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Background: Onsite workstation-based CT-derived Fractional-Flow-Reserve (CT-FFR) is accurate in assessing hemodynamic-significance of coronary stenoses. We aim to describe the influence of operator expertise and luminal-segmentation technique on the diagnostic performance, precision and reproducibility of CT-FFR in identifying hemodynamically-significant stenosis (FFR<=0.8). Method(s): Forty-eight consecutive stable-patients (86 vessels) with suspected CAD underwent research indicated invasive-FFR and 320-detector CT-coronary-angiography (CTA). CT-FFR was derived using reduced-order model on standard desktop-computer. Semi-automated coronary luminal segmentation was performed using focused-technique with manual adjustments at regions of stenosis and calcification or comprehensive-technique with manual adjustments along the entire course of the vessel. CT-FFR analysis was performed using 3 blinded operators; core-laboratory engineer using focused-technique and radiographer and cardiologist using the comprehensive-technique. Diagnostic performance was assessed by area under receiver-operating-curve (AUC). Precision with invasive FFR was determined by Bland-Altman analysis, and reproducibility by intraclass-correlation-coefficient (ICC). Result(s): Diagnostic performance was comparable among operators (Engineer: AUC = 0.88, Radiographer 0.84; Cardiologist 0.87; P = 0.59). Coronary luminal-segmentation time was shortest using focused technique (engineer 6:17 +/- 2.43 min), compared with comprehensive technique (cardiologist 14.83 +/- 7.09, radiographer 24.74 +/- 12.65; P < 0.001). Use of focused technique was associated with widest limits of agreement (LOA) with FFR and moderate intra-operator reproducibility (engineer LOA -0.20-0.33; ICC 0.66), when compared with the comprehensive technique which demonstrated narrower LOA and excellent reproducibility [radiographer (LOA -0.17-0.20, ICC = 0.91) and cardiologist (LOA-0.15-0.23, ICC = -0.93)] Conclusion(s): A workstation

According to previous epidemiological studies, we can reduce the thickness of epicardial fat and improve cardiovascular risk factors through exercise, and the changes may depend on the form of exercise. We systemically reviewed published studies that evaluated exercise intervention on epicardial adipose tissue (EAT) levels. We included randomized controlled trials (RCTs) comparing one exercise with another exercise or diet for the treatment to reduce EAT. We used fixed effects models for meta-analyses; effects of exercise on outcomes were described as mean differences (MD) or standardized difference of means (SMD) was used, their 95% confidence intervals (CI). Five RCTs were included (n = 299), 156 in exercise group and 143 in the control. In comparison to the control group, exercise significantly reduced EAT (SMD - 0.57, 95%CI - 0.97 to - 0.18) and waist circumference (MD - 2.95 cm, 95%CI - 4.93 to - 0.97). Exercise did not have an effect on BMI (MD - 0.23 kg/m2, 95%CI - 0.73 to 0.27), weight (MD - 0.06 kg, 95%CI - 1.46 to 1.34), or HDL (SMD 0.26, 95%CI - 0.06 to 0.57).VO2 was significantly increased by exercise (SMD 1.58, 95%CI 1.17 to 1.99). Risk of bias was high for 3 studies, and GRADE quality of evidence was very low to moderate. Exercise reduced epicardial adipose tissue and waist circumference, and did not have effect on weight, BMI, or HDL. Newer trials with better design and methods are necessary to improve the quality of the evidence. PROSPERO registration number (CRD42018096581)Copyright © 2020, Springer Science+Business Media, LLC, part of Springer Nature.

Epicardial adipose tissue (EAT) is associated with cardiovascular risk. The longitudinal change in EAT volume (EATv) and density (EATd), and potential modulators of these parameters, has not been described. We prospectively recruited 90 patients with non-obstructive coronary atherosclerosis on baseline computed tomography coronary angiography (CTCA) performed for suspected coronary artery disease to undergo a repeat research CTCA. EATv in millilitres (mL) and EATd in Hounsfield units (HU) were analysed and multivariable regression analysis controlling for traditional cardiovascular risk factors (CVRF) performed to assess for any predictors of change. Secondary analysis was performed based on statin therapy. The median duration between CTCA was 4.3years. Mean EATv increased at follow-up (72+/-33mL to 89+/-43mL, p<0.001) and mean EATd decreased (baseline -76+/-6 HU vs. -86+/-5 HU, p<0.001). There were no associations between baseline variables of body mass index, age, sex, hypertension, hyperlipidaemia, diabetes or smoking on change in EATv or EATd. No difference in baseline, follow-up or delta EATv or EATd was seen in patients with (60%) or without baseline statin therapy. In this select group of patients, EATv consistently increased and EATd consistently decreased at long-term follow-up and these changes were independent of CVRF, age and statin use. Together with the knowledge of strong associations between EAT and cardiac disease, these findings may suggest that EAT is an independent parameter rather than a surrogate for cardiovascular risk.

Background: Spontaneous coronary artery dissection (SCAD) is an uncommon, non-iatrogenic, non-atherosclerotic cause of acute coronary syndrome. A lack of large prospective cohort studies and randomised controlled trials means that important questions about clinical characteristics and outcomes of patients with SCAD are yet to be fully answered. Method(s): A literature search of PUBMED, EMBASE and SCOPUS was undertaken up to and including the 23rd January 2020. Studies reporting any cohort of 10 or more SCAD patients presenting with acute coronary syndrome, with appropriate clinical follow-up data were included in the analysis. Incidences of major adverse cardiovascular events (MACE), myocardial infarction and SCAD recurrence were meta-analysed using Poisson regression. Result(s): 19 studies, totalling p=2,172 patients, were included in the analysis. There was significant heterogeneity across the studies in all baseline characteristics and clinical outcomes. Prevalence of traditional cardiovascular risk factors was low; however, hypertension had a prevalence of 45% (95% CI; [35-54]) and fibromuscular dysplasia (FMD) was present in 68% (95% CI; [61-74]). Across all cohorts, the incidence of MACE in patients with SCAD was 7.80 per 100 person years (n=19, p=2172, 95% CI; [4.50-13.54]) and SCAD recurrence was 5.49 per 100 person years (n=13, p=1408, 95% CI; [3.75-8.02]). Conclusion(s): This meta-analysis confirms that SCAD is not an inconsequential cause of acute coronary syndrome and heralds the need for further prospective research to identify predictors of recurrent events and therapies to prevent them.Copyright © 2020

