OBJECTIVES:The Swedish CArdioPulmonary bioImage Study reexamination (SCAPIS reexamination) is the first population-based study to employ coronary CT angiography (CCTA) using photon-counting detector CT (PCD-CT). It includes 15,000 participants from SCAPIS baseline. This work aims to describe the PCD-CT protocol in SCAPIS reexamination, compare diagnostic image quality with energy-integrating detector CT (EID-CT) at SCAPIS baseline, and assess the comparability of Agatston scores and degree of stenosis between the studies. METHODS:The PCD-CT protocol in SCAPIS reexamination is provided. CCTA data from 1,147 participants in SCAPIS reexamination (51% women, age 65 [IQR 61-69]) and 29,554 participants in SCAPIS (52% women, age 58 [54-61]) were analyzed. The image quality in eleven proximal and middle coronary segments was compared, stratified by Agatston score. Agatston scores and stenosis degree were compared in age- and sex-matched samples. RESULTS:Full diagnostic image quality was more frequent in SCAPIS reexamination (1,036/1,147, 90%) compared with SCAPIS baseline (20,468/26,188, 78%), p < 0.001, despite a higher calcium burden (Agatston score 8 [0-106] vs. 0 [0-20]). Of participants with Agatston score > 400, 89/116, 77%, and 246/945, 26%, had full diagnostic image quality, respectively, p < 0.001. Agatston score distributions and stenosis ≥ 50% were similar in matched samples (p = 0.51 and p = 0.08). Of those with ≥ 50% stenosis at SCAPIS baseline, 30% (12/40) were reclassified to < 50% in SCAPIS reexamination. CONCLUSION:The optimized PCD-CT protocol in SCAPIS reexamination provided high image quality, irrespective of Agatston scores, outperforming the EID-CT protocol used at SCAPIS baseline. Agatston scores were comparable, but potential differences in stenosis grading warrant further investigation.

AIMS:This study aimed to evaluate the prognostic value of segment involvement score (SIS) from coronary computed tomography angiography (CCTA) and compare it with coronary artery calcium score (CACS) in clinical practice. METHODS AND RESULTS:Patients undergoing CCTA for suspected coronary artery disease between 2006 and 2022 at 27 centres were included. SIS was defined by the number of segments with plaque. CACS was calculated using the Agatston method. Patients were followed for all-cause death and/or myocardial infarction (MI). A total of 23,034 patients were followed for a median of 2.5 years. SIS = 0 was found in 61.4% of patients, SIS = 1 in 12.6%, SIS = 2 in 8.2%, SIS = 3 in 5.7%, and SIS ≥ 4 in 12.2%. Compared with SIS = 0, SIS ≥ 4 was associated with higher adjusted risk of death (HR [95% CI]: 1.39 [1.17-1.66]), MI (3.53 [2.72-4.59]), and death or MI (1.88 [1.62-2.18]). Obstructive stenosis (≥50%) was also independently associated with all outcomes but showed lower discrimination than SIS in receiver operating characteristic curve analyses. SIS and CACS had similar ability to predict death or MI (Area under the curve: 0.70 [0.67-0.74] vs. 0.68 [0.65-0.72], P = 0.08) and MI alone (0.72 [0.67-0.77] vs. 0.72 [0.67-0.78], P = 0.69). CACS performed better than SIS in predicting death (0.70 [0.66-0.74] vs. 0.67 [0.63-0.70], P = 0.008). CONCLUSION:Both the extent of coronary atherosclerosis, measured by SIS, and the presence of obstructive disease are important predictors of outcomes. However, they do not provide additional prognostic value over CACS when used in routine clinical practice.

