CASE PRESENTATION:A 77-year-old woman had a 6-mm right upper lobe nodule that was under surveillance. It had originally been detected on a CT pulmonary angiogram to investigate breathlessness.

OBJECTIVES:Imaging diastolic dysfunction in pre-clinical heart failure (HF) is challenging. We evaluated a novel cardiac MRI (CMR) biomarker, CMR e-prime (CMR-MARV), in patients at risk of HF. METHODS:In this substudy of the PARABLE trial (NCT04687111), 236 patients (71.6 ± 7.7 years, 61.6% male) fulfilling trial-defined ALVDD citeria underwent CMR with measurement of mitral annular relaxation velocity (CMR-MARV) at four mitral annular anchor points. Diastolic strain rates from FT were also assessed. Twenty-five age- and sex-matched controls were included (73.8 ± 3.1 years, 52% male). Group differences were tested with t-tests, diagnostic accuracy with ROC analysis, and predictors of diastolic dysfunction with adjusted logistic regression. RESULTS:Compared with controls, patients had significantly higher indexed maximal left atrial volume (LAVimax), LV end-diastolic and end-systolic volumes, and LV mass (all p < 0.001). Of FT variables, only peak diastolic longitudinal velocity differed between groups (p < 0.001). In multivariate models, CMR-MARV correlated with radial, circumferential, and longitudinal diastolic strain rates, radial and longitudinal diastolic velocities (all p < 0.001), echocardiographic e' (r = 0.20, p = 0.007), LV mass (r = -0.18, p = 0.008), LAVimax (r = -0.18, p = 0.008), and NT-proBNP (r = -0.30, p < 0.0001). LAVimax and CMR-MARV were strongly independently associated with ALVDD (AUC 0.89 and 0.76, respectively; p < 0.0001). A combined model (LAVimax + CMR-MARV) achieved excellent discrimination (AUC 0.91, 95% CI 0.86-0.97, p < 0.0001). Independent predictors included LAVimax, CMR-MARV, and peak diastolic longitudinal velocity (all p < 0.001). CONCLUSION:CMR-MARV provides a simple cine-derived measure of longitudinal relaxation that correlates with established structural and biochemical markers of diastolic burden. Within an at-risk population, it offers incremental functional information beyond conventional parameters and may support multiparametric CMR phenotyping of preclinical diastolic dysfunction.

The prognostic role of high-risk plaque (HRP) features, including high coronary calcium scores detected by CT, beyond traditional cardiovascular risk factors and obstructive coronary artery disease (CAD), remains uncertain. This study evaluated the prognostic value of a combined HRP definition in stable chest pain patients with low-to-intermediate pretest probability of CAD. This prespecified analysis included participants randomized to the CT arm of the pragmatic, prospective 26-center European DISCHARGE trial (NCT02400229). The primary endpoint was major adverse cardiovascular events (MACE: cardiovascular death, nonfatal myocardial infarction, or stroke); the secondary endpoint was expanded MACE (transient ischemic attack and major procedure-related complications). Our combined HRP definition was any coronary plaque with positive remodeling, napkin-ring sign, low attenuation, or total calcium score ≥ 400 Agatston units. Among 1745 participants (age: 60 ± 10 years, 990 female), 35 MACE and 47 expanded MACE occurred at a median follow-up of 3.5 years (IQR: 2.9–4.2). After risk factor adjustment, the combined HRP definition was associated with a higher risk of MACE (HR: 3.81; 95

