Abstract Background and Aims The long-term prognostic value of a guideline-recommended selective sequential anatomical-functional imaging strategy using coronary computed tomography angiography (CCTA) followed by quantitative [15O]H2O positron emission tomography (PET) remains uncertain. We evaluated its long-term prognostic value in patients with first symptoms suggestive of obstructive coronary artery disease (CAD). Methods In this multicentre European cohort, symptomatic patients first underwent CCTA and were selectively referred to quantitative [15O]H2O PET in case of suspected obstructive stenosis (≥50%). Patients were stratified according to CCTA findings and PET-derived ischaemia (normal CCTA; non-obstructive CAD on CCTA; obstructive CAD on CCTA without ischaemia; obstructive CAD on CCTA with ischaemia). The primary endpoint was a composite of all-cause mortality, non-fatal myocardial infarction (MI), and hospitalization for unstable angina (UA). Adjusted hazard ratios (aHRs) were calculated. Results Among 3,918 patients (61.0±9.8 years; 54.3% female) with a median follow-up of 5.1 [3.8-8.0] years, 278 (7.1%) experienced the primary endpoint. aHRs increased stepwise across CCTA-PET categories. Compared to normal CCTA, non-obstructive CAD and obstructive CAD without ischaemia were associated with a higher risk of the combined primary endpoint (aHR 1.89, [95%CI: 1.23-2.91], p=0.004; aHR 3.20, [95%CI: 1.95-5.25], p<0.001). Among patients with obstructive CAD on CCTA, PET-derived ischaemia further increased the risk of the primary endpoint (aHR 1.55, [95%CI: 1.05-2.30]; p=0.029), but not when excluding UA from the composite endpoint (aHR 1.37, [95%CI 0.90-2.07]; p=0.141). PET-derived ischaemia primarily predicted events within the first year, while obstructive CCTA findings remained associated with long-term hard outcomes. Conclusions A sequential strategy combining CCTA and quantitative [15O]H2O PET provides robust and incremental long-term risk stratification. While PET-derived ischaemia refines prediction of short-term and symptom-driven events, CCTA-derived CAD remains the principal determinant of long-term hard outcomes.
Abstract Aims Rest late gadolinium enhancement cardiovascular magnetic resonance (LGE-CMR) identifies infarct-pattern scar but does not assess coronary anatomy. We estimated the prevalence of angiographic coronary artery disease (CAD) among adults with heart failure and reduced ejection fraction (HFrEF) or otherwise unexplained left ventricular systolic dysfunction without infarct-pattern LGE. Methods and results MEDLINE, Embase, CENTRAL, and ClinicalTrials.gov were searched to 27 July 2026. Eligible studies provided separable scar-negative denominators and corresponding angiographic CAD counts from invasive coronary angiography (ICA). Scar-negative was defined as the absence of subendocardial or transmural LGE in a coronary distribution. Random-effects logit meta-analysis used restricted maximum likelihood and Hartung-Knapp confidence intervals. Twenty-two reports representing 20 studies included 2,236 paired LGE-CMR and ICA. 818 patients had infarct-pattern scar, and 1,418 were scar-negative. Eight studies contributed 44 CAD cases among 468 scar-negative patients for ≥50% stenosis, giving a pooled prevalence of 10.8% (95% confidence interval [CI] 7.4–15.4). Five studies contributed 19 CAD cases among 271 scar-negative patients for ≥70% stenosis, giving a pooled prevalence of 7.6% (95% CI 4.4–12.6). Seven studies contributed 33 CAD cases among 679 scar-negative patients for high-risk-pattern CAD, giving a pooled prevalence of 4.9% (95% CI 2.2–10.6) and a 95% prediction interval of 0.8–24.8%. These strata represented different study subsets and were not nested. Conclusion Among selected adults with HFrEF or otherwise unexplained LVSD who underwent paired LGE-CMR and ICA, absence of infarct-pattern LGE did not exclude angiographic CAD. Further coronary assessment should be considered when resolving that uncertainty would alter diagnosis or management.
Abstract Aims Bicuspid aortic valve-associated aortopathy (BAVA) and heritable thoracic aortic disease (HTAD) share clinical manifestations but may represent distinct pathophysiological entities. We aimed to compare morphological and haemodynamic profiles between both groups using cardiovascular magnetic resonance imaging (CMR) and non-invasive systemic haemodynamic assessment. Methods and results A total of 185 patients (111 BAVA, 74 HTAD) were prospectively enrolled. CMR 4D-flow assessed aortic distensibility (ADCMR), pulse wave velocity (PWVCMR), global wall shear stress (WSSCMR) and energy loss (ELCMR). Oscillometry assessed systemic PWVM, augmentation index (AIxM) and systemic vascular resistance (SVRM). Composite adverse aortic events (AAE) comprised acute aortic syndrome, cardiovascular death or guideline diameter-based indication for surgery over 42.1±17.6 months. BAVA showed greater tubular ascending aorta and sinotubular junction dilation, ascending aorta WSSCMR (0.42±0.18 vs 0.28±0.12 Pa, p=0.020), ELCMR (19.8±8.4 vs. 12.3±6.1 mW, p<0.001) and ADCMR (6.1 ± 3.5 vs. 4.8 ± 2.9 ×10−3 mmHg−1, p=0.023), yet lower systemic stiffness than HTAD (PWVM 6.2±1.7 vs 7.8±2.1 m/s; AIxM 12.1±7.6 vs 18.4±9.2%; both p<0.001). AAE rates were similar. In exploratory aetiology-specific analyses, ascending aorta WSSCMR was associated with events in BAVA (HR 8.92, 95% CI 2.85-27.95) and systemic PWVM in HTAD (HR 2.16, 95% CI 1.30-3.57). Conclusion BAVA and HTAD show distinct morphological and haemodynamic phenotypes: BAVA with focal dilation, elevated WSSCMR/ELCMR and preserved systemic function; HTAD with reduced local distensibility and greater systemic stiffness. These aetiology-specific predictors are exploratory and require external validation.
