Hidden Flaws Behind Expert-Level Accuracy of Multimodal GPT-4 Vision in Medicine.

Recent studies indicate that Generative Pre-trained Transformer 4 with Vision (GPT-4V) outperforms human physicians in medical challenge tasks. However, these evaluations primarily focused on the accuracy of multi-choice questions alone. Our study extends the current scope by conducting a comprehensive analysis of GPT-4V's rationales of image comprehension, recall of medical knowledge, and step-by-step multimodal reasoning when solving New England Journal of Medicine (NEJM) Image Challenges - an imaging quiz designed to test the knowledge and diagnostic capabilities of medical professionals. Evaluation results confirmed that GPT-4V performs comparatively to human physicians regarding multi-choice accuracy (81.6% vs. 77.8%). GPT-4V also performs well in cases where physicians incorrectly answer, with over 78% accuracy. However, we discovered that GPT-4V frequently presents flawed rationales in cases where it makes the correct final choices (35.5%), most prominent in image comprehension (27.2%). Regardless of GPT-4V's high accuracy in multi-choice questions, our findings emphasize the necessity for further in-depth evaluations of its rationales before integrating such multimodal AI models into clinical workflows.

Application of deep neural networks for inferring pressure in polymeric acoustic transponders/sensors.

Passive sensor-transponders have raised interest for the last few decades, due to their capability of low-cost remote monitoring without the need for energy storage. Their operating principle includes receiving a signal from a source and then reflecting the signal. While well-established transponders operate through electromagnetic antennas, those with a fully acoustic design have advantages such as lower cost and simplicity. Therefore, detection of pressures using the ultrasound signal that is backscattered from an acoustic resonator has been of interest recently. In order to infer the pressure from the backscattered signal, the established approach has been based upon the principle of detection of the shift to the frequency of resonance. Nevertheless, regression of the pressure from the signal with a small error is challenging and has been subject to research. Here in this paper, we explore an approach that employs deep learning for inferring pressure from the ultrasound reflections of polymeric resonators. We assess if neural network regressors can efficiently infer pressure reflected from a fully acoustic transponder. For this purpose, we compare the performance of several regressors such as a convolutional neural network, a network inspired by the ResNet, and a fully connected neural network. We observe that deep neural networks are advantageous in inferring pressure information with a minimal need for analyzing the signal. Our work suggests that a deep learning approach has the potential to be integrated with or replace other traditional approaches for inferring pressure from an ultrasound signal reflected from fully acoustic transponders or passive sensors.

Low-cost prototyping of nitinol wires/frames using polymeric cores and sacrificial fixtures with application in individualized frames anchoring through the atrial septum.

Self-expanding frames for minimally invasive implants are typically made from nitinol wires and are heat treated to maintain the desired shapes. In the process of heat treatment, nitinol structures are placed in a high-temperature oven, while they are confined by a fixture. During this process, nitinol exerts a high amount of force. Accordingly, a fixture requires high mechanical strength and temperature resistance; this is why fixtures are typically made from metals. The use of metal fixture also increases the turnaround time and cost. However, accelerating this process is beneficial in many applications, such as rapid development of medical implants that are patient-specific. Inspired by the use of sacrificial layers in microfabrication technology, here we propose a novel method for shape setting nitinol wires using a sacrificial metal fixture. In this process, the nitinol wires are first aligned inside copper hypotubes. Next, the forming process is done using hand-held tools to shape complex geometrical structures, annealing the nitinol reinforced by copper, and then selectively etching copper hypotubes in ammonium persulfate solutions. In this process, other sacrificial cores, which are 3D printed or cast from low-cost polymers, are also used. This combination of polymeric cores and minimal use of metals enables reducing the cost and the turnaround time. As a proof of concept, we showed that this process was capable of fabricating springs with mm or sub-mm diameters. The result showed a change of less than 5% in the intended diameter of the nitinol spring with diameters ranging from ~ 0.7 to 1.9 mm, which confirms copper as a suitable sacrificial fixture to obtain the desired complex geometry for nitinol. A metric, based on the elastic strain stored in copper is suggested to predict the possible variation of the intended dimensions in this process. Finally, to demonstrate the potential of this method, as proof of concept, we fabricated NiTi wire frames designed for anchoring through the atrial septum. These frames demonstrated septal defect occluders that were designed based on a patient's cardiac image available in the public domain. This low-cost rapid fabrication technique is highly beneficial for a variety of applications in engineering and medicine with specific applications in rapid prototyping of medical implants.