Background: On-site workstation based computed tomography derived fractional flow reserve (CT-FFR) is an emerging method to assess the vessel specific ischaemia in coronary artery disease (CAD). The impact of coronary calcification on its diagnostic performance is unknown. Purpose(s): To evaluate the impact of coronary calcification on the diagnostic performance of reduced-order CT-FFR at detecting vessel specific ischaemia. Method(s): This is a retrospective pooled analysis of 141 patients with suspected CAD enrolled from 3 global centres who underwent CTcoronary angiography (CTA), onsite CT-FFR and invasive FFR. Coronary calcification was assessed by Agatston score (AS). The diagnostic performance of CT-FFR (<=0.8) and CTA (>=50%) in evaluation of vessel specific ischaemia (FFR <= 0.8) was assessed across AS quartiles (Q1-4). A comparison of diagnostic performance of the low to mid AS (Q1 to Q3) versus high AS (Q4) was performed. Result(s): Mean age and median AS was 65.8 +/- 9.9 and 327.3 (interquartile range = 78.5 - 798.1). Diagnostic accuracy, sensitivity and specificity of CT-FFR for low-mid AS (0-798) and high AS (799-4019) were 77.4% vs 82.9%; 78.9% vs 94.7%; 68.8% vs 76.5% respectively with no statistical difference between the two groups. The AUC for ischaemia of CT-FFR in low to mid AS was comparable with AUC in the high AS (0.76 [95% CI: 0.66-0.86] vs 0.84 [0.69-0.99]; P = 0.397). The AUC for ischemia for CT-FFR in both low to mid AS and high AS was significantly higher than for CTA (0.76 [0.66-0.86] vs 0.57 [0.50-0.64]; P = 0.003 and 0.84 [0.69-0.99] vs 0.48 [0.38-0.57]; P < 0.001 respectively). Conclusion(s): On-site workstation CT-FFR demonstrated consistently high diagnostic performance in patients with high AS. Its diagnostic performance was superior when compared with significant stenosis assessment on CTA across all spectrum of Agatston scores.

Background: Although obstructive sleep apnea (OSA) is frequently associated with obesity, body mass index (BMI) is not a good measure of body adiposity. Epicardial adipose tissue (EAT) is a metabolically active fat depot, and its thickness has been shown to correlate with OSA. Computed tomography permits quantification of EAT volume and density. Lower epicardial fat density associates with the presence of inflammatory white EAT. No studies have evaluated the association between EAT parameters with coronary plaque burden in patients with OSA. Aim(s): To compare the association between OSA severity with EAT volume, EAT density and BMI Methods: Participants underwent clinically indicated overnight polysomnography, and the degree of OSA was determined by the apnoea/hypopnea index (AH I), and severe OSA was defined as AH I > 30. Participants also underwent clinically indicated coronary computed tomography angiography (CTCA). EAT volume and Leaman scores were quantified on CTCA, and significant coronary plaque burden was defined as Leaman score > 8.3. Result(s): Participants (n = 71, age 59.7 years, BMI 32.6 kg/m, 24% female, 31% severe OSA) had a median EAT volume 98 ml- and Leaman score 6.57. EAT volume correlated with AHI (r = 0.29; p = 0.01), BMI (r = 0.29, p = 0.01) and Leaman score (r = 0.32; p = 0.01). EAT mean density correlated with Leaman score (r = -0.35; p = 0.02) but not AHI (p = 0.90) or BMI (p = 0.80). AHI correlated with EAT volume (r = 0.29; p = 0.01) and BMI (r = 0.20, p = 0.03) but not mean EAT density (p = 0.90), age (p = 0.94) or gender (p = 0.27). On multivariate linear regression, EAT volume continued to independently associate with AHI (p = 0.01). Patients with severe OSA had higher EAT volume (116 mL vs. 86 mL, p = 0.05) compared to those without severe OSA. On multivariate analysis, EAT volume independently associated with the presence of severe OSA (p = 0.01). Conclusion(s): EAT volume associated with OSA severity and may be a potential marker o

Objectives: This study sought to determine whether coronary computed tomography angiography (CCTA)-based radiomic analysis of pericoronary adipose tissue (PCAT) could distinguish patients with acute myocardial infarction (MI) from patients with stable or no coronary artery disease (CAD). Background(s): Imaging of PCAT with CCTA enables detection of coronary inflammation. Radiomics involves extracting quantitative features from medical images to create big data and identify novel imaging biomarkers. Method(s): In a prospective case-control study, 60 patients with acute MI underwent CCTA within 48 h of admission, before invasive angiography. These subjects were matched to patients with stable CAD (n = 60) and controls with no CAD (n = 60) by age, sex, risk factors, medications, and CT tube voltage. PCAT was segmented around the proximal right coronary artery (RCA) in all patients and around culprit and nonculprit lesions in patients with MI. PCAT segmentations were analyzed using Radiomics Image Analysis software. Result(s): Of 1,103 calculated radiomic parameters, 20.3% differed significantly between MI patients and controls, and 16.5% differed between patients with MI and stable CAD (critical p < 0.0006); whereas none differed between patients with stable CAD and controls. On cluster analysis, the most significant radiomic parameters were texture or geometry based. At 6 months post-MI, there was no significant change in the PCAT radiomic profile around the proximal RCA or nonculprit lesions. Using machine learning (XGBoost), a model integrating clinical features (risk factors, serum lipids, high-sensitivity C-reactive protein), PCAT attenuation, and radiomic parameters provided superior discrimination of acute MI (area under the receiver operator characteristic curve [AUC]: 0.87) compared with a model with clinical features and PCAT attenuation (AUC: 0.77; p = 0.001) or clinical features alone (AUC: 0.76; p < 0.001). Conclusion(s): Patients with acute MI have a dist

