Glagov revisited: coronary artery disease phenotype on non-invasive imaging provides rationale for implementing preventive pharmacotherapy-a case report.

Background: Glagov et al. showed that no reduction in vessel lumen occurred until the atherosclerotic plaque burden exceeded 40% of the vessel area. Most major adverse cardiac events occurring in the first 4 years after a myocardial infarction arise from untreated angiographically mild, non-flow-limiting lesions at the time of the index event. We report how computed tomography (CT) coronary angiography (CCTA) can be used to non-invasively risk stratify a patient with non-obstructive coronary artery disease (CAD) and guide further management. Case summary: A 69-year-old non-smoking female with hypertension, dyslipidaemia, and hypothyroidism presented with atypical chest pain. Electrocardiogram and left ventricular ejection fraction were normal. Her lipidic profile was normal. CCTA showed a lipid-rich plaque with very low attenuation (<30 HU) in the left main stem (LMS) extending into the proximal left anterior descending (LAD) and in the mid LAD artery. The maximum plaque burden in the LMS was 67% with a remodelling index of 1.375, and an area stenosis of 22%. Tissue characterization showed a lipid-rich plaque with a thin fibrous cap. The perivascular fat attenuation index (FAI) in the proximal LAD was suggestive of (-69 HU) inflamed perivascular fat. Shear stress analysis of the LMS plaque showed normal wall shear stress (WSS); however, the axial plaque stress was high. Her medications were intensified to rosuvastatin 20 mg once daily (OD) and ezetimibe 10 mg OD. The patient remained asymptomatic at 6 months follow-up. Discussion: Our case exemplifies the value of CCTA as a diagnostic 'one-stop shop' (CCTA, finite element analysis, computed tomographic density [CTD], tissue characterization analysis, FAI analysis, WSS and wall strain, and etc.) when stratifying a patient with non-obstructive CAD. With further development of novel potent anti-lipidaemic and anti-inflammatory drugs, non-obstructive lesions with adverse plaque and haemodynamic parameters will have the opportunity to be treated with additional preventive pharmacological therapy.

3D echocardiographic reference ranges for normal left ventricular volumes and strain: results from the EACVI NORRE study.

AIM: To obtain the normal ranges for 3D echocardiography (3DE) measurement of left ventricular (LV) volumes, function, and strain from a large group of healthy volunteers. METHODS AND RESULTS: A total of 440 (mean age: 45 ± 13 years) out of the 734 healthy subjects enrolled at 22 collaborating institutions of the Normal Reference Ranges for Echocardiography (NORRE) study had good-quality 3DE data sets that have been analysed with a vendor-independent software package allowing homogeneous measurements regardless of the echocardiographic machine used to acquire the data sets. Upper limits of LV end-diastolic and end-systolic volumes were larger in men (97 and 42 mL/m2) than in women (82 and 35 mL/m2; P < 0.0001). Conversely, lower limits of LV ejection fraction were higher in women than in men (51% vs. 50%; P < 0.01). Similarly, all strain components were higher in women than in men. Lower range was -18.6% in men and -19.5% in women for 3D longitudinal strain, -27.0% and -27.6% for 3D circumferential strain, -33.2% and -34.4% for 3D tangential strain and 38.8% and 40.7% for 3D radial strain, respectively. LV volumes decreased with age in both genders (P < 0.0001), whereas LV ejection fraction increased with age only in men. Among 3DE LV strain components, the only one, which did not change with age was longitudinal strain. CONCLUSION: The NORRE study provides applicable 3D echocardiographic reference ranges for LV function assessment. Our data highlight the importance of age- and gender-specific reference values for both LV volumes and strain.

Appropriateness criteria for cardiovascular imaging use in clinical practice: a position statement of the ESC/EACVI taskforce.

There is a growing interest from the scientific community in the appropriate use of cardiovascular imaging techniques for diagnosis and decision making in Europe. To develop appropriateness criteria for cardiovascular imaging use in clinical practice in Europe, a dedicated taskforce has been appointed by the European Society of Cardiology (ESC) and the European Association of Cardiovascular Imaging (EACVI). The present paper describes the appropriateness criteria development process.

Myocardial contrast echocardiography in the assessment of patients with chronic coronary artery disease.

UNLABELLED: The development of new contrast agents and new imaging methods has lead to an emerging field of applications for myocardial contrast echocardiography (MCE) in patients suffering from chronic ischemic heart disease. Echo contrast allows the assessment of myocardial perfusion (MP) by imaging the coronary microcirculation. Several echocardiographic modalities are available, the main difference between them being the acoustic power needed to perform the study. MP is evaluated by assessing the changes in myocardial videointensity that occur after intravenous contrast injection. Evaluation of these patients is performed by using different techniques. Evaluation of coronary stenosis may be performed by using stress tests or without its use. Coronary artery stenosis > 50% of the coronary luminal diameter reveals a decreased hyperemic response when myocardial oxygen demand is increased. Different methods to evaluate the presence of relevant coronary stenosis have been developed: evaluation of myocardial blood flow reserve, evaluation of myocardial blood volume, and evaluation of the transmural distribution of myocardial blood flow. The combination of wall motion analysis with MCE assessment has been demonstrated to achieve the best balance between sensitivity (86%) and specificity (88%), with the highest accuracy (86%). Without the need of any stress, the ratio systolic/diastolic myocardial blood volume has been described to increase with the presence of a epicardial coronary stenosis and it may be measured by MCE. Myocardial viability is also one of the potentials of MCE. Microvascular integrity, demonstrated by MCE, is an indicator of preserved viability and predicts functional recovery that has been validated in the setting of chronic left ventricular dysfunction secondary to chronic coronary artery disease and in the setting of post acute myocardial infarction left ventricular dysfunction. IN CONCLUSION: contrast echocardiography provides an interesting tool that offers the potential of a complete evaluation of patients with chronic coronary artery disease. This includes both diagnostic and prognostic evaluation.