Measurement and Application of Incidentally Detected Coronary Calcium: JACC Review Topic of the Week.

Coronary artery calcium (CAC) scoring is a powerful tool for atherosclerotic cardiovascular disease risk stratification. The nongated, noncontrast chest computed tomography scan (NCCT) has emerged as a source of CAC characterization with tremendous potential due to the high volume of NCCT scans. Application of incidental CAC characterization from NCCT has raised questions around score accuracy, standardization of methodology including the possibility of deep learning to automate the process, and the risk stratification potential of an NCCT-derived score. In this review, the authors aim to summarize the role of NCCT-derived CAC in preventive cardiovascular health today as well as explore future avenues for eventual clinical applicability in specific patient populations and broader health systems.

Radiology: Cardiothoracic Imaging Highlights 2023.

Radiology: Cardiothoracic Imaging publishes novel research and technical developments in cardiac, thoracic, and vascular imaging. The journal published many innovative studies during 2023 and achieved an impact factor for the first time since its inaugural issue in 2019, with an impact factor of 7.0. The current review article, led by the Radiology: Cardiothoracic Imaging trainee editorial board, highlights the most impactful articles published in the journal between November 2022 and October 2023. The review encompasses various aspects of coronary CT, photon-counting detector CT, PET/MRI, cardiac MRI, congenital heart disease, vascular imaging, thoracic imaging, artificial intelligence, and health services research. Key highlights include the potential for photon-counting detector CT to reduce contrast media volumes, utility of combined PET/MRI in the evaluation of cardiac sarcoidosis, the prognostic value of left atrial late gadolinium enhancement at MRI in predicting incident atrial fibrillation, the utility of an artificial intelligence tool to optimize detection of incidental pulmonary embolism, and standardization of medical terminology for cardiac CT. Ongoing research and future directions include evaluation of novel PET tracers for assessment of myocardial fibrosis, deployment of AI tools in clinical cardiovascular imaging workflows, and growing awareness of the need to improve environmental sustainability in imaging. Keywords: Coronary CT, Photon-counting Detector CT, PET/MRI, Cardiac MRI, Congenital Heart Disease, Vascular Imaging, Thoracic Imaging, Artificial Intelligence, Health Services Research © RSNA, 2024.

[Summary: International consensus statement on nomenclature and classification of the congenital bicuspid aortic valve and its aortopathy, for clinical, surgical, interventional and research purposes]. / Resumen: Consenso internacional para la nomenclatura y clasificación de la válvula aórtica bicúspide congénita y su aortopatía, con fines clínicos, quirúrgicos, intervencionistas y de investigación.

This consensus of nomenclature and classification for congenital bicuspid aortic valve and its aortopathy is evidence-based and intended for universal use by physicians (both pediatricians and adults), echocardiographers, advanced cardiovascular imaging specialists, interventional cardiologists, cardiovascular surgeons, pathologists, geneticists, and researchers spanning these areas of clinical and basic research. In addition, as long as new key and reference research is available, this international consensus may be subject to change based on evidence-based data1.

Este consenso de nomenclatura y clasificación para la válvula aórtica bicúspide congénita y su aortopatía está basado en la evidencia y destinado a ser utilizado universalmente por médicos (tanto pediatras como de adultos), médicos ecocardiografistas, especialistas en imágenes avanzadas cardiovasculares, cardiólogos intervencionistas, cirujanos cardiovasculares, patólogos, genetistas e investigadores que abarcan estas áreas de investigación clínica y básica. Siempre y cuando se disponga de nueva investigación clave y de referencia, este consenso internacional puede estar sujeto a cambios de acuerdo con datos basados en la evidencia1.

The current and future role of imaging of thoracic aortic disease: a North American society for cardiovascular imaging commentary on the 2022 AHA/ACC guidelines for the diagnosis and management of aortic disease.

The 2022 AHA/ACC Guidelines for the Diagnosis and Management of Aortic Disease introduced important updates for managing thoracic aorta aortic disease (TAD). In particular, the Guidelines underscore multimodality imaging's role in diagnosis, risk assessment, and monitoring of patients with TAD. This commentary aims to distill key imaging aspects from the Guidelines to provide a concise reference for the cardiovascular imaging community. Primary areas of focus include: (1) The importance of imagers in the multidisciplinary TAD care team, (2) Appropriate imaging techniques along with their strengths and weaknesses, (3) Aortic measurement methods and how aortic size and growth should contribute to TAD risk assessment, (4) Imaging evaluation of acute aortic syndrome. We have also highlighted several areas of ongoing uncertainty and confusion, specifically related to aortic measurement techniques and descriptive terminology. Finally, a perspective on the future of TAD imaging is discussed with a focus on advanced imaging tools and techniques as well as the potential role of artificial intelligence.

