Morteza Naghavi MD , Nathan D. Wong PhD , Michael V. McConnell MD, MSEE , David J. Maron MD , Khurram Nasir MD , Claudia I. Henschke MD, PhD , David F. Yankelevitz MD , Zahi A. Fayad PhD , Rozemarijn Vliegenthart MD, PhD , Kim A. Williams Sr. MD , Roxana Mehran MD , Mathew Budoff MD , Daniel Berman MD , Jamal S. Rana MD, PhD , Prediman K. Shah MD , Robert A. Kloner MD, PhD , Jagat Narula MD, PhD , Philip Greenland MD , Valentin Fuster MD, PhD
{"title":"Coronary Artery Calcium (CAC) Imaging as a Diagnostic Test","authors":"Morteza Naghavi MD , Nathan D. Wong PhD , Michael V. McConnell MD, MSEE , David J. Maron MD , Khurram Nasir MD , Claudia I. Henschke MD, PhD , David F. Yankelevitz MD , Zahi A. Fayad PhD , Rozemarijn Vliegenthart MD, PhD , Kim A. Williams Sr. MD , Roxana Mehran MD , Mathew Budoff MD , Daniel Berman MD , Jamal S. Rana MD, PhD , Prediman K. Shah MD , Robert A. Kloner MD, PhD , Jagat Narula MD, PhD , Philip Greenland MD , Valentin Fuster MD, PhD","doi":"10.1016/j.jcmg.2025.10.020","DOIUrl":"10.1016/j.jcmg.2025.10.020","url":null,"abstract":"<div><div>Atherosclerotic cardiovascular disease (ASCVD), in particular atherosclerotic coronary artery disease (CAD), is the leading cause of death in the United States and globally. In the majority of ASCVD victims, the first sign is an acute event (heart attack or stroke) with a high fatality rate. It is widely accepted that most CAD deaths are preventable if asymptomatic at-risk patients are diagnosed and treated before the onset of clinical symptoms. In the past 30 years, numerous studies conclusively demonstrated that coronary artery calcium (CAC) imaging diagnoses patients with subclinical CAD and predicts adverse outcomes beyond conventional risk factors such as hyperlipidemia, hypertension, smoking, and diabetes. Current ASCVD prevention guidelines issued by U.S. cardiovascular professional societies recommend risk factor assessment to screen individuals who may be at risk, followed by CAC imaging in the borderline- and intermediate-risk categories to diagnose and quantify the severity of CAD to guide treatment. However, most payers do not follow these guidelines to cover CAC imaging requiring patients to pay out of pocket, resulting in underdiagnosis and failure to prevent costly cardiovascular events. In this statement, we elaborate on the diagnostic use of CAC imaging and call on health care providers, payers, and policymakers to follow the ASCVD prevention guidelines and provide coverage. Covering the appropriate diagnostic use of CAC will enable physicians to perform shared decision-making for the treatment of patients with asymptomatic CAD and personalize the intensity of the treatment based on the extent of CAD. Specifically, this statement focuses on the diagnostic role of CAC imaging rather than its potential as a universal screening test. Although there are rationales for population-wide screening, such an approach would require large-scale outcome studies and is beyond the scope of this paper.</div></div>","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 266-273"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145717981","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Davide Margonato MD , Bernardo B. Lopes MD , Go Hashimoto MD , Miho Fukui MD, PhD , Asa Phichaphop MD , Cheng Wang MD , Takahiro Nishihara MD , Ellen Cravero MS , Paul Sorajja MD , Vinayak Bapat MD , Maurice Enriquez-Sarano MD , João L. Cavalcante MD
