Positron emission tomography (PET) is the most advanced myocardial perfusion (MPI) technique for the non-invasive assessment of coronary artery disease and its many manifestations, including ischaemia, hibernation, and scar. This comprehensive overview aims to empower clinicians, technicians, and patients with clear, structured knowledge on performing and interpreting PET MPI. This document will describe stress protocols, patient preparation, tracer pharmacodynamics and nuclear properties, camera capabilities, post-acquisition processing, and a comprehensive and clear reporting system for both perfusion and viability imaging.

Aims:Morphometric analysis of the thoracic aorta (TA) and left ventricle (LV) plays a fundamental role in detecting anatomical abnormalities and functional alterations to support pre-operative planning, predict disease risk and inform device design. However, conventional approaches to morphometric evaluation are typically performed manually using visualization software, thus resulting in time-consuming, operator-dependent processes that are usually limited to static imaging. This work presents an automated three-dimensional image-based methodological framework for dynamic morphometric analysis, from ECG-gated CT datasets. Methods and results:A multi-label 3D U-Net was trained for the automatic segmentation of the TA and LV using a dataset of 50 single-phase CT scans, with ground-truth label maps validated under expert radiological supervision. Model performance was tested on an independent multi-phase cohort of 10 patients. The network achieved high segmentation accuracy, with Dice scores of 97.77 ± 0.31% for the TA and 91.45 ± 1.26% for the LV on the multi-phase test set. The resulting 3D surface models enabled the computation of geometric descriptors, including volumetric indices, displacement fields, and centreline-based diameters, across cardiac phases on 42 patients. Overall, the framework demonstrated robustness to variations in contrast intensity, cardiac motion, and inter-patient anatomical variability, providing a reliable and reproducible pipeline for comprehensive, three-dimensional, and time-resolved morphometric analysis of the ventriculo-arterial complex with physiological or mildly altered anatomy. Conclusion:This approach has strong potential for future clinical translation, supporting quantitative assessment of cardiac function, and aortic pathophysiology.

AIMS:Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a heterogeneous group of clinical entities requiring further investigation to assess aetiology. The European Society of Cardiology guidelines recommend advanced tests to establish an underlying mechanism. We evaluated advanced diagnostic testing utilization and real-world adherence to the current guideline in an international MINOCA registry. METHODS AND RESULTS:DOMINO is a prospective, multicentre, non-commercial registry enrolling 365 patients with MINOCA across 17 centres in 13 countries. Advanced testing was defined as cardiac magnetic resonance (CMR), intracoronary imaging, and/or invasive coronary functional assessment. The association between advanced testing and diagnostic resolution was assessed by multivariable logistic regression, with standard, cluster-robust, and generalized estimating equation (GEE) approaches to account for clustering by centre. Guideline-directed testing was performed in 254/365 (69.6%) and varied markedly by country (0-100%, P < 0.0001). A specific etiologic diagnosis was reached in 337/365 patients (92.3%). Advanced testing was associated with diagnostic resolution in the standard and GEE models, with a directionally consistent but non-significant cluster-robust estimate [standard odds ratio (OR) 3.94, 95% confidence interval (CI) 1.59-10.06; cluster-robust OR 3.75, 95% CI 0.95-14.72, P = 0.058; GEE OR 3.69, 95% CI 1.04-13.11]. Diagnostic resolution increased progressively with the extent of testing performed, from 85.6% with no advanced testing to 97.1% with CMR plus invasive/functional assessment (trend P = 0.02). Discharge pharmacotherapy varied significantly by etiologic diagnosis (P = 0.0001). CONCLUSION:Advanced diagnostic testing was associated with a higher likelihood of a determined etiologic diagnosis in MINOCA, despite marked international variability in its use; however, this association is partly definitional, as advanced testing directly contributes to diagnostic ascertainment for several etiologic categories. These findings nonetheless support closing the guideline-practice gap in advanced testing, while underscoring the need to distinguish mechanistically confirmed diagnoses from presumptive ones.