ACR Appropriateness Criteria® Congenital or Acquired Heart Disease.

Pediatric heart disease is a large and diverse field with an overall prevalence estimated at 6 to 13 per 1,000 live births. This document discusses appropriateness of advanced imaging for a broad range of variants. Diseases covered include tetralogy of Fallot, transposition of great arteries, congenital or acquired pediatric coronary artery abnormality, single ventricle, aortopathy, anomalous pulmonary venous return, aortopathy and aortic coarctation, with indications for advanced imaging spanning the entire natural history of the disease in children and adults, including initial diagnosis, treatment planning, treatment monitoring, and early detection of complications. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Accuracy of incidental visual coronary artery calcium assessment compared with dedicated coronary artery calcium scoring.

INTRODUCTION: CAC can be detected on routine chest computed tomography (CT) scans and may contribute to CVD risk estimation, but the accuracy of visual CAC scoring may be affected by the specialty of the interpreting radiologist and/or the use of contrast. METHODS: The accuracy of visual CAC estimation on non-gated CT scans was evaluated at UT Southwestern Medical Center (UTSW) and Parkland Health and Hospital System (PHHS). All adults who underwent CAC scanning and a non-gated CT scan within 6 months were identified and the scores from the two CTs were compared overall and stratified by type of reader and whether contrast was used. Visual CAC categories of none, small, moderate, and large were compared to CAC â€‹= â€‹0, 1-99, 100-399, and ≥400, respectively. RESULTS: From 2016 to 2021, 934 patients (mean age 60 â€‹± â€‹12 â€‹y, 43% male, 61% White, 34% Black, 24% Hispanic, 54% from PHHS) had both CT scans. Of these, 441 (47%) had no CAC, 278 (30%) small, 147 (16%) moderate, and 66 (7%) large CAC on non-gated CT. Visual CAC estimates were highly correlated with CAC scores (Kendalls tau-b â€‹= â€‹0.76, p â€‹< â€‹0.0001). Among those with no visual CAC, 76% had CAC â€‹= â€‹0 (72% of contrast-enhanced vs 85% of non-contrast scans, 88% of scans interpreted by CT radiologist vs 78% of those interpreted by other radiologist). In those with moderate-to-large visual CAC, 99% had CAC >0 and 88% had CAC ≥100, including 89% of those with contrast, 90% of those without contrast, 80% of those read by a CT radiologist, and 88% of those read by a non-CT radiologist. DISCUSSION: Visual CAC estimates on non-gated CT scans are concordant with Agatston score categories from cardiac CT scans. A lack of visual CAC on non-gated CT scans may not be sufficient to "de-risk" patients, particularly for contrast-enhanced scans and those read by non-CT radiologists. However, the presence of moderate-to-large CAC, including on contrasted scans and regardless of radiologist type, is highly predictive of CAC and may be used to identify high-risk patients for prevention interventions.

Deep Learning for Detection of Pneumothorax and Pleural Effusion on Chest Radiographs: Validation Against Computed Tomography, Impact on Resident Reading Time, and Interreader Concordance.

PURPOSE: To study the performance of artificial intelligence (AI) for detecting pleural pathology on chest radiographs (CXRs) using computed tomography as ground truth. PATIENTS AND METHODS: Retrospective study of subjects undergoing CXR in various clinical settings. Computed tomography obtained within 24 hours of the CXR was used to volumetrically quantify pleural effusions (PEfs) and pneumothoraxes (Ptxs). CXR was evaluated by AI software (INSIGHT CXR; Lunit) and by 3 second-year radiology residents, followed by AI-assisted reassessment after a 3-month washout period. We used the area under the receiver operating characteristics curve (AUROC) to assess AI versus residents' performance and mixed-model analyses to investigate differences in reading time and interreader concordance. RESULTS: There were 96 control subjects, 165 with PEf, and 101 with Ptx. AI-AUROC was noninferior to aggregate resident-AUROC for PEf (0.82 vs 0.86, P < 0.001) and Ptx (0.80 vs 0.84, P = 0.001) detection. AI-assisted resident-AUROC was higher but not significantly different from the baseline. AI-assisted reading time was reduced by 49% (157 vs 80 s per case, P = 0.009), and Fleiss kappa for Ptx detection increased from 0.70 to 0.78 (P = 0.003). AI decreased detection error for PEf (odds ratio = 0.74, P = 0.024) and Ptx (odds ratio = 0.39, P < 0.001). CONCLUSION: Current AI technology for the detection of PEf and Ptx on CXR was noninferior to second-year resident performance and could help decrease reading time and detection error.

Comparative Effectiveness of Coronary CT Angiography and Standard of Care for Evaluating Acute Chest Pain: A Living Systematic Review and Meta-Analysis.