{"title":"Tricuspid Anatomic Regurgitant Orifice Area by Cardiac Computed Tomography","authors":"Davide Margonato MD , Bernardo B. Lopes MD , Go Hashimoto MD , Miho Fukui MD, PhD , Asa Phichaphop MD , Cheng Wang MD , Takahiro Nishihara MD , Ellen Cravero MS , Paul Sorajja MD , Vinayak Bapat MD , Maurice Enriquez-Sarano MD , João L. Cavalcante MD","doi":"10.1016/j.jcmg.2025.08.021","DOIUrl":"10.1016/j.jcmg.2025.08.021","url":null,"abstract":"<div><h3>Background</h3><div>Anatomic regurgitant orifice area (AROA) can be measured by 4-dimensional (4D)–computed tomography angiography (CTA) to define tricuspid regurgitation (TR) severity, but its association with outcomes has not been established.</div></div><div><h3>Objectives</h3><div>This study aims to assess the independent prognostic value of TR quantification by 4D-CTA AROA measurement.</div></div><div><h3>Methods</h3><div>Comprehensive clinical, echocardiographic and 4D-CTA data were collected from patients with clinically significant TR evaluated at 4 Allina Health centers between 2019 and 2023 for TR intervention. The outcome of interest was all-cause mortality under medical management after diagnosis.</div></div><div><h3>Results</h3><div>AROA measurement was obtained in 174 patients (median age 83 years [Q1-Q3: 77- 97 years], left ventricular ejection fraction 58% [Q1-Q3: 51%-60%], right ventricular [RV] ejection fraction 46% [Q1-Q3: 41%-51%] and tricuspid AROA 0.74 cm<sup>2</sup> [Q1-Q3: 0.55-1.42 cm<sup>2</sup>]). During a median follow-up of 2.3 years [Q1-Q3: 1.1-3.2 years], 49 (28%) patients died under medical management with 3-year survival rate of 55% [Q1-Q3: 45%-67%]. Spline curve analysis showed that AROA 1.1 cm<sup>2</sup> was the threshold associated with increased mortality within the cohort. Patients with AROA ≥1.1 cm<sup>2</sup> had higher TRI-SCOREs, larger tricuspid annulus dimension, tricuspid maximum coaptation gap, RV and right atrial volumes (all <em>P <</em> 0.001). Despite similar RV ejection fraction, patients with AROA ≥1.1 cm<sup>2</sup> had worse RV function denoted by lower RV free-wall longitudinal strain (<em>P <</em> 0.001) compared to those with AROA <1.1 cm<sup>2</sup>. In multivariable analysis, AROA ≥1.1 cm<sup>2</sup> remained independently associated with excess mortality (adjusted HR 2.23 [95% CI: 1.02-4.85]; <em>P =</em> 0.040) and worse 3-year survival under medical management (68% [Q1-Q3: 56%-82%] vs 36% [Q1-Q3: 28%-52%]; <em>P =</em> 0.013).</div></div><div><h3>Conclusions</h3><div>This first outcome study of patients with clinically significant TR examined by 4D-CTA shows that higher AROA measurement strongly associates with worse right heart remodeling and independently associates with excess mortality. Therefore, 4D-CTA, beyond anatomical assessment, provides prognostically relevant assessment of TR severity. Thus, AROA measurement should be considered in patients with TR evaluated by 4D-CTA.</div></div>","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 197-207"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145373952","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Wissam Rahi MD , Hossam Lababidi MD , Imad Hussain MD, Miguel A. Quinones MD, Sherif F. Nagueh MD
{"title":"Improving the Diagnosis of HFpEF","authors":"Wissam Rahi MD , Hossam Lababidi MD , Imad Hussain MD, Miguel A. Quinones MD, Sherif F. Nagueh MD","doi":"10.1016/j.jcmg.2025.09.011","DOIUrl":"10.1016/j.jcmg.2025.09.011","url":null,"abstract":"<div><h3>Background</h3><div>The H<sub>2</sub>FPEF score was developed for heart failure with preserved ejection fraction (HFpEF) diagnosis based on clinical parameters, septal E/e′ ratio and pulmonary artery systolic pressure. Diagnostic accuracy can be improved by additional echocardiographic parameters.</div></div><div><h3>Objectives</h3><div>This report aims to study the impact of echocardiography in improving the accuracy of The H<sub>2</sub>FPEF score, using the score as the initial step for HFpEF diagnosis.</div></div><div><h3>Methods</h3><div>Stable patients with ejection fraction ≥50% who underwent right heart catheterization and echocardiographic imaging within 30 days were included. H<sub>2</sub>FPEF score was computed. Echocardiographic measurements recommended in ASE (American Society of Echocardiography) 2025 diastolic function guidelines update were included.