Importance:Risk stratification strategies in primary prevention of coronary events lack precision. Objective:To determine whether prediction of first coronary events is improved by adding information on coronary atherosclerosis from coronary computed tomography angiography (CCTA) to a model using the pooled cohort equation (PCE) risk score tool and the coronary artery calcification score (CACS). Design, Setting, and Participants:Observational cohort study including individuals aged 50 to 64 years randomly recruited from the general population and examined at 6 university hospitals in Sweden from 2013 to 2018, with a median follow-up of 7.8 years. A sample of 30 154 individuals underwent cardiopulmonary imaging, physical examinations, routine laboratory tests, questionnaires, and/or functional tests. This study included 24 791 individuals without previous cardiovascular disease for whom high-quality CCTA images were available. Events were followed up via registers until September 2024. Exposures:The information used from the CCTA images was the extent of coronary atherosclerosis (segment involvement score), presence of noncalcified atherosclerosis, and presence of coronary obstructive disease (stenosis ≥50%). Main Outcomes and Measures:The outcome was a composite of first occurrence of nonfatal myocardial infarction or death from coronary heart disease. Results:During follow-up, 304 coronary events occurred. Segment involvement scores of 3 to 4 and greater than 4 and presence of noncalcified atherosclerosis were associated with hazard ratios of 2.71 (95% CI, 1.34-5.44), 5.27 (95% CI, 2.50-11.07), and 1.66 (95% CI, 1.23-2.22), respectively. In a model based on the PCE and CACS, CCTA-derived data improved risk discrimination (C statistic improved from 0.764 to 0.779; P = .004) and risk reclassification (net reclassification improvement of 0.133 [95% CI, 0.031-0.165]), conferred a net correct upward reclassification of 14.2% in those with events and incorrectly classified 1.6% of participants not experiencing an event into a higher-risk category. Because of the low event rate in the cohort, reclassification mainly occurred in the group classified as at low risk (<5%) according to the PCE. Conclusions and Relevance:Information on coronary atherosclerosis from CCTA modestly improved risk prediction beyond traditional risk factors and CACS in identifying individuals at risk of coronary events and in need of primary prevention.

OBJECTIVES:To describe the rationale, design and data collection procedures of the Swedish CArdioPulmonary bioImage Study (SCAPIS) re-examination, which, in its further scope, aims to quantify and explain the development of atherosclerosis, pathological cardiovascular ageing, longitudinal decline in lung function and the malignant transformation of pulmonary nodules among middle-aged Swedes in the longitudinal SCAPIS. METHODS:SCAPIS re-examination is a prospective observational study reassessing approximately 15,000 participants (50% of the original SCAPIS cohort) from six university hospitals. Participants were aged 55-75 years at follow-up, occurring a median of 8.1 years after the baseline investigation. Standardized protocols replicated baseline imaging and functional assessments, including questionnaires, clinical assessments and extensive computer tomography imaging. RESULTS:Interim analyses of the first 5000 participants (50% women; median age 65.5 [61.8-69.1] years) indicated an expected age-related increase in the prevalence and treatment of hypertension (from 22% to 37%) and diabetes (from 4% to 8%), together with a modest rise in central adiposity. Body mass index (median 26.6 kg/m2) and the proportion of obesity (22%) remained largely stable, whereas current smoking decreased from 7.5% to 3.4%. The observed patterns were consistent in men and women. CONCLUSION:Here we present the rationale, design, methods and management of incidental findings in the SCAPIS re-examination. By integrating serial imaging, functional testing and biomarker profiling, the re-examination will furnish unprecedented insight into cardiopulmonary disease dynamics in an ageing population. These data will underpin personalized risk prediction and inform preventive strategies, while serving as a benchmark for future population-based imaging cohorts.

To describe the rationale, design and data collection procedures of the Swedish CArdioPulmonary bioImage Study (SCAPIS) re-examination, which, in its further scope, aims to quantify and explain the development of atherosclerosis, pathological cardiovascular ageing, longitudinal decline in lung function and the malignant transformation of pulmonary nodules among middle-aged Swedes in the longitudinal SCAPIS. SCAPIS re-examination is a prospective observational study reassessing approximately 15,000 participants (50% of the original SCAPIS cohort) from six university hospitals. Participants were aged 55–75 years at follow-up, occurring a median of 8.1 years after the baseline investigation. Standardized protocols replicated baseline imaging and functional assessments, including questionnaires, clinical assessments and extensive computer tomography imaging. Interim analyses of the first 5000 participants (50% women; median age 65.5 [61.8–69.1] years) indicated an expected age-related increase in the prevalence and treatment of hypertension (from 22% to 37%) and diabetes (from 4% to 8%), together with a modest rise in central adiposity. Body mass index (median 26.6 kg/m 2 ) and the proportion of obesity (22%) remained largely stable, whereas current smoking decreased from 7.5% to 3.4%. The observed patterns were consistent in men and women. Here we present the rationale, design, methods and management of incidental findings in the SCAPIS re-examination. By integrating serial imaging, functional testing and biomarker profiling, the re-examination will furnish unprecedented insight into cardiopulmonary disease dynamics in an ageing population. These data will underpin personalized risk prediction and inform preventive strategies, while serving as a benchmark for future population-based imaging cohorts.