Background: To compare computed tomography coronary angiography (CTCA) with intravascular ultrasound (IVUS) in quantitative and qualitative plaque assessment. Method(s): Patients who underwent IVUS and CTCA within 3 months for suspected coronary artery disease were retrospectively studied. Plaque volumes on CTCA were quantified manually and with automated-software and were compared to IVUS. High-risk plaque features were compared between CTCA and IVUS. Result(s): There were 769 slices in 32 vessels (27 patients). Manual plaque quantification on CTCA was comparable to IVUS per slice (mean difference of 0.06 +/- 0.07, p = 0.44; Bland-Altman 95% limits of agreement -2.19-2.08 mm3, bias of -0.06 mm3) and per vessel (3.1 mm3 +/- -2.85 mm3, p = 0.92). In contrast, there was significant difference between automated-software and IVUS per slice (2.3 +/- 0.09mm3, p < 0.001; 95% LoA -6.78 to 2.25 mm3, bias of -2.2 mm3) and per vessel (33.04 +/- 10.3 mm3, p < 0.01). The sensitivity, specificity, positive and negative predictive value of CTCA to detect plaques that had features of echo-attenuation on IVUS was 93.3%, 99.6%, 93.3% and 99.6% respectively. The association of >=2 high-risk plaque features on CTCA with echo attenuation (EA) plaque features on IVUS was excellent (86.7%, 99.6%, 92.9% and 99.2%). In comparison, the association of high-risk plaque features on CTCA and plaques with echo-lucency on IVUS was only modest. Conclusion(s): Plaque volume quantification by manual CTCA method is accurate when compared to IVUS. The presence of at least two high-risk plaque features on CTCA is associated with plaque features of echo attenuation on IVUS.Copyright © 2019

Background: Percutaneous coronary intervention (PCI) remains an established therapeutic option for myocardial revascularisation. Use of intravascular imaging to guide PCI is known to improve clinical outcomes, with this benefit most pronounced when tackling complex lesion subsets. We therefore sought to ascertain the current uptake and use of intravascular imaging based on anonymised data from the Victorian Cardiac Outcomes Registry (VCOR). Method(s): All consecutive patients undergoing PCI for coronary artery disease (CAD) were included (n=51,044) from January 2013 through December 2018. Intravascular imaging included intravascular ultrasound (IVUS) and optical coherence tomography (OCT) use. Patient/lesion characteristics were obtained and compared between angiographic- and imaging-PCI guided groups. Result(s): Overall, 873 (1.7%) of patients had intravascular imaging to guide PCI during the study period, with IVUS used in 602 (1.2%), OCT in 246 (0.48%) and both in 25 (0.05%) cases. There was an increase in case rates of intravascular imaging year on year (p=0.001). Intravascular imaging was more commonly used in patients with diabetes (p=0.04) and those with stable CAD (p<0.001). Although angiographically-guided PCI remained the default modality used for treatment of all complex lesion subsets, rates of intravascular imaging use were higher for left-main stem intervention (14.7%), stent thrombosis (9.4%), in-stent restenosis (4.6%), treatment of chronic total occlusions (3.0%) and AHA Type B2/C lesions (1.9%). Conclusion(s): The uptake of intravascular imaging use during PCI remains limited in Victoria, even when considering more complex PCI procedures. These data should renew our focus on education, reimbursement and support for using intravascular imaging in Australia.Copyright © 2020

Background: The presence of diabetes mellitus (DM) is a known predictor of restenosis and late stent thrombosis (ST) in patients undergoing percutaneous coronary intervention (PCI) with drug-eluting stents (DESs). However, there remains a paucity of real-world, all-comer data on whether DM is associated with early ST in patients receiving third-generation DESs. These data are particularly important considering the push toward abbreviated dual-antiplatelet therapy. We sought to compare outcomes of patients with and without DM from the Victorian Cardiac Outcomes Registry. Method(s): All consecutive patients undergoing PCI with DESs were included from January 2014 through December 2018. The primary outcome was ST at 30 days with secondary outcomes of major adverse cardiac events (MACEs) and mortality. Long-term survival analysis was obtained through linkage with the National Death Index. Multivariable logistic regression was performed with ST as the outcome and independent predictors added to the model on the basis of a univariable association (p < 0.2). Model fit was assessed by the Akaike information criterion to develop a parsimonious regression model. Result(s): A total of 43,209 patients underwent PCI during the study period with 9,730 (22.5%) having DM. At 30 days, DM was independently associated with higher rates of ST (0.72% vs. 0.52%; odds ratio: 1.41; 95% confidence interval: 1.05 to 1.87; p = 0.02), MACEs (4.1% vs. 3.5%, p = 0.004), and mortality (1.9% vs. 1.5%, p = 0.01). Increased risk was not simply due to treatment, with those on insulin and hypoglycemic agents equally affected in terms of MACEs (4.7% vs. 3.9%, p = 0.069) and mortality (1.9% vs. 1.8%, p = 0.746). National Death Index linkage showed patients with DM had an increased risk of death over a 6-year follow-up period (odds ratio: 1.69; 95% confidence interval: 1.55 to 1.83; p <= 0.001). Conclusion(s): In this large real-world registry, DM was an independent predictor of ST, MACEs, and mortality

