​mm 3 and -15.8 to 10.5 ​mm 3 respectively) had relatively wider 95% limits of agreement reflecting the lower absolute plaque volumes., Conclusion: In the presence of advanced coronary disease, semi-automated plaque quantification provides excellent reproducibility, particularly for total and non-calcified plaque volumes. This approach has major potential to assess change in disease over time and optimize risk stratification in patients with established coronary artery disease., Competing Interests: Declaration of competing interest Drs. Dey and Slomka received software royalties from Cedars-Sinai Medical Center and have a patent. The remaining authors have no disclosures to report., (Copyright © 2020 The Authors. Published by Elsevier Inc. All rights reserved.)