RATIONALE:Progressive structural lung disease (SLD) is a key hallmark of cystic fibrosis (CF). Elexacaftor/tezacaftor/ivacaftor (ETI) is associated with short-term improvements in SLD measured on chest computed tomography (CT). Longer-term changes in SLD outcomes with ETI are unknown. OBJECTIVES:Using multicenter standardized image collection and automated analysis, we sought to establish whether improvements in SLD with ETI continued in the second year of treatment. METHODS:Spirometry-controlled CT scans were performed at 6 sites in people with CF aged ≥12 years homozygous for the F508del mutation or heterozygous for the F508del and a minimum function mutation at baseline and 12 months and 24 months after commencing ETI. CT scans were analyzed using the automated LungQ platform (Thirona) to measure mucus plugging, trapped air, and bronchus-artery (BA) pair measurements: bronchial outer diameter (Bout), bronchial inner diameter (Bin), bronchial wall thickness (Bwt), arterial diameter (A), and BA ratios: Bout/A, Bin/A, Bwt/A, and bronchial wall area/bronchial outer area (Bwa/Boa). Scans were also visually scored using the PRAGMA-CF scoring system, divided into % disease (%DIS), % bronchiectasis (%BX), % mucus plugging (%MP), % bronchial wall thickening (%BWT), and % trapped air (%TA). RESULTS:CT scans were performed on 79 participants at baseline, 64 at 12 months, and 52 at 24 months. Automated analysis showed a significant reduction BwtA, and Bwa/Boa at 12 months, which were sustained to 24 months. No change was seen in Bin/A or Bout/A at 12 or 24 months. Improvements in mucus plug numbers, plug volume, and %TA at 12 months were sustained at 24 months. ETI was associated with a reduction in the ratio of pulmonary blood volume in the arterial system compared to the venous system in vessels of <1 mm, 1-2 mm, and >2 mm diameter. Manual PRAGMA-CF scores demonstrated improvements in %DIS, %BX, %MP, %BWT, and %TA at 12 months, and these changes were sustained, unchanged to 24 months. CONCLUSIONS:ETI is associated with substantial improvements in bronchial wall thickening, mucus plugging, and trapped air at 12 months. Changes were maintained to 24 months and did not continue to improve. Abnormal bronchial widening remained stable and did not improve with ETI therapy. Changes in the distribution of pulmonary arterial/venous blood volumes with ETI suggest a beneficial impact on pulmonary vascular pressures.

Cardiac amyloidosis is an infiltrative cardiomyopathy caused by the deposition of abnormally folded proteins within the myocardium. Several amyloid subtypes have been documented, with diagnosis supported by abnormal serum plasma electrophoresis, multimodality imaging, and endomyocardial biopsy. Herein, we describe the atypical MRI findings of vascular-variant cardiac amyloid supported by histopathological diagnosis. Knowledge of the vascular-variant cardiac amyloid, in which amyloid deposits in the myocardial vasculature rather than the interstitium, will enable clinicians to proceed down appropriate diagnostic and treatment pathways.

Diffuse cystic lung diseases (DCLDs) are a diverse group of pulmonary diseases characterized by the presence of multiple thin-walled pulmonary cysts on chest imaging. They are becoming increasingly encountered due to the widespread use of CT screening. Many of these diseases have overlapping features, leading to diagnostic dilemmas. However, differences in treatment, surveillance and prognosis mean that confirming the diagnosis is crucial. We present three complex cases of cystic lung disease. A 52 year old woman presented with progressive shortness of breath, on a background of a post-partum pneumothorax 15 years prior with a normal VATS lung biopsy. CT chest revealed diffuse pulmonary cysts with a distribution suggestive of Birt-Hogg-Dubé syndrome (BHD). Pulmonary function testing was normal. VEGF-D levels were normal at 255pg/mL. A lung biopsy was carried out targeting cystic areas seen intra-operatively. Histological analysis showed cystic disease with negative staining for HMB-45 and estrogen receptor (ER), and positive SMA and Cathepsin K, suggestive of lymphangioleiomyomatosis (LAM). Cathepsin K is a novel biomarker for LAM and is over-expressed 40-fold in LAM compared to normal tissue. A 36 year old woman was referred by ophthalmology after presenting with uveitis, following a CT chest demonstrating multiple scattered cysts of varying sizes with the largest in the upper lobes. VEGF-D and FLCN genetic testing were normal. Lung biopsy showed non-necrotizing granulomas with no LAM cells, and negative ER/HMB-45/Cathepsin K staining. At specialist MDM, the consensus diagnosis was of sarcoid cystic lung disease. While sarcoid is a very rare cause of DCLD it has been reported in the literature and should be considered in appropriate circumstances. A 39 year old woman was referred with an incidental pulmonary abnormality on abdominal imaging. CT chest showed multiple scattered thin-walled homogenous pulmonary cysts and a renal lesion concerning for angiomyolipoma (AML). On specific questioning, she reported sicca symptoms. Autoimmune screen revealed positive ANA (titre 400), ENA and anti-Ro antibodies. Serum electrophoresis showed elevated IgG and IgA levels with a faint monoclonal lambda light chain. LAM was diagnosed given the imaging appearances and the presence of a renal AML. The presence of definite Sjogren's syndrome and its’ association with lymphoid interstitial pneumonia (LIP) confounds the picture, with a rare occurrence of LAM and LIP in the same individual. Expert review in a specialist center is essential for the extremely rare difficult cases of DLCD which cannot be diagnosed via classic pathways, as illustrated by these complex cases.

