Lukas Damian Weberling

Background: High-sensitivity troponin assays detect myocardial injury early, but only a subset reflects coronary plaque rupture requiring invasive therapy. Cardiovascular magnetic resonance (CMR) is the non-invasive reference standard for tissue characterization and functional assessment. Fast Strain-ENCoded imaging (fSENC) enables rapid strain analysis, and layer-specific strain may help identify ischemic causes. Methods: In this prospective, single-centre observational study, patients presenting with chest pain and low-to-intermediate pretest probability for major adverse cardiac events (MACE) underwent rapid CMR prior to further therapy. Based on final clinical diagnosis, patients were classified as Healthy, acute coronary syndrome (ACS), or other cardiac abnormality (OCA). Global longitudinal strain (GLS) and the difference between endocardial and epicardial GLS (GLS-Dif) were quantified using fSENC. Follow-up assessed death and MACE. Results: A total of 108 patients (50 female; age 57.5 ± 17.4 years) were included. Total scanning time was 14 ± 3 min. GLS was significantly reduced in ACS (− 17.1%) and OCA (− 15.8%) compared with Healthy patients (− 20.1%; both p < 0.001), predicting any cardiac abnormality with an AUC of 86.5%. GLS-Dif was negative in ACS (− 0.6%) and significantly lower than in Healthy patients (1.5%) and OCA (0.95%), predicting ACS with an AUC of 91.3%. Combining GLS and GLS-Dif yielded excellent discrimination for cardiac abnormality (AUC 93.0%) and ACS (AUC 93.2%; sensitivity 100%; specificity 71.4%) and would have potentially reduced 35.3% of performed invasive coronary angiographies. Over a median follow-up > 5 years, death and MACE rates were low and unrelated to strain parameters. Conclusions: Layer-specific CMR strain analysis using fSENC reliably identifies ischemic myocardial injury in suspected ACS, supporting clinical decision-making and potentially reducing unnecessary invasive procedures. Graphical

Aim: To evaluate the impact of different lipid-lowering treatment intensities on high-risk plaque features and pericoronary adipose tissue (PCAT) attenuation in patients undergoing serial coronary computed tomography angiography (CCTA). Methods: Individuals with suspected or known coronary artery disease (CAD) from 11 imaging centers who underwent serial CCTA examinations were retrospectively analyzed. Plaque volumes and PCAT were quantified, and the presence of high-risk plaque features was semi-quantitatively assessed using the plaque feature score (PFS). Results: In total, 216 consecutive patients (mean age 63.1 ± 9.7 years, 26.4% female) were included. The mean observation and treatment timespan between the CCTA scans was 824.5 (interquartile range (IQR) = 463.0–1323.0) days (27.5 months). The regression of high-risk features was more common with high-intensity versus low or no lipid-lowering treatment (HR = 4.6, 95%CI = 1.8–12.0, p < 0.001) and was associated with the attenuated increase in non-calcified plaque volume (p < 0.001). PCAT_mean decreased with increasing intensity of lipid-lowering treatment (p = 0.01) but no associations were observed between the changes in PCAT and PFS or plaque volumes. Lipid-lowering drug intensity was predictive of PFS regression (p < 0.001), whereas baseline PCAT_RCA was predictive for PFS progression (p = 0.03), both independent of age, cardiovascular risk factors, and baseline plaque volumes. Conclusions: PCAT predicts the progression of high-risk coronary plaque features. High-intensity lipid-lowering drugs may cause the regression of high-risk plaque features through a plaque ‘delipidization’ process. Future trials are now warranted, studying if this process is potentially associated with improved clinical outcomes.

BACKGROUND: Cardiac amyloidosis is associated with poor outcomes and is caused by the interstitial deposition of misfolded proteins, typically ATTR (transthyretin) or AL (light chains). Although specific therapies during early disease stages exist, the diagnosis is often only established at an advanced stage. Cardiovascular magnetic resonance (CMR) is the gold standard for imaging suspected myocardial disease. However, differentiating cardiac amyloidosis from hypertrophic cardiomyopathy may be challenging, and a reliable method for an image-based classification of amyloidosis subtypes is lacking. This study sought to investigate a CMR machine learning (ML) algorithm to identify and distinguish cardiac amyloidosis. METHODS: This retrospective, multicenter, multivendor feasibility study included consecutive patients diagnosed with hypertrophic cardiomyopathy or AL/ATTR amyloidosis and healthy volunteers. Standard clinical information, semiautomated CMR imaging data, and qualitative CMR features were integrated into a trained ML algorithm. RESULTS: Four hundred participants (95 healthy, 94 hypertrophic cardiomyopathy, 95 AL, and 116 ATTR) from 56 institutions were included (269 men aged 58.5 [48.4–69.4] years). A 3-stage ML screening cascade sequentially differentiated healthy volunteers from patients, then hypertrophic cardiomyopathy from amyloidosis, and then AL from ATTR. The ML algorithm resulted in an accurate differentiation at each step (area under the curve, 1.0, 0.99, and 0.92, respectively). After reducing included data to demographics and imaging data alone, the performance remained excellent (area under the curve, 0.99, 0.98, and 0.88, respectively), even after removing late gadolinium enhancement imaging data from the model (area under the curve, 1.0, 0.95, 0.86, respectively). CONCLUSIONS: A trained ML model using semiautomated CMR imaging data and patient demographics can accurately identify cardiac amyloidosis and differentiate subtypes.