</div></div><div><h3>Results</h3><div>There were 511 patients with 237 having pulmonary capillary wedge pressure >15 mm Hg at rest or >25 mm Hg with exercise. Heart failure probability of <30% was present in 60 patients, whereas 58 had a probability of 30%-49%, 113 had a probability of 50%-80%, and 280 had a probability of >80%. Accuracy of The H<sub>2</sub>FPEF score was not improved with the addition of echocardiographic assessment when HF probability was <30% (<em>P =</em> 0.083). For all other probabilities, echocardiographic assessment significantly added to H<sub>2</sub>FPEF score accuracy. Net reclassification improvement was 1.38 (<em>P <</em> 0.001), and integrated discrimination improvement was 0.38 (<em>P <</em> 0.001).</div></div><div><h3>Conclusions</h3><div>The H<sub>2</sub>FPEF score has good accuracy in excluding HF diagnosis when HF probability based on the score is <30%. When probability is >30%, 2025 ASE diastolic function guidelines approach to the estimation of mean left atrial pressure adds to accuracy.</div></div>","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 166-174"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145357616","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Maan Malahfji MD , Mujtaba Saeed MD , Duc T. Nguyen MD, PhD , Yodying Kaolawanich MD , Hossam Lababidi MD , El-Moatasem Gabr MD , Alan Pan MS , Valentina Crudo MD , Michael J. Reardon MD , Michael Elliott MD , João L. Cavalcante MD , Venkateshwar Polsani MD , Sherif F. Nagueh MD , Robert O. Bonow MD , William A. Zoghbi MD , Raymond J. Kim MD , Dipan J. Shah MD
{"title":"Cardiac Remodeling and Outcomes of Patients With Combined Aortic and Mitral Regurgitation","authors":"Maan Malahfji MD , Mujtaba Saeed MD , Duc T. Nguyen MD, PhD , Yodying Kaolawanich MD , Hossam Lababidi MD , El-Moatasem Gabr MD , Alan Pan MS , Valentina Crudo MD , Michael J. Reardon MD , Michael Elliott MD , João L. Cavalcante MD , Venkateshwar Polsani MD , Sherif F. Nagueh MD , Robert O. Bonow MD , William A. Zoghbi MD , Raymond J. Kim MD , Dipan J. Shah MD","doi":"10.1016/j.jcmg.2025.09.022","DOIUrl":"10.1016/j.jcmg.2025.09.022","url":null,"abstract":"<div><h3>Background</h3><div>Management of patients with combined aortic and mitral regurgitation (AR and MR) is largely based on expert opinion. Specifically, the outcomes of patients with combined moderate AR and moderate MR under medical surveillance are uncertain.</div></div><div><h3>Objectives</h3><div>This study aimed to evaluate cardiac remodeling using cardiac magnetic resonance (CMR) in patients with combined AR/MR compared with isolated AR, to assess degree of MR associated with adverse outcomes, and evaluate the outcomes of asymptomatic patients with combined moderate AR and moderate MR under medical surveillance.</div></div><div><h3>Methods</h3><div>The authors conducted a multicenter observational outcome study of patients with moderate or severe AR on CMR, and evaluated the etiology and degree of concomitant MR in patients with combined AR and MR. They excluded patients if they had prior valvular surgery, > mild valve stenosis, hypertrophic or infiltrative cardiomyopathy, or congenital heart disease except bicuspid aortic valve. The authors evaluated ventricular volumes and function across the spectrum of regurgitation severity. Receiver-operating characteristic analyses for the association of concomitant MR severity with outcomes were performed. The primary outcome was all-cause death. Secondary outcome was all-cause death or heart failure (HF) hospitalization. Patients were censored at the time of valvular surgery or intervention. Propensity score matching was done between isolated AR and the combined AR/MR groups.