Machine Learning in Cardiovascular Risk Prediction and Precision Preventive Approaches.

PURPOSE OF REVIEW: In this review, we sought to provide an overview of ML and focus on the contemporary applications of ML in cardiovascular risk prediction and precision preventive approaches. We end the review by highlighting the limitations of ML while projecting on the potential of ML in assimilating these multifaceted aspects of CAD in order to improve patient-level outcomes and further population health. RECENT FINDINGS: Coronary artery disease (CAD) is estimated to affect 20.5 million adults across the USA, while also impacting a significant burden at the socio-economic level. While the knowledge of the mechanistic pathways that govern the onset and progression of clinical CAD has improved over the past decade, contemporary patient-level risk models lag in accuracy and utility. Recently, there has been renewed interest in combining advanced analytic techniques that utilize artificial intelligence (AI) with a big data approach in order to improve risk prediction within the realm of CAD. By virtue of being able to combine diverse amounts of multidimensional horizontal data, machine learning has been employed to build models for improved risk prediction and personalized patient care approaches. The use of ML-based algorithms has been used to leverage individualized patient-specific data and the associated metabolic/genomic profile to improve CAD risk assessment. While the tool can be visualized to shift the paradigm toward a patient-specific care, it is crucial to acknowledge and address several challenges inherent to ML and its integration into healthcare before it can be significantly incorporated in the daily clinical practice.

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.

Comparing the pooled cohort equations and coronary artery calcium scores in a symptomatic mixed Asian cohort.

Background: The value of pooled cohort equations (PCE) as a predictor of major adverse cardiovascular events (MACE) is poorly established among symptomatic patients. Coronary artery calcium (CAC) assessment further improves risk prediction, but non-Western studies are lacking. This study aims to compare PCE and CAC scores within a symptomatic mixed Asian cohort, and to evaluate the incremental value of CAC in predicting MACE, as well as in subgroups based on statin use. Methods: Consecutive patients with stable chest pain who underwent cardiac computed tomography were recruited. Logistic regression was performed to determine the association between risk factors and MACE. Cohort and statin-use subgroup comparisons were done for PCE against Agatston score in predicting MACE. Results: Of 501 patients included, mean (SD) age was 53.7 (10.8) years, mean follow-up period was 4.64 (0.66) years, 43.5% were female, 48.3% used statins, and 50.0% had no CAC. MI occurred in 8 subjects while 9 subjects underwent revascularization. In the general cohort, age, presence of CAC, and ln(Volume) (OR = 1.05, 7.95, and 1.44, respectively) as well as age and PCE score for the CAC = 0 subgroup (OR = 1.16 and 2.24, respectively), were significantly associated with MACE. None of the risk factors were significantly associated with MACE in the CAC > 0 subgroup. Overall, the PCE, Agatston, and their combination obtained an area under the receiver operating characteristic curve (AUC) of 0.501, 0.662, and 0.661, respectively. Separately, the AUC of PCE, Agatston, and their combination for statin non-users were 0.679, 0.753, and 0.734, while that for statin-users were 0.585, 0.615, and 0.631, respectively. Only the performance of PCE alone was statistically significant (p = 0.025) when compared between statin-users (0.507) and non-users (0.783). Conclusion: In a symptomatic mixed Asian cohort, age, presence of CAC, and ln(Volume) were independently associated with MACE for the overall subgroup, age and PCE score for the CAC = 0 subgroup, and no risk factor for the CAC > 0 subgroup. Whilst the PCE performance deteriorated in statin versus non-statin users, the Agatston score performed consistently in both groups.

Prolactin Inhibition in Peripartum Cardiomyopathy: Systematic Review and Meta-analysis.

