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Background The proper imaging modality for use in the selection of patients for endovascular thrombectomy (EVT) presenting in the late window remains controversial, despite current guidelines advocating the use of advanced imaging in this population. We sought to understand if clinicians with different specialty training differ in their approach to patient selection for EVT in the late time window. Methods We conducted an international survey of stroke and neurointerventional clinicians between January and May 2022 with questions focusing on imaging and treatment decisions of large vessel occlusion (LVO) patients presenting in the late window. Interventional neurologists, interventional neuroradiologists, and endovascular neurosurgeons were defined as interventionists whereas all other specialties were defined as non-interventionists. The non-interventionist group was defined by all other specialties of the respondents: stroke neurologist, neuroradiologist, emergency medicine physician, trainee (fellows and residents) and others. Results Of 3000 invited to participate, 1506 (1027 non-interventionists, 478 interventionists, 1 declined to specify) physicians completed the study. Interventionist respondents were more likely to proceed directly to EVT (39.5% vs. 19.5%; p  < 0.0001) compared to non-interventionist respondents in patients with favorable ASPECTS (Alberta Stroke Program Early CT Score). Despite no difference in access to advanced imaging, interventionists were more likely to prefer CT/CTA alone (34.8% vs. 21.0%) and less likely to prefer CT/CTA/CTP (39.1% vs. 52.4%) for patient selection ( p  < 0.0001). When faced with uncertainty, non-interventionists were more likely to follow clinical guidelines (45.1% vs. 30.2%) while interventionists were more likely to follow their assessment of evidence (38.7% vs. 27.0%) ( p  < 0.0001). Conclusion Interventionists were less likely to use advanced imaging techniques in selecting LVO patients presenting in the late window and more likely to base their decisions on their assessment of evidence rather than published guidelines. These results reflect gaps between interventionists and non-interventionists reliance on clinical guidelines, the limits of available evidence, and clinician belief in the utility of advanced imaging.

ObjectiveThe study evaluates the relationship of coronary stenosis, atherosclerotic plaque characteristics (APCs) and age using artificial intelligence enabled quantitative coronary computed tomographic angiography (AI-QCT).MethodsThis is a post-hoc analysis of data from 303 subjects enrolled in the CREDENCE (Computed TomogRaphic Evaluation of Atherosclerotic Determinants of Myocardial IsChEmia) trial who were referred for invasive coronary angiography and subsequently underwent coronary computed tomographic angiography (CCTA). In this study, a blinded core laboratory analysing quantitative coronary angiography images classified lesions as obstructive (≥50%) or non-obstructive (<50%) while AI software quantified APCs including plaque volume (PV), low-density non-calcified plaque (LD-NCP), non-calcified plaque (NCP), calcified plaque (CP), lesion length on a per-patient and per-lesion basis based on CCTA imaging. Plaque measurements were normalised for vessel volume and reported as % percent atheroma volume (%PAV) for all relevant plaque components. Data were subsequently stratified by age <65 and ≥65 years.ResultsThe cohort was 64.4±10.2 years and 29% women. Overall, patients >65 had more PV and CP than patients <65. On a lesion level, patients >65 had more CP than younger patients in both obstructive (29.2 mm3 vs 48.2 mm3; p<0.04) and non-obstructive lesions (22.1 mm3 vs 49.4 mm3; p<0.004) while younger patients had more %PAV (LD-NCP) (1.5% vs 0.7%; p<0.038). Younger patients had more PV, LD-NCP, NCP and lesion lengths in obstructive compared with non-obstructive lesions. There were no differences observed between lesion types in older patients.ConclusionAI-QCT identifies a unique APC signature that differs by age and degree of stenosis and provides a foundation for AI-guided age-based approaches to atherosclerosis identification, prevention and treatment.