Intermittent hypoxia (IH)-mediated adipose tissue inflammation with M1 macrophage polarisation plays a key role in the pathogenesis of metabolic diseases in obstructive sleep apnoea (OSA). Effective treatment strategies are so far lacking. Here, we hypothesised that a glucagon-like peptide (GLP)-1 (Liraglutide)-based weight loss regimen improves IH-induced metabolic perturbations. To test the hypothesis, we employed a comprehensive translational approach consisting of an innovative IH system for cell cultures, a murine IH model of diet-induced obese mice and a proof-of-concept randomised-controlled study in OSA (NCT04186494). Liraglutide significantly attenuated IH-mediated pro-inflammatory polarisation of bone marrow-derived murine macrophages in cell culture. However, this did not translate into improved IH-induced insulin resistance in C57Bl/6 mice fed on a high-fat diet despite significant weight loss. In OSA subjects without diabetes (n = 30, 50 ± 7 years, 80% males, apnoea-hypopnoea index [AHI] 50 ± 19/h, body mass index [BMI] 35.0 ± 3 kg/m2), Liraglutide in contrast to CPAP over 24 weeks led to improvement in insulin sensitivity (mean difference 1.91 ± 1.46 vs. -1.02 ± 2.75, p = 0.03) in correlation with reduction in anthropometric measures and visceral adipose tissue volume. However, in conjunction with its limited effect on OSA parameters, the combination of Liraglutide with CPAP therapy appeared superior to Liraglutide alone for improvement of other glycaemic parameters such as fasting glucose, glucose tolerance, or HbA1c. In summary, while Liraglutide is effective in mediating weight loss, a lack of improvement in IH-triggered metabolic dysfunction does not support its role as monotherapy for metabolic diseases in OSA.

A 64 year-old man presented with episodic wheeze for 3 months. He had a background of asthma. He was an ex-smoker with a 20 pack year history and worked as an accountant. He had no new environmental exposures or precipitating factors. His medications included Budesonide/Formoterol and Umeclidinium. Physical examination revealed bilateral polyphonic wheeze. Blood tests showed eosinophils of 0.6 109/l and IGE of 173 k U/L. Chest radiograph demonstrated a new left upper lobe lung collapse and opacity against the superior mediastinum.Pulmonary function tests (PFTs) showed normal spirometry and DLCO with FeNO 38ppb. CT thorax demonstrated a mass causing obstruction of the left upper lobe bronchus with enlarged ipsilateral hilar and mediastinal nodes. Bronchoscopy demonstrated no endobronchial lesion but an inflamed left upper airway with possible extrinsic compression, washings were taken from here. These showed no malignant cells.Multidisciplinary team (MDT) discussion recommended CT guided biopsy of the mass. This demonstrated fibrous tissue with lymphocytic abundant plasma cells and eosinophils, 23 IgG4 positive plasma cells were seen. The serum IgG4 level was 0.534 k U/L. Repeat MDT discussion recommended wedge resection of the lesion due to uncertainty if the biopsy findings were secondary to peri-tumoural inflammation or IgG4-related disease. This demonstrated parenchyma containing abscesses, inflammatory infiltrate, associated fibrosis and organising pneumonia. There was no evidence of carcinoma and stains were negative for mycobacteria and fungal culture. Station 10 and 11 lymph nodes were benign. Immunohistochemical staining showed a ratio of IgG4/IgG of 10% which was insufficient for diagnosis of IgG4 related disease (IgG4- RD) however final MDT discussion concluded the overall radiological and histologic features of this mass were suggestive of a pulmonary manifestation of IgG4-RD. This case is a rare manifestation of IgG4- RD, itself a rare condition. IgG4 disease can affect any organ system with the lungs affected in approximately 10% of cases (1). Diagnosis of IgG4-RD can challenging as pulmonary manifestations can be difficult to distinguish from malignancy or inflammatory conditions based on imaging alone (2). Diagnosis should be based on MDT discussion of radiologic and histologic findings (2).10%-30% of patients with IgG4-RD may have normal serum IgG4 levels despite histopathological criteria suggesting IgG4-RD (4).Optimal therapy is unclear as no randomised control trials have been performed to date (2). It can be a progressive fibrotic process so systemic therapy should be considered (1). Corticosteroids are typically used (3) however there are steroid sparing options (3).