Background: Angiographic assessment of left main coronary artery (LMCA) stenosis is challenging. When uncertainty exists, intravascular ultrasound (IVUS) minimal lumen area (MLA) >=6 mm2 is used as safe threshold for deferral of revascularization. With emergence of Computed Tomography Coronary Angiography (CTCA) as a first-line investigation, we sought to assess which quantitative CT-measure best compared with current IVUS standards. Method(s): Patients who underwent both IVUS and CTCA assessment of angiographically intermediate LMCA stenosis (n=48) were included. All CTCA were performed <90 days prior to IVUS. The cohort was divided into those with significant (S-LMCA) versus non-significant (NS-LMCA) disease, using IVUS >=6 vs <6 mm2. Result(s): Mean age (60.3+/-12.4 vs 59.9+/-11.9yrs, p=0.91) and % male (57.7% vs 54.6%, p=0.83) were similar between groups. Mean time from CTCA to IVUS assessment was 17.4+/-19.8 days, with mean QCA stenosis severity of 46.0+/-18.6%. On CTCA, patients with NS-LMCA had significantly higher luminal area (8.3+/-3.8 vs 5.2+/-1.6 mm2, p=0.005), minimal lumen diameter (MLD) (3.2+/-0.7 vs 2.5+/-0.4 mm, p<0.001), with similar luminal volumes (99.9+/-50.5 vs 113.5+/-73.9 mm3, p=0.47). There was a significant positive correlation between CTCA and IVUS MLA (r=0.77, p <0.001) and MLD (r=0.73, p<0.001). ROC analysis demonstrated CTCA MLA <8.29 mm2 had the best diagnostic accuracy for predicting IVUS MLA <6 mm2 (area under the curve=0.76, sensitivity=100%, specificity=54% p=0.002). Conclusion(s): CTCA luminal measures correlate well with IVUS within the LMCA. These results suggest that CTCA measures could potentially be used to safely defer revascularisation for LMCA disease.Copyright © 2020

BACKGROUND: The aim was to assess whether periprocedural myocardial injury (PPMI) predicts outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). PPMI is a strong predictor of outcomes following coronary intervention, but its impact in the context of TAVR remains unclear. We performed a systematic review and meta-analysis to ascertain the association between PPMI and short- or long-term outcomes. METHODS AND RESULTS: Electronic searches identified studies reporting PPMI following TAVR. Primary end point was 30-day all-cause mortality, with secondary end points, including 1-year all-cause mortality, neurological events, post-TAVR pacemaker implantation, and aortic regurgitation. Analyses were performed using random effects modeling and reported as summary odds ratio (OR) with 95% CI. Nine studies comprising 3442 patients (mean age 81.0+/-6.6 years, 51.2% female) were included. PPMI occurred in 25.5% of patients following TAVR. The pooled all-cause mortality at 30-days and 1-year was 5.2% and 18.6%, respectively. The occurrence of PPMI following TAVR was associated with significantly increased risk of both 30-day (OR, 4.23; CI, 1.95-9.19; P<0.001) and 1-year all-cause mortality (OR, 1.77; CI, 1.05-2.99; P<0.001). Similarly, PPMI was associated with post-TAVR neurological events (OR, 2.72; CI, 1.69-4.37; P<0.001) and post-TAVR permanent pacing (OR, 1.43; CI, 1.02-2.00; P=0.04) but not with a statistically significant increase in aortic regurgitation post-TAVR (OR, 1.39; CI, 0.93-2.08; P=0.11). CONCLUSION(S): PPMI is common following TAVR and is strongly associated with 30-day and 1-year mortality. Detection of PPMI has potential to identify TAVR patients at highest risk of subsequent adverse events.Copyright © 2018 American Heart Association, Inc.

Objectives: CASE: A previously well 62-year-old female presented to the emergency department with central chest pain. Initial electrocardiogram demonstrated sinus rhythm with ST-elevation in V1-V2 and she underwent emergent coronary angiography which demonstrated no obstructive coronary artery stenosis, however left ventriculography demonstrated focal dyskinesis / aneurysm of the mid anterior left ventricular (LV) wall. Contrast enhanced transthoracic echocardiography (TTE) confirmed the appearance and demonstrated a pericardial effusion, raising the suspicion of a contained LV rupture. Cardiacmagnetic resonance (CMR) imaging confirmed the presence of an anterior wall aneurysm with associated oedema on T2 weighted images (Fig 1) however there was no evidence of associated late gadolinium enhancement (LGE) in the region (Fig 1). The patient had been involved in an argument before presenting to hospital and the findings were thought to be most consistent with an atypical Takotsubo cardiomyopathy (TC), and repeat transthoracic echocardiography 1 month later demonstrated complete normalisation of LV contraction. DISCUSSION: TC is a rare syndrome characterized by transient regional systolic dysfunction of the LV, mimickingmyocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. Focal involvement of the myocardium is its rarest form. A large multi-centre study in this population found CMR can accurately identify TC through a typical pattern of LV dysfunction and demonstrates myocardial edema in 81% patients, and no significant LGE in 91%. These findings were consistent with our patient. Interestingly in this study 40% of this patient population also had a pericardial effusion. (Figure Presented).

