BACKGROUND:The association between OSA and sudden cardiac death (SCD) risk in patients with hypertrophic cardiomyopathy (HCM) is poorly defined. We hypothesized that OSA may be associated with the risk of cardiac arrest and ventricular fibrillation (CA-VF) in HCM patients. METHODS:We conducted a retrospective analysis of the National Inpatient Sample (2016-2020), including adults with HCM without prior history of SCD. Patients were stratified by the presence of OSA. The primary outcome was a composite of CA-VF. Multivariate logistic regression and propensity score matching (PSM) assessed the association between OSA and outcomes, adjusting for age, gender, family history of SCD, CIHD, AF, use of ICD, syncope, and LVEF<50%. Mediation analysis was performed to assess whether AF, a known outcome of OSA and predictor of SCD in HCM, mediates the association between OSA and the composite endpoint. RESULTS:Of 52,106 HCM admissions, 8848 (16.98%) had OSA. In a multivariate model excluding AF, OSA was associated with CA-VF (OR 1.16, 95% CI 1.10-1.27, p = 0.002). However, after adjusting for AF, this association was no longer significant (OR 1.001, 95% CI 0.91-1.10, p = 0.97). Mediation analysis showed a significant average causal mediation effect (ACME, p < 0.001), with AF accounting for approximately 98.5% of the total effect of OSA on CA-VF. CONCLUSION:In this large cohort of HCM patients, the association between OSA and CA-VF appeared to be predominantly mediated by AF, with no significant independent direct effect observed. These findings suggest that OSA may contribute to arrhythmic risk in HCM primarily through its relationship with AF and should be considered hypothesis-generating.

BACKGROUND:Epicardial adipose tissue (EAT) is associated with coronary artery disease (CAD), but its relationship with plaque progression (PP)-a predictor of major adverse cardiovascular events (MACE)-remains unclear. OBJECTIVES:This study examines the interplay between EAT, PP, and subsequent MACE. METHODS:From the PARADIGM (Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging) registry, serial coronary computed tomography angiography assessed plaque volume (PV), percent atheroma volume (PAV), and PP. Rapid plaque progression (RPP) was defined as annual PAV increase ≥1%. EAT volume (EATv) and advanced plaque characteristics were measured. CAD was defined as any plaque. Multivariable models assessed associations between EATv, plaque, PP, and RPP. The prognostic value of PP and RPP for MACE was evaluated. RESULTS:Among 773 patients (mean age 62 ± 9 years; 324 women [43%]), those with CAD had significantly higher EATv than did those without CAD (95 cm3 [Q1-Q3: 72.5-127 cm3] vs 83.5 cm3 [Q1-Q3: 63-112.8 cm3]; P < 0.001). Progression of PV, PAV, and calcified and noncalcified plaque components was significantly greater in the highest (third) EATv tertile (T3) than in T1 (PV: P = 0.001; PAV: P = 0.028; calcified component: P = 0.025; noncalcified component: P = 0.022). The prevalences of PP (T1: 78.9% vs T2: 83.9% vs T3: 88.5%; P = 0.013) and RPP (T1: 25.2% vs T2: 32.3% vs T3: 36.4%; P = 0.021) also increased across EATv tertiles. In multivariable analyses, high EATv was independently associated with plaque, PP, and RPP across 2 different models adjusted for age, sex, body mass index, diabetes, dyslipidemia, hypertension, hypertriglyceridemia, smoking, and statin therapy. Patients with PP and RPP had lower 10-year MACE-free survival (log-rank; P = 0.006 and log-rank; P < 0.001, respectively). CONCLUSIONS:High EATv is independently associated with CAD presence and progression, underscoring its potential as a marker for risk stratification and a therapeutic target for earlier or more intensive treatment.

PURPOSE OF REVIEW:Nonobstructive coronary artery disease (NOCA) is now frequently detected by coronary CT angiography (CCTA), but the term compresses biologically distinct patterns into a single anatomic label. This review examines how CT-derived markers can reorganize NOCA around plaque burden, inflammatory activity, clinical expression, and temporal change. RECENT FINDINGS:Recent work distinguishes three related but distinct tasks in NOCA: identify disease, stratify risk, and define phenotypes that may inform future prevention strategies. CCTA addresses the atherosclerotic and prognostic dimensions by quantifying plaque burden, plaque composition, and high-risk features; CT-derived inflammatory and cardiometabolic markers may further identify active vascular and metabolic phenotypes. In symptomatic patients, CCTA and fractional flow reserve CT can evaluate epicardial anatomy and lesion-specific hemodynamic significance, but normal or nonobstructive findings do not exclude coronary microvascular dysfunction or vasospasm. In asymptomatic patients, coronary artery calcium and CCTA can reveal subclinical atherosclerosis and refine preventive risk assessment. Serial imaging and intervention studies suggest that adverse plaque phenotypes can stabilize or change with intensive prevention, but outcome-proven CCTA-guided treatment algorithms are still lacking. SUMMARY:CCTA is evolving into a multidimensional phenotyping tool for NOCA. Its immediate value is refined risk stratification; whether these markers will improve outcomes remains unproven and should be tested prospectively.