Heart failure (HF) is one of the leading causes of maternal mortality and morbidity in the United States. Peripartum cardiomyopathy (PPCM) constitutes up to 70% of all HF in pregnancy. Cardiac angiogenic imbalance caused by cleaved 16kDa prolactin has been hypothesized to contribute to the development of PPCM, fueling investigation of prolactin inhibitors for the management of PPCM. We conducted a systematic review and meta-analysis to assess the impact of prolactin inhibition on left ventricular (LV) function and mortality in patients with PPCM. We included English language articles from PubMed and EMBASE published upto March 2022. We pooled the mean difference (MD) for left ventricular ejection fraction (LVEF) at follow-up, odds ratio (OR) for LV recovery and risk ratio (RR) for all-cause mortality using random-effects meta-analysis. Among 548 studies screened, 10 studies (3 randomized control trials (RCTs), 2 retrospective and 5 prospective cohorts) were included in the systematic review. Patients in the Bromocriptine + standard guideline directed medical therapy (GDMT) group had higher LVEF% (pMD 12.56 (95% CI 5.84-19.28, I2=0%) from two cohorts and pMD 14.25 (95% CI 0.61-27.89, I2=88%) from two RCTs) at follow-up compared to standard GDMT alone group. Bromocriptine group also had higher odds of LV recovery (pOR 3.55 (95% CI 1.39-9.1, I2=62)). We did not find any difference in all-cause mortality between the groups. Our analysis demonstrates that the addition of Bromocriptine to standard GDMT was associated with a significant improvement in LVEF% and greater odds of LV recovery, without significant reduction in all-cause mortality.

Cardiac magnetic resonance for prophylactic implantable-cardioverter defibrillator therapy international study: prognostic value of cardiac magnetic resonance-derived right ventricular parameters substudy.

AIMS: Right ventricular systolic dysfunction (RVSD) is an important determinant of outcomes in heart failure (HF) cohorts. While the quantitative assessment of RV function is challenging using 2D-echocardiography, cardiac magnetic resonance (CMR) is the gold standard with its high spatial resolution and precise anatomical definition. We sought to investigate the prognostic value of CMR-derived RV systolic function in a large cohort of HF with reduced ejection fraction (HFrEF). METHODS AND RESULTS: Study cohort comprised of patients enrolled in the CarDiac MagnEtic Resonance for Primary Prevention Implantable CardioVerter DefibrillAtor ThErapy registry who had HFrEF and had simultaneous baseline CMR and echocardiography (n = 2449). RVSD was defined as RV ejection fraction (RVEF) <45%. Kaplan-Meier curves and cox regression were used to investigate the association between RVSD and all-cause mortality (ACM). Mean age was 59.8 ± 14.0 years, 42.0% were female, and mean left ventricular ejection fraction (LVEF) was 34.0 ± 10.8. Median follow-up was 959 days (interquartile range: 560-1590). RVSD was present in 936 (38.2%) and was an independent predictor of ACM (adjusted hazard ratio = 1.44; 95% CI [1.09-1.91]; P = 0.01). On subgroup analyses, the prognostic value of RVSD was more pronounced in NYHA I/II than in NYHA III/IV, in LVEF <35% than in LVEF ≥35%, and in patients with renal dysfunction when compared to those with normal renal function. CONCLUSION: RV systolic dysfunction is an independent predictor of ACM in HFrEF, with a more pronounced prognostic value in select subgroups, likely reflecting the importance of RVSD in the early stages of HF progression.

Gender Differences and Outcomes of Hypoattenuated Leaflet Thickening (HALT) Following Transcatheter Aortic Valve Replacement: A Meta-analysis of Randomized and Cohort Studies.