Background: Fractional flow reserve derived from CT-coronary angiography (FFRCT) accurately identifies ischaemic vessels which may be associated with clinical outcomes. Its predictive value in grey zone FFRCT values between 0.7-0.8 is not defined. The technique permits estimation of burden of ischaemic myocardium subtended by FFRCT significant vessels. Purpose(s): To evaluate the prognostic value and incremental benefit of FFRCT defined ischaemic myocardial burden when compared to FFRCT alone. Method(s): This is a subanalysis of NXT (Analysis of Coronary Blood-Flow Using CTA:Next-Steps), a prospective study of stable coronary artery disease (CAD) patients referred for invasive angiography (ICA) undergoing invasive FFR, CTA and FFRCT in whom treating physicians had been blinded to FFRCT results. Primary endpoint, defined as a composite of non-fatal myocardial infarction and any revascularisation, was determined in 206 patients (age 64+/-9.5 years, 64% male) and 618 vessels. Burden of ischaemic myocardium was defined as percentage of myocardium subtended beyond the point at which a vessel's FFRCT becomes <=0.8 as estimated by APPROACH score (FFRCT-APPROACH). In significant FFRCT vessels, the predictive value and incremental benefit of FFRCT-APPROACH was compared with significant FFRCT (<=0.8) for primary endpoint as measured by area under the receiver operator characteristic curve (AUC). Significant ischaemic myocardial burden was defined as >10%. The incidence and relationship between the primary endpoint with each 10% increase in FFRCT-APPROACH and 0.05-unit decrease in FFRCT values <=0.8 was determined. Result(s): Significant FFRCT was identified in 52.9% of patients (109/206) and 29.3% of vessels (181/618). At 4.7 years median follow-up the incidence of the primary endpoint in vessels with significant FFRCTAPPROACH was 58.9% (96/163) which was comparable with vessels with significant FFRCT (55.2%,100/181; P=0.50). The predictive value of FFRCT-APPROACH for the pri

BACKGROUND: Computed tomographic coronary angiography is a noninvasive imaging modality that permits identification and characterization of coronary plaques. Despite consensus statements supporting routine reporting of computed tomographic coronary angiography plaque characteristics, there remains uncertainty whether these data convey prognostic information. We performed a systematic review and meta-analysis assessing the strength of association between computed tomographic coronary angiography-derived plaque characterization and major adverse cardiovascular events (MACE). METHODS AND RESULTS: Electronic databases were searched for studies reporting computed tomographic coronary angiography plaque characterization and MACE. Data were gathered on plaque morphology (noncalcified, partially calcified, and calcified) and high-risk plaque (HRP) features, including low-attenuation plaque, napkin-ring sign, spotty calcification, and positive remodeling. Of 5496 citations, 13 studies met inclusion criteria. Five hundred fifty-two (3.9%) MACE occurred in 13977 patients with mean follow-up ranging between 1.3 and 8.2 years. In terms of plaque morphology, the strongest association was observed for noncalcified plaque (hazard ratio [HR], 1.45; 95% confidence interval [CI], 1.24-1.70; P<0.001), with weaker associations found for partially calcified (HR, 1.37; 95% CI, 1.18-1.60; P<0.001) and calcified plaques (HR, 1.23; 95% CI, 1.16-1.30; P<0.001). All HRP features were strongly associated with MACE, including napkin-ring sign (HR, 5.06; 95% CI, 3.23-7.94; P<0.001), low-attenuation plaque (HR, 2.95; 95% CI, 2.03-4.29; P<0.001), positive remodeling (HR, 2.58; 95% CI, 1.84-3.61; P<0.001), and spotty calcification (HR, 2.25; 95% CI, 1.26-4.04; P=0.006). The presence of >=2 HRP features had highest risk of MACE (HR, 9.17; 95% CI, 4.10-20.50; P<0.001). CONCLUSION(S): These data demonstrate that HRP is most likely an independent predictor of MACE, which supports the inclusion of HRP re

Background: When compared with Caucasian populations, East Asians (EA) have a lower prevalence of coronary artery disease, myocardial infarction and cardiovascular mortality. Ethnic differences in coronary atherosclerotic burden and plaque composition are not known. Objective(s): To compare CT-assessed coronary atherosclerotic burden, plaque composition and quantitative high risk plaque features in a matched cohort of Caucasian and EA patients with stable chest pain. Method(s): Two-hundred symptomatic patients (age 58.8+/-7.9, male 51%) underwent clinically mandated CT coronary angiography (CTA) were matched for age, gender, BMI and diabetes (100 for each ethnic group). Visual CTA assessment and quantitative plaque analysis using dedicated semiautomatic software was performed by a blinded core laboratory to measure plaque volume and burden. Plaque composition was determined from measurement of total, calcified and non-calcified plaque (NCP) volumes. NCP was further separated by differences in Hounsfield Units (HU). Quantitative high risk plaque features were defined as low attenuation necrotic core (-30 to 30 HU) and intermediate fibrofatty plaque (31-130 HU). Favourable plaque was defined as high attenuation fibrous plaque (131-350 HU). Result(s): Segment Involvement Score, percent diameter and area stenosis were comparable in both groups. Similarly, there was no significant difference in total plaque, calcified and non-calcified plaque volume and burden. Compared with Caucasians, plaque composition in East Asians was associated with significantly less high risk features of necrotic core (3.47 vs 5.09%, P=0.003) and fibrofatty plaque (29.28 vs 37.20% P=0.002). Fibrous plaque composition was highest in East Asians (65.65 vs 57.58% P=0.009). Conclusion(s): Based on this matched cohort with comparable overall plaque volume and burden, East Asians exhibited significantly lower composition of high risk plaque features and had higher favourable plaque composition compare

Recent evidence suggests plaque morphology evaluated on coronary computed tomography angiography has prognostic implications. East Asians have a lower prevalence of myocardial infarction and cardiovascular mortality compared with European-origin Caucasians. We aimed to compare coronary atherosclerotic burden and plaque composition in a matched cohort of Caucasian and East Asians patients with stable chest pain who underwent computed tomography angiography. Two-hundred symptomatic patients (age 58.8 +/- 7.9, male 51%) were matched for age, gender, body mass index, and diabetes (100 each ethnic group). A blinded core-laboratory quantified calcified and noncalcified plaque (NCP) volume and burden. Components of NCP were differentiated by plaque hounsfield unit (HU) thresholds which defined high-risk necrotic core (-30 to 30HU), fibrofatty plaque (31 to 130HU); and low-risk fibrous plaque (131 to 350HU). Composition of NCP components was derived as (NCP component volume/total NCP volume) x 100%. Segment Involvement Score, percent diameter and area stenosis were comparable in both groups. Similarly, there was no difference in the volume and burden of total, calcified and NCP. Compared with Caucasians, East Asians demonstrated lower composition of plaque attenuation corresponding to necrotic core (3.5 vs 5.1%; p = 0.004) and fibrofatty plaque (29.6 vs 37.3%; p = 0.005), and higher fibrous plaque (65.7 vs 57.6%; p = 0.004). On multivariable analysis East Asian ethnicity was independently associated with lower composition of high-risk plaque after adjustment for risk factors and scan parameters. These findings were consistent in a propensity-matched sensitivity-analysis. In conclusion, based on this matched cohort, East Asian ethnicity is associated with significantly less composition of high-risk NCP (necrotic core and fibrofatty plaque) and a higher composition of low-risk fibrous plaque compared with Caucasians; which may confer a lower risk of cardiovascular events.Copy