The Scottish Computed Tomography of the Heart (SCOT-HEART) trial demonstrated that management guided by coronary CT angiography (CCTA) improved the diagnosis, management, and outcome of patients with stable chest pain. We aimed to assess whether CCTA-guided care results in sustained long-term improvements in management and outcomes. SCOT-HEART was an open-label, multicentre, parallel group trial for which patients were recruited from 12 outpatient cardiology chest pain clinics across Scotland. Eligible patients were aged 18–75 years with symptoms of suspected stable angina due to coronary heart disease. Patients were randomly assigned (1:1) to standard of care plus CCTA or standard of care alone. In this prespecified 10-year analysis, prescribing data, coronary procedural interventions, and clinical outcomes were obtained through record linkage from national registries. The primary outcome was coronary heart disease death or non-fatal myocardial infarction on an intention-to-treat basis. This trial is registered at ClinicalTrials.gov (NCT01149590) and is complete. Between Nov 18, 2010, and Sept 24, 2014, 4146 patients were recruited (mean age 57 years [SD 10], 2325 [56·1%] male, 1821 [43·9%] female), with 2073 randomly assigned to standard care and CCTA and 2073 to standard care alone. After a median of 10·0 years (IQR 9·3–11·0), coronary heart disease death or non-fatal myocardial infarction was less frequent in the CCTA group compared with the standard care group (137 [6·6%] vs 171 [8·2%]; hazard ratio [HR] 0·79 [95% CI 0·63–0·99], p=0·044). Rates of all-cause, cardiovascular, and coronary heart disease death, and non-fatal stroke, were similar between the groups (p>0·05 for all), but non-fatal myocardial infarctions (90 [4·3%] vs 124 [6·0%]; HR 0·72 [0·55–0·94], p=0·017) and major adverse cardiovascular events (172 [8·3%] vs 214 [10·3%]; HR 0·80 [0·65–0·97], p=0·026) were less frequent in the CCTA group. Rates of coronary revascularisation procedures were similar (315 [15·2%] vs 318 [15·3%]; HR 1·00 [0·86–1·17], p=0·99) but preventive therapy prescribing remained more frequent in the CCTA group (831 [55·9%] of 1486 vs 728 [49·0%] of 1485 patients with available data; odds ratio 1·17 [95% CI 1·01–1·36], p=0·034). After 10 years, CCTA-guided management of patients with stable chest pain was associated with a sustained reduction in coronary heart disease death or non-fatal myocardial infarction. Identification of coronary atherosclerosis by CCTA improves long-term cardiovascular disease prevention in patients with stable chest pain. The Chief Scientist Office of the Scottish Government Health and Social Care Directorates, Edinburgh and Lothian's Health Foundation Trust, British Heart Foundation, and Heart Diseases Research Fund.

Objectives To explore the use of 70-kVp tube voltage combined with high-strength deep learning image reconstruction (DLIR-H) in reducing radiation and contrast doses in coronary CT angiography (CCTA) in patients with body mass index (BMI) < 26 kg/m 2 , in comparison with the conventional scan protocol using 120 kVp and adaptive statistical iterative reconstruction (ASIR-V). Methods A total of 100 patients referred to CCTA were prospectively enrolled and randomly divided into two groups: low-dose group ( n  = 50) with 70 kVp, Smart mA for noise index (NI) of 36HU, contrast dose rate of 16mgI/kg/s, and DLIR-H, and conventional group ( n  = 50) with 120 kV, Smart mA for NI of 25HU, contrast dose rate of 32mgI/kg/s, and 60%ASIR-V. Radiation and contrast dose, subjective image quality score, and objective image quality measurement (image noise, contrast-noise-ratio (CNR), and signal–noise-ratio (SNR) for vessel) were compared between the two groups. Results Low-dose group used significantly reduced contrast dose (23.82 ± 3.69 mL, 50.6% reduction) and radiation dose (0.75 ± 0.14 mSv, 54.5% reduction) compared to the conventional group (48.23 ± 6.38 mL and 1.65 ± 0.66 mSv, respectively) (all p  < 0.001). Both groups had similar enhancement in vessels. However, the low-dose group had lower background noise (23.57 ± 4.74 HU vs. 35.04 ± 8.41 HU), higher CNR in RCA (48.63 ± 10.76 vs. 29.32 ± 5.52), LAD (47.33 ± 10.20 vs. 29.27 ± 5.12), and LCX (46.74 ± 9.76 vs. 28.58 ± 5.12) (all p  < 0.001) compared to the conventional group. Conclusions The use of 70-kVp tube voltage combined with DLIR-H for CCTA in normal size patients significantly reduces radiation dose and contrast dose while further improving image quality compared with the conventional 120-kVp tube voltage with 60%ASIR-V. Key Points •  The combination of 70-kVp tube voltage and high-strength deep learning image reconstruction (DLIR-H) algorithm protocol reduces approximately 50% of radiation and contrast doses in coronary computed tomography angiography (CCTA) compared with the conventional scan protocol . •  CCTA of normal size (BMI < 26 kg/m 2 ) patients acquired at sub-mSv radiation dose and 24 mL contrast dose through the combination of 70-kVp tube voltage and DLIR-H algorithm achieves excellent diagnostic image quality with a good inter-rater agreement . •  DLIR-H algorithm shows a higher capacity of significantly reducing image noise than adaptive statistical iterative reconstruction algorithm in CCTA examination .