Cardiac undifferentiated pleomorphic sarcoma (UPS) is a rare and highly malignant tumor, commonly arising in the left atrium. It is associated with poor prognosis, nonspecific symptoms, and difficulty in early diagnosis. Here, we report a case of a 71-year-old woman who presented with palpitations, chest pressure, and exertional dyspnea, in whom initial cardiac magnetic resonance imaging revealed only subtle atrial septal thickening, evaluated as nonspecific, whereas follow-up imaging 2 years later showed progressive growth, ultimately interpreted as a cardiac myxoma. Surgical resection was performed, and histopathologic examination revealed a high-grade UPS with immunohistochemistry and molecular profiling supporting the diagnosis, including amplification of MDM2 and PDGFRA. No metastases were detected, and after multidisciplinary discussion a decision was made to abstain from adjuvant therapy. This case highlights the diagnostic challenge posed by cardiac UPS mimicking benign tumors such as myxoma on imaging and the importance of longitudinal imaging review and a high index of suspicion in cases with atypical radiological features of myxoma. It also raises awareness of an unusually indolent behavior of an UPS that otherwise pursues an aggressive course.

Radiographic axial spondyloarthritis (r-axSpA) is associated with increased cardiovascular disease (CVD) risk. The coronary artery calcification (CAC) score, an atherosclerosis burden indicator that predicts CVD risk, is not well studied in r-axSpA. This study investigates CAC scores in patients with r-axSpA compared to controls without rheumatic disease and factors associated with CAC scores in r-axSpA patients. Fifty-eight r-axSpA patients from southwestern Sweden were assessed cross-sectionally using clinical disease measures, physical function, spinal mobility, lipid profiles, inflammation markers, and long-term time-averaged C-reactive protein (CRP). Four controls per patient were selected from the Swedish CArdioPulmonary bioImage Study (SCAPIS). CAC was scored on cardiac computed tomography (CT) using the Agatston method. The presence of CAC in the right coronary artery (RCA) was higher in patients compared to controls. However, no significant difference in total CAC scores was observed between r-axSpA patients and controls, despite numerically higher total CAC scores in patients. In r-axSpA patients, CAC scores correlated positively with time-averaged CRP, reduced physical function, and impaired spinal mobility. These findings suggest that chronic inflammation may contribute to coronary calcification and CVD risk in r-axSpA, highlighting the need for effective anti-inflammatory treatments. Further research is warranted to explore the association between coronary calcification, spinal immobility, and limitations in physical function.

Background Lead is an established causal risk factor for coronary heart disease. Atherosclerosis may be the key mediator for this association, but evidence from studies in humans is limited. Our objective was to test the hypothesis that environmental lead exposure is associated with coronary atherosclerosis. Methods We used cross‐sectional data from the SCAPIS (Swedish Cardiopulmonary Bioimage Study), including 5627 men and women aged 50 to 64 years. Coronary artery calcium score (CACS), measured using computed tomography, was used as a marker of atherosclerosis, and blood lead was used as a biomarker of lead exposure. The prevalence ratio (PR) of positive (>0) and high (≥100) CACSs in relation to blood lead (continuous variable) was modeled using Poisson regression with robust SEs, adjusted for age, sex, smoking, low‐density lipoprotein/high‐density lipoprotein ratio, waist circumference, heredity for cardiovascular diseases, statin use, diabetes, blood cadmium, low physical activity, and educational level. Results Median blood lead was 14.2 μg/L. Positive CACS (prevalence, 41%) was not significantly associated with blood lead (PR per Δ10 μg/L, 1.02 [95% CI, 0.99–1.04]), whereas the association was stronger for high CACS (prevalence, 13%; and PR per Δ10 μg/L, 1.05 [95% CI, 1.00–1.11]). The estimate for high CACS was stronger in men (PR per Δ10 μg/L, 1.07 [95% CI, 1.01–1.13]) than among women (PR per Δ10 μg/L, 1.01 [95% CI, 0.85–1.20]). Conclusions Our study, which found that lead is associated with coronary artery calcification in men, provides further evidence that lead is a risk factor for atherosclerosis and coronary heart disease.