AIMS:Understanding sex-related cardiovascular differences in those with pre-HFpEF (asymptomatic with normal ejection fraction, elevated natriuretic peptides and structural or functional heart disease) could help explain why females are more likely to develop symptomatic HFpEF compared with males. This study analyses sex-related cardiovascular differences in pre-HFpEF, including measures of cardiovascular stiffness and vascular resistance derived from cardiac magnetic resonance imaging (CMR) and Doppler echocardiography. METHODS AND RESULTS:This post hoc analysis of the PARABLE trial enrolled 250 patients with pre-HFpEF. CMR and Doppler echocardiography were used to estimate baseline markers of cardiovascular stiffness and resistance, including effective arterial elastance (EAE), systemic vascular resistance (SVR), total arterial compliance (TAC), left ventricular end diastolic pressure (LVEDP) and left ventricular end diastolic chamber stiffness index (LVSId). The population median age was 72.0 [IQR 68.0; 77.0] years and 38.4% were female. Both sexes had a similar age, blood pressure, HbA1c, renal function and H2FPEF score. Fewer female participants had a diagnosis of diabetes and coronary artery disease. When adjusted for age, hypertension, diabetes, obesity and vascular disease, female participants had higher pulse pressures (62.1 (SD 15.3) vs. 60.1 (SD 12.5) mmHg, P < 0.001) as well as higher median [IQR] levels of LDL-cholesterol (2.50 [2.10; 3.25] vs. 2.00 [1.60; 2.40] mmol/L, P < 0.001), EAE (1.55 [1.26; 1.84] vs. 1.26 [1.05; 1.51] mmHg/mL/m2, P < 0.001), SVR (1609 [1288; 1887] vs. 1336 [1132; 1734] mmHg/mL/min2, P = 0.001), LVEDP (18.5 [17.2; 20.1] vs. 18.0 [16.9; 19.3] mmHg, P < 0.001) and LVSId (0.28 [0.24; 0.31] vs 0.24 [0.20; 0.29] mmHg/mL/m2, P < 0.001) than males. Females had higher median [IQR] NT-proBNP (176 [95.8; 286] vs. 127 [81.5; 242] pg/mL, P < 0.001) and lower median [IQR] TAC (1.24 [0.99; 1.58] vs. 1.55 [1.18; 1.91] mL/mmHg, P < 0.001) than male participants. CONCLUSIONS:Markers of elevated cardiovascular stiffness and vascular resistance are seen in female versus male participants with pre-HFpEF, suggesting that sex-related pathophysiological mechanisms are present before symptoms of HF develop.

Purpose To compare functional testing and management after cardiac CT-first versus invasive coronary angiography (ICA)-first strategies in participants with stable chest pain and low to intermediate probability of obstructive coronary artery disease (CAD) initially referred for ICA. Materials and Methods This study was a prespecified secondary analysis of the prospective, multicenter, randomized DISCHARGE (Diagnostic Imaging Strategies for Participants with Stable Chest Pain and Intermediate Risk of Coronary Artery Disease) trial (ClinicalTrials.gov no. NCT02400229) conducted between October 2015 and April 2019. The primary outcome was functional testing rates at each of the study sites after first test; secondary outcomes included revascularization, major postprocedure complications, and angina after a 3.5-year follow-up, all stratified by CAD severity. Comparisons were performed using adjusted multiple regression. Results Of 3561 participants (mean age, 60.1 years ± 10.1 [SD]; 2002 [56.2%] female), 3414 were included in the final analysis. CT-first resulted in more functional testing for obstructive CAD without high-risk anatomy as compared with ICA-first (114 of 214 [53.3%] vs 62 of 255 [24.3%]; adjusted odds ratio [OR], 3.55; 95% CI: 2.40, 5.28; Pinteraction < .001). Revascularizations were lower for CT-first in obstructive CAD with high-risk anatomy (146 of 251 [58.2%] vs 161 of 196 [82.1%]; adjusted OR, 0.3; 95% CI: 0.19, 0.47) and without high-risk anatomy (81 of 214 [37.9%] vs 152 of 255 [59.6%]; adjusted OR, 0.41; 95% CI: 0.28, 0.60). ICA-first had more major complications with high-risk anatomy (11 of 196 [5.6%] vs five of 251 [2.0%]) and non-high-risk anatomy (11 of 255 [4.3%] vs two of 214 [0.9%]) than CT-first. Angina rates were similar (38 of 465 [8.2%] vs 32 of 451 [7.1%]; adjusted OR, 1.13; 95% CI: 0.69, 1.86). Conclusion A CT-first strategy increased functional testing, was influenced by CAD severity, and reduced revascularizations and major complications with similar angina rates after a 3.5-year follow-up compared with an ICA-first strategy in participants with stable chest pain. Keywords: CT Coronary Angiography, Coronary Arteries, Percutaneous, MR Perfusion, Cardiac, Heart, Comparative Studies Clinical trial registration no. NCT02400229 Supplemental material is available for this article. © RSNA, 2025.