Cardiovascular imaging is integral to modern clinical trials of new pharmaceuticals or devices, enabling refined eligibility, mechanistic insight, and sensitive assessment of treatment response and safety. Potential heterogeneity in data acquisition, analysis, and reporting may affect reproducibility and interpretability across multicentre settings. Rigorous standardization and fit-for-purpose validation of imaging endpoints can improve statistical efficiency, reduce trial duration and cost, and strengthen generated evidence. This Scientific Statement outlines a reference framework for the implementation of cardiovascular imaging in clinical trials. We provide considerations on use of imaging parameters as eligibility criteria in clinical trials, for efficacy signals evaluation, and for assessment of safety. We define principles for clinical, analytical, and operational validation of imaging endpoints, and discuss concepts of minimal clinically important change and minimal detectable change. Additionally, we discuss feasibility considerations for use of cardiovascular imaging endpoints in multicentre clinical trials where differences in equipment and local experience may exist. We delineate standards for harmonization, centralized analysis, and quality control in clinical trials, as well as challenges and opportunities of the integration of artificial intelligence within core-lab workflows. Lastly, we identify gaps in knowledge, challenge of preclinical-clinical translatability and highlight training needs and innovation priorities.

BACKGROUND:Anomalous aortic origin of a coronary artery (AAOCA) may be associated with exertional ischemia, ventricular arrhythmias, and adverse outcomes. The relationship between high-risk anatomic features and functional consequences remains incompletely defined. Coronary computed tomography angiography (CCTA) and exercise-stress myocardial perfusion scintigraphy (SPECT) present as complementary modalities for integrated assessment of anatomy, ischemia, and arrhythmias. METHODS:We retrospectively studied consecutive adults with AAOCA undergoing CCTA and exercise-stress ^99mTc-SPECT between 2010 and 2025 at two centers. Inducible ischemia was defined as a summed difference score (SDS) ≥4. A composite endpoint (death, myocardial infarction, angina requiring evaluation, ventricular arrhythmias, or coronary revascularization) was assessed during follow-up. Discriminative performance of ECG, CCTA, SPECT, and combined imaging models was evaluated using ROC analysis. RESULTS:Thirty-five patients (mean age 51 ± 15 years; 89% men) were included. At least one high-risk CCTA feature was present in 60% of cases, and inducible ischemia occurred in 51%. An interarterial course was significantly associated with SPECT positivity (67% vs. 12%, p = 0.007). Ventricular arrhythmias during exercise were more frequent in SPECT-positive patients (50% vs. 13%, p = 0.03). During a median follow-up of 59 months, the combined CCTA+SPECT model showed the highest discrimination (AUC 0.76). CONCLUSIONS:Integrating CCTA with exercise-SPECT links high-risk anatomy to functional and arrhythmic manifestations and may improve risk stratification in adults with AAOCA.

The number of individuals engaging in sports continues to rise, and identifying those with cardiac substrates associated with increased risk of exercise-related adverse events is crucial. Athlete evaluation requires a refined diagnostic strategy to distinguish physiological cardiac remodelling from pathology. This joint European Association of Preventive Cardiology/European Association of Cardiovascular Imaging consensus provides a multimodality approach for advanced cardiovascular imaging in sports cardiology. Cardiovascular magnetic resonance, cardiac computed tomography, and nuclear imaging each offer complementary insights into cardiac structure, function, coronary anatomy, tissue characterization, perfusion, and inflammation. When integrated with clinical data and first-line tests, they improve diagnostic precision and risk stratification in scenarios frequently encountered in athletes, including ventricular arrhythmias, cardiomyopathies, congenital coronary anomalies, inflammatory myocardial disease, and coronary artery disease. Standardized protocols tailored to age, training, and clinical indication are essential to ensure reliability and avoid misinterpreting physiological adaptation as disease. The consensus emphasizes responsible reporting, considering performance and legal implications of diagnoses, and recommends second-line imaging when justified. Functional imaging, for ischaemia or inflammation, is central in guiding return-to-play decisions. Persistent evidence gaps include limited normative datasets across athletic subgroups and uncertain significance of subtle tissue abnormalities. Overall, this consensus supports harmonized, safe, and judicious multimodality imaging to protect athletes while preventing unnecessary sport restriction.