AIMS:Spontaneous coronary artery dissection (SCAD), causing acute coronary syndrome (ACS), primarily in middle-aged women, is diagnosed with invasive coronary angiography (ICA). Due to the risk of dissection propagation with ICA, a non-invasive diagnostic tool is needed. We investigated coronary computed tomography angiography (CCTA) findings in acute SCAD, as well as the inter-modality agreement between CCTA and ICA. METHODS AND RESULTS:Thirty-two (92 ​% women, mean age 52.4 years) SCAD patients at eight Swedish hospitals were investigated with ICA as well as dual source CCTA during the index hospitalisation between April 2021 and October 2022. ICA identified 46 dissected segments whereas CCTA detected 25, Cohen's kappa (κ) ​= ​0.595 (95 ​% confidence interval [CI] 0.46-0.73). CCTA primary and secondary features were identified in 24 dissected coronary artery segments in 21 patients, 8 (32 ​%) tapered luminal stenosis, 11 (44 ​%) abrupt luminal stenosis, 3 (12 ​%) visible dissection membrane, 4 (16 ​%) intramural-hematomas, 9 (36 ​%) epicardial fat stranding and 8 (25 ​%) with coronary artery tortuosity. ICA identified 3 dissected proximal segments whereas CCTA identified 5, (κ ​= ​0.74, 95 ​% CI 0.40-1.00). In distal segments, ICA identified 43 and CCTA 20 dissections, (κ ​= ​0.57, 95 ​% CI 0.43-0.72). CONCLUSIONS:In patients presenting with acute SCAD, CCTA should not be considered a substitute for ICA. While CCTA demonstrated good diagnostic performance in identifying proximal SCAD lesions, its sensitivity was notably reduced in distal coronary segments, where SCAD is more frequent. Among the 25 lesions detected, CCTA successfully detected specific features in 24 lesions.

Purpose: We aim to investigate the localization, visibility, and measurement of lung nodules in digital chest tomosynthesis (DTS). Approach Computed tomography (CT), maximum intensity projections (CT-MIP) (transaxial versus coronal orientation), and computer-aided detection (CAD) were used as location reference, and inter- and intra-observer agreement regarding lung nodule size was assessed. Five radiologists analyzed DTS and CT images from 24 participants with lung nodules >= 100 mm(3), focusing on lung nodule localization, visibility, and measurement on DTS. Visual grading was used to compare if coronal or transaxial CT-MIP better facilitated the localization of lung nodules in DTS. Results: The majority of the lung nodules (79%) were rated as visible in DTS, although less clearly in comparison with CT. Coronal CT-MIP was the preferred orientation in the task of locating nodules on DTS. On DTS, area-based lung nodule size estimates resulted in significantly less measurement variability when compared with nodule size estimated based on mean diameter (mD) (p<0.05). Also, on DTS, area-based lung nodule size estimates were more accurate (SEE=38.7 mm(3)) than lung nodule size estimates based on mean diameter (SEE=42.7 mm(3)). Conclusions: Coronal CT-MIP images are superior to transaxial CT-MIP images in facilitating lung nodule localization in DTS. Most nodules >= 100 mm(3) found on CT can be visualized, correctly localized, and measured in DTS, and area-based measurement may be the key to more precise and less variable nodule measurements on DTS.

To develop and evaluate a deep learning model for segmentation of the coronary artery vessels and coronary plaques in coronary computed tomography angiography (CCTA). CCTA image data from the Swedish CardioPulmonary BioImage Study (SCAPIS) was used for model development (n = 463 subjects) and testing (n = 123) and for an interobserver study (n = 65). A dataset from Linköping University Hospital (n = 28) was used for external validation. The model’s ability to detect coronary artery disease (CAD) was tested in a separate SCAPIS dataset (n = 684). A deep ensemble (k = 6) of a customized 3D vision transformer model was used for voxelwise classification. The Dice coefficient, the average surface distance, Pearson’s correlation coefficient, analysis of segmented volumes by intraclass correlation coefficient (ICC), and agreement (sensitivity and specificity) were used to analyze model performance. PlaqueViT segmented coronary plaques with a Dice coefficient = 0.55, an average surface distance = 0.98 mm and ICC = 0.93 versus an expert reader. In the interobserver study, PlaqueViT performed as well as the expert reader (Dice coefficient = 0.51 and 0.50, average surface distance = 1.31 and 1.15 mm, ICC = 0.97 and 0.98, respectively). PlaqueViT achieved 88

