Aims: The purpose of this study was to determine (a) the ability of serial high-sensitivity cardiac troponin T measurements to rule out acute myocardial infarction and (b) the ability of a single high baseline high-sensitivity cardiac troponin T measurement to rule in acute myocardial infarction in patients presenting to the emergency department with acute chest pain. Methods and results: Embase, Medline, Cochrane, Web of Science and Google scholar were searched for prospective cohort studies that evaluated parameters of diagnostic accuracy of serial high-sensitivity cardiac troponin T to rule out acute myocardial infarction and a single baseline high-sensitivity cardiac troponin T value>50 ng/l to rule in acute myocardial infarction. The search yielded 21 studies for the systematic review, of which 14 were included in the meta-analysis, with a total of 11,929 patients and an overall prevalence of acute myocardial infarction of 13.0%. For rule-out, six studies presented the sensitivity of serial measurements <14 ng/l. This cut-off classified 60.1% of patients as rule-out and the summary sensitivity was 96.7% (95% confidence interval: 92.3–99.3). Three studies presented the sensitivity of a one-hour algorithm with a baseline high-sensitivity cardiac troponin T value<12 ng/l and delta 1 hour <3 ng/l. This algorithm classified 60.2% of patients as rule-out and the summary sensitivity was 98.9% (96.4–100). For rule-in, six studies reported the specificity of baseline high-sensitivity cardiac troponin T value>50 ng/l. The summary specificity was 94.6% (91.5–97.1). Conclusion: Serial high-sensitivity cardiac troponin T measurement strategies to rule out acute myocardial infarction perform well, and a single baseline high-sensitivity cardiac troponin T value>50 ng/l to rule in acute myocardial infarction has a high specificity.

MBF had weaker correlation with FFR (r=0.456, p=0.0024) than CFVR. The opti- mal cut-off value of MBF to detect CFVR < 2.0 was 1.43mL/g/min, and this cut-off value could diagnose CFVR < 2.0 with 84.0% diagnostic accuracy. The optimal cut-off value of MBF to detect FFR ≤ 0.75 was 1.38mL/g/min, and this cut-off value could diagnose FFR ≤ 0.75 with 78.6% diagnostic accuracy. Conclusions: The MBF using CTP had good diagnostic accuracy to detect myocardial ischemia. In our study, MBF seems to reflect the myocardial ischemia that is nearer to CFVR than FFR. Background: The burden of coronary artery disease (CAD) in women may still be under-recognized. This might be the result of distinct pathophysiological differ-ences or disease perception by patients and physicians. In this pre-specified sub- analysis of the Better Evaluation of Acute Chest Pain with Coronary Computed Tomography Angiography (BEACON) trial, we compare the clinical effectiveness of early coronary CT angiography (CCTA) in women and men. Methods: In the BEACON-trial, we randomized 500 patients suspected of ACS (47% women) at the emergency departments (ED) of 7 hospitals to either a diagnostic strategy supplemented by early CCTA or standard optimal care (SOC) with high-sensitivity troponins (hs-troponins) available in both groups. To assess inter-actions between sex and diagnostic group we used logistic regression analysis for with a good prognosis despite risk of non-calcified plaques Background: A coronary artery calcium (CAC) score of zero does not exclude the diagnosis of coronary artery disease (CAD), particularly in symptomatic patients due to the existence of non-calcified atherosclerotic plaques. Purpose: We evaluated the prevalence of CAD in patients with a zero CAC score, as well as the incidence of major adverse cardiac events (MACE) in these patients vs. those with a non-zero CAC score. Methods: In this prospective cohort study, consecutive patients with suspected CAD underwent CAC scoring +/− coronary CT angiography (CCTA) using a 128x2-slice dual source CT scanner as part of routine clinical care in a single centre. CAC score was calculated using the Agatston method. The primary end-point, MACE, was defined as cardiac death, non-fatal myocardial infarction and/or non-elective revascularisation. Results: A total 668 of 1279 (52%) symptomatic patients with low-to-intermediate cardiovascular risk (mean age 56±12 years; 48% male) who underwent CAC scoring between November 2009 and July 2015 had a zero CAC score. Of the 619 (93%) patients with a zero CAC in whom CCTA was performed, 552 (89.2%) had normal coronaries, 52 (8.4%) had non-obstructive CAD, 11 (1.8%) had ob- structive CAD ( > 50% stenosis), and 4 (0.6%) had non-diagnostic CCTAs. Over a median follow-up period of 2.8 years (IQR 2.1–4.4 years), the incidence of MACE was 4 (0.6%) in the zero CAC cohort vs. 14 (2.3%) in the non-zero CAC cohort, Background: Parallel to advanced imaging techniques as magnetic resonance imaging (MRI) and computed tomography (CT) becoming more affordable and accessible, the diagnosis of pathologies previously considered uncommon is in- creasing. Current ESC guidelines for pulmonary hypertension (PH) recommend high-resolution CT in all patients with PH during diagnostic workup (IIa-C). Pulmonary artery aneurysms (PAA) are a rare condition and, although its our Future should include or MRI during follow-up of PAH patients to improve the diagnosis of PAA and its potentially lethal