Subclinical leaflet thrombosis is characterized by hypoattenuated leaflet thickening (HALT) after transcatheter aortic valve replacement (TAVR) on computed tomography. However, given the low incidence of HALT after TAVR, the clinical significance of HALT is still being investigated. We sought to generate a more reliable estimate of the risk factors and adverse outcomes associated with HALT after TAVR by pooling data from randomized trials and cohort studies. PubMed/Medline database was systematically searched from inception until November 24, 2021, using the following terms: ("hypoattenuated leaflet thickening" and "transcatheter aortic valve replacement") and ("Subclinical leaflet thrombosis" and "transcatheter aortic valve replacement"). A random effects model meta-analysis was conducted using Mantel-Haenszel odds ratios (ORs) and the associated 95% confidence intervals (CIs), mean difference and the associated 95%. Ten studies with a total of 1462 patients were included, with follow-up ranging between 4 months and 3 years. HALT occurred in 14.4% of the patients undergoing TAVR. HALT was not associated with increased risk of stroke/TIA (OR 1.38; 95% CI [0.61-3.11]; I2=0%) or increased risk of all-cause mortality (OR 0.67; 95% CI [0.25-1.80]; I2=0). HALT was associated with a greater post-procedural mean aortic valve gradient (mean difference 2.31 mmHg; 95% CI [0.27, 4.35]; I2=71%). Interestingly, there was a trend of higher risk of HALT in men (OR 1.37; 95% CI [0.82-2.30]; I2=44%) while there was a trend towards lower risk of HALT in the presence of CKD (OR 0.76; 95% CI [0.49-1.19]; I2=0%); these trends did not reach statistical significance. This meta-analysis shows that the occurrence of HALT following TAVR is associated with a greater post-procedural mean aortic valve gradient but no excess risk of death or cerebrovascular events. The clinical significance of this higher post-procedural mean aortic valve gradient is uncertain and requires further investigations.

Artificial Intelligence, Wearables and Remote Monitoring for Heart Failure: Current and Future Applications.

Substantial milestones have been attained in the field of heart failure (HF) diagnostics and therapeutics in the past several years that have translated into decreased mortality but a paradoxical increase in HF-related hospitalizations. With increasing data digitalization and access, remote monitoring via wearables and implantables have the potential to transform ambulatory care workflow, with a particular focus on reducing HF hospitalizations. Additionally, artificial intelligence and machine learning (AI/ML) have been increasingly employed at multiple stages of healthcare due to their power in assimilating and integrating multidimensional multimodal data and the creation of accurate prediction models. With the ever-increasing troves of data, the implementation of AI/ML algorithms could help improve workflow and outcomes of HF patients, especially time series data collected via remote monitoring. In this review, we sought to describe the basics of AI/ML algorithms with a focus on time series forecasting and the current state of AI/ML within the context of wearable technology in HF, followed by a discussion of the present limitations, including data integration, privacy, and challenges specific to AI/ML application within healthcare.

Influence of Iron Deficiency on Clinical and Haemodynamic Parameters in Pulmonary Arterial Hypertension Cohorts.

BACKGROUND: Iron deficiency (Fedef) has been shown to be common in patients with group 1 or pulmonary arterial hypertension (PAH). Several studies have shown a negative impact of Fedef on clinical and haemodynamic parameters of the disease, but data from individual studies have not been strong enough to lead to incorporation of the finding of Fedef into prognostic or therapeutic algorithms. The goal of this meta-analysis was to combine data from available studies to better define any associations between Fedef and established variables of prognostic importance in PAH. METHODS: A literature search identified nine studies with extractable data relevant to the study questions. The impact of Fedef upon the following parameters was evaluated: 6-minute walk distance (6MWD), WHO-functional class, N-terminal pro-brain natriuretic peptide (NT-proBNP) levels, echocardiography, and findings from right heart catheterisation (RHC). Pooled results were reported as mean difference or risk difference with 95% confidence intervals utilising a random effects modeling approach. RESULTS: Fedef in the PAH population was common (47% of cases) and was associated with cardiovascular dysfunction (lower tricuspid annular plane systolic excursion [TAPSE], elevated NT-proBNP, and lower mixed venous oxygen saturation) and with reduction in functional capacity (lower 6MWD and higher functional class). CONCLUSION: This meta-analysis strengthens the relationships between Fedef and several markers of poor outcome in PAH. Fedef in patients with PAH warrants further scrutiny and merits consideration as a cause of clinical deterioration. Even though causation and longitudinal relationships between Fedef and PAH could not be identified, effect of Fedef on factors that affect disease prognosis is noteworthy and worthy of more focussed studies.

Contemporary Applications of Machine Learning for Device Therapy in Heart Failure.