Exercise imaging, particularly exercise stress echocardiography (ESE), has become a pivotal non-invasive tool for evaluating cardiovascular function in athletes and for distinguishing physiological adaptations from pathological conditions. This Clinical Consensus Statement by the European Association of Preventive Cardiology and the European Association of Cardiovascular Imaging synthesizes current evidence and provides practical guidance on indications, protocols, and interpretation of exercise imaging modalities in both competitive and recreational athletes. The document emphasizes the role of ESE in assessing cardiac reserve, unmasking concealed cardiomyopathies, and stratifying risk in clinical scenarios such as T-wave inversion, exercise-induced repolarization abnormalities, and extreme ventricular remodelling. Special attention is given to imaging protocols tailored to the athletic population, including dynamic assessment of the right and left ventricles, atria, and valvular function during various exercise modalities, highlighting the importance of the functional evaluation in athletes and active individuals. Additionally, the consensus explores the integration of advanced techniques such as cardiopulmonary exercise testing and exercise cardiac magnetic resonance imaging, highlighting their complementary roles in comprehensive cardiovascular evaluation. The statement advocates for individualized testing strategies that consider sport-specific demands, demographic factors such as body size, sex, ethnicity, and the underlying pathology. It also underscores the importance of exercise imaging in guiding sports eligibility and in tailoring exercise prescription for competitive athletes, as well as for patients willing to participate in recreational sports or exercise programs.

Post-myocardial infarction ventricular septal defect (post-MI VSD) is a rare but life-threatening complication, with an incidence of approximately 0.3% and high early mortality despite advances in reperfusion therapy. Management remains challenging and requires multidisciplinary decision-making. We conducted a narrative review of the literature through May 2024 using PubMed, Scopus, and Google Scholar, focusing on surgical, percutaneous, and mechanical circulatory support (MCS) strategies for post-MI VSD. A narrative approach was adopted due to the rarity of the condition, the heterogeneity of available evidence, and the predominance of registries and case series. Surgical repair remains the gold standard, employing approaches such as the Daggett, David, and double-patch infarct exclusion techniques. Delayed surgery (>7 days) in hemodynamically stable patients is associated with improved outcomes, whereas urgent intervention is warranted in refractory shock. Percutaneous closure, using dedicated or adapted occluder devices, offers an option for high-risk or unstable patients, either as definitive therapy or as a bridge to surgery, though residual shunts are more common. Hybrid procedures and novel beating-heart techniques have shown promise in selected cases. MCS, including intra-aortic balloon pump, veno-arterial extracorporeal membrane oxygenation, and Impella, facilitates hemodynamic stabilization, allowing myocardial recovery before repair. Overall, in-hospital mortality remains high, particularly in acute-phase interventions. In conclusion, management of post-MI VSD demands individualized strategies integrating patient stability, defect anatomy, and institutional expertise. While surgical closure offers superior long-term outcomes, percutaneous and hybrid approaches expand therapeutic options. Future studies should clarify optimal timing, refine patient selection, and evaluate the impact of advanced MCS strategies on survival and recovery.

L’intelligenza artificiale (AI) sta trasformando profondamente l’imaging cardiovascolare, rendendolo sempre più quantitativo, standardizzato e integrato nel processo decisionale clinico. L’aumento della complessità e della quanti-tà dei dati generati da ecocardiografia, tomografia computerizzata coronarica (TC), risonanza magnetica cardiaca (RMC) e imaging nucleare (SPECT e PET) ha reso necessario lo sviluppo di strumenti in grado di supportare il car-diologo nell’analisi e nell’interpretazione delle immagini. L’AI consente l’automazione della ricostruzione, della segmentazione e della quantificazione di parametri funzionali e strutturali, riducendo la variabilità intra- e inter-osservatore e migliorando l’efficienza del workflow. Nella TC coronarica permette la quantificazione automatica della placca e la stima non invasiva della FFR; nella RMC facilita l’analisi volumetrica e la caratterizzazione tissutale; nell’ecocardiografia automatizza la valutazione della funzione ventricolare e dello strain; nell’imaging nucleare migliora la ricostruzione, la quantificazione della perfusione e la stratificazione prognostica. Accanto ai benefici emergono tuttavia criticità rilevanti, tra cui domain shift, bias dei dataset, limitata generalizzabilità e necessità di modelli interpretabili. Strumenti di explainability e l’utilizzo di dati sintetici rappresentano aree di sviluppo promettenti, ma richiedono validazione rigorosa. L’AI non sostituisce il cardiologo: ne potenzia le capacità analitiche, mantenendo centrale il ruolo clinico nella validazione, integrazione e responsabilità decisionale. Parole chiave: Intelligenza artificiale; Imaging cardiovascolare; Machine learning; Stratificazione del rischio; Explainability.