Background: Coronary CT angiography with noninvasive fractional flow reserve (FFR) predicts lesion-specific ischemia when compared with invasive FFR. The longer term prognostic value of CT-derived FFR (FFRCT) is unknown. Purpose(s): To determine the prognostic value of FFRCT when compared with coronary CT angiography and describe the relationship of the numeric value of FFRCT with outcomes. Material(s) and Method(s): This prospective subanalysis of the NXT study (Clinicaltrials.gov: NCT01757678) evaluated participants suspected of having stable coronary artery disease who were referred for invasive angiography and who underwent FFR, coronary CT angiography, and FFRCT. The incidence of the composite primary end point of death, myocardial infarction, and any revascularization and the composite secondary end point of major adverse cardiac events (MACE: cardiac death, myocardial infarction, unplanned revascularization) were compared for an FFRCT of 0.8 or less versus stenosis of 50% or greater on coronary CT angiograms, with treating physicians blinded to the FFRCT result. Result(s): Long-term outcomes were obtained in 206 individuals (age, 64 years 6 9.5), including 64% men. At median follow-up of 4.7 years, there were no cardiac deaths or myocardial infarctions in participants with normal FFRCT. The incidence of the primary end point was more frequent in participants with positive FFRCT compared with clinically significant stenosis at coronary CT angiography (73.4% [80 of 109] vs 48.7% [91 of 187], respectively; P , .001), with the majority of outcomes being planned revascularization. Corresponding hazard ratios (HRs) were 9.2 (95% confidence interval [CI]: 5.1, 17; P , .001) for FFRCT and 5.9 (95% CI: 1.5, 24; P = .01) for coronary CT angiography. FFRCT was a superior predictor compared with coronary CT angiography for primary end point (C-index FFRCT, 0.76 vs coronary CT angiography, 0.54; P , .001) and MACE (FFRCT, 0.71 vs coronary CT angiography, 0.52; P = .001).

Introduction: Familial hypercholesterolaemia (FH) is a common hereditary lipid disorder which causes premature coronary artery disease. Pericoronary adipose tissue (PCAT) attenuation is a novel computed tomography coronary angiography (CTCA) biomarker of coronary inflammation with prognostic validation. We sought to compare PCAT attenuation in FH patients with and without significant coronary artery disease (CAD). Method(s): Patients with probable/definite FH as per Dutch Lipid Clinical Network Criteria who underwent 320-detector CTCA were included in this cross-sectional study. More than 50% coronary stenoses in CTCA were defined as significant CAD. Using semi-automated software (Autoplaque version 2.0), PCAT attenuation was measured around the proximal 10-50 mm of the right coronary artery (RCA). In patients with significant CAD, PCAT attenuation was measured around the lesion with highest-grade stenosis. Result(s): Sixty patients with phenotypic FH (40 with significant CAD and 20 with no CAD) were included. Median low-density lipoprotein cholesterol (LDL-C) was higher in patients without CAD compared to those with significant CAD (5.3 [IQR 3.85-6.7] vs. 3.3 [2.65-4.55] mmol/L, p < 0.001]. PCAT attenuation was significantly higher in patients with significant CAD compared to those without CAD (-80.9 +/- 12.2 vs. -90.6 +/- 7.6 HU, p = 0.004). PCAT attenuation around the proximal RCA was not statistically significant between the two groups (-85.3 +/- 11.9 vs. -90.6 +/- 7.6, p = 0.09). PCAT attenuation did not correlate with plasma LDL-C levels. Conclusion(s): FH patients with significant CAD had a higher PCAT attenuation than those without CAD, perhaps reflecting a greater degree of coronary inflammation. Future studies are required to assess whether PCAT attenuation can enhance risk stratification and guide therapy in FH patients.Copyright © 2019

Background and aims: There remains a substantial residual risk of ischaemic heart disease (IHD) despite optimal low-density lipoprotein cholesterol (LDLC) reduction. Part of this risk may be attributable to remnant cholesterol, which is carried in triglyceride-rich lipoproteins. We evaluated the relationship between remnant cholesterol and coronary atherosclerotic plaque burden assessed non-invasively by computed tomography coronary angiography (CTCA) in patients with suspected coronary artery disease (CAD). Methods and Results: This was a multicentre study of 587 patients who had a CTCA and fasting lipid profile within 3 months. Calculated remnant cholesterol was total cholesterol minus LDLC minus high-density lipoprotein cholesterol (HDLC). Significant coronary atherosclerotic burden was defined as CT-Leaman score >5 (CT-LeSc), an established predictor of cardiac events. Mean age was 61 +/- 12 years and mean pretest probability of CAD was 23.2 +/- 19.8%. LDLC levels were <1.8 mmol/L in 134 patients (23%), of whom 82% were statin-treated. Patients with CT-LeSc >5 had higher mean remnant cholesterol than those with CT-LeSc <=5 (0.76 +/- 0.36 mmol/L vs. 0.58 +/- 0.33 mmol/L, p = 0.01). On univariable analysis, remnant cholesterol (p = 0.01), LDLC (p = 0.002) and HDLC (p < 0.001) levels predicted CT-LeSc >5, whilst triglycerides (p = 0.79) had no association with CT-LeSc >5. On multivariable analysis in the subset of patients with optimal LDLC levels, remnant cholesterol levels remained predictive of CT-LeSc >5 (OR 3.87, 95% confidence interval 1.34-7.55, p = 0.004), adjusted for HDLC and traditional risk factors. Conclusion(s): Remnant cholesterol levels are associated with significant coronary atherosclerotic burden as assessed by CTCA, even in patients with optimal LDLC levels. Future studies examining whether lowering of remnant cholesterol can reduce residual IHD risk are warranted.Copyright © 2019 Elsevier B.V.