BACKGROUND:Combining pretest probability (PTP) with computed tomography angiography (CTA) for diagnosing obstructive coronary artery disease (CAD) has not yet been determined. OBJECTIVES:The purpose of this study was to evaluate the accuracy of PTP calculation alone and with CTA for diagnosing CAD. METHODS:A total of 65 prospective diagnostic accuracy studies of patients clinically referred to invasive coronary angiography with stable chest pain were included in this international collaborative individual patient data Collaborative Meta-Analysis of Cardiac CT (COME-CCT) meta-analysis. Mixed-effects logistic regression with a data set-specific random intercept for clustering was applied to 4 models: the traditional Diamond-Forrester models, a PTP model based on the COME-CCT data (termed COME-CCT-PTP calculator), a CTA alone model, and a combined COME-CCT-PTP with CTA model. RESULTS:Individual patient data from 5,332 patients with clinically indicated invasive coronary angiography from 22 countries were included. The COME-CCT-PTP calculator was more accurate than the original Diamond-Forrester model (AUC: 0.68; 95% CI: 0.66-0.69 vs 0.63; 95% CI: 0.62-0.65). The COME-CCT-PTP with CTA model significantly improved accuracy compared with either model alone (AUC: 0.86; 95% CI: 0.85-0.87 vs 0.81; 95% CI: 0.80-0.82). The improved prediction was consistent in decision curve analysis with an increased net benefit for all chest pain subtypes and was almost equally seen in patients with typical or atypical angina (0.85; 95% CI: 0.84-0.86) and nonanginal or other chest discomfort (0.88; 95% CI: 0.86-0.89). CONCLUSIONS:Combining the COME-CCT-PTP calculator with CTA provides more accurate prediction than the PTP or CTA alone for the diagnosis of obstructive CAD, for all chest pain subtypes.

The effect of computed tomography (CT) vs invasive coronary angiography (ICA) on health status outcomes is unknown. To evaluate CT and ICA first-test strategies on quality of life (QOL) and angina. The Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) randomized clinical trial, conducted between October 2015 and April 2019 in 26 European centers, followed up patients with stable chest pain and intermediate probability of coronary artery disease for a median 3.5 years. Data analysis was from December 2023 to July 2024. Random assignment to CT or ICA. Patient-reported Euro QOL 5-dimensions descriptive system (EQ-5D-3L) visual analog scale (EQ-5D-3L-VAS) and 12-item Short Form Health Survey (SF-12) physical component score (SF-12-PCS) were primary prespecified QOL outcomes. Angina was the primary prespecified chest pain outcome. The EQ-5D-3L-VAS, summary index (EQ-5D-3L-SI), mental component summary (SF-12-MCS), and Hospital Anxiety and Depression Scale–anxiety subscale (HADS-A) and Hospital Anxiety and Depression Scale–anxiety subscale (HADS-D) were also evaluated. Among 3561 patients (mean [SD] age, 60.1 [10.1] years; 2002 female [56.2%]), 1735 (96.0%) in the CT group and 1671 (95.3%) in the ICA group completed at least 1 health status assessment during 3.5 years of follow-up. Health status outcomes were similar between groups, with significant improvements in all QOL outcomes (eg, mean EQ-5D-3L-VAS 3.5 year minus baseline score: CT = 4.0; 95% CI, 3.1-4.9; P < .001; ICA = 4.6; 95% CI, 3.6-5.6; P =.002), except HADS-D, which improved only in the CT group (mean EQ-5D-3L-VAS 3.5 year minus baseline score: CT = −0.2; 95% CI, −0.4 to 0; P = .04; ICA = −0.2; 95% CI, −0.4 to 0; P = .12). Female patients had worse baseline and follow-up QOL than male patients (eg, baseline EQ-5D-3L-VAS difference between men and women = 5.2; 95% CI, 4.0-6.3; P <.001 and at 3.5 years = 3.1; 95% CI, 1.9-4.4; P < .001) but showed greater improvements in EQ-5D-3L-VAS (−1.9; 95% CI, −3.4 to −0.5; P = .009), SF-12-PCS (−1.4; −2.1 to −0.7; P < .001), and HADS-A (0.3; 0-0.7; P = .04). Angina outcomes were comparable between groups at 3.5 years, with similar 1-year rates in the CT group but higher rates in female than male patients in the ICA group (10.2% vs 6.2%; P = .007). Results of this secondary analysis of the DISCHARGE randomized clinical trial reveal that there was no significant difference in QOL or chest pain outcomes with CT vs ICA at 3.5 years. Female patients had worse health status than male patients at baseline and follow-up, and CT or ICA did not affect these differences. ClinicalTrials.gov Identifier: NCT02400229