Physicians practicing cardiovascular medicine are every day confronted with patients presenting with symptoms suggestive of an acute coronary syndrome (ACS). Over the years, there have been substantial technical advances, such as the introduction of new non-invasive imaging techniques and the introduction of new highly sensitive cardiac biomarkers. Physicians have adopted these new assets and have become more experienced with them thus improving medical care. Nevertheless, the search for an efficient, yet safe diagnostic work-up for patients presenting with symptoms suggestive of ACS is ongoing. A large proportion of patients will require some form of non-invasive testing and the choice for the diagnostic modality as well as its timing are important steps in this process. Cardiac computed tomography (CT), a non-invasive imaging technique that rapidly provides visualization of the coronary artery tree, is an attractive option, with its unparalleled negative predictive value for obstructive coronary artery disease (CAD). With the introduction of highly-sensitive troponins (hsTn), the role of non-invasive testing, including cardiac CT, has changed. This review will provide an oversight on what is known about cardiac CT in acute chest presentations. Furthermore, we will discuss the changing role of cardiac CT in the era of hsTn and the possibility of their combined use in the work-up of suspected ACS patients. hsTn is currently an established tool for the diagnosis and triage of patients with suspected ACS. The role of cardiac CT has shifted now to a secondary, comprehensive rule-out test in patients with inconclusive biomarker status, providing information on stenosis severity, plaque burden, high-risk features and the presence of other serious conditions that can also give rise to hsTn.

BACKGROUND Cardiac computed tomography (CT) represents an alternative diagnostic strategy for women with suspected coronary artery disease, with potential benefits in terms of effectiveness and cost-efficiency. METHODS AND RESULTS The CRESCENT trial (Calcium Imaging and Selective CT Angiography in Comparison to Functional Testing for Suspected Coronary Artery Disease) prospectively randomized 350 patients with stable angina (55% women; aged 55±10 years), mostly with an intermediate coronary artery disease probability, between cardiac CT and functional testing. The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. Sex differences were studied as a prespecified subanalysis. Enrolled women presented more frequently with atypical chest pain and had a lower pretest probability of coronary artery disease compared with men. Independently of these differences, cardiac CT led in both sexes to a fast final diagnosis when compared with functional testing, although the effect was larger in women (P interaction=0.01). The reduced need for further testing after CT, compared with functional testing, was most evident in women (P interaction=0.009). However, no sex interaction was observed with respect to changes in angina and quality of life, cumulative diagnostic costs, and applied radiation dose (all P interactions≥0.097). CONCLUSIONS Cardiac CT is more efficient in women than in men in terms of time to reach the final diagnosis and downstream testing. However, overall clinical outcome showed no significant difference between women and men after 1 year. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01393028.

markdownabstractCoronary CT angiography is a well-established diagnostic modality for stable angina pectoris. It provides an angiographic, non-invasive alternative for the diagnosis of coronary artery disease, exceeding in the ability to exclude important coronary artery disease. Having the ability to reliably exclude coronary artery disease might be of particular benefit to patients who present at the emergency department with suspected coronary artery disease. Although the majority of them have a benign cause for their complaints, missing an acute coronary syndrome can have grave consequences. In the first part, we investigated the value of coronary CT angiography in patients presenting to the emergency department suspected of an acute coronary syndrome. The findings on a coronary CT angiogram might not only be useful for diagnostic purposes, they also may serve as markers of future cardiac adverse events. It seems likely that the presence and degree of coronary artery disease detected by coronary CT angiography will also provide information regarding cardiac adverse events in the future. In the second part, we investigate the prognostic value of coronary CT angiography in different patient populations

AIMS To compare the effectiveness and safety of a cardiac computed tomography (CT) algorithm with functional testing in patients with symptoms suggestive of coronary artery disease (CAD). METHODS AND RESULTS Between April 2011 and July 2013, 350 patients with stable angina, referred to the outpatient clinic of four Dutch hospitals, were prospectively randomized between cardiac CT and functional testing (2 : 1 ratio). The tiered cardiac CT protocol included a calcium scan followed by CT angiography if the Agatston calcium score was between 1 and 400. Patients with test-specific contraindications were not excluded from study participation. By 1 year, fewer patients randomized to cardiac CT reported anginal complaints (P = 0.012). The cumulative radiation dose was slightly higher in the CT group (6.6 ± 8.7 vs. 6.1 ± 9.3 mSv; P < 0.0001). After 1.2 years, event-free survival was 96.7% for patients randomized to CT and 89.8% for patients randomized to functional testing (P = 0.011). After CT, the final diagnosis was established sooner (P < 0.0001), and additional downstream testing was required less frequently (25 vs. 53%, P < 0.0001), resulting in lower cumulative diagnostic costs (€369 vs. €440; P < 0.0001). CONCLUSION For patients with suspected stable CAD, a tiered cardiac CT protocol offers an effective and safe alternative to functional testing. Incorporating the calcium scan into the diagnostic workup was safe and lowered diagnostic expenses and radiation exposure.