Despite a better understanding of the underlying pathogenesis of heart failure (HF), pharmacotherapy, surgical, and percutaneous interventions do not prevent disease progression in all patients, and a significant proportion of patients end up requiring advanced therapies. Machine learning (ML) is gaining wider acceptance in cardiovascular medicine because of its ability to incorporate large, complex, and multidimensional data and to potentially facilitate the creation of predictive models not constrained by many of the limitations of traditional statistical approaches. With the coexistence of "big data" and novel advanced analytic techniques using ML, there is ever-increasing research into applying ML in the context of HF with the goal of improving patient outcomes. Through this review, the authors describe the basics of ML and summarize the existing published reports regarding contemporary applications of ML in device therapy for HF while highlighting the limitations to widespread implementation and its future promises.

Early versus late acute coronary syndrome risk patterns of coronary atherosclerotic plaque.

AIMS: The temporal instability of coronary atherosclerotic plaque preceding an incident acute coronary syndrome (ACS) is not well defined. We sought to examine differences in the volume and composition of coronary atherosclerosis between patients experiencing an early (≤90 days) versus late ACS (>90 days) after baseline coronary computed tomography angiography (CCTA). METHODS AND RESULTS: From a multicenter study, we enrolled patients who underwent a clinically indicated baseline CCTA and experienced ACS during follow-up. Separate core laboratories performed blinded adjudication of ACS events and quantification of CCTA including compositional plaque volumes by Hounsfield units (HU): calcified plaque >350 HU, fibrous plaque 131-350 HU, fibrofatty plaque 31-130 HU and necrotic core <30 HU. In 234 patients (mean age 62 ± 12 years, 36% women), early and late ACS occurred in 129 and 105 patients after a mean of 395 ± 622 days, respectively. Patients with early ACS had a greater maximal diameter stenosis and maximal cross-sectional plaque burden as compared to patients with late ACS (P < 0.05). Larger total, fibrous, fibrofatty, and necrotic core volumes were observed in the early ACS group (P < 0.05). Findings for total, fibrous, fibrofatty, and necrotic core volumes were reproduced in an external validation cohort (P < 0.05). CONCLUSIONS: Volumetric differences in composition of coronary atherosclerosis exist between ACS patients according to their timing antecedent to the acute event. These data support that a large burden of non-calcified plaque on CCTA is strongly associated with near-term plaque instability and ACS risk.

HDL cholesterol levels and susceptibility to COVID-19.

BACKGROUND: Host cell-membrane cholesterol, an important player in viral infections, is in constant interaction with serum high-density lipoprotein-cholesterol (HDL-C) and low-density lipoprotein-cholesterol (LDL-C). Low serum lipid levels during hospital admission are associated with COVID-19 severity. However, the effect of antecedent serum lipid levels on SARS-CoV-2 infection risk has not been explored. METHODS: From our retrospective cohort from the Arkansas Clinical Data-Repository, we used log-binomial regression to assess the risk of SARS-CoV-2 infection among the trajectories of lipid levels during the 2 years antecedent to COVID-19 testing, identified using group-based-trajectory modelling. We used mixed-effects linear regression to assess the serum lipid level trends followed up to the time of, and 2-months following COVID-19 testing. FINDINGS: Among the 11001 individuals with a median age of 59 years (IQR 46-70), 1340 (12.2%) tested positive for COVID-19. The highest trajectory for antecedent serum HDL-C was associated with the lowest SARS-CoV-2 infection risk (RR 0.63, 95%CI 0.46-0.86). Antecedent serum LDL-C, total cholesterol (TC), and triglycerides (TG) were not independently associated with SARS-CoV-2 infection risk. In COVID-19 patients, serum HDL-C (-7.7, 95%CI -9.8 to -5.5 mg/dL), and LDL-C (-6.29, 95%CI -12.2 to -0.37 mg/dL), but not TG levels, decreased transiently at the time of testing. INTERPRETATION: Higher antecedent serum HDL-C, but not LDL-C, TC, or TG, levels were associated with a lower SARS-CoV-2 infection risk. Serum HDL-C, and LDL-C levels declined transiently at the time of infection. Further studies are needed to determine the potential role of lipid-modulating therapies in the prevention and management of COVID-19. FUNDING: Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health under Award Number UL1 TR003107.

