BACKGROUND:Despite a significant association of atherogenic index of plasma (AIP) with plasma atherogenicity as well as insulin resistance and new onset of diabetes, data on the risk of rapid plaque progression (RPP) of major epicardial coronary arteries related to AIP according to established diabetes is limited. METHODS:This study evaluated the association between AIP and RPP according to diabetes in 1485 adults (60.9 ​± ​9.2 years, 58.9% men, 23.8% diabetes) using serial coronary computed tomography angiography. AIP was defined as the base 10 logarithm of the ratio of triglycerides to high-density lipoprotein cholesterol (mmol/L). RPP was defined as a change in percent atheroma volume (PAV) ≥1.0%/year. RESULTS:During a median follow-up of 3.4 years, the incidence of RPP was 26.1%. Compared with non-diabetic subjects, diabetic subjects exhibited significantly higher AIP levels, larger baseline plaque burden, and higher RPP incidence. After adjusting for age, sex, hypertension, overweight or obesity, current smoking, low-density lipoprotein cholesterol and creatinine levels, baseline total PAV, and the use of aspirin, beta-blockers, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, or statins, AIP (per 0.1-unit increase) was associated with the risk of RPP in non-diabetic subjects (odds ratio [OR] 1.07, 95% confidence interval [CI] 1.01-1.13; p ​< ​0.05) but not in diabetic subjects (OR 1.04, 95% CI 0.95-1.14; p ​= ​0.430). CONCLUSION:AIP is independently associated with the risk of RPP in the absence of established diabetes. This finding suggests that AIP may be an effective biomarker for predicting RPP in the population of non-diabetic adults. TRIAL REGISTRATION:ClinicalTrials.govNCT02803411.

Suspected acute coronary syndrome (ACS) is one of the most common reasons for urgent cardiology evaluation in the emergency department (ED). This study aimed to evaluate the characteristics and outcomes of patients with suspected ACS who were referred for coronary computed tomography angiography (CCTA) in the ED. We retrospectively enrolled consecutive patients who underwent cardiology assessment and CCTA for suspected ACS in the ED from January 2020 through December 2022. The primary endpoint was a composite of major adverse cardiovascular events (MACE) including all-cause death, acute myocardial infarction, or myocardial revascularization. The study included 198 patients, of whom 175 (51

INTRODUCTION:No previous data specifically addressed the prevalence and distribution of coronary atherosclerosis in patients with family history (FH) of CAD. Aim of the present multicenter study was to explore the prevalence of atherosclerosis at coronary computed tomography angiography (CCTA) among patients with or without FH of CAD. MATERIAL AND METHODS:We performed a retrospective analysis of multicenter observational study including a consecutive cohort of patients who prospectively underwent clinically indicated CCTA for suspected CAD. A group of patients with FH of CAD were matched in a 2:1 fashion with a control group without FH of CAD from the same consecutive cohort. All CCTA were evaluated in a core lab for advanced atherosclerosis evaluation and quantification. Differences in prevalence of atherosclerosis at CCTA were reported and compared between patients with or without FH of CAD. RESULTS:A total of 480 patients were enrolled, 160 with FH of CAD and 320 without (mean age 61.7±9.6, female prevalence 41.9%). Clinical characteristics did not differ between the two groups, but the prevalence of high-risk atherosclerosis was significantly higher among those with FH of CAD (62% vs. 43%, respectively, p=0.0001). Among patients clinically classified as very low probability of obstructive CAD, high-risk atherosclerosis or obstructive CAD was found at CCTA in 42% of those with FH of CAD vs. 19% of those without (p=0.0009). CONCLUSION:This prospective multicenter study shows that patients with a family history of CAD have a higher prevalence of high-risk atherosclerosis. Moreover, nearly half of those with very-low pre-test probability of obstructive CAD and a family history of CAD had high-risk atherosclerosis at CCTA.

