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Background In patients with suspected coronary artery disease (CAD) who underwent coronary computed tomographic angiography (CCTA), the prognostic value of nonobstructive stenosis is not entirely understood. Aims We sought to assess the long-term incremental prognostic utility of functionally non-significant CAD in patients without known prior CAD who underwent CCTA. Methods We included 2142 consecutive patients (51±14 years, 53% men) without prior documented CAD who underwent CCTA between 2008–2016 (excluding anomalous coronaries and functionally significant CAD). Traditional risk factors were recorded and pretest likelihood of CAD was calculated. All epicardial coronary arteries were classified as follows: No plaque, minimal luminal irregularities ( Results 188 (9%) patients had low, 1712 (80%) had intermediate and 242 (11%) patients had high pre-test likelihood of CAD. 45%, 10%, 52% and 22% had hypertension, diabetes, Dyslipedimia and history of smoking respectively. Breakdown of CAD severity was: 1197 (56%) none, 480 (22%) minimal, 267 (13%) mild and 198 (9%) moderate stenoses. 82 (4%) had noncalcified, 245 (11%) had calcified and 618 (29%) had mixed plaque. 465 (22%) had high-risk plaque features. At 6±3 years, 90 (4%) patients had composite events (68 deaths) and 24 (1%) needed coronary revascularization >90 days post-CCTA. 880 (41%) were on statins post-CCTA. Results of multivariable Cox Survival Analysis are shown in Figure 1A. Kaplan-Meier survival curves for a) more severe CAD and b) high-risk plaque features (vs. not) are shown in Figure 1B and C. Longer-term event rates for increasing CAD were 2.8%, 4.6%, 6% and 9.6%, respectively. Conclusion In mostly low/intermediate risk patients without documented CAD who underwent CCTA, a higher burden of nonobstructive coronary plaque (or presence of high-risk features) provide incremental prognostic value. Initiating statin therapy following detection of plaque on CCTA was associated with improved longer-term freedom from composite events.

Saphenous vein graft aneurysm is a relatively rare but serious complication of coronary artery bypass grafting (CABG). The diagnosis of such cases is clinically challenging and requires a high index of suspicion, especially if presented atypically or very late after CABG. Herein, we report a case of a saphenous vein graft pseudoaneurysm that presented 36 years after CABG and was masquerading as a right atrial myxoma on serial echocardiograms over a 2-year follow-up period.

Aims Although multislice computed tomography (MSCT) detects obstructive coronary artery disease (CAD) with high diagnostic accuracy, there is a paucity of long-term prognostic data. We sought to assess the incremental prognostic value of 64-slice CT in patients with suspected but no documented CAD. Methods and results Coronary MSCT was performed on 227 individuals (61% men, mean age 54 ± 12 years, 63% with intermediate pre-test probability) without documented CAD, referred for coronary evaluation. Coronary artery disease by MSCT was categorized as follows: none or mild CAD (

This editorial refers to “Safety and feasibility of high-dose dobutamine-atropine stress cardiovascular magnetic resonance for diagnosis of myocardial ischaemia: experience in 1000 consecutive cases”1 by A. Wahl et al. on page 1230 Cardiovascular magnetic resonance imaging (CMRI) has had particularly rapid advances in the evaluation of ischaemic heart disease over the last five years. The introduction of steady-state free precession sequences has improved both spatial and temporal resolution in cine imaging for evaluation of global and regional left ventricular function,1 the advent of delayed-enhancement imaging has thrust CMRI into the forefront of myocardial viability assessment,2 and on-going advances on multiple fronts are bringing magnetic resonance angiography of the coronary arteries for stenosis detection closer to clinical reality.3 Nonetheless, it is perhaps in the area of pharmacological stress ischaemia evaluation that CMRI may show the broadest clinical utility and greatest promise. In this edition of the European Heart Journal , Wahl et al.4 report a five-year experience in performing high-dose dobutamine (Dob) stress CMRI examinations for determination of myocardial ischaemia. This group of investigators brings extensive experience to this arena, having been the first to report a large study of Dob-CMRI with a head-to-head comparison with Dob-echocardiography.5 In the current study, Wahl et al. performed 1000 Dob-CMRI studies in 960 patients from a clinically referred pool of 1075 potential patient studies. Patients were not excluded from analysis for lack of imaging as a result of claustrophobia or obesity – well-acknowledged limitations of MRI technology in clinical evaluations. Of the 1000 … *Correspondence to: Scott D. Flamm, M.D., Department of Radiology, MC 2-270, St. Luke's Episcopal Hospital, 6720 Bertner Avenue, Houston, TX 77030, USA. Tel.: +1-832-355-4201; fax: +1-832-355-2591 E-mail address: sflamm{at}sleh.com