Background: Left ventricular (LV) thrombus formation is a common but potentially serious complication, typically occurring after myocardial infarction. Due to perceived high thromboembolic risk and lack of safety data, stress cardiac magnetic resonance (CMR) imaging especially with dobutamine is usually avoided despite its high diagnostic yield. This study aimed to investigate the characteristics, safety and outcome of patients with LV thrombus undergoing dobutamine or vasodilator stress CMR. Methods: Patients undergoing stress CMR with concomitant LV thrombus were retrospectively included. Risk factors, comorbidities, and previous embolic events were recorded. Periprocedural safety was assessed for up to 48 h following the examination. Major adverse cardiac events (MACE) 12 months before the diagnosis were compared to 12 months after the exam and between patients and a matched control group. Additionally, patients were followed up for all-cause mortality. Results: 95 patients (78 male, 65 ± 10.7 years) were included. Among them, 43 patients underwent dobutamine (36 high-dose, 7 low-dose) and 52 vasodilator stress CMR. Periprocedural safety was excellent with no adverse events. During a period of 24 months, 27 MACE (14.7%) occurred in patients and controls with no statistical difference between groups. During a median follow-up of 33.7 months (IQR 37.6 months), 6 deaths (6.3%) occurred. Type of stress agent, thrombus mobility, or protrusion were not correlated to embolic events or death. Conclusion: The addition of a stress test to a CMR exam is safe and does increase the generally high cardioembolic event rate in LV thrombus patients. Therefore, it is useful to support reperfusion decision-making. Graphical

Introduction: Advanced chronic kidney disease (CKD) is an independent risk factor for coronary artery disease (CAD). Due to its unique uremia-derived pathophysiology of atherosclerosis and the limitations of using potentially harmful contrast agents, the best non-invasive approach to assess CAD in these patients remains unclear. We sought to investigate the accuracy, safety, and prognosis of patients with severe CKD undergoing dobutamine stress cardiac magnetic resonance imaging (CMR).Materials and methods: In this retrospective, single-center study, patients on dialysis or with a glomerular filtration rate of 2 who underwent dobutamine stress CMR were included. A rest and stress wall motion analysis was performed using dobutamine/atropine as stressor. The target heart rate was 85% of the maximum heart rate. Periprocedural adverse events and 1-year follow-up data were obtained.Results: A total of 176 patients (127 men, 49 women) with a mean age of 60.9 ± 14.7 years were included, of which 156 patients were on permanent dialysis. Short-term symptoms such as angina or shortness of breath during stress CMR were frequent (22.1%), but major complications were rare (one patient with myocardial infarction, 0.6%). The 1-year event rate was high (16.4%) with a significant independent correlation to reduced ejection fraction at rest (p = 0.037) and failure to achieve the target heart rate (p = 0.029). The overall accuracy for predicting significant CAD was good (sensitivity of 71.4%, specificity of 98.4%) and excellent if the target heart rate was achieved (83.3%, 97.9%). A negative stress CMR was highly predictive for the absence of major adverse cardiac event or any coronary revascularization during the 1-year follow-up (negative predictive value of 95.0%).Discussion: Dobutamine stress CMR is a safe and accurate diagnostic imaging technique in patients at advanced stages of chronic kidney disease. A reduced ejection fraction and the inability to reach the target heart rate are independent predictors of a poor outcome.

Coronary artery disease (CAD) represents a widespread burden to both individual and public health, steadily rising across the globe. The current guidelines recommend non-invasive anatomical or functional testing prior to invasive procedures. Both coronary computed tomography angiography (cCTA) and stress cardiac magnetic resonance imaging (CMR) are appropriate imaging modalities, which are increasingly used in these patients. Both exhibit excellent safety profiles and high diagnostic accuracy. In the last decade, cCTA image quality has improved, radiation exposure has decreased and functional information such as CT-derived fractional flow reserve or perfusion can complement anatomic evaluation. CMR has become more robust and faster, and advances have been made in functional assessment and tissue characterization allowing for earlier and better risk stratification. This review compares both imaging modalities regarding their strengths and weaknesses in the assessment of CAD and aims to give physicians rationales to select the most appropriate modality for individual patients.