Aims:Metabolic syndrome (Mes) and diabetes are emerging cardiometabolic determinants of coronary atherosclerotic disease (CAD) risk besides LDL-cholesterol (LDL-C) and established risk factors. We aimed to assess whether, in patients with chronic coronary syndrome (CCS), cardiometabolic risk is prevalent and independently associated with residual CAD risk in subjects with low LDL-C. Methods and results:The cross-sectional HURRICANE study (Health improvement by Understanding RR In CAd and NEw targets for treatment) included 479 patients with CCS (mean age 65 ± 11 years, 70% male), undergoing cardiac computed tomography angiography (CCTA). A severe/extensive CAD or a moderate-high CAD risk were defined, on patient level, by CCTA-derived CAD-RADS2 and Leiden scores. Metabolic syndrome was present in 31% of patients, diabetes or pre-diabetes in 21% and 26%, severe/extensive CAD and moderate-high Leiden score in 51% and in 61%, more frequently in the two lower LDL-C categories. Multivariate logistic regression models, included age, sex, smoking status, family history, LDL-C categories (<70, 70-99 100-129, and ≥130 mg/dL), MeS, or its components and medications. Independent predictors of moderate-high Leiden score were age, male sex, the lowest LDL-C category and MeS (OR 2.12, 95% CI: 1.26-3.56) or pre-diabetes (OR 1.90, 95% CI: 1.12-3.21) and diabetes (OR 6.13, 95% CI: 1.93-19.45). In the lowest LDL-C group, higher CAD-RADS2 and Leiden scores were more frequent in patients with cardiometabolic risk. Conclusion:Results of this cross-sectional study suggest that dysregulation of glucose metabolism is the prevalent component of residual cardiometabolic and coronary atherosclerotic risk in patients with CCS and low LDL-C under current treatment.

Cardiovascular disease is the leading cause of death in women, yet significant disparities persist in diagnosis, treatment, and research representation. This clinical consensus statement outlines the rationale and framework for establishing women's heart centres (WHCs) in Europe. Women's heart centres are proposed as hub-and-spoke reference networks embedded within existing cardiovascular systems, delivering multidisciplinary, sex-sensitive care across the life course. The document defines referral pathways, operational standards, and core and advanced training competencies in women's cardiovascular health. Key domains include ischaemia/myocardial infarction with non-obstructive coronary arteries, cardio-obstetrics, cardio-oncology, autoimmune disease, mental health, and cardiac rehabilitation. Implementation strategies emphasize scalable models, integration with primary care, telemedicine, quality improvement, and research engagement. Although long-term outcome data remain limited, available evidence suggests improved diagnostic precision, risk factor control, and patient-reported outcomes. Establishing WHC offers a structured approach to reduce inequities and strengthen cardiovascular care for women across Europe.

Aims:Multiple and mixed valvular heart disease (MMVD) are frequent situations in clinical practice. Despite a high prevalence, comprehensive insights into their clinical presentation, management strategies, impact of multimodality imaging, and outcomes are not well established, due to a lack of dedicated studies. Methods and results:The 'EACVI-MMVD Study' will be a large prospective, multicentre, observational cohort study led by the Heart Imagers of Tomorrow of the European Association of Cardiovascular Imaging (EACVI). It will assess the proportion, management, and prognosis of MMVD over a 1-year period of follow-up. All consecutive patients diagnosed with MMVD using transthoracic echocardiography will be recruited over a 6-month recruitment period in 88 centres from 24 different countries. Baseline evaluation will be determined by physicians and encompass the whole spectrum of multimodality imaging including transthoracic and transoesophageal echocardiography, stress echocardiography, computed tomography, and cardiovascular magnetic resonance. Centres will have the opportunity to send cardiovascular imaging data for core laboratory analysis and to extend recruitment throughout a 5-year follow-up period. Conclusion:The EACVI-MMVD study will be the largest international multicentre study evaluating the prevalence of MMVD in clinical routine and determining the impact of multimodality cardiovascular imaging in MMVD patients.Clinical Trial Registration: NCT06235385 URL: https://classic.clinicaltrials.gov/ct2/show/NCT06235385.

