Cost-effectiveness of a novel AI technology to quantify coronary inflammation and cardiovascular risk in patients undergoing routine Coronary Computed Tomography Angiography.

AIMS: Coronary Computed Tomography Angiography (CCTA) is a first line investigation for chest pain in patients with suspected obstructive coronary artery disease (CAD). However, many acute cardiac events occur in the absence of obstructive CAD. We assessed the lifetime cost-effectiveness of integrating a novel artificial intelligence-enhanced image analysis algorithm (AI-Risk) that stratifies the risk of cardiac events by quantifying coronary inflammation, combined with the extent of coronary artery plaque and clinical risk factors, by analysing images from routine CCTA. METHODS AND RESULTS: A hybrid decision-tree with population cohort Markov model was developed from 3,393 consecutive patients who underwent routine CCTA for suspected obstructive CAD and followed up for major adverse cardiac events over a median(IQR) of 7.7(6.4-9.1) years. In a prospective real-world evaluation survey of 744 consecutive patients undergoing CCTA for chest pain investigation, the availability of AI-Risk assessment led to treatment initiation or intensification in 45% of patients. In a further prospective study of 1,214 consecutive patients with extensive guideline recommended cardiovascular risk profiling, AI-Risk stratification led to treatment initiation or intensification in 39% of patients beyond the current clinical guideline recommendations. Treatment guided by AI-Risk modelled over a lifetime horizon could lead to fewer cardiac events (relative reductions of 4%, 4%, 11%, and 12% for myocardial infarction, ischaemic stroke, heart failure and cardiac death, respectively). Implementing AI-Risk classification in routine interpretation of CCTA is highly likely to be cost-effective (Incremental cost-effectiveness ratio £1,371-3,244), both in scenarios of current guideline compliance or when applied only to patients without obstructive CAD. CONCLUSIONS: Compared with standard care, the addition of AI-Risk assessment in routine CCTA interpretation is cost effective, by refining risk guided medical management.

A new business paradigm to make coronary CT angiography (CCTA) accessible to all.

Recently, the Centers for Medicare and Medicaid proposed a classification change that, if enacted, could double reimbursement for coronary CT angiography (CCTA) in the U.S. [1]. With this comes the potential to realistically build an economically viable and sustainable model to deliver cardiac CT outside of major urban (hospital and private practice) and academic centers. The value of CCTA in reducing cardiovascular morbidity and mortality has been demonstrated in large, randomized control trials and real-world studies, but access to CCTA in rural, socially deprived, and low-resource settings (including poorer urban areas with a lack of specialist equipment and specialty-based services) remains a significant challenge. This paper discusses the end-to-end business aspects required to deliver a sustainable cardiac CT service in these areas, exploring technologist-delivered services, with remote support from physicians, and the potential to leverage developing artificial intelligence (AI) decision aid tools and mobile scanners.

Cardiac CT in the context of value-based care.

Cardiac computed tomography (CCT) is often used synonymously with coronary CT angiography (CCTA) and coronary artery calcium scoring (CACS), but also encompasses the use of CT for the assessment of structural, valvular, and congenital heart disease, and other cardiovascular pathology. This paper looks at the role of cardiac CT in the context of value-based care and predominantly focuses on the role of cardiac CT in the assessment of coronary artery disease (CAD), as this is where most of the clinical use and evidence of value can be found. Critical questions as to the defining of quality health care using cardiac CT are highllighted and the wider use of CT for the assessment of non-coronary disease is commented on towards the end of the manuscript but does not yet have the same level of health economic and value-based evidence.

The journal of cardiovascular computed tomography: A year in review: 2022.

This review aims to summarize key articles published in the Journal of Cardiovascular Computed Tomography (JCCT) in 2022, focusing on those that had the most scientific and educational impact. The JCCT continues to expand; the number of submissions, published manuscripts, cited articles, article downloads, social media presence, and impact factor continues to grow. The articles selected by the Editorial Board of the JCCT in this review highlight the role of cardiovascular computed tomography (CCT) to detect subclinical atherosclerosis, assess the functional relevance of stenoses, and plan invasive coronary and valve procedures. A section is dedicated to CCT in infants and other patients with congenital heart disease, in women, and to the importance of training in CT. In addition, we highlight key consensus documents and guidelines published in JCCT last year. The Journal values the tremendous work by authors, reviewers, and editors to accomplish these contributions.

Challenges and opportunities in improving left ventricular remodelling and clinical outcome following surgical and trans-catheter aortic valve replacement.

Over the last half century, surgical aortic valve replacement (SAVR) has evolved to offer a durable and efficient valve haemodynamically, with low procedural complications that allows favourable remodelling of left ventricular (LV) structure and function. The latter has become more challenging among elderly patients, particularly following trans-catheter aortic valve implantation (TAVI). Precise understanding of myocardial adaptation to pressure and volume overloading and its responses to valve surgery requires comprehensive assessments from aortic valve energy loss, valvular-vascular impedance to myocardial activation, force-velocity relationship, and myocardial strain. LV hypertrophy and myocardial fibrosis remains as the structural and morphological focus in this endeavour. Early intervention in asymptomatic aortic stenosis or regurgitation along with individualised management of hypertension and atrial fibrillation is likely to improve patient outcome. Physiological pacing via the His-Purkinje system for conduction abnormalities, further reduction in para-valvular aortic regurgitation along with therapy of angiotensin receptor blockade will improve patient outcome by facilitating hypertrophy regression, LV coordinate contraction, and global vascular function. TAVI leaflet thromboses require anticoagulation while impaired access to coronary ostia risks future TAVI-in-TAVI or coronary interventions. Until comparable long-term durability and the resolution of TAVI related complications become available, SAVR remains the first choice for lower risk younger patients.

Controversies in Diagnostic Imaging of Patients With Suspected Stable and Acute Chest Pain Syndromes.

There has been a tremendous growth quantity of high-quality imaging evidence in the area of acute and stable ischemic heart disease (SIHD). A number of recent comparative effectiveness trials have spurned significant controversies in the field of cardiovascular imaging. The result of this evidence is that many health care policies and national guidelines have undergone significant revisions. With all of this evidence, many challenges remain and the optimal evaluation strategy for evaluation of patients presenting with chest pain remains ill-defined. This paper enlisted the guidance of numerous experts in the field of cardiovascular imaging to garner their perspective on available imaging research in chest pain syndromes. Each of these vignettes represent editorial perspectives and diverse opinions as to which, if any, should be the primary test in the evaluation of stable chest pain. These perspectives are not meant to be all inclusive but to highlight many of the commonly discussed controversies in the evaluation of chest pain symptoms. These perspectives are presented as a pre-amble to an upcoming American College of Cardiology/American Heart Association clinical practice guideline that is undergoing revision from the previous report published in 2012. The evidence has changed considerably since the 2012 SIHD guideline, and the current perspectives represent the diversity of available evidence as to the optimal imaging strategy for evaluation of the symptomatic patient.