AIMS:Men are more likely to suffer a myocardial infarction than women, but population-based studies on sex differences in imaging-detected atherosclerosis are lacking. The aims were to assess sex differences in the prevalence of imaging-detected coronary and carotid atherosclerosis, as well as multivariable adjusted associations between sex and atherosclerosis. METHODS AND RESULTS:Participants aged 50-65, recruited from the general population to the Swedish Cardiopulmonary bioImage Study (SCAPIS), were included in this population-based cross-sectional study. Comprehensive diagnostics, including coronary computed tomography angiography and carotid ultrasound, were performed. The image findings were any coronary atherosclerosis, coronary stenosis ≥ 50%, segment involvement score (SIS) ≥ 4, coronary artery calcium score (CACS) > 100, and any ultrasound-detected carotid plaque. In 25 580 participants (50% women), men had more hypertension (20.3% vs. 17.0%), hyperlipidaemia (9.0% vs. 5.5%), and diabetes (8.5% vs. 4.7%). The prevalence was 56.2% vs. 29.5% for any coronary atherosclerosis (P < 0.01), 9.0% vs. 2.3% for coronary stenosis ≥ 50% (P < 0.01), 20.2% vs. 5.3% for SIS ≥ 4 (P < 0.01), 18.2% vs. 5.6% for CACS > 100 (P < 0.01), and 60.9% vs. 48.7% for carotid plaque (P < 0.01), in men vs. women, respectively. Multivariable adjustment only marginally changed these associations: odds ratios (ORs) (95% confidence interval): 2.75 (2.53-2.99) for coronary atherosclerosis, 2.88 (2.40-3.45) for coronary stenosis ≥ 50%, 3.99 (3.50-4.55) for SIS ≥ 4, 3.29 (2.88-3.75) for CACS > 100, and 1.57 (1.45-1.70) for carotid plaque. CONCLUSION:Men had higher prevalence of imaging-detected carotid and coronary atherosclerosis with prevalence in women aged 65 corresponding to men 11-13 years younger. The associations remained after extensive multivariable adjustment.

AbstractTo investigate whether coronary artery disease (CAD) burden is associated with plasma levels of the myocardial biomarkers Troponin I (TropI) and NT-proBNP in a large population-based sample using a cross-sectional design. Coronary computerized tomography (CT) angiography was performed in 25,859 subjects without a history of atherosclerotic disease from SCAPIS study (age 50–65, 52% women). TropI and NT-proBNP were measured in plasma. Segment involvement score (SIS) was the primary exposure and TropI the primary outcome. Both SIS and coronary artery calcium score, were associated with TropI levels following adjustment for age, sex and multiple confounders (p < 0.001), with similar relationships in men and women. Proximal segments from all three coronary arteries were related to TropI levels independently of one another. Adding TropI to traditional risk factors marginally increased discrimination of atherosclerosis as compared to risk factors alone (C-statistics + 0.0005, p = 0.014). SIS was related also to NT-proBNP levels, mainly in men, but with lower estimates than TropI. The burden of CAD was related to TropI levels in both men and women. All three major coronary arteries contributed to this relationship. Adding TropI to traditional risk factors resulted in only marginally improved discrimination of coronary atherosclerosis.

