Coronary computed tomography angiography has emerged as an important diagnostic modality for evaluation of acute chest pain in the emergency department for patients at low to intermediate risk for acute coronary syndromes. Several clinical trials have shown excellent negative predictive value of coronary computed tomography angiography to detect obstructive coronary artery disease. Cardiac biomarkers such as troponins and creatine kinase MB, along with history, electrocardiogram, age, risk factors, troponin score, and Thrombolysis in Myocardial Infarction score should be used in conjunction with coronary computed tomography angiography for safe and rapid discharge of patients from the emergency department. Coronary computed tomography angiography along with high-sensitivity troponin assays could be effective for rapid evaluation of acute chest pain in the emergency department, but high-sensitivity troponins are not always available. Emergency department physicians are not quite comfortable making clinical decisions, especially if the coronary stenosis is in the range of 50% to 70%. In these cases, further evaluation with functional testing, such as nuclear stress testing or stress echocardiogram, is a common approach in many centers; however, newer methods such as fractional flow reserve computed tomography could be safely incorporated in coronary computed tomography angiography to help with clinical decision-making in these scenarios.

Iodixanol is an iso-osmolar non-ionic dimeric hydrophilic contrast agent with a higher viscosity than the monomeric agents. It is the only Food and Drug Administration (FDA)-approved iso-osmolar agent in the United States, and it is the only contrast agent with an FDA-approved indication for use in cardiac computed tomographic angiography (CCTA), to assist in the diagnostic evaluation of patients with suspected coronary artery disease. In clinical studies, it has been noted to have fewer side effects and similar image quality when compared to low-osmolar contrast media. This can be attributed to the pharmacological properties of iodixanol. These contrast agents are used for coronary computed tomography angiography and cardiac catheterization. In this article, the use, tolerability, and efficacy of iodixanol are reviewed, specifically evaluating the use of CCTA and coronary angiography, including outcome studies, randomized trials, and comparisons to other contrast agents.

Background

It is increasingly evident that patients with chronic kidney disease (CKD) are more likely to die from heart disease than kidney failure. This study evaluated whether pre- dialysis CKD is an independent risk factor for coronary artery calcium (CAC).

Methods

A total of 544 consecutive patients who underwent CAC scoring were analyzed. Eleven patients requiring hemodialysis were excluded. Patients were divided into three groups: normal glomerular filtration rate (GFR) (GFR > 90 mL/min/1.73 m²), mild CKD (90 ≥ GFR > 60 mL/min/1.73 m²), and moderate CKD (60 ≥ GFR > 30 mL/min/1.73 m²). Continuous and categorical variables were compared using analysis of variance and the χ² statistic. A multiple logistic regression model was used for detecting the association between total CAC score and GFR. An unadjusted model was used, followed by a second model adjusted for covariates known to be related to CAC. Another multivariable binary logistic model predicting the presence of CAC (>10) was performed and odds of incidence of CAC (>10) were calculated among the three GFR subgroups.

Results

After adjustment for covariates, patients with mild CKD had mean CAC scores 175 points higher than those with the referent normal GFR (P = 0.048), while those with moderate CKD had mean CAC scores 693 points higher than the referent (P < 0.001). After adjustment for covariates, patients with mild CKD were found to be 2.2 times more likely (95% confidence interval 1.3-3.7, P = 0.004) and patients with moderate CKD were 6.4 times more likely (95% confidence interval 2.9-14.3, P < 0.001) to have incident CAC compared with the group with normal GFR.

Conclusion

Mild and moderate pre-dialysis CKD are independent risk factors for increased mean and incident CAC.

Purpose of review

To provide an update and to outline the status of coronary computer tomography angiography (CCTA) in evaluation of coronary plaques and discuss the relevance of serial CCTA in guiding cardiovascular risk stratification and anti- atherosclerotic medical therapy.

Recent findings

Coronary CTA is now the imaging modality of choice in monitoring changes in coronary plaque. It has been used in innumerable clinical trials which have demonstrated the benefits of several therapeutic agents and has excellent correlation with previously used invasive imaging modalities. It is safe, fast, less cumbersome, and a cost-effective testing method compared to other invasive imaging modalities for coronary plaque analysis.

Summary

The emergence of a noninvasive imaging modality such as CCTA, now permits quantification not only of plaque burden but also allows for further distinction of plaque components and identification of vulnerable plaques. Application of these findings continues to extend the prospect of coronary CTA in evaluation and management of atherosclerotic coronary artery disease (CAD) in clinical practice. In the future artificial intelligence and machine learning will play a significant role in plaque analysis allowing for high accuracy and reproducibility which will lead to a substantial increase in the utilization of coronary CTA.

