Rationale and Design of SCOT-HEART 2 Trial: CT Angiography for the Prevention of Myocardial Infarction.

Coronary artery disease continues to be the leading cause of death globally. Identifying patients who are at risk of coronary artery disease remains a public health priority. At present, the focus of cardiovascular disease prevention relies heavily on probabilistic risk scoring despite no randomized controlled trials demonstrating their efficacy. The concept of using imaging to guide preventative therapy is not new, but has previously focused on indirect measures such as carotid intima-media thickening or coronary artery calcification. In recent trials, patients found to have coronary artery disease on computed tomography (CT) coronary angiography were more likely to be started on preventative therapy and had lower rates of cardiac events. This led to the design of the SCOT-HEART 2 (Scottish Computed Tomography of the Heart 2) trial, which aims to determine whether screening with the use of CT coronary angiography is more clinically effective than cardiovascular risk scoring to guide the use of primary preventative therapies and reduce the risk of myocardial infarction.

Radiologist opinions regarding reporting incidental coronary and cardiac calcification on thoracic CT.

Objectives: Coronary and cardiac calcification are frequent incidental findings on non-gated thoracic computed tomography (CT). However, radiologist opinions and practices regarding the reporting of incidental calcification are poorly understood. Methods: UK radiologists were invited to complete this online survey, organised by the British Society of Cardiovascular Imaging (BSCI). Questions included anonymous information on subspecialty, level of training and reporting practices for incidental coronary artery, aortic valve, mitral and thoracic aorta calcification. Results: The survey was completed by 200 respondents: 10% trainees and 90% consultants. Calcification was not reported by 11% for the coronary arteries, 22% for the aortic valve, 35% for the mitral valve and 37% for the thoracic aorta. Those who did not subspecialise in cardiac imaging were less likely to report coronary artery calcification (p = 0.005), aortic valve calcification (p = 0.001) or mitral valve calcification (p = 0.008), but there was no difference in the reporting of thoracic aorta calcification. Those who did not subspecialise in cardiac imaging were also less likely to provide management recommendations for coronary artery calcification (p < 0.001) or recommend echocardiography for aortic valve calcification (p < 0.001), but there was no difference for mitral valve or thoracic aorta recommendations. Conclusion: Incidental coronary artery, valvular and aorta calcification are frequently not reported on thoracic CT and there are differences in reporting practices based on subspeciality. Advances in knowledge: On routine thoracic CT, 11% of radiologists do not report coronary artery calcification. Radiologist reporting practices vary depending on subspeciality but not level of training.

United Kingdom standards for non-invasive cardiac imaging: recommendations from the Imaging Council of the British Cardiovascular Society.

Heart and circulatory diseases affect more than seven million people in the UK. Non-invasive cardiac imaging is a critical element of contemporary cardiology practice. Progressive improvements in technology over the last 20 years have increased diagnostic accuracy in all modalities and led to the incorporation of non-invasive imaging into many standard cardiac clinical care pathways. Cardiac imaging tests are requested by a variety of healthcare practitioners and performed in a range of settings from the most advanced hospitals to local health centres. Imaging is used to detect the presence and consequences of cardiovascular disease, as well as to monitor the response to therapies. The previous UK national imaging strategy statement which brought together all of the non-invasive imaging modalities was published in 2010. The purpose of this document is to collate contemporary standards developed by the modality-specific professional organisations which make up the British Cardiovascular Society Imaging Council, bringing together common and essential recommendations. The development process has been inclusive and iterative. Imaging societies (representing both cardiology and radiology) reviewed and agreed on the initial structure. The final document therefore represents a position, which has been generated inclusively, presents rigorous standards, is applicable to clinical practice and deliverable. This document will be of value to a variety of healthcare professionals including imaging departments, the National Health Service or other organisations, regulatory bodies, commissioners and other purchasers of services, and service users, i.e., patients, and their relatives.

Reporting incidental coronary, aortic valve and cardiac calcification on non-gated thoracic computed tomography, a consensus statement from the BSCI/BSCCT and BSTI.

Incidental coronary and cardiac calcification are frequent findings on non-gated thoracic CT. We recommend that the heart is reviewed on all CT scans where it is visualised. Coronary artery calcification is a marker of coronary artery disease and it is associated with an adverse prognosis on dedicated cardiac imaging and on non-gated thoracic CT performed for non-cardiac indications, both with and without contrast. We recommend that coronary artery calcification is reported on all non-gated thoracic CT using a simple patient-based score (none, mild, moderate, severe). Furthermore, we recommend that reports include recommendations for subsequent management, namely the assessment of modifiable cardiovascular risk factors and, if the patient has chest pain, assessment as per standard guidelines. In most cases, this will not necessitate additional investigations. Incidental aortic valve calcification may also be identified on non-gated thoracic CT and should be reported, along with ancillary findings such as aortic root dilation. Calcification may occur in other parts of the heart including mitral valve/annulus, pericardium and myocardium, but in many cases these are an incidental finding without clinical significance.