Rationale: The most important structural lung abnormalities that can be observed on inspiratory chest CTs of people with cystic fibrosis(PwCF) are bronchial widening and thickening, mucus plugs and, on expiratory scans, large low attenuation regions (LAR). LAR are most likely reflecting the combination of hypoventilation and hypoperfusion secondary to airways obstruction and hypoxic pulmonary vasoconstriction. Using sensitive visual scoring techniques and sensitive AI-based image analysis algorithms we previously demonstrated important improvements in airway wall thickening, mucus plug number and in LAR in PwCF aged 12 years and over after 12 Months(M12) and 24 Months(M24) of Elexacaftor-Tezacaftor-Ivacaftor(ETI) therapy. For the current study we sought to establish the impact of ETI on arterial and venous blood volume distribution and LAR. We hypothesized that a reduction in LAR would correlate with a reduction in the upstream arterial blood volumes reflecting reduced upstream pulmonary arterial pressures. Methods: Standardized spirometry-controlled CT scans were performed at baseline (M0), M12, and M24. CTs were fully automatically analyzed (Thirona, Nijmegen) using: LungQ-VERA: measurement of LAR (% total lung volume); LungQ-AVX: Total arterial and venous blood volumes were computed based on the outer diameter and length of pulmonary arteries and veins. Results were divided in bins: 0.2-1mm, 1-2mm, and >2mm. Blood volume in each bin is expressed as % of total lung blood volume. Differences in arterial blood volumes for each bin were compared between M0 vs M12 and between M0 and M24 (mixed model) and between changes(Δ) M0-M12 in arterial blood volumes vs Δ%LAR. Results are shown as: median [Q1, Q3]. Results: Number CT scans: M0=65, M12=43, M24=38. Arterial blood volumes for M0, M12, M24: Bin 0.2-1 mm: 6.7[6.0,7.6], 6.6[5.7-7.5], 6.5[5.7,7.1]% (differences ns); Bin 1-2mm: 10.9[10.0,12.2], 9.4[8.7,10.2], 9.6[8.8, 10.4]% (differences P<0.001); Bin>2; 38.4 [35.6,41.7], 37.4[34.8, 39.2], 37.7[34.8, 39.7] (differences p<0.001). For all venous bins an increase in %volumes were observed for M12 and M24 (all p<0.001). %LAR for M0, M12, M24 were 13.1[7.9, 20.7], 4.9[2.6, 10.4], 6.2[3.6,12.6] (differences <0.001). Δblood volumes versus Δ%LAR showed a positive correlation(r=0.27, p=0.09) in the arterial bin>2mm, and an negative correlation for the 0.2-1 bin (r=-0.39, p=0.014). Discussion: Substantial changes are seen in the pulmonary arterial and venous blood volume distribution in response to ETI therapy. The reduction in upstream large vessel %arterial blood volume suggests a reduction in pulmonary arterial pressures. Furthermore, the increase of the %venous blood volume suggests improved pulmonary perfusion.