Objective To evaluate radiation dose and image quality of a double-low CCTA protocol reconstructed utilizing high-strength deep learning image reconstructions (DLIR-H) compared to standard adaptive statistical iterative reconstruction (ASiR-V) protocol in non-obese patients. Materials and methods From June to October 2022, consecutive patients, undergoing clinically indicated CCTA, with BMI < 30 kg/m 2 were prospectively included and randomly assigned into three groups: group A (100 kVp, ASiR-V 50%, iodine delivery rate [IDR] = 1.8 g/s), group B (80 kVp, DLIR-H, IDR = 1.4 g/s), and group C (80 kVp, DLIR-H, IDR = 1.2 g/s). High-concentration contrast medium was administered. Image quality analysis was evaluated by two radiologists. Radiation and contrast dose, and objective and subjective image quality were compared across the three groups. Results The final population consisted of 255 patients (64 ± 10 years, 161 men), 85 per group. Group B yielded 42% radiation dose reduction (2.36 ± 0.9 mSv) compared to group A (4.07 ± 1.2 mSv; p  < 0.001) and achieved a higher signal-to-noise ratio (30.5 ± 11.5), contrast-to-noise-ratio (27.8 ± 11), and subjective image quality (Likert scale score: 4, interquartile range: 3–4) compared to group A and group C (all p  ≤ 0.001). Contrast medium dose in group C (44.8 ± 4.4 mL) was lower than group A (57.7 ± 6.2 mL) and B (50.4 ± 4.3 mL), all the comparisons were statistically different (all p  < 0.001). Conclusion DLIR-H combined with 80-kVp CCTA with an IDR 1.4 significantly reduces radiation and contrast medium exposure while improving image quality compared to conventional 100-kVp with 1.8 IDR protocol in non-obese patients. Clinical relevance statement Low radiation and low contrast medium dose coronary CT angiography protocol is feasible with high-strength deep learning reconstruction and high-concentration contrast medium without compromising image quality. Key Points Minimizing the radiation and contrast medium dose while maintaining CT image quality is highly desirable . High-strength deep learning iterative reconstruction protocol yielded 42% radiation dose reduction compared to conventional protocol . “Double-low” coronary CTA is feasible with high-strength deep learning reconstruction without compromising image quality in non-obese patients .

AbstractObjectivesTo establish if the use of early computed tomography (CT) coronary angiography improves one year clinical outcomes in patients presenting to the emergency department with acute chest pain and at intermediate risk of acute coronary syndrome and subsequent clinical events.DesignRandomised controlled trial.Setting37 hospitals in the UK.ParticipantsAdults with suspected or a provisional diagnosis of acute coronary syndrome and one or more of previous coronary heart disease, raised levels of cardiac troponin, or abnormal electrocardiogram.InterventionsEarly CT coronary angiography and standard of care compared with standard of care only.Main outcome measuresPrimary endpoint was all cause death or subsequent type 1 or 4b myocardial infarction at one year.ResultsBetween 23 March 2015 and 27 June 2019, 1748 participants (mean age 62 years (standard deviation 13), 64% men, mean global registry of acute coronary events (GRACE) score 115 (standard deviation 35)) were randomised to receive early CT coronary angiography (n=877) or standard of care only (n=871). Median time from randomisation to CT coronary angiography was 4.2 (interquartile range 1.6-21.6) hours. The primary endpoint occurred in 51 (5.8%) participants randomised to CT coronary angiography and 53 (6.1%) participants who received standard of care only (adjusted hazard ratio 0.91 (95% confidence interval 0.62 to 1.35), P=0.65). Invasive coronary angiography was performed in 474 (54.0%) participants randomised to CT coronary angiography and 530 (60.8%) participants who received standard of care only (adjusted hazard ratio 0.81 (0.72 to 0.92), P=0.001). There were no overall differences in coronary revascularisation, use of drug treatment for acute coronary syndrome, or subsequent preventive treatments between the two groups. Early CT coronary angiography was associated with a slightly longer time in hospital (median increase 0.21 (95% confidence interval 0.05 to 0.40) days from a median hospital stay of 2.0 to 2.2 days).ConclusionsIn intermediate risk patients with acute chest pain and suspected acute coronary syndrome, early CT coronary angiography did not alter overall coronary therapeutic interventions or one year clinical outcomes, but reduced rates of invasive angiography while modestly increasing length of hospital stay. These findings do not support the routine use of early CT coronary angiography in intermediate risk patients with acute chest pain and suspected acute coronary syndrome.Trial registrationISRCTN19102565, NCT02284191.