Purpose: To perform a living systematic review and meta-analysis of randomized controlled trials comparing the effectiveness of coronary CT angiography (CCTA) and standard of care (SOC) in the evaluation of acute chest pain (ACP). Materials and Methods: Multiple electronic databases were systematically searched, with the most recent search conducted on October 31, 2022. Studies were stratified into two groups according to the pretest probability for acute coronary syndrome (group 1 with predominantly low-to-intermediate risk vs group 2 with high risk). A meta-regression analysis was also conducted using participant risk, type of SOC used, and the use or nonuse of high-sensitivity troponins as independent variables. Results: The final analysis included 22 randomized controlled trials (9379 total participants; 4956 assigned to CCTA arms and 4423 to SOC arms). There was a 14% reduction in the length of stay and a 17% reduction in immediate costs for the CCTA arm compared with the SOC arm. In group 1, the length of stay was 17% shorter and costs were 21% lower using CCTA. There was no evidence of differences in referrals to invasive coronary angiography, myocardial infarction, mortality, rate of hospitalization, further stress testing, or readmissions between CCTA and SOC arms. There were more revascularizations (relative risk, 1.45) and medication changes (relative risk, 1.33) in participants with low-to-intermediate acute coronary syndrome risk and increased radiation exposure in high-risk participants (mean difference, 7.24 mSv) in the CCTA arm compared with the SOC arm. The meta-regression analysis found significant differences between CCTA and SOC arms for rate of hospitalization, further stress testing, and medication changes depending on the type of SOC (P < .05). Conclusion: The results support the use of CCTA as a safe, rapid, and less expensive in the short term strategy to exclude acute coronary syndrome in low- to intermediate-risk patients presenting with acute chest pain.Keywords: Acute Coronary Syndrome, Chest Pain, Emergency Department, Coronary Computed Tomography, Usual Care Supplemental material is available for this article. Published under a CC BY 4.0 license.

Standardized Medical Terminology for Cardiac Computed Tomography 2023 Update: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), American Association of Physicists in Medicine (AAPM), American College of Radiology (ACR), North American Society for Cardiovascular Imaging (NASCI), and Radiological Society of North America (RSNA) with endorsement by the Asian Society of Cardiovascular Imaging (ASCI), the European Association of Cardiovascular Imaging (EACI), and the European Society of Cardiovascular Radiology (ESCR).

Since the emergence of cardiac computed tomography (Cardiac CT) at the turn of the 21st century, there has been an exponential growth in research and clinical development of the technique, with contributions from investigators and clinicians from varied backgrounds: physics and engineering, informatics, cardiology, and radiology. However, terminology for the field is not unified. As a consequence, there are multiple abbreviations for some terms, multiple terms for some concepts, and some concepts that lack clear definitions and/or usage. In an effort to aid the work of all those who seek to contribute to the literature, clinical practice, and investigation of the field, the Society of Cardiovascular Computed Tomography updates a standard set of medical terms commonly used in clinical and research activities related to cardiac CT. Keywords: Cardiac, CT, Medical Terminology Supplemental material is available for this article. This article is published synchronously in Radiology: Cardiothoracic Imaging and Journal of Cardiovascular Computed Tomography. ©2023 Society of Cardiovascular Computed Tomography. Published by RSNA with permission.

Detection of Low Blood Hemoglobin Levels on Pulmonary CT Angiography: A Feasibility Study Combining Dual-Energy CT and Machine Learning.

OBJECTIVES: To evaluate if dual-energy CT (DECT) pulmonary angiography (CTPA) can detect anemia with the aid of machine learning. METHODS: Inclusion of 100 patients (mean age ± SD, 51.3 ± 14.8 years; male-to-female ratio, 42/58) who underwent DECT CTPA and hemoglobin (Hb) analysis within 24 h, including 50 cases with Hb below and 50 controls with Hb ≥ 12 g/dL. Blood pool attenuation was assessed on virtual noncontrast (VNC) images at eight locations. A classification model using extreme gradient-boosted trees was developed on a training set (n = 76) for differentiating cases from controls. The best model was evaluated in a separate test set (n = 24). RESULTS: Blood pool attenuation was significantly lower in cases than controls (p-values < 0.01), except in the right atrium (p = 0.06). The machine learning model had sensitivity, specificity, and accuracy of 83%, 92%, and 88%, respectively. Measurements at the descending aorta had the highest relative importance among all features; a threshold of 43 HU yielded sensitivity, specificity, and accuracy of 68%, 76%, and 72%, respectively. CONCLUSION: VNC imaging and machine learning shows good diagnostic performance for detecting anemia on DECT CTPA.

Radiology: Cardiothoracic Imaging Highlights 2022.