Importance The effect of computed tomography (CT) vs invasive coronary angiography (ICA) on health status outcomes is unknown. Objective To evaluate CT and ICA first-test strategies on quality of life (QOL) and angina. Design, Setting, and Participants The Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) randomized clinical trial, conducted between October 2015 and April 2019 in 26 European centers, followed up patients with stable chest pain and intermediate probability of coronary artery disease for a median 3.5 years. Data analysis was from December 2023 to July 2024. Interventions Random assignment to CT or ICA. Main Outcomes and Measures Patient-reported Euro QOL 5-dimensions descriptive system (EQ-5D-3L) visual analog scale (EQ-5D-3L-VAS) and 12-item Short Form Health Survey (SF-12) physical component score (SF-12-PCS) were primary prespecified QOL outcomes. Angina was the primary prespecified chest pain outcome. The EQ-5D-3L-VAS, summary index (EQ-5D-3L-SI), mental component summary (SF-12-MCS), and Hospital Anxiety and Depression Scale-anxiety subscale (HADS-A) and Hospital Anxiety and Depression Scale-anxiety subscale (HADS-D) were also evaluated. Results Among 3561 patients (mean [SD] age, 60.1 [10.1] years; 2002 female [56.2%]), 1735 (96.0%) in the CT group and 1671 (95.3%) in the ICA group completed at least 1 health status assessment during 3.5 years of follow-up. Health status outcomes were similar between groups, with significant improvements in all QOL outcomes (eg, mean EQ-5D-3L-VAS 3.5 year minus baseline score: CT = 4.0; 95% CI, 3.1-4.9; P < .001; ICA = 4.6; 95% CI, 3.6-5.6; P =.002), except HADS-D, which improved only in the CT group (mean EQ-5D-3L-VAS 3.5 year minus baseline score: CT = -0.2; 95% CI, -0.4 to 0; P = .04; ICA = -0.2; 95% CI, -0.4 to 0; P = .12). Female patients had worse baseline and follow-up QOL than male patients (eg, baseline EQ-5D-3L-VAS difference between men and women = 5.2; 95% CI, 4.0-6.3; P <.001 and at 3.5 years = 3.1; 95% CI, 1.9-4.4; P < .001) but showed greater improvements in EQ-5D-3L-VAS (-1.9; 95% CI, -3.4 to -0.5; P = .009), SF-12-PCS (-1.4; -2.1 to -0.7; P < .001), and HADS-A (0.3; 0-0.7; P = .04). Angina outcomes were comparable between groups at 3.5 years, with similar 1-year rates in the CT group but higher rates in female than male patients in the ICA group (10.2% vs 6.2%; P = .007). Conclusions and Relevance Results of this secondary analysis of the DISCHARGE randomized clinical trial reveal that there was no significant difference in QOL or chest pain outcomes with CT vs ICA at 3.5 years. Female patients had worse health status than male patients at baseline and follow-up, and CT or ICA did not affect these differences. Trial Registration ClinicalTrials.gov Identifier: NCT02400229

Rationale: Obstructive sleep apnea (OSA) is an independent risk factor for cardiovascular (CV) morbidity and mortality, but the benefit of continuous positive airway pressure (CPAP) is uncertain. However, most randomized controlled trials have focused on the role of CPAP in secondary prevention, although there is growing evidence of a potential benefit on early CV disease. Weight loss in combination with CPAP may be superior but is difficult to achieve and maintain with conventional measures alone. Objectives: The aim of this study was to gain insights into the effect of CPAP on early atherosclerotic processes and to compare it with a glucagon-like peptide (GLP)-1-mediated weight loss regimen in patients with OSA. Methods: We performed a randomized proof-of-concept study comparing CPAP, a GLP1-mediated weight-loss regimen (liraglutide [Lir]), and both in combination for 24 weeks in 30 consecutive patients with OSA (apnea-hypopnea index >15 events/h; body mass index 30-40 kg/m2; and no history of diabetes, heart failure, or unstable CV disease). In addition to extensive evaluation for CV risk factors and endothelial function at baseline and end of study, subjects underwent 18F-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography (18F-FDG PET-CT) for the measurement of aortic wall inflammation (target-to-background ratio) and coronary computed tomography angiography for semiautomated coronary plaque analysis. Results: Baseline characteristics were similar between groups. CPAP alone and in combination resulted in greater reduction in apnea-hypopnea index than Lir alone (mean difference, -45 and -43 events/h, respectively, vs. -12 events/h; P < 0.05). Both Lir and combination treatment led to significant weight loss, but only CPAP alone resulted in significant decrease in vascular inflammation (aortic wall target-to-background ratio from 2.03 ± 0.34 to 1.84 ± 0.43; P = 0.010), associated with an improvement in endothelial function and a decrease in C-reactive protein. Low-attenuation coronary artery plaque volume as a marker of unstable plaque also decreased with CPAP (from 571 ± 490 to 334 ± 185 mm3) and with combination therapy (from 401 ± 145 to 278 ± 126 mm3) but not with Lir. Conclusions: These data suggest that CPAP therapy, but not GLP1-mediated weight loss, improves vascular inflammation and reduces unstable plaque volume in patients with OSA. Further large randomized controlled studies are warranted to assess the benefit of CPAP therapy in modifying early CV disease. Clinical trial registered with www.clinicaltrials.gov (NCT04186494).