Coronary artery aneurysms (CAAs) in Noonan syndrome (NS) are rare, and their true prevalence remains unclear. While previous cases have been reported, the natural history of this association and its management have not been described. We present a 31-year-old male followed for over 16 years, who was found to have an uncomplicated thrombus during his most recent coronary computed tomography angiography (CCTA) follow-up. We aim to illustrate the natural history of CAAs in NS by presenting findings from transthoracic echocardiography (TTE) and CCTA, discussing diagnostic challenges, and showing how current Kawasaki disease (KD) guidelines can be extrapolated for management. In conclusion, CCTA and TTE play a pivotal role in monitoring CAA progression and guiding individualized therapeutic strategies, with KD guidelines serving as a reference for management. Learning objective The association between Noonan syndrome (NS) and giant coronary artery aneurysms (GCAAs) is rare, posing challenges for long-term management. Multimodality imaging, particularly coronary computed tomography angiography, is essential for monitoring GCAA progression, evaluating complications, and guiding thromboprophylaxis and surgery. The potential application of Kawasaki disease guidelines may provide valuable insights into thromboprophylaxis and long-term care in NS patients with GCAAs, helping to address the current lack of condition-specific management strategies.

Cardiac computed tomography (CT) is a cornerstone imaging modality for the diagnosis and management of cardiovascular disease, with widespread applications from the evaluation of chest pain to planning a wide range of minimally invasive procedures. The field of view obtained during imaging includes the heart and surrounding structures, including pericardium, thoracic great vessels, mediastinum, lungs, bones, and upper abdomen. Extracardiac findings have been reported in up to 61

Computed tomography (CT)-derived Epicardial Adipose Tissue (EAT) is linked to cardiovascular disease outcomes. However, its role in patients undergoing Transcatheter Aortic Valve Replacement (TAVR) and the interplay with aortic stenosis (AS) cardiac damage (CD) remains unexplored. We aim to investigate the relationship between EAT characteristics, AS CD, and all-cause mortality. We retrospectively included consecutive patients who underwent CT-TAVR followed by TAVR. EAT volume and density were estimated using a deep-learning platform and CD was assessed using echocardiography. Patients were classified according to low/high EAT volume and density. All-cause mortality at 4 years was compared using Kaplan-Meier and Cox regression analyses. A total of 666 patients (median age 81 [74–86] years; 54

Hypertrophic cardiomyopathy remains underdiagnosed despite a growing number of effective treatment interventions that can improve care. Multimodality imaging has become integral to diagnosing and managing hypertrophic cardiomyopathy, providing a comprehensive assessment of the disease. In particular, it enhances the diagnostic accuracy and deepens the understanding of the mechanisms underlying patient symptoms, enabling targeted therapeutic approaches. Additionally, multimodality imaging allows for better risk stratification, assessment of therapy response, and guidance of interventions to deliver personalized medicine. The practical tools outlined in this review can help providers integrate multimodality imaging strategies to provide better care and improve the patient experience.

BACKGROUND:Aortic stenosis (AS) involves calcific and fibrotic degeneration of the valve tissue. The only noninvasive method for evaluating both processes is contrast-enhanced computed tomography angiography. We aimed to explore the differences in aortic valve (AV) tissue composition across sex, race/ethnicity, and AS hemodynamic phenotype in US patients referred for transcatheter AV replacement planning. METHODS:We retrospectively analyzed symptomatic patients with AS who underwent computed tomography angiography for transcatheter AV replacement planning between 2015 and 2022. Using semi-automated software, we quantified the AV tissue composition by fibrotic, calcific, and fibro-calcific volumes, and the fibro-calcific ratio (fibrotic/calcific volume) as a measure of valve phenotype. RESULTS:The study included 651 patients (mean age 84 years; 55% women) with 38% non-Hispanic (NH)-White, 27% Hispanic, and 13% NH-Black. Women had lower fibro-calcific (230 versus 293 mm³/cm²; P<0.001) and calcific volumes (85 versus 149 mm³/cm²; P<0.001), and higher fibro-calcific ratio (1.47 versus 0.83; P<0.001). No differences were observed in the fibrotic volumes (P=0.805). NH-White women had higher fibro-calcific (256 mm³/cm², P=0.002) and fibrotic volumes (145 mm³/cm²; P<0.001), and fibro-calcific ratio (1.57; P=0.01) compared with Hispanic and NH-Black women. No differences were found among men. High-gradient AS had higher fibro-calcific (295 versus 219 mm3/cm2; P<0.001) and calcific volumes (148 versus 88 mm3/cm2; P<0.001), and a lower fibro-calcific ratio (0.90 versus 1.45; P<0.001), although no difference in fibrotic volume (P=0.099) compared with low-gradient AS. CONCLUSIONS:Phenotypic differences in computed tomography angiography valve tissue composition exist in patients with AS referred for transcatheter AV replacement, with women and low-gradient AS showing a proportionally more fibrotic phenotype. NH-White women have the highest fibrotic tissue composition, and no differences are evident among men.