Age related compositional plaque burden by CT in patients with future ACS.

BACKGROUND: We examined age differences in whole-heart volumes of non-calcified and calcified atherosclerosis by coronary computed tomography angiography (CCTA) of patients with future ACS. METHODS: A total of 234 patients with core-lab adjudicated ACS after baseline CCTA were enrolled. Atherosclerotic plaque was quantified and characterized from the main epicardial vessels and side branches on a 0.5 â€‹mm cross-sectional basis. Calcified plaque and non-calcified plaque were defined by above or below 350 Hounsfield units. Patients were categorized according to their age by deciles. Also, coronary artery calcium scores (CACS) were evaluated when available. RESULTS: Patients were on average 62.2 â€‹± â€‹11.5 years old. On the pre-ACS CCTA, patients showed diffuse, multi-site, predominantly non-obstructive atherosclerosis across all age categories, with plaque being detected in 93.5% of all ACS cases. The proportion calcified plaque from the total plaque burden increased significantly with older presentation (10% calcification in those <50 years, and 50% calcification in those >80 years old). Patients with ACS <50 years had remarkably lower atherosclerotic burden compared with older patients, but a high proportion of high risk markers such as low-attenuation plaque. CACS was >0 in 85% of the patients older than 50 years, and in 57% of patients younger than 50 years. CONCLUSION: The proportion of calcified plaque varied depending on patient age at the time of ACS. Only a small proportion of plaque was calcified when ACS occurred at <50 years old, while this increased gradually with older age. Purely non-calcified atherosclerotic plaque was not uncommon in patients <50 years.

Significance of indeterminate and abnormal stress electrocardiography despite normal imaging in patients with suspected coronary artery disease - An analysis of the PROMISE trial.

BACKGROUND: Abnormal and indeterminate electrocardiographic (ECG) changes during cardiac stress imaging are not uncommon. While the prognostic importance of abnormal ECG despite normal imaging has been previously studied, prognosis of indeterminate stress ECG changes is uncertain. METHODS: We studied the prognostic value of stress ECG changes in symptomatic patients without known CAD and normal stress imaging from the PROMISE trial. Patients with normal ECG (concordant), indeterminate ECG and abnormal ECG (discordant) were identified among those with negative exercise imaging stress test (EIST) and negative vasodilator nuclear stress test (PIST). Outcomes of interest were major adverse cardiovascular endpoint (MACE, including all-cause mortality, myocardial infarction, and unstable angina hospitalization) and likelihood of coronary revascularization. RESULTS: In EIST, indeterminate stress ECG [1.1% vs. 0.2% adjusted hazard ratio (aHR) 4.2, (95% CI 1.11-15.6), p = 0.034] and discordant ECG [7.2% vs. 0.2% adjusted hazard ratio (aHR) 27.6, (95% CI 9.6-79.8), p < 0.0001] were associated with increased likelihood of revascularization compared to normal stress ECG. Similar findings were observed with PIST [indeterminate vs concordant [1.7% vs. 0.5% adjusted hazard ratio (aHR) 5.9, (95% CI 1.1-31.7), p = 0.041; discordant vs concordant 15.4% vs. 0.5% adjusted hazard ratio (aHR) 24.2, (95% CI 4.6-127.7), p = 0.0002]. MACE rates were similar between ECG subgroups, in both EIST and PIST. CONCLUSION: In symptomatic patients without known CAD undergoing stress imaging, indeterminate and discordant ECG changes results may indicate presence of obstructive CAD despite normal imaging results and predict increased likelihood of coronary revascularization despite no significant difference in MACE.

The Journal of cardiovascular computed tomography: A year in review 2021.

This review aims to summarize original articles published in the Journal of Cardiovascular Computed Tomography (JCCT) for the year 2021, 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 increase. The articles selected by the Editorial Board of the JCCT in this review focus on coronary artery disease, coronary physiology, structural heart disease, and technical advances in cardiovascular CT. In addition, we highlight key consensus documents and guidelines published in the Journal in 2021. The Journal recognizes the tremendous work done by each author and reviewer this year - thank you.