Background Coronary computed tomography angiography (CCTA) is often avoided in elderly patients due to a presumption that a high proportion of patients will have heavily calcified plaque limiting an accurate assessment. We sought to assess the image quality, luminal stenosis and utility of CCTA in elderly patients with suspected coronary artery disease (CAD) and stable chest pain. Methods Retrospective analysis of elderly patients (> 75 years) who underwent 320-detector row CCTA between 2012-2017 at MonashHeart. The CCTA was analysed for degree maximal coronary stenosis by CAD-RADS classification, image quality by a 5-point Likert score (1-poor, 2-adequate, 3-good, 4-very good, 5-excellent) and presence of artefact limiting interpretability. Results 1011 elderly patients (62% females, 78.8 +/- 3.3 years) were studied. Cardiovascular risk factor prevalence included: hypertension (65%), hyperlipidaemia (48%), diabetes (19%) and smoking (21%). The CCTA was evaluable in 68% of patients which included 52% with non-obstructive CAD (< 50% stenosis), 48% with obstructive CAD (> 50%) stenosis. Mean Likert score was 3.1 +/- 0.6 corresponding to good image quality. Of the 323 (32%) of patients with a non-interpretable CCTA, 80% were due to calcified plaque and 20% due to motion artefact. Male gender (P = 0.009), age (P = 0.02), excess motion (P < 0.01) and diabetes mellitus (P = 0.03) were associated with non-interpretable CCTA. Conclusion Although CCTA is a feasible non-invasive tool for assessment of elderly patients with stable chest pain, clinicians should still be cautious about referring elderly patients for CCTA. Patients who are male, diabetic and >78 years of age are significantly less likely to have interpretable scans.Copyright © 2019 JGC All rights reserved

Objectives. To assess whether periprocedural myocardial injury (PPMI) predicts outcomes in patients undergoing transcatheter aortic valve replacement (TAVR). Background. PPMI is a strong predictor of outcomes following coronary intervention, but its impact in the context of TAVR remains unclear. We performed a systematic review and meta-analysis to ascertain the association between PPMI and short or long-term clinical outcomes. Methods. Electronic searches identified studies reporting PPMI following TAVR. Primary endpoint was 30-day all-cause mortality, with secondary endpoints including 1-year all-cause mortality, neurological events, post-TAVR pacemaker implantation and aortic regurgitation (AR). Analyses were performed using random effects modelling and reported as summary odds ratio (OR) with 95% confidence intervals (CI). Results. Nine studies comprising 3,442 patients (mean age 81.0+/-6.6 years, 51.2% female) were included. PPMI occurred in 25.5% of patients following TAVR. The pooled all-cause mortality at 30 days and 1 year was 5.2% and 18.6%, respectively. The occurrence of PPMI following TAVR was associated with significantly increased risk of both 30-day (OR 4.23, CI 1.95-9.19, p<0.001) and 1-year all-cause mortality (OR 1.77, CI 1.05-2.99, p<0.001). Similarly, PPMI was associated with post-TAVR neurological events (OR 2.72, CI 1.69-4.37, p<0.001) and post-TAVR need for permanent pacing (OR 1.43, CI 1.02-2.00, p=0.04), but not with statistically significant increase in AR post-TAVR (OR 1.39, CI 0.93-2.08, PVL (p=0.11). Conclusions. PPMI is common following TAVR and is strongly associated with 30-day and 1-year mortality, with occurrence of post-TAVR neurological events and need for permanent pacemaker implantation. Detection of PPMI has potential to identify TAVR patients at highest risk of subsequent adverse events.

Purpose of Review: Perivascular adipose tissue (PVAT) has a complex, bidirectional relationship with the vascular wall. In disease states, PVAT secretes pro-inflammatory adipocytokines which may contribute to atherosclerosis. Recent evidence demonstrates that pericoronary adipose tissue (PCAT) may also function as a sensor of coronary inflammation. This review details PVAT biology and its clinical translation to current imaging phenotyping. Recent Findings: PCAT attenuation derived from routine coronary computed tomography (CT) angiography is a novel noninvasive imaging biomarker of coronary inflammation. Pro-inflammatory cytokines released from the arterial wall diffuse directly into the surrounding PCAT and inhibit adipocyte lipid accumulation in a paracrine manner. This can be detected as an increased PCAT CT attenuation, a metric which associates with high-risk plaque features and independently predicts cardiac mortality. There is also evidence that PCAT attenuation relates to coronary plaque progression and is modified by systemic anti-inflammatory therapies. Summary: Due to its proximity to the coronary arteries, PCAT has emerged as an important fat depot in cardiovascular research. PCAT CT attenuation has the potential to improve cardiovascular risk stratification, and future clinical studies should examine its role in guiding targeted medical therapy.Copyright © 2019, Springer Science+Business Media, LLC, part of Springer Nature.