Background: Coronary artery calcium (CAC) has prognostic value for major adverse cardiovascular events (MACE) in asymptomatic individuals, whereas its role in symptomatic patients is less clear. Purpose: To assess the prognostic value of CAC scoring for MACE in participants with stable chest pain initially referred for invasive coronary angiography (ICA). Materials and Methods: This prespecified subgroup analysis from the Diagnostic Imaging Strategies for Patients With Stable Chest Pain and Intermediate Risk of Coronary Artery Disease (DISCHARGE) trial, conducted between October 2015 and April 2019 across 26 centers in 16 countries, focused on adult patients with stable chest pain referred for ICA. Participants were randomly assigned to undergo either ICA or coronary CT. CAC scores from noncontrast CT scans were categorized into low, intermediate, and high groups based on scores of 0, 1-399, and 400 or higher, respectively. The end point of the study was the occurrence of MACE (myocardial infarction, stroke, and cardiovascular death) over a median 3.5 -year follow-up, analyzed using Cox proportional hazard regression tests. Results: The study involved 1749 participants (mean age, 60 years +/- 10 [SD]; 992 female). The prevalence of obstructive coronary artery disease (CAD) at CT angiography rose from 4.1% (95% CI: 2.8, 5.8) in the CAC score 0 group to 76.1% (95% CI: 70.3, 81.2) in the CAC score 400 or higher group. Revascularization rates increased from 1.7% to 46.2% across the same groups (P < .001). The CAC score 0 group had a lower MACE risk (0.5%; HR, 0.08 [95% CI: 0.02, 0.30]; P < .001), as did the 1-399 CAC score group (1.9%; HR, 0.27 [95% CI: 0.13, 0.59]; P = .001), compared with the 400 or higher CAC score group (6.8%). No significant difference in MACE between sexes was observed (P = .68). Conclusion: In participants with stable chest pain initially referred for ICA, a CAC score of 0 showed very low risk of MACE, and CAC scores showed risk of obstructive CAD, revascularization, and MACE at

Objective: Glucagon-like peptide-1 (GLP-1) analogues are currently the most widely used pharmacotherapies for weight loss. Their primary mechanism of action is attributed to reduction in energy intake. Data from murine studies also support an additional impact of those agents on energy homeostasis through upregulation of visceral adipose tissue (VAT) metabolic activity, but this remains uncertain in humans. Methods: Here, we present data from a proof-of-concept study on 30 individuals with obstructive sleep apnea and obesity who were randomized to a GLP-1 therapy-based weight loss regimen, continuous positive airway pressure, or a combination of both for 24 weeks. At baseline and study completion, 18F-fluorodeoxyglucose (18F-FDG) positron emission tomography-computed tomography (PET-CT) was performed to evaluate VAT metabolic activity, expressed as VAT target to background ratio. Results: Treatment with GLP-1, but not with continuous positive airway pressure, was associated with a significant increase in VAT target to background ratio. There was a strong correlation between the increase in VAT metabolic activity and the degree of weight loss. Conclusions: These data support the hypothesis that upregulation of VAT metabolic activity by GLP-1 contributes to its weight loss action in humans, and this subject warrants further detailed investigation.

In this review, the authors examine recent advancements in noninvasive cardiac imaging, focusing on cardiac CT, MRI, and PET, reviewing key publications from imaging and multidisciplinary journals from 2023. The authors discuss the increasing adoption of photon-counting CT and its applications in coronary and structural imaging, and explore various aspects of plaque and functional assessment, emphasizing their clinical implications. Radiation exposure analysis from the SCOT-HEART (Scottish Computed Tomography of the Heart) trial is also discussed. The authors highlight the integration of artificial intelligence applications in cardiac imaging. Three-year follow-up data from the ADVANCE Registry are described, showcasing the potential of using artificial intelligence to improve diagnostic accuracy and patient outcomes in cardiovascular care. The authors explore the latest studies evaluating different cardiomyopathies using cardiac MRI. Radiologists' growing understanding of the brain-heart axis is presented through discussion of several studies. The authors also discuss the prognostic advantages of MRI over PET in patients with cardiac sarcoidosis. Finally, the authors outline society statements and guidelines from 2023 that are pertinent to cardiac imaging, offering a comprehensive review of current trends and applications in noninvasive imaging modalities.