</div></div><div><h3>Results</h3><div>The authors studied 915 patients with a median age of 61 years (Q1-Q3: 49-72 years), 79.5% male, 29% with bicuspid aortic valve, and a median AR fraction of 38% (Q1-Q3: 32%-45%). In 251 of 915 patients (27.4%) with concomitant MR, the median MR fraction was 24% (Q1-Q3: 17%-35%). The presence of concomitant ≥moderate MR (14.2% of the total population) was associated with a greater increase in ventricular volumes per unit increase in AR severity, and a decline in ventricular function (<em>P</em> for interaction ≤0.01). During a median follow-up of 3.0 years (Q1-Q3: 1.1-5.6 years), there were 152 deaths. Presence of concomitant ≥moderate MR was associated with an increased hazard for all-cause death (HR: 2.77; 95% CI: 1.91-4.01; <em>P <</em> 0.001), and the secondary outcome of death or HF (HR: 2.62; 95% CI: 1.87-3.67; <em>P <</em> 0.001). In asymptomatic or minimally symptomatic patients undergoing medical surveillance, the presence of combined moderate AR and moderate MR was independently associated with a higher hazard for the primary and secondary outcomes compared with isolated AR, independent of age, sex, comorbidities, ejection fraction, and end-systolic volume. Findings were consistent in the propensity matched cohort.</div></div><div><h3>Conclusions</h3><div>The presence of combined AR and MR on CMR is associated with a greater extent of ventricular remodeling and incr","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 180-193"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145411491","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Rafail A. Kotronias MBChB, MS , Leonardo Portolan MD , Cheng Xie MBChB, DPhil, Vanessa M. Ferreira MD, Dphil, Betty Raman MD, Dphil, Ernst Klotz Dipl Phys, Giovanni L. De Maria MD, PhD, Ron Blankstein MD, Keith M. Channon MBChB, MD, Stefan Neubauer MD, Charalambos Antoniades MD, PhD
{"title":"Evaluating Acute Ischemic Myocardial Injury With Photon-Counting Computed Tomography","authors":"Rafail A. Kotronias MBChB, MS , Leonardo Portolan MD , Cheng Xie MBChB, DPhil, Vanessa M. Ferreira MD, Dphil, Betty Raman MD, Dphil, Ernst Klotz Dipl Phys, Giovanni L. De Maria MD, PhD, Ron Blankstein MD, Keith M. Channon MBChB, MD, Stefan Neubauer MD, Charalambos Antoniades MD, PhD","doi":"10.1016/j.jcmg.2025.08.016","DOIUrl":"10.1016/j.jcmg.2025.08.016","url":null,"abstract":"","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 284-287"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145194456","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Osnat Itzhaki Ben Zadok MD, MS, Stephen J. Hankinson MD, Ashraf Hamdan MD, Sylvain L. Carre MS, Yee-Ping Sun MD, Rhanderson N. Cardoso MD, MHS, Tzlil Grinberg MD, Pinak B. Shah MD, Anju Nohria MD, MS, Sanjay Divakaran MD, MPH
{"title":"The Predictive Accuracy of Aortic Valve Calcium Score in Mediastinal Radiation Therapy Survivors","authors":"Osnat Itzhaki Ben Zadok MD, MS, Stephen J. Hankinson MD, Ashraf Hamdan MD, Sylvain L. Carre MS, Yee-Ping Sun MD, Rhanderson N. Cardoso MD, MHS, Tzlil Grinberg MD, Pinak B. Shah MD, Anju Nohria MD, MS, Sanjay Divakaran MD, MPH","doi":"10.1016/j.jcmg.2025.08.014","DOIUrl":"10.1016/j.jcmg.2025.08.014","url":null,"abstract":"","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 282-283"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145134074","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Jolien Geers MD , Neil Craig MD , Kajetan Grodecki MD, PhD , Maria Lembo MD, PhD , Shruti S. Joshi MD, PhD , Trisha Singh MD, PhD , Rong Bing MD, PhD , Jacek Kwieciński MD, PhD , Lorenzo Carnevale PhD , Dorien Kimenai PhD , Soongu Kwak MD, PhD , Seung-Pyo Lee MD, PhD , Kush Patel MD , Thomas Treibel MD, PhD , Aroa Ruiz Muñoz MS , Jose F. Rodriguez Palomares MD, PhD , Jae-Kwan Song MD, PhD , Marie-Annick Clavel DVM, PhD , Pamela Piña MD , Daniel Lorenzatti MD , Marc R. Dweck MD, PhD