The optimal noninvasive diagnostic imaging strategy for patients with suspected coronary artery disease (CAD) is widely debated. Computed Tomography Coronary Angiography (CTCA) and functional imaging are both guideline-recommended, although comparative effectiveness in patients with intermediate-high pretest likelihood (PTL) is limited. Primary Hypothesis: We aim to establish if a personalized investigation strategy compared to CTCA first-line for allcomers, leads to improved patient outcomes. In a multi-center, randomized trial, 4,000 patients newly referred for the investigation of suspected cardiac chest pain will be recruited and randomized (1:1) to either personalized care (first-line CTCA or functional imaging based on PTL) or CTCA first-line for allcomers. The primary endpoint is time to a composite of cardiovascular death, myocardial infarction, or unobstructed coronary arteries on invasive angiography. Follow up will occur at 6 and 12 months and then annually for up to 4 years for symptoms, quality of life, and guideline directed medical therapy usage. A cost-effectiveness analysis will be performed capturing impacts on health, measured in quality adjusted life years (QALYs) using the EQ-5D-5L, and costs (including investigations, procedures, procedural complications, medical treatment costs and any future hospital admissions) calculated. It will be possible for the whole trial pathway to be conducted remotely with the option to perform non-face-to-face consent, randomization, and follow-up data collection including health-related quality of life. About 20 UK sites. First site opened April 2022 and recruitment is due to complete by July 2025, with an average recruitment of 135 patients a month to date. About 3,407 patients recruited and randomized by the end of February 2025 This trial will address whether, in patients with suspected cardiac chest pain, a strategy of personalized investigation according to pretest likelihood (PTL), compared to CTCA for allcomers, leads to improved patient outcomes, quality of life and cost-effectiveness.

Objectives To compare vascular attenuation (VA) of an experimental half iodine-load dual-layer spectral detector CT (SDCT) lower limb computed tomography angiography (CTA) with control (standard iodine-load conventional 120-kilovolt peak (kVp) CTA). Methods Ethical approval and consent were obtained. In this parallel RCT, CTA examinations were randomized into experimental or control. Patients received 0.7 vs 1.4 mL/kg of iohexol 350 mgI/mL in the experimental- vs the control group. Two experimental virtual monoenergetic image (VMI) series at 40 and 50 kiloelectron volts (keV) were reconstructed. Primary outcome: VA. Secondary outcomes: image noise (noise), contrast- and signal-to-noise ratio (CNR and SNR), and subjective examination quality (SEQ). Results A total of 106 vs 109 were randomized and 103 vs 108 were analyzed in the experimental vs, control groups, respectively. VA was higher on experimental 40 keV VMI than on control ( p  < 0.0001), but lower on 50 keV VMI ( p  < 0.022). Noise was higher on experimental 40 keV VMI than on control ( p  = 0.00022), but lower on 50 keV VMI ( p  = 0.0033). CNR and SNR were higher than the control on experimental 40 keV VMI (both p  < 0.0001) and 50 keV ( p  = 0.0058 and p  = 0.0023, respectively) .  SEQ was better on both VMIs in the experimental group than in the control (both p  < 0.0001). Conclusions Half iodine-load SDCT lower limb CTA at 40 keV achieved higher VA than the control. CNR, SNR, noise, and SEQ were higher at 40 keV, while 50 keV showed lower noise. Clinical relevance statement Spectral detector CT with low-energy virtual monoenergetic imaging performed halved iodine contrast medium (CM) lower limb CT-angiography with sustained objective and subjective quality. This facilitates CM reduction, improvement of low CM-dosage examinations, and examination of patients with more severe kidney impairment. Trial registration Retrospectively registered 5 August 2022 at clinicaltrials.gov NCT05488899. Key Points • Contrast medium dosage may be halved in lower limb dual-energy CT angiography with virtual monoenergetic images at 40 keV, which may reduce contrast medium consumption in the face of a global shortage. • Experimental half-iodine-load dual-energy CT angiography at 40 keV showed higher vascular attenuation, contrast-to-noise ratio, signal-to-noise ratio, and subjective examination quality than standard iodine-load conventional. • Half-iodine dual-energy CT angiography protocols may allow us to reduce the risk of PC-AKI, examine patients with more severe kidney impairment, and provide higher quality examinations or salvage poor examinations when impaired kidney function limits the CM dose.