Coronary artery calcification (CAC) is an established imaging biomarker of subclinical atherosclerosis, but its relationship to diurnal preference is not well studied. We investigated the association between chronotype and CAC in the Swedish CArdioPulmonary bioImage Study (SCAPIS) pilot cohort. Participants aged 50-64 years were randomly recruited and underwent extensive examination including imaging and accelerometry-assessed physical activity. 771 participants (47.3 % male, 57.6 +/- 4.4 years) were included in this cross-sectional analysis. CAC was assessed by non-contrast computed tomography, and a CAC score > 10 was considered significant calcification. Self-assessed chronotype was classified as extreme morning, moderate morning, intermediate, moderate evening, or extreme evening. 10-year risk of first-onset cardiovascular disease was estimated by the Systemic Coronary Risk Evaluation 2 (SCORE2). Significant CAC was present in 29 % of the cohort. CAC prevalence increased from extreme morning to extreme evening type (22 %, 28 %, 29 %, 27 %, 41 % respectively, p = 0.018). In a multivariate logistic regression model controlling for confounders, extreme evening chronotype was independently associated with increased CAC prevalence compared to extreme morning type (OR 1.90, [95%CI 1.04-3.46], p = 0.037). When stratified by SCORE2 risk category (low: <5 %; moderate: 5 to <10 %; high: >= 10 %), significant CAC was most prevalent among extreme evening chronotypes in the low and moderate-risk groups, while chronotype seemed less important in the high-risk group (p = 0.011, p = 0.023, p = 0.86, respectively). Our findings suggest circadian factors may play an important role in atherosclerosis and should be considered in early cardiovascular prevention.

Image noise and vascular attenuation are important factors affecting image quality and diagnostic accuracy of coronary computed tomography angiography (CCTA). The aim of this study was to develop an algorithm that automatically performs noise and attenuation measurements in CCTA and to evaluate the ability of the algorithm to identify non-diagnostic examinations. The algorithm, “NoiseNet”, was trained and tested on 244 CCTA studies from the Swedish CArdioPulmonary BioImage Study. The model is a 3D U-Net that automatically segments the aortic root and measures attenuation (Hounsfield Units, HU), noise (standard deviation of HU, HUsd) and signal-to-noise ratio (SNR, HU/HUsd) in the aortic lumen, close to the left coronary ostium. NoiseNet was then applied to 529 CCTA studies previously categorized into three subgroups: fully diagnostic, diagnostic with excluded parts and non-diagnostic. There was excellent correlation between NoiseNet and manual measurements of noise (r = 0.948; p < 0.001) and SNR (r = 0.948; <0.001). There was a significant difference in noise levels between the image quality subgroups: fully diagnostic 33.1 (29.8–37.9); diagnostic with excluded parts 36.1 (31.5–40.3) and non-diagnostic 42.1 (35.2–47.7; p < 0.001). Corresponding values for SNR were 16.1 (14.0–18.0); 14.0 (12.4–16.2) and 11.1 (9.6–14.0; p < 0.001). ROC analysis for prediction of a non-diagnostic study showed an AUC for noise of 0.73 (CI 0.64–0.83) and for SNR of 0.80 (CI 0.71–0.89). In conclusion, NoiseNet can perform noise and SNR measurements with high accuracy. Noise and SNR impact image quality and automatic measurements may be used to identify CCTA studies with low image quality.

BACKGROUND:Patients with bacteraemia caused by gram-positive bacteria are at risk for infective endocarditis (IE). Because IE needs long antibiotic treatment and sometimes heart valve surgery, it is very important to identify patients with IE.OBJECTIVES:In this narrative review we present and discuss how to determine which investigations to detect IE that are needed in individual patients with gram-positive bacteraemia.SOURCES:Published original studies and previous reviews in English, within the relevant field are used.CONTENT:First, the different qualities of the bacteraemia in relation to IE risk are discussed. The risk for IE in bacteraemia is related to the species of the bacterium but also to monomicrobial bacteraemia and the number of positive cultures. Second, patient-related factors for IE risk in bacteraemia are presented. Next, the risk stratification systems to determine the risk for IE in gram-positive bacteraemia caused by Staphylococcus aureus, viridans streptococci, and Enterococcus faecalis are presented and their use is discussed. In the last part of the review, an account for the different modalities of IE-investigations is given. The main focus is on echocardiography, which is the cornerstone of IE-investigations. Furthermore, 18F-fluorodesoxyglucose positron emission tomography/computed tomography and cardiac computed tomography are presented and their use is also discussed. A brief account for investigations used to identify embolic phenomena in IE is also given. Finally, we present a flowchart suggesting which investigations to perform in relation to IE in patients with gram-positive bacteraemia.IMPLICATIONS:For the individual patient as well as the healthcare system, it is important both to diagnose IE and to decide when to stop looking for IE. This review might be helpful in finding that balance.