Anderson-Fabry disease (AFD) is a rare genetic disease with X-linked transmission characterized by a defect in the enzyme alpha-galactosidase A, which impairs glycosphingolipid metabolism and leads to an excessive storage of globotriaosylceramide (Gb3) within lysosomes. AFD involves renal, cardiac, vascular, and nervous systems and is mainly observed in male patients with onset in childhood, although cardiac manifestation is often shown in adults. AFD cardiomyopathy is caused by the accumulation of Gb3 within myocytes first showed by left ventricular hypertrophy and diastolic dysfunction, leading to restrictive cardiomyopathy and systolic heart failure with biventricular involvement. The diagnosis of AFD cardiomyopathy may be insidious in the first stages and requires accurate differential diagnosis with other cardiomyopathies with hypertrophic phenotype. However, it is fundamental to promptly initiate specific therapies that have shown promising results, particularly for early treatment. A careful integration between clinical evaluation, genetic tests, and cardiac imaging is required to diagnose AFD with cardiac involvement. Basic and advanced echocardiography, cardiac magnetic resonance, and nuclear imaging may offer pivotal information for early diagnosis (Graphical Abstract), and the management of these patients is often limited to centres with high expertise in the field. This clinical consensus statement, developed by experts from the European Society of Cardiology (ESC) Working Group on Myocardial and Pericardial Diseases and the European Association of Cardiovascular Imaging of the ESC, aims to provide practical advice for all clinicians regarding the use of multimodality imaging to simplify the diagnostic evaluation, prognostic stratification, and management of cardiac involvement in AFD.

BACKGROUND:To assess the accuracy of myocardial perfusion imaging (MPI) on a cadmium-zinc-telluride camera in detecting coronary artery disease (CAD) and predicting prognosis in older patients. METHODS:Six hundred and twenty-seven older patients (aged >70 years) and the same number of matched controls were submitted to exercise or vasodilator-stress MPI and coronary angiography. The rate-pressure product (RPP) reserve (stress/rest) was computed as a measure of cardiac workload during exercise. Ischemia was defined as a summed difference score (SDS) >3. Coronary stenoses >70% were considered obstructive. Patients were followed (mean 4.1 ± 2.4 years) for a composite of cardiovascular death, nonfatal myocardial infarction, and urgent revascularization (MACE). RESULTS:Obstructive CAD was revealed in 426/627 patients (68%) and 410/627 controls (65%). While in the overall population MPI showed a significant accuracy for detecting obstructive CAD (AUC: .79, 95% confidence interval [CI]: .77-.82; P < .001), test accuracy seemed to decrease with older age, with older patients showing lower specificity than controls (72% vs 64%, respectively; P = .002). This difference was exclusively limited to patients undergoing exercise-stress, whereby the overall test accuracy was significantly lower in older patients than controls (AUC: .82 vs .75; P = .03). Older patients attained a significantly lower peak workload (101 ± 26 W vs 111 ± 34 W; P < .001) and RPP reserve during exercise than controls (1.9 ± .9 vs 2.2 ± .7, P < .001), resulting in an independent predictor of reduced diagnostic specificity (odds ratio: .68, 95% CI: .50-.96; P = .027). At multivariable Cox regression analysis, a higher SDS was an independent predictor of major adverse cardiac events (MACE) (HR 1.11, 95% CI: 1.07-1.14; P < .001). CONCLUSIONS:In older patients, exercise-stress MPI shows a lower diagnostic accuracy than in controls because of an impaired exercise capacity.