Christopher D. Maroules

Noncardiac Incidental Findings on Cardiac CT: A Step-by-Step Approach

Noncardiac incidental findings on cardiac CT are remarkably common and some of these may have a significant impact on patient management. Herein, we present a straightforward and cost-effective step-by-step approach for identifying and reporting noncardiac incidental findings. In Step 1, we discuss the ‘ABCDEFG’ search pattern for systematically reviewing noncardiac organ systems. The most prevalent and clinically significant incidental findings are highlighted with strategies for increasing their conspicuity. In Step 2, the importance of reviewing clinical history and prior imaging studies is discussed. In Step 3, we provide a classification scheme and follow-up recommendations for incidental findings based on their potential clinical significance.

Abdominal Aortic Atherosclerosis at MR Imaging Is Associated with Cardiovascular Events: The Dallas Heart Study

PURPOSE To determine the value of two abdominal aortic atherosclerosis measurements at magnetic resonance (MR) imaging for predicting future cardiovascular events. MATERIALS AND METHODS This study was approved by the institutional review board and complied with HIPAA regulations. The study consisted of 2122 participants from the multiethnic, population-based Dallas Heart Study who underwent abdominal aortic MR imaging at 1.5 T. Aortic atherosclerosis was measured by quantifying mean aortic wall thickness (MAWT) and aortic plaque burden. Participants were monitored for cardiovascular death, nonfatal cardiac events, and nonfatal extracardiac vascular events over a mean period of 7.8 years ± 1.5 (standard deviation [SD]). Cox proportional hazards regression was used to assess independent associations of aortic atherosclerosis and cardiovascular events. RESULTS Increasing MAWT was positively associated with male sex (odds ratio, 3.66; P < .0001), current smoking (odds ratio, 2.53; P < .0001), 10-year increase in age (odds ratio, 2.24; P < .0001), and hypertension (odds ratio, 1.66; P = .0001). A total of 143 participants (6.7%) experienced a cardiovascular event. MAWT conferred an increased risk for composite events (hazard ratio, 1.28 per 1 SD; P = .001). Aortic plaque was not associated with increased risk for composite events. Increasing MAWT and aortic plaque burden both conferred an increased risk for nonfatal extracardiac events (hazard ratio of 1.52 per 1 SD [P < .001] and hazard ratio of 1.46 per 1 SD [P = .03], respectively). CONCLUSION MR imaging measures of aortic atherosclerosis are predictive of future adverse cardiovascular events.

Assessment and reproducibility of aortic atherosclerosis magnetic resonance imaging: impact of 3-Tesla field strength and parallel imaging.

Objectives:To investigate image quality and interstudy reproducibility of aortic atherosclerosis imaging at 1.5 T, and to explore the impact of parallel imaging techniques at 3 T. Materials and Methods:Institutional review board approval and informed consent were obtained. Thirty-two subjects (20 normal, 12 patients with impaired cardiac function) underwent 4 black-blood T2-weighted imaging studies of the abdominal aorta: 2 conventional studies at 1.5 T, a conventional study at 3 T, and an accelerated 3-T study with parallel imaging (SENSE). Contrast-to-noise ratio and image quality score (1–5 scale, 5 = highest quality) were determined for each study. Studies were analyzed for mean wall thickness and area plaque burden as endpoints for aortic atherosclerosis. Bland-Altman analyses were performed to determine interstudy reproducibility between imaging methods. Wilcoxon signed-rank tests were used to identify significant differences between methods (P < 0.05). Results:Image quality scores were comparable between 1.5 T and 3 T with SENSE (4.0 ± 0.6 vs. 4.2 ± 0.6, P = 0.21). Bland-Altman reproducibility for mean wall thickness was −0.03 mm ± 0.15 (1.5 T vs. 1.5 T), 0.01 mm ± 0.17 (1.5 T vs. 3 T without SENSE), and −0.01 mm ± 0.18 (1.5 T vs. 3 T with SENSE), P = 0.83. Detection of the presence or absence of plaque was comparable. Bland-Altman reproducibility for area plaque burden was −0.02% ± 0.32% (1.5 T vs. 1.5 T), 0.06% ± 0.41% (1.5 T vs. 3 T without SENSE), and 0.11% ± 0.33% (1.5 T vs. 3 T with SENSE), P = 0.41. Conclusion:Black-blood MR imaging of aortic atherosclerosis is very reproducible. Parallel imaging at 3 T permits shorter scan time compared with conventional 1.5-T imaging with comparable measures of atherosclerosis extent.

Coronary Artery Disease - Reporting and Data System (CAD-RADS): An Expert Consensus Document of SCCT, ACR and NASCI: Endorsed by the ACC

The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.

Measurement of coronary flow response to cold pressor stress in asymptomatic women with cardiovascular risk factors using spiral velocity-encoded cine MRI at 3 tesla

Background: Coronary sinus (CS) flow in response to a provocative stress has been used as a surrogate measure of coronary flow reserve, and velocity-encoded cine (VEC) magnetic resonance imaging (MRI) is an established technique for measuring CS flow. In this study, the cold pressor test (CPT) was used to measure CS flow response because it elicits an endothelium-dependent coronary vasodilation that may afford greater sensitivity for detecting early changes in coronary endothelial function. Purpose: To investigate the feasibility and reproducibility of CS flow reactivity (CSFR) to CPT using spiral VEC MRI at 3 Tesla in a sample of asymptomatic women with cardiovascular risk factors. Material and Methods: Fourteen asymptomatic women (age 38 years ± 10) with cardiovascular risk factors were studied using 3D spiral VEC MRI of the CS at 3 T. The CPT was utilized as a provocative stress to measure changes in CS flow. CSFR to CPT was calculated from the ratio of CS flow during peak stress to baseline CS flow. Results: CPT induced a significant hemodynamic response as measured by a 45% increase in rate-pressure product (P<0.01). A significant increase in CS volume flow was also observed (baseline, 116 ± 26 ml/min; peak stress, 152 ± 34 ml/min, P=0.01). CSFR to CPT was 1.31 ± 0.20. Test-retest variability of CS volume flow was 5% at baseline and 6% during peak stress. Conclusion: Spiral CS VEC MRI at 3 T is a feasible and reproducible technique for measuring CS flow in asymptomatic women at risk for cardiovascular disease. Significant changes in CSFR to CPT are detectable, without demanding pharmacologic stress.

Interstudy reproducibility of