Since its inaugural issue in 2019, Radiology: Cardiothoracic Imaging has disseminated the latest scientific advances and technical developments in cardiac, vascular, and thoracic imaging. In this review, we highlight select articles published in this journal between October 2021 and October 2022. The scope of the review encompasses various aspects of coronary artery and congenital heart diseases, vascular diseases, thoracic imaging, and health services research. Key highlights include changes in the revised Coronary Artery Disease Reporting and Data System 2.0, the value of coronary CT angiography in informing prognosis and guiding treatment decisions, cardiac MRI findings after COVID-19 vaccination or infection, high-risk features at CT angiography to identify patients with aortic dissection at risk for late adverse events, and CT-guided fiducial marker placement for preoperative planning for pulmonary nodules. Ongoing research and future directions include photon-counting CT and artificial intelligence applications in cardiovascular imaging. Keywords: Pediatrics, CT Angiography, CT-Perfusion, CT-Spectral Imaging, MR Angiography, PET/CT, Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR), Cardiac, Pulmonary, Vascular, Aorta, Coronary Arteries © RSNA, 2023.

Standardized medical terminology for cardiac computed tomography 2023 update: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), American Association of Physicists in Medicine (AAPM), American College of Radiology (ACR), North American Society for Cardiovascular Imaging (NASCI) and Radiological Society of North America (RSNA) with endorsement by the Asian Society of Cardiovascular Imaging (ASCI), the European Association of Cardiovascular Imaging (EACI), and the European Society of Cardiovascular Radiology (ESCR).

Since the emergence of cardiac computed tomography (Cardiac CT) at the turn of the 21st century, there has been an exponential growth in research and clinical development of the technique, with contributions from investigators and clinicians from varied backgrounds: physics and engineering, informatics, cardiology, and radiology. However, terminology for the field is not unified. As a consequence, there are multiple abbreviations for some terms, multiple terms for some concepts, and some concepts that lack clear definitions and/or usage. In an effort to aid the work of all those who seek to contribute to the literature, clinical practice, and investigation of the field, the Society of Cardiovascular Computed Tomography updates a standard set of medical terms commonly used in clinical and research activities related to cardiac CT.

ACR Appropriateness Criteria® Workup of Noncerebral Systemic Arterial Embolic Source.

Noncerebral systemic arterial embolism, which can originate from cardiac and noncardiac sources, is an important cause of patient morbidity and mortality. When an embolic source dislodges, the resulting embolus can occlude a variety of peripheral and visceral arteries causing ischemia. Characteristic locations for noncerebral arterial occlusion include the upper extremities, abdominal viscera, and lower extremities. Ischemia in these regions can progress to tissue infarction resulting in limb amputation, bowel resection, or nephrectomy. Determining the source of arterial embolism is essential in order to direct treatment decisions. This document reviews the appropriateness category of various imaging procedures available to determine the source of the arterial embolism. The variants included in this document are known arterial occlusion in the upper extremity, lower extremity, mesentery, kidneys, and multiorgan distribution that are suspected to be of embolic etiology. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

RadioGraphics Update: Pictorial Guide to CAD-RADS 2.0.

Editor's Note.-RadioGraphics Update articles supplement or update information found in full-length articles previously published in RadioGraphics. These updates, written by at least one author of the previous article, provide a brief synopsis that emphasizes important new information such as technological advances, revised imaging protocols, new clinical guidelines involving imaging, or updated classification schemes.

ACR Appropriateness Criteria® Suspected Pulmonary Embolism: 2022 Update.

Pulmonary embolism (PE) remains a common and important clinical condition that cannot be accurately diagnosed on the basis of signs, symptoms, and history alone. The diagnosis of PE has been facilitated by technical advancements and multidetector CT pulmonary angiography, which is the major diagnostic modality currently used. Ventilation and perfusion scans remain largely accurate and useful in certain settings. MR angiography can be useful in some clinical scenarios and lower-extremity ultrasound can substitute by demonstrating deep vein thrombosis; however, if negative, further studies to exclude PE are indicated. In all cases, correlation with the clinical status, particularly with risk factors, improves not only the accuracy of diagnostic imaging but also overall utilization. Other diagnostic tests have limited roles. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer-reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer-reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI).

Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care. Keywords: Coronary Artery Disease, Coronary CTA, CAD-RADS, Reporting and Data System, Stenosis Severity, Report Standardization Terminology, Plaque Burden, Ischemia Supplemental material is available for this article. This article is published synchronously in Radiology: Cardiothoracic Imaging, Journal of Cardiovascular Computed Tomography, JACC: Cardiovascular Imaging, Journal of the American College of Radiology, and International Journal for Cardiovascular Imaging. © 2022 Society of Cardiovascular Computed Tomography. Published by RSNA with permission.