INTRODUCTION:A family history (FH) of premature coronary artery disease (CAD) is a major cardiovascular risk factor often underestimated by traditional scoring systems like SCORE2, which do not incorporate FH. The FAMILY trial (NCT07352111) is a prospective study investigating the role of cardiac CT (CCT) in identifying high-risk atherosclerosis in this specific population. RATIONAL AND OBJECTIVES:To enable personalized primary prevention, this study integrates genotypic and bio-humoral profiling with CCT plaque imaging in asymptomatic individuals with an FH of CAD. The primary objective of the study is to determine the prevalence of high-risk atherosclerosis in this specific cohort. METHODS:and Preliminary Data: We are prospectively enrolling asymptomatic first-degree relatives of patients with early-onset myocardial infarction (males <55, females <60 years). Participants undergo clinical evaluation, SCORE2 risk calculation, and advanced 256-slice CCT. High-risk atherosclerosis is defined by the presence of at least two high-risk plaque features and/or elevated volumes of low-attenuation/non-calcified plaque. A nested cohort (10-20%) of risk-reclassified patients will undergo comprehensive genetic profiling. Preliminary, data on the first 16 subjects enrolled (mean age 54 ± 6 years) were collected and analysed supporting the feasibility of the study. CONCLUSION:Traditional risk scores often underestimate CAD risk in individuals with a strong family history. By utilizing advanced CCT to detect high-risk atherosclerosis, the FAMILY trial aims to accurately reclassify patient risk and, potentially, guide early, targeted prevention. Feasibility data are presented but, given the limited size of this preliminary cohort, definitive conclusions await full enrolment.

AIMS:Pre-participation cardiovascular screening (PPS) is essential for preventing SCD in athletes, yet ECG interpretation requires expertise and remains resource-intensive. We aimed to evaluate the feasibility and diagnostic performance of a deep learning (DL) model for analysis of clinical data and resting 12‑lead ECG obtained during routine PPS in competitive athletes. METHODS:In this prospective single center observational study, competitive athletes aged 18 to 60 years and undergoing routine PPS were enrolled. PPS included medical history, physical examination, resting and exercise ECG. Athletes were classified as fit or not fit for competitive sports according to clinical evaluation. Resting ECG and clinical variables were analyzed using a multimodal DL architecture. Model performance was assessed using stratified 10-fold cross-validation against PPS clinical classification. RESULTS:A total of 526 athletes were enrolled (72% male, median age of 27 years (IQR: 20-41); 166 (32%) had a negative PPS result. The test setting (10-fold cross-validation), the model achieved moderate discrimination with an accuracy of 0.64 ± 0.08, SE 0.68 ± 0.15, SP 0.61 ± 0.17, F1-score 0.72 ± 0.1, PPV 0.80 ± 0.07, NPV 0.48 ± 0.12, AUC 0.72(0.66-0.78). Training performances reached accuracy of 0.70 ± 0.06, SE 0.73 ± 0.12, SP 0.67 ± 0.14, F1-score 0.77 ± 0.07, AUC 0.79 (0.74-0.83. CONCLUSION:Automated DL-based analysis of 12‑lead ECG during PPS is feasible and showed encouraging diagnostic performance in competitive athletes. Although wider experience and external validation is required, AI-assisted multimodal ECG interpretation may represent a useful adjunct to physician assessment for cardiovascular risk stratification in sport screening programs.

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.

Takotsubo Syndrome (TTS) is a cardiac condition that mimics myocardial infarction, often in the absence of obstructive coronary disease. TTS is typically described as triggered by stressful/traumatic events, which are often categorized as either emotional/psychosocial or physical; nevertheless, emerging evidence suggests that this stark classification may be limiting. We hypothesize that, in most cases, clinicians may overlook possible physical and emotional components or concurrent intense emotional experiences of physical TTS triggers during patients’ assessment. We searched through four databases for clinical case reports of TTS patients with clearly identified antecedents that may have elicited the cardiac event. After a thorough study selection, 219 studies were included in the final scoping review and a total of 259 cases were presented, 210 of which were female. Most of the studies reported in selected literature described physical stressors (n = 135) as triggers of TTS, while 38 reported emotional triggers; in 45 case studies, both physical and affective stressors were present. Most physical triggers may have an emotional side that seems to be overlooked by physicians; we thus propose a new perspective where the boundaries between physical and emotional stressors in TTS may be fuzzy, promoting the role of clinical psychology in cardiological settings.

