Recent studies have demonstrated that coronary plaque burden carries greater prognostic value in predicting adverse atherosclerotic cardiovascular disease outcomes than myocardial ischemia, thereby challenging the existing paradigm. Advances in plaque quantification through both noncontrast and contrast-enhanced computed tomography (CT) methods have led to earlier and more cost-effective detection of coronary disease compared with traditional stress testing. The 2 principal techniques of noninvasive coronary plaque quantification assessment are coronary artery calcium scoring by noncontrast CT and coronary CT angiography, both of which correlate with disease burden on invasive angiography. Plaque quantification from these imaging modalities has shown utility in risk stratification and prognostication of adverse cardiovascular events, leading to increased incorporation into clinical practice guidelines and preventive care pathways. Furthermore, due to their expanding clinical value, emerging technologies such as artificial intelligence are being integrated into plaque quantification platforms, placing more advanced measures of plaque burden at the forefront of coronary plaque evaluation. In this review, we summarize recent clinical data on coronary artery calcium scoring and coronary CT angiography plaque quantification in the evaluation of adverse atherosclerotic cardiovascular disease in patients with and without chest pain, highlight how these methods compare to invasive quantification approaches, and directly compare the performance characteristics of coronary artery calcium scoring and coronary CT angiography.

Atrial fibrillation (AF) is the most common arrhythmia worldwide and is associated with increased risk of heart failure, stroke, and death. In current medical practice, multimodality imaging is routinely used in the management of AF. Twenty-one years ago, the ACUTE trial (Assessment of Cardioversion Using Transesophageal Echocardiography) results were published, and the management of AF changed forever by incorporating transesophageal echocardiography guided cardioversion of patients in AF for the first time. Current applications of multimodality imaging in AF in 2022 include the use of transesophageal echocardiography and computed tomography before cardioversion to exclude left atrial thrombus and in left atrial appendage occlusion device implantation. Transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance are clinically used for AF ablation planning. The decision to use a particular imaging modality in AF is based on patient’s characteristics, guideline recommendation, institutional preferences, expertise, and cost. In this first of 2-part review series, we discuss the preprocedural role of echocardiography, computed tomography, and cardiac magnetic resonance in the AF, with regard to their clinical applications, relevant outcomes data and unmet needs, and highlights future directions in this rapidly evolving field.

Background: Subaortic stenosis (SAS) is characterized by a fibromuscular membrane located just below the aortic valve, causing fixed outflow tract obstruction. There is a paucity of studies evaluating this condition. This cohort study reviewed the contemporary characteristics and outcomes of SAS in adult patients in a single large referral center. Methods and Results: We retrospectively studied adult patients with SAS evaluated at our center during 2011 to 2022. The primary outcome was all‐cause mortality and heart failure hospitalizations during follow‐up, with secondary end points including recurrence of SAS and repeat surgery after initial SAS surgery. Among 484 patients with SAS, key characteristics included mean age 55±18 years, 67.5% female, left ventricular outflow tract peak velocity 352±140 cm/s and gradient 57±40 mm Hg, left ventricular ejection fraction 60%±14%, 54.8% had prior SAS surgery, and 45.1% had surgery during follow‐up. Over a median follow‐up of 5.5 (1.5–12.3) years, 11.5% (n=56) died, 6.8% (n=33) had heart failure hospitalizations, 8.0% (n=39) experienced SAS recurrence, and 14 (5.9%) underwent repeat SAS surgery. Multivariable analyses identified older age per 10‐years (hazard ratio [HR], 1.37 [95% CI, 1.12–1.68]) and baseline New York Heart Association class (HR, 2.48 [95% CI, 1.54–3.99]) to be statistically significantly associated with the primary end point; higher body mass index, New York Heart Association class, and peak left ventricular outflow tract gradient were also statistically significantly associated with SAS recurrence and redo surgery. Conclusions: Almost half of patients with SAS had surgery in the past or during follow‐up, and a significant minority had mortality or morbidity events during follow‐up. Identified prognosticators warrant further research to guide management.

Aims: Left atrial strains [reservoir (LASr), conduit (LAScd), and contractile (LASct)] are increasingly utilized, primarily in the areas of heart failure and valvulopathy. Commercially available software to measure strain are marketed as imaging machine vendor independent, although the normal ranges of their performance and external validation studies are lacking. We evaluated and compared LAS values, reference ranges, and associated factors using contemporary strain software. Methods and results: Healthy subjects (n = 100) undergoing transthoracic echocardiography during January to April 2023 were studied, with equal number by age groups, sex, and GE vs. Philips equipment. LASs were quantified using TomTec version 51.02 (AutoStrain LA), EchoPAC version 206 (AFILA), velocity vector imaging (VVI) version 2.00, and Epsilon version 5.0.2.11295 software. Means and lower limits of normal [95% confidence interval (CI)] of LASr (%) were 44.1 (41.9, 46.3) and 30.3 (26.4, 34.1) for TomTec; 34.8 (33.6, 36.0) and 26.3 (24.2, 28.4) for EchoPAC (on GE scans only); 42.5 (40.2, 44.8) and 28.4 (24.4, 32.4) for VVI; and 37.0 (34.9, 39.1) and 25.2 (21.5, 28.8) for Epsilon. Factors significantly associated with variability in LASr measurements and their beta-coefficients (95% CI) were age −2.37 (−3.41, −1.33) per 10 years, EchoPAC (vs. TomTec) −9.63 (−12.75, −6.51), and Epsilon (vs. TomTec) −7.04 (−9.40, −4.67). Reference ranges and factors significantly associated with LAScd and LASct were reported. LAS measurements and normal ranges by strain software and associated clinical and echocardiographic factors were determined. Conclusion: EchoPAC and Epsilon have lower magnitude mean LAS values compared with TomTec and VVI, and all software were vendor neutral except EchoPAC.