Pseudoaneurysm is a rare but fatal complication of myocardial infarction (MI). With the advances in cardiovascular disease detection and treatments, fatal structural complications post-MI are now rare. When they occur, advanced diagnostic modalities can be used for early diagnosis, aiding surgical planning, and improving prognosis. In our case, post-MI left ventricle pseudoaneurysm complicated by hemopericardium was diagnosed using cardiac computed tomography angiography (CCTA). Use of attenuation measurement on CCTA helped diagnose active extravasation into the hemopericardium. This case highlights the high index of suspicion needed for rare but fatal complications post-MI and the utility of CCTA in their management.

The coronary artery calcium (CAC) score is a marker of advanced coronary atherosclerosis. Numerous prospective cohorts have validated CAC as an independent marker that improves prognostication in atherosclerotic cardiovascular disease (ASCVD) beyond traditional risk factors. Accordingly, CAC is now incorporated into international cardiovascular guidelines as a tool to inform medical decision-making. Particular interest concerns the significance of zero CAC score (CAC=0). While many studies report CAC=0 to virtually exclude obstructive coronary artery disease (CAD), non-negligible rates of obstructive CAD despite CAC=0 are reported in certain populations. Overall, the current literature supports the power of zero CAC as a strong downward risk classifier in older patients, whose CAD burden predominantly involves calcified plaque. However, with their higher burden of non-calcified plaque, CAC=0 does not reliably exclude obstructive CAD in patients under 40 years. Illustrating this point, we present a cautionary case of a 31-year-old patient found to have severe two-vessel CAD despite CAC=0. We highlight the value of coronary computed tomography angiography (CCTA) as the gold-standard non-invasive imaging modality when the diagnosis of obstructive CAD is in question.

Despite reducing progression and promoting regression of coronary atherosclerosis, statin therapy does not fully address residual cardiovascular (CV) risk. High-purity eicosapentaenoic acid (EPA) added to a statin has been shown to reduce CV events and induce regression of coronary atherosclerosis in imaging studies; however, data are from Japanese populations without high triglyceride (TG) levels and baseline EPA serum levels greater than those in North American populations. Icosapent ethyl is a high-purity prescription EPA ethyl ester approved at 4 g/d as an adjunct to diet to reduce TG levels in adults with TG levels >499 mg/dL. The objective of the randomized, double-blind, placebo-controlled EVAPORATE study is to evaluate the effects of icosapent ethyl 4 g/d on atherosclerotic plaque in a North American population of statin-treated patients with coronary atherosclerosis, TG levels of 200 to 499 mg/dL, and low-density lipoprotein cholesterol levels of 40 to 115 mg/dL. The primary endpoint is change in low-attenuation plaque volume measured by multidetector computed tomography angiography. Secondary endpoints include incident plaque rates; quantitative changes in different plaque types and morphology; changes in markers of inflammation, lipids, and lipoproteins; and the relationship between these changes and plaque burden and/or plaque vulnerability. Approximately 80 patients will be followed for 9 to 18 months. The clinical implications of icosapent ethyl 4 g/d treatment added to statin therapy on CV endpoints are being evaluated in the large CV outcomes study REDUCE-IT. EVAPORATE will provide important imaging-derived data that may add relevance to the clinically derived outcomes from REDUCE-IT.

Trisomy 13 is a rare chromosomal disorder in which all or a percentage (mosaicism) of cells contain an extra 13th chromosome. Sinus of Valsalva aneurysms are rare, with an incidence of 0.1% to 3.5% of all congenital heart defects. This article reports the case of a patient with trisomy 13 with a new systolic murmur found to have a ruptured sinus of Valsalva aneurysm diagnosed on coronary computed tomography angiography. This is the first case to report sinus of Valsalva aneurysm rupture secondary to Streptococcus viridans endocarditis in a patient with trisomy 13 syndrome and highlights the importance of coronary computed tomography angiography in noninvasive imaging and surgical planning.

Evidence suggests that asymptomatic and mild SARS-CoV-2 infections comprise > 95% of all cases. Developing a test that indicates past infection and possible immunity against the virus is important. We administered 244 antibody tests to three groups of high-risk population. The test consisted of an IgG component and an IgM component. The overall IgM/IgG positivity for patients with none, mild, moderate, and severe symptoms were 21.1%, 21.8%, 14.2%, and 26.9%, respectively. Those with moderate or severe symptoms were no more or less likely to have positive antibody tests than those with no or mild symptoms.