Background:Pectus excavatum (PEX) is the most common congenital chest wall deformity, occasionally associated with cardiac displacement and mild functional impairment. Its role in masking or mimicking cardiomyopathy remains poorly defined, particularly in athletes. Case summary:We report the case of a 24-year-old asymptomatic male athlete with severe PEX, frequent monomorphic premature ventricular contractions (PVCs), and mildly reduced left ventricular ejection fraction (LVEF). Despite successful PVC ablation and absence of genetic mutations, fibrosis, or structural abnormalities on cardiac magnetic resonance and electroanatomic mapping, the patient maintained borderline LV dysfunction. These findings raised the possibility of either a mild non-dilated left ventricular cardiomyopathy (NDLVC) or a reversible functional impairment due to chest wall distortion. Based on Italian guidelines, the patient was deemed ineligible for competitive sports. However, we explored how this case might be handled in other European countries with more permissive or flexible criteria. Discussion:This case underscores the diagnostic uncertainty posed by overlapping anatomical and functional findings, and the potentially profound impact of disqualification from sport on young athletes. It also reveals discrepancies in national approaches to eligibility and the interpretation of borderline findings. The case prompts reflection on the need for more harmonized guidelines and, in selected cases, structured shared decision-making processes involving expert centres and the athlete. Conclusion:In the evolving context of NDLVC, this case highlights the difficulty of acting in rigid frameworks and diagnostic loops, advocating instead for individualized, responsible decision-making that balances safety with athlete well-being.

Background Coronary computed tomography angiography (CCTA) is the gold standard for non-invasive coronary atherosclerosis evaluation. Purpose To evaluate the performance of advanced atherosclerosis analysis by CCTA in predicting long-term major cardiac events in subjects enrolled in the multicenter CAPIRE study. Materials and methods CAPIRE prospectively enrolled subjects with suspected coronary artery disease (CAD) who underwent advanced plaque assessment by CCTA. Outcome measures were two combined endpoints: acute coronary syndrome (ACS) and major adverse cardiac events MACE (ACS+cardiac death+late non-urgent revascularization). Results The final CAPIRE population comprised 528 subjects (age 60 ± 8 years, 308 men). CCTA showed no CAD in 348 (65.9

Purpose To assess the association of low-attenuation noncalcified plaque (LAP) morphologic features, including shape and degree of intraplaque embeddedness, using atherosclerotic imaging-enabled quantitative CT with acute coronary syndrome (ACS). Materials and Methods In this secondary analysis of the Incident Coronary Syndromes Identified by CT (ICONIC) study, a retrospective-nested, case-control, multicenter study of patients with future ACS after coronary CT angiography propensity matched with controls, atherosclerotic imaging-enabled quantitative CT analysis was performed between February and September 2022. LAP morphology was determined qualitatively according to geometric shape (crescent, lobular, spherical, or bean) and degree of intraplaque embeddedness (<90°, 90°-179°, 180°-269°, 270°-360°) within the vessel wall. Shapes were based on visual assessment of LAP contours, including features of curvature, symmetry, and lobulated and protruding components. Adverse LAP morphology (ALM) was defined by morphologic features associated with ACS using log-rank testing. Multivariable Cox regression was performed with ALM as the independent variable, adjusting for plaque burden and diameter stenosis. Results A total of 446 patients (mean age ± SD, 62.44 years ± 11.05; 277 male; 223 cases, 223 controls) with a mean follow-up of 2.45 years ± 2.49 were included in this study. Twenty-two patients were excluded due to missing images or poor image quality. Lobular, bean, and spherical LAP shape or LAP with a degree of intraplaque embeddedness greater than or equal to 180° was associated with increased ACS risk (log-rank P < .05 for each). These morphologic features thus defined ALM. Among 74 of 446 (16.6%) patients with ALM, 57 patients experienced ACS. Patients with ALM had a 3.24-fold increased risk for ACS (adjusted hazard ratio, 3.24 [95% CI: 1.44, 7.30]; P = .005). Conclusion ALM was independently associated with ACS. Keywords: Coronary Angiography, Coronary Arteries ClinicalTrials.gov identifier: NCT02959099 Supplemental material is available for this article. © The Author(s) 2026. Published by the Radiological Society of North America under a CC BY 4.0 license.