Background: Off-pump coronary artery bypass grafting (CABG) negates the requirement for extracorporeal circulation used with the traditional on-pump approach. However, off-pump CABG is technically more challenging and may theoretically lead to less complete revascularisation. Recent data suggests a prognostic benefit for traditional on-pump CABG, but the mechanism for this remains unclear. We hypothesised that the inferior outcomes with off-pump CABG could be driven by the need for repeat revascularisation, with this benefit only becoming clear at long-term follow-up. We therefore evaluated short, medium and long-term outcomes of patients undergoing revascularisation with on vs. off-pump CABG. Method(s): Electronic databases were searched to identify suitable randomised controlled trials enrolling >=100 patients in each arm. Clinical outcomes were extracted at 30-days, 12-months or >4 years. The primary outcome was long-term all-cause death, while secondary outcomes included 30-day, 12-month and >4-year cardiac death, stroke, myocardial infarction or revascularisation. Result(s): Thirteen (13) studies comprising 13,234 patients were included. Off-pump CABG was associated with an increased risk of all-cause death (Odds Ratio [OR] 1.18, 95% confidence interval [CI] 1.02-1.32, p = 0.01) and repeat bypass surgery (OR 2.57, 95%CI 1.23-5.39, p = 0.01) at long-term follow-up. A significant, increased requirement for revascularisation in off-pump was seen at 12-month follow-up (OR 1.59, 95%CI 1.09-2.33, p = 0.02). No differences were noted between groups at 30-days, 12-months and >4 years for myocardial infarction or stroke. Conclusion(s): Off-pump CABG is associated with significantly higher rates of all-cause mortality rate at long-term follow-up. These outcomes demonstrate a temporal relationship that may be driven by a greater requirement for repeat revascularisation at 1- and 5-year follow-up. Study registration: CRD42018102019 (PROSPERO).Copyright © 2018 Australian an

Aims: Leaflet thrombosis (LT) has become increasingly recognised following transcatheter and surgical aortic bioprosthetic valve (ABV) replacement and can be reliably identified by computed tomography (CT). However, it is unclear whether CT-defined LT is associated with adverse cerebrovascular outcomes. We performed a meta-analysis to assess the incidence and clinical outcomes associated with CT-defined LT following ABV replacement. Method(s): Electronic databases were searched for studies that performed manda-tory CT imaging following ABV. The primary endpoint was the incidence of cerebrovascular events (CVE), defined as composite of stroke and transient ischaemic attack (TIA). Secondary endpoints included major adverse cerebrovascular and cardiovascular events (MACCE), stroke, TIA, death or myocardial infarction. Pre-specified analysis was also performed to compare the CT imaging features of reduced leaflet motion (RELM) and hypoattenuated leaflet thickening (HALT) with regards to risk of CVE. In Makkar et al., we only reported the Portico cohort as the rest was later updated in Chakravarty et al. Result(s): 8 studies met inclusion criteria with a prevalence of 12.5% (229/1828) patients having CT-defined LT. The prevalence of LT following transcatheter and surgical ABV was 12.8% and 9.8%, respectively. CVE were significantly increased in patients with LT(Odds Ratio (OR) 2.96, 95% CI 1.63-5.38, p<0.01). The risk of stroke (OR2.45, 95% CI 1.19-5.03, p=0.02)and MACCE (OR2.14, 95% CI 1.26-3.64, p<0.01) were also increased in patients with LT. The risk of TIA increased in patients with LT, reaching borderline statistical significance (OR 3.19, 95% CI 0.99-10.29, p=0.05). The risk of death and myocardial infarction were similar between groups. CT feature of RELM was related with higher CVE (OR 3.34, 95% CI 1.7-6.56, p<0.01) than HALT (OR 1.88, 95% CI 0.51-6.9, p=0.34) [Table Presented] Conclusion(s): CT-defined LT following ABV replacement is associated with a sig-nific

BACKGROUND: Low socioeconomic status is associated with cardiovascular diseases, and an association with atrial fibrillation (AF) could guide screening. AIM: To investigate if indices of advantage/disadvantage (IAD), index of education/occupation (IEO) and index of economic resources were associated with incident AF, independent of risk factors and cardiac function. METHODS: We studied community-based participants aged ≥65 years with AF risk factors (n = 379, age 70 ± 4 years, 45% men). The CHARGE-AF score (a well validated AF risk score) was used to assess 5-year risk of developing AF. Participants also had baseline echocardiograms. IAD, IEO and index of economic resources were obtained from the 2011 Socio-Economic Indexes for Areas score, in which higher decile ranks indicate more advantaged areas. Patients were followed up for incident AF (median 21 (range 5-31) months), with AF diagnosed by clinical review, including 12-lead electrocardiogram (ECG), as well as single-lead portable ECG monitoring used to record 60 s ECG tracings five times/day for 1 week. Cox proportional hazards models were used to assess the association between socioeconomic status and incident AF. RESULTS: Subjects with AF (n = 50, 13%) were more likely to be male (64 vs 42%, P = 0.003) and had higher CHARGE-AF score (median 7.1% (5.2-12.8%) vs 5.3% (3.3-8.6%), P < 0.001). Areas with lower socioeconomic status (IAD and IEO) had a higher risk of incident AF independent of LV function and CHARGE-AF score (hazard ratio for IAD 1.16, 95% confidence interval 1.05-1.29, P = 0.005 and hazard ratio for IEO 1.18, 95% confidence interval 1.07-1.30, P = 0.001). CONCLUSION: Regional socioeconomic status is associated with risk of incident AF, independent of LV function and clinical risk. This association might permit better regional targeting of prevention.

The accuracy of photoplethysmography (PPG) for heart rate (HR) estimation in cardiac arrhythmia is unknown. PPG-HR was evaluated in 112 hospitalised inpatients (cardiac arrhythmias (n = 60), sinus rhythm (n = 52)) using a continuous electrocardiogram monitoring as a reference standard. Strong agreement was observed in sinus rhythm HR < 100 and atrial flutter (bias 1 beat), modest agreement in sinus tachycardia (bias 24 beats) and complete heart block (bias -6 beats) and weak agreement with significant HR underestimation was seen in atrial fibrillation (bias 23 beats). Routine utilisation of PPG for HR estimation may delay early recognition of clinical deterioration in certain arrhythmias and sinus tachycardia.Copyright © 2018 Royal Australasian College of Physicians