Tirzepatide is a novel once-week dual GIP/GLP-1 RA agonist approved for T2DM and its role to reduce cardiovascular events remains to be elucidated. The goal of this trial is to assess how tirzepatide affects the progression of atherosclerotic plaque as determined by multidetector computed tomography angiography (MDCTA). This trial is a double blind, randomized, prospective, placebo-controlled multicenter phase IV trial. Participant eligible for the study will be adults with T2DM between 40 and 80 years of age who have HbA1c ≥ 7.0% to ≤ 10.5% and at least 20% stenosis in major epicardial vessel on CCTA. Baseline examination will include the results of their demographics, lab tests, coronary calcium, as well as coronary plaque volume/composition. Following randomization, tirzepatide or placebo will be given at a weekly dose of 2.5 mg, and a fixed dose-escalation strategy will be followed. Patients will undergo quarterly visits for safety assessments and labs, and follow up with repeat CCTA at 1 year. This study evaluates the antiatherogenic potential of tirzepatide, providing a mechanism of potential CV benefit. This is crucial to our understanding of T2DM treatment and CVD since plaque progression portends worse outcomes in these populations. MDCTA is a noninvasive method that assesses the volume, composition, and degree of coronary vessel stenosis. This study will be the first study to assess the effects of tirzepatide on atherosclerotic plaque progression measured by MDCTA in participants with T2DM.

Coronary computed tomography angiography (CTA) is the preferred primary diagnostic modality when examining patients with low to intermediate pre-test probability of coronary artery disease (CAD). Only 20-30% of these have potentially obstructive CAD. Because of the relatively poor positive predictive value of coronary CTA, unnecessary invasive coronary angiographies (ICAs) are conducted with the costs and risks associated with the procedure. Hence, an optimized diagnostic CAD algorithm may reduce the numbers of ICAs not followed by revascularization. The Dan-NICAD 2 study has 3 equivalent main aims: (1) To examine the diagnostic precision of a sound-based diagnostic algorithm, The CADScor®System (Acarix A/S, Denmark), in patients with a low to intermediate pre-test risk of CAD referred to a primary examination by coronary CTA. We hypothesize that the CADScor®System provides better stratification prior to coronary CTA than clinical risk stratification scores alone. (2) To compare the diagnostic accuracy of 3T cardiac magnetic resonance imaging (3T CMRI), 82rubidium positron emission tomography (82Rb-PET), and CT-derived fractional flow reserve (FFRCT) in patients where obstructive CAD cannot be ruled out by coronary CTA using ICA fractional flow reserve (FFR) as reference standard. (3) To compare the diagnostic performance of quantitative flow ratio (QFR) and ICA-FFR in patients with low to intermediate pre-test probability of CAD using 82Rb-PET as reference standard. Dan-NICAD 2 is a prospective, multicenter, cross-sectional study including approximately 2,000 patients with low to intermediate pre-test probability of CAD and without previous history of CAD. Patients are referred to coronary CTA because of symptoms suggestive of CAD, as evaluated by a cardiologist. Patient interviews, sound recordings, and blood samples are obtained in connection with the coronary CTA. If coronary CTA does not rule out obstructive CAD, patients will be examined by 3T CMRI 82Rb-PET, FFRCT, ICA, and FFR. Reference standard is ICA-FFR. Obstructive CAD is defined as an FFR ≤0.80 or as high-grade stenosis (>90% diameter stenosis) by visual assessment. Diagnostic performance will be evaluated as sensitivity, specificity, predictive values, likelihood ratios, calibration, and discrimination. Enrolment started January 2018 and is expected to be completed by June 2020. Patients are followed for 10 years after inclusion. The results of the Dan-NICAD 2 study are expected to contribute to the improvement of diagnostic strategies for patients suspected of CAD in 3 different steps: risk stratification prior to coronary CTA, diagnostic strategy after coronary CTA, and invasive wireless QFR analysis as an alternative to ICA-FFR.