Research priorities in cardiovascular imaging.

AIM: A modified Delphi approach was used to develop consensus opinion among British Society for Cardiac Imaging/British Society of Cardiac CT (BSCI/BSCCT) members in order to prioritise research questions in cardiovascular imaging. METHODS: All members of the BSCI/BSCCT were invited to submit research questions that they considered to be of the highest clinical and/or academic priority in the field of cardiovascular imaging (phase 1). Subsequently a steering committee removed duplicate questions and combined questions of a similar theme by consensus agreement where appropriate. BSCI/BSCCT members were invited to rank the resulting research questions in two further iterative rounds (phases 2 and 3) to determine a final list of high-priority research questions. RESULTS: A total of 111 research questions were submitted in phase 1 by 30 BSCI/BSCCT members. While there was a broad range of topics, from determining the optimal features/markers of the vulnerable plaque to investigating how cardiac imaging can best be used to maximise clinical outcomes and economic costs, multimodality imaging-related (n=44, 40%) questions dominated the categories and coronary artery imaging (n=40, 36%) was the most common topic. Over two iterative rounds of prioritisation of these research questions, the original 111 were reduced to 75 questions in round 2, and 25 in round 3. From these 25 a final Top 10 list was distilled by consensus grouping. CONCLUSION: This study has identified and ranked the top research priorities in cardiovascular imaging, as identified by the BSCI/BSCCT membership. This is a first step towards identifying the cardiovascular imaging research priorities within the UK and may assist researchers and funding bodies alike in setting priorities.

A prospective national survey of coronary CT angiography radiation doses in the United Kingdom.

BACKGROUND: Little real-world radiation dose data exist for the majority of cardiovascular CT. Some data have been published for coronary CT angiography (coronary CTA) specifically, but they invariably arise from high-volume centres with access to the most recent technology. OBJECTIVE: The aim of this study was to document real-world radiation doses for coronary CTA in the United Kingdom, and to establish their relationship to clinical protocol selection, acquisition heart rate, and scanner technology. METHODS: A dose survey questionnaire was distributed to members of the British Society of Cardiovascular Imaging and other UK cardiac CT units. All participating centres collected data for consecutive coronary CTA cases over one month. The survey captured information about the exam conducted, patient demographics, pre-scan details such as beta-blocker administration, acquisition heart rate and scan technique, and post-scan dose indicators - series volumetric CT dose index (CTDIvol), series dose-length product (DLP), and exam DLP. RESULTS: Fifty centres provided data on a total of 1341 coronary CTA exams. Twenty-nine centres (58%) performed at least 20 coronary CTA scans in the collection period. The median BMI, acquisition heart rate and exam DLP were 28 kg/m2, 60 bpm and 209 mGycm respectively. The corresponding effective dose was estimated as 5.9 mSv using a conversion factor of 0.028 mSv/mGycm. There was no statistically significant difference in radiation dose between low and high-volume centres. Median exam DLP increased with the acquisition heart rate due to the selection of wider temporal windows. The highest exam DLPs were obtained on the older scanner technology. CONCLUSION: This study provides baseline data for benchmarking practice, optimizing radiation dose and improving service quality locally.

Recommendations for accurate CT diagnosis of suspected acute aortic syndrome (AAS)--on behalf of the British Society of Cardiovascular Imaging (BSCI)/British Society of Cardiovascular CT (BSCCT).

Accurate and timely assessment of suspected acute aortic syndrome is crucial in this life-threatening condition. Imaging with CT plays a central role in the diagnosis to allow expedited management. Diagnosis can be made using locally available expertise with optimized scanning parameters, making full use of recent advances in CT technology. Each imaging centre must optimize their protocols to allow accurate diagnosis, to optimize radiation dose and in particular to reduce the risk of false-positive diagnosis that may simulate disease. This document outlines the principles for the acquisition of motion-free imaging of the aorta in this context.

'New World' imaging for an 'Old World' disease: Use of cardiac magnetic resonance imaging and 3D transesophageal echocardiography in severe rheumatic mitral valve disease.

We report a case of severe rheumatic mixed mitral valve disease in a young adult male where a combination of imaging techniques was utilized. We demonstrate that cardiac magnetic resonance imaging may be used as an alternative imaging modality in patients not suitable for the more established techniques of transthoracic and transesophageal echocardiography. Additionally, the use of 3D-transesophageal imaging offered the cardiothoracic surgeon additional anatomical information at the time of mitral valve replacement.

Ostial left coronary stenosis following aortic root reconstruction with BioGlue.

Haemorrhage is a major concern during repair of acute aortic dissection. In such circumstances, glue is often used for tissue reconstruction and also to fortify vascular anastomoses. In this report, we describe a rare case of ostial left main coronary artery stenosis potentially related to previous use of BioGlue.