Migraine is a chronic neurovascular disease with a complex, not fully understood pathophysiology with multiple causes. People with migraine suffer from recurrent moderate to severe headache attacks varying from 4 to 72 h. The prevalence of migraine is two to three times higher in women compared with men. Importantly, it is the most disabling disease in women <50 years of age due to a high number of years lived with disability, resulting in a very high global socioeconomic burden. Robust evidence exists on the association between migraine with aura and increased incidence of cardiovascular disease (CVD), in particular ischaemic stroke. People with migraine with aura have an increased risk of atrial fibrillation, myocardial infarction, and cardiovascular death compared with those without migraine. Ongoing studies investigate the relation between migraine and angina with non-obstructive coronary arteries and migraine patients with patent foramen ovale. Medication for the treatment of migraine can be preventative medication, such as beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, antiepileptics, antidepressants, some of the long-acting calcitonin gene-related peptide receptor antagonists, or monoclonal antibodies against calcitonin gene-related peptide or its receptor, or acute medication, such as triptans and calcitonin gene-related peptide receptor antagonists. However, these medications might raise concerns when migraine patients also have CVD due to possible (coronary) side effects. Specifically, knowledge gaps remain for the contraindication to newer treatments for migraine. All cardiologists will encounter patients with CVD and migraine. This state-of-the-art review will outline the basic pathophysiology of migraine and the associations between migraine and CVD, discuss current therapies, and propose future directions for research.

Aims: To assess the prognostic utility of coronary artery calcium (CAC) scoring and coronary computed tomography angiography (CCTA)-derived quantitative plaque metrics for predicting adverse cardiovascular outcomes. Methods and results: The study enrolled 2404 patients with suspected coronary artery disease (CAD) but without a prior history of CAD. All participants underwent CAC scoring and CCTA, with plaque metrics quantified using an artificial intelligence (AI)-based tool (Cleerly, Inc). Percent atheroma volume (PAV) and non-calcified plaque volume percentage (NCPV%), reflecting total plaque burden and the proportion of non-calcified plaque volume normalized to vessel volume, were evaluated. The primary endpoint was a composite of all-cause mortality and non-fatal myocardial infarction (MI). Cox proportional hazard models, adjusted for clinical risk factors and early revascularization, were employed for analysis. During a median follow-up of 7.0 years, 208 patients (8.7%) experienced the primary endpoint, including 73 cases of MI (3%). The model incorporating PAV demonstrated superior discriminatory power for the composite endpoint (AUC = 0.729) compared to CAC scoring (AUC = 0.706, P = 0.016). In MI prediction, PAV (AUC = 0.791) significantly outperformed CAC (AUC = 0.699, P < 0.001), with NCPV% showing the highest prognostic accuracy (AUC = 0.814, P < 0.001). Conclusion: AI-driven assessment of coronary plaque burden enhances prognostic accuracy for future adverse cardiovascular events, highlighting the critical role of comprehensive plaque characterization in refining risk stratification strategies.

Various non-invasive images are used in clinical practice for the diagnosis and prognostication of chronic coronary syndromes. Notably, quantitative myocardial perfusion imaging (MPI) through positron emission tomography (PET) has seen significant technical advancements and a substantial increase in its use over the past two decades. This progress has generated an unprecedented wealth of clinical information, which, when properly applied, can diagnose and fine-tune the management of patients with different types of ischemic syndromes. This state-of-art review focuses on quantitative PET MPI, its integration into clinical practice, and how it holds up at the eyes of modern cardiac imaging and revascularization clinical trials, along with future perspectives.

Background The diagnostic performance of non-invasive imaging techniques for detecting obstructive coronary artery disease (CAD) in patients with a history of myocardial infarction or percutaneous coronary intervention has not been comprehensively evaluated. This meta-analysis assesses the diagnostic value of coronary CT angiography (CCTA), CCTA combined with CT perfusion (CCTA+CTP), cardiac MRI (CMR) and single-photon emission CT (SPECT) compared with invasive reference standards. Methods We systematically searched PubMed, Embase, Web of Science and the Cochrane Library from 2005 to September 2022 for prospective, blinded studies including populations with ≥50% prior CAD. Results We identified 18 studies encompassing 3265 patients, with obstructive CAD present in 64%. The per-patient sensitivity of CCTA (0.95; 95% CI 0.92 to 0.98), CCTA+CTP (0.93; 95% CI 0.84 to 0.98) and CMR (0.91; 95% CI 0.86 to 0.94) was high, while SPECT showed lower sensitivity (0.63; 95% CI 0.52 to 0.73). SPECT had higher specificity compared with CCTA (0.66; 95% CI 0.56 to 0.76 vs 0.37; 95% CI 0.29 to 0.46), but was comparable to CCTA+CTP (0.59; 95% CI 0.49 to 0.69) and CMR (0.69; 95% CI 0.53 to 0.81). The area under the curve for SPECT was the lowest (0.70; 95% CI 0.58 to 0.87), while CCTA (0.91; 95% CI 0.86 to 0.98), CCTA+CTP (0.89; 95% CI 0.73 to 1.00) and CMR (0.91; 95% CI 0.80 to 1.00) showed similar high values. Conclusions In patients with prior CAD, CCTA, CCTA+CTP and CMR demonstrated high diagnostic performance, whereas SPECT had lower sensitivity. These findings can guide the selection of non-invasive imaging techniques in this high-risk population. PROSPERO registration number CRD42022322348.

Aims: The homogeneity of coronary microvascular dysfunction (CMD) across different myocardial territories in angina with non-obstructive coronary artery disease (ANOCA) patients is scarcely explored. This study investigates the variability in microvascular resistance reserve (MRR) across the 3 main perfusion territories of the coronary circulation to investigate the homogeneity or dishomogeneity of microcirculatory function. Methods and results: This post hoc analysis of the PACIFIC trials included symptomatic ANOCA patients with [15O]H2O positron emission tomography (PET) and three-vessel invasive fractional flow reserve (FFR). MRR was computed in the three main coronary branches by integrating PET-derived coronary flow reserve and invasive FFR. A total of 155 patients (50% male, age 59 ± 10 years) and 465 vessels (MRR: 3.92 ± 1.21) were included. There were no significant differences in MRR among the three coronary branches. Correlations in MRR among the three coronary branches were good (r = 0.76 to 0.86). The mean difference between MRR measurements in different arteries was small (2.4 to 7.5%), without any consistent directional bias. The overall intra-class correlation coefficient for absolute agreement was 0.80 (95% CI: 0.74–0.85), indicating good single-measure reliability. Approximately 80% (123/155) of patients showed diagnostic concordance of CMD (MRR ≤3.0) across the three vessels. Conclusion: In most ANOCA patients, microvascular function is homogeneously distributed across the three major coronary territories. Single-artery testing may suffice in many cases, aligning with guidelines. However, some patients exhibit notable inter-territorial variation, suggesting that multi-vessel evaluation may be prudent in borderline scenarios.