BACKGROUND:Statins are a cornerstone medication for coronary atherosclerosis. This study assessed whether radiomic analysis of coronary computed tomography angiography (CCTA) could predict patient response to statin therapy. METHODS:Patients from a multinational registry with serial CCTA (≥2-year intervals) on statin therapy were analyzed. Radiomic scores were calculated, categorizing patients as statin responders or non-responders (≥1.0% increase in percent atheroma volume (PAV) per year indicated non-response). Data were split into training (79%) and test (21%) sets based on sites. Four predictive models were developed: Model 1 used clinical risk factors (CRF), Model 2 included CRF, calcified and non-calcified PAV, and number of high-risk plaques. Model 3 used only the radiomic score, and Model 4 combined Models 2 and 3. RESULTS:A total of 386 statin responders (mean age 61.2 ​± ​8.4 years, 60.1% male) and 177 statin non-responders (mean age 63.2 ​± ​9.0 years, 44.1% male) were analyzed. Model 3, based solely on the radiomic score, demonstrated superior predictive power compared to Model 1 (area under the receiver operating characteristic curve [AUC] [95% confidence interval (CI)]: 0.75 [0.67-0.83] vs 0.54 [0.45-0.63], p ​< ​0.05) and was comparable to Model 2 (AUC [95% CI]: 0.82 [0.74-0.88], p ​> ​0.05) in the test set. Model 4 exhibited the highest power (AUC [95% CI]: 0.84 [0.77-0.90], all p ​< ​0.05 compared to Model 2 and Model 3). CONCLUSION:CCTA radiomic features show proof-of-concept for predicting statin response, warranting further validation. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov NCT0280341.

Rapid progression of coronary atherosclerosis is associated with an increased risk of future adverse cardiovascular events. However, evidence regarding the association between glycemic status and rapid plaque progression (RPP) in the major epicardial coronary arteries remains limited. A total of 1296 subjects (mean age, 61 ± 9 years; 56.9

Sporting activity is beneficial for cardiovascular prevention1. However, excessive physical exertion, especially in endurance activities, is emerging as a factor associated with the development of coronary artery disease, particularly in masters athletes2. In this prospective, observational study, we analyzed our findings in a cohort of 350 athletes evaluated in our sports cardiology clinic for suspected cardiac disease between September 2023 and November 2024. In sportsmen with a suspicion of coronary artery disease (CAD), we examined the coronary arteries using either coronary CT (CCTA) or invasive coronary angiography by following the COCIS 2023 recommendations. A total of 110 athletes were studied, of which 82 were masters. Of the 82 master athletes studied, 68 underwent CCTA, while 14 proceeded directly to coronary angiography. Additionally, 21 athletes underwent coronary angiography following an CCTA. Forty-seven masters were found to have CAD, with a prevalence of 56.8%. Among the masters, 24 individuals had obstructive CAD, with a prevalence of 28.4%. The prevalence of CAD rises to 63.4% among masters engaged in endurance sports (running at least half marathons, cycling > 100 km/week). Furthermore, the prevalence of CAD was higher in endurance athletes compared to non-endurance athletes, considering both masters and non-masters (OR 3.06, p=0.006). Our study reveals a significant prevalence of CAD among master athletes, particularly in those performing endurance sports, suggesting a potential link between high-intensity activity and CAD risk. The observed higher prevalence of CAD among endurance athletes underscores the need for careful cardiovascular screening in older athletes with significant training loads. Coronary imaging is crucial for early detection in this setting, advocating for tailored cardiovascular screening and balanced training to mitigate risks. Further studies are needed to understand long-term impacts.

Coronary artery disease is one of the leading causes of mortality worldwide. While early identification and treatment of major cardiovascular risk factors are crucial, recent data suggest the possibility of non-invasively detecting early stages of coronary atherosclerosis and potentially stabilizing or even reversing the burden of atherosclerosis with innovative and existing treatments. Moreover, therapies from lipid-lowering to anti-inflammatory drugs were recently demonstrated to influence atherosclerosis progression and potentially lead to different grades of plaque regression. The present is Part 1 of a scientific consensus document divided into two separate manuscripts. This first part provides an up-to-date scientific statement on the pathophysiology mechanism of atherosclerosis progression and regression and on the role of invasive and non-invasive imaging techniques in evaluating and quantifying plaque.

Cardiac computed tomography angiography (CCTA) has acquired a pivotal role in modern cardiology. It represents the gold standard for noninvasive coronary imaging. Moreover, CCTA permits a comprehensive evaluation of atheromatic burden and plaque composition. This study aims to review the impact of CCTA across the different presentations of ischemic heart disease, from primary prevention to the evaluation of patients requiring revascularization.