{"title":"Indexed Aortic Valve Calcium Volume by Computed Tomography Angiography in Patients With Aortic Stenosis","authors":"Jolien Geers MD , Neil Craig MD , Kajetan Grodecki MD, PhD , Maria Lembo MD, PhD , Shruti S. Joshi MD, PhD , Trisha Singh MD, PhD , Rong Bing MD, PhD , Jacek Kwieciński MD, PhD , Lorenzo Carnevale PhD , Dorien Kimenai PhD , Soongu Kwak MD, PhD , Seung-Pyo Lee MD, PhD , Kush Patel MD , Thomas Treibel MD, PhD , Aroa Ruiz Muñoz MS , Jose F. Rodriguez Palomares MD, PhD , Jae-Kwan Song MD, PhD , Marie-Annick Clavel DVM, PhD , Pamela Piña MD , Daniel Lorenzatti MD , Marc R. Dweck MD, PhD","doi":"10.1016/j.jcmg.2025.09.013","DOIUrl":"10.1016/j.jcmg.2025.09.013","url":null,"abstract":"<div><h3>Background</h3><div>Calcium scoring from noncontrast computed tomography (CT) is used clinically to adjudicate aortic stenosis severity in patients with discordant echocardiography.</div></div><div><h3>Objectives</h3><div>The aim of this study was to investigate whether quantification of aortic valve calcium volume from computed tomography angiography (CTA) can provide robust diagnostic discrimination of disease severity and inform risk stratification of patients with aortic stenosis.</div></div><div><h3>Methods</h3><div>Patients with mild to severe aortic stenosis who underwent concurrent CTA and echocardiography were included in a retrospective international multicenter observational cohort study. Accuracy of aortic valve calcium volume to diagnose severe aortic stenosis in patients with concordant disease on echocardiography was assessed. Association of aortic valve calcium volume with the incidence of aortic valve replacement or all-cause death was investigated.</div></div><div><h3>Results</h3><div>The study included 1,521 patients (mean age: 74 ± 10 years; 44% female; median peak aortic jet velocity: 3.8 m/s [Q1-Q3: 3.1-4.5 m/s]). Indexed aortic valve calcium volume correlated with peak aortic jet velocity (ρ = 0.723; <em>P <</em> 0.001) and noncontrast CT calcium score (ρ = 0.896; <em>P <</em> 0.001). In the derivation cohort (n = 689), sex-specific thresholds for indexed calcium volume (men: 122 mm<sup>3</sup>/cm<sup>2</sup>; women: 61 mm<sup>3</sup>/cm<sup>2</sup>) provided excellent diagnostic discrimination for severe aortic stenosis (C-statistic: 0.900 for men; 0.926 for women). Similar diagnostic discrimination was observed in the validation cohort (n = 459; C-statistic: 0.933 for men; 0.944 for women). Clinical outcomes were available in 711 patients (25% with discordant echocardiography), with 249 reaching the primary endpoint after 26 months (Q1-Q3: 12-53 months). Indexed calcium volume thresholds were independently associated with aortic valve replacement or all-cause mortality in both the cohort as a whole (HR: 2.01 [95% CI: 1.30-3.10]; <em>P <</em> 0.01) and those with discordant echocardiography (HR: 1.58 [95% CI: 1.01-2.44]).</div></div><div><h3>Conclusions</h3><div>In patients with aortic stenosis, indexed aortic valve calcium volume from CTA provides accurate discrimination of disease severity and additive prognostic information. This technique can be easily applied to patients undergoing CTA for transcatheter aortic valve replacement or coronary artery evaluation without the need for a separate noncontrast CT scan.</div></div>","PeriodicalId":14767,"journal":{"name":"JACC. Cardiovascular imaging","volume":"19 2","pages":"Pages 210-221"},"PeriodicalIF":15.2,"publicationDate":"2026-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145357618","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":1,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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