Chronic coronary syndromes (CCS) are the most common clinical manifestation of coronary atherosclerosis. Coronary computed tomography angiography (CCTA) is a recent innovation in non-invasive cardiac imaging. It is the only anatomical imaging method that allows direct visualization of the coronary lumen, vessel walls, and atherosclerotic plaques, offering high sensitivity and a strong negative predictive value. CCTA is particularly useful in identifying or ruling out coronary atherosclerosis in the context of CCS and serves as an excellent filter for invasive coronary angiography. Compared to other non-invasive functional imaging tests (stress echocardiography, single photon emission computed tomography, magnetic resonance imaging, positron emission tomography), CCTA provides detailed characterization of both obstructive and non-obstructive plaques, enabling accurate risk stratification and guiding therapy. Recent advances in computed tomography technology and imaging techniques further extend the use of CCTA beyond plaque and stenosis evaluation, offering also functional lesion information. This consensus document aims to detail the technical aspects of CCTA and illustrate its role in optimizing CCS diagnostic and therapeutic management, enhancing precision medicine and personalized patient care.

Background: Congenital coronary artery anomalies (CAAs) are a significant cause of sudden cardiac death and a key factor in determining athletes’ eligibility for competitive sports. Their prevalence varies with diagnostic modalities and may present as asymptomatic or with life-threatening ischemic or arrhythmic events. This case series highlights the diverse manifestations of CAAs and the clinical approaches used to determine sports eligibility. Cases description: five competitive athletes with different CAAs are presented. These cases include anomalous coronary origins, intramyocardial bridges, and coronary fistulas. Diagnostic tools, including coronary CT angiography (CCTA), cardiac magnetic resonance imaging (CMR), and stress tests, were essential in evaluating these anomalies and determining treatment strategies. In some cases, such as intramyocardial bridges, surgical intervention was necessary, while others required conservative management or exclusion from competitive sports. Conclusions: CAAs require individualized care based on risk stratification through advanced imaging techniques and functional assessment. Surgical interventions are reserved for high-risk anomalies, while others may be managed conservatively. Early detection and tailored management are crucial for ensuring athletes’ safety, and ongoing research is needed to optimize long-term outcomes.

BACKGROUND:Ventricular arrhythmias (VAs) are a major concern in athletes. We sought to determine the prognostic role of noninvasive and invasive assessments in athletes with complex VAs. METHODS:One-hundred-ninety athletes (82% men; 28 [19-43] years; 148 [78%] competitive athletes) with frequent or exercise-induced premature ventricular complexes or nonsustained ventricular tachycardia were included in a multicenter cohort study and categorized based on VA ECG morphology into common (n=99) and uncommon (n=91) VA groups. Each athlete underwent a comprehensive diagnostic workup, including cardiac magnetic resonance in 94% (n=178) and electrophysiology study/electroanatomical mapping in 87% (n=166). The primary end point was the occurrence of sudden death or sustained VAs during long-term follow-up. RESULTS:Athletes with uncommon VA morphology had higher rates of abnormal findings at multimodality assessment and more final diagnoses of structural heart disease. Over a median follow-up of 6.2 (4.3-8.1) years, 7 (4%) athletes experienced a primary outcome event, including 1 sudden death. Interestingly, no events occurred in athletes with common morphology VAs. In univariable Cox models, factors associated with the primary end point included uncommon VA morphology (P=0.003), lack of VA suppression (P=0.049), and nonsustained ventricular tachycardia/ventricular tachycardia induction (P=0.010) during stress testing, late gadolinium enhancement (P=0.045), electroanatomical scar regions (P=0.022), and sustained VA inducibility by electrophysiology study (P<0.001). Incorporating findings of invasive tests improved prediction of primary outcome events over clinical/noninvasive findings in isolation (log-likelihood ratio for nested models, P=0.004). A survival tree model based on VA morphology, late gadolinium enhancement, VA response to exercise testing, and electroanatomical mapping allowed risk stratification, identifying subgroups of athletes without primary outcome events during follow-up. Among 148 competitive athletes, 101 (68%) regained eligibility after 3 months of detraining, but only 42 (28%) continued long-term. CONCLUSIONS:A comprehensive diagnostic assessment integrating ECG, stress testing, and imaging findings, along with the selective use of invasive electrophysiology assessments, may help refine the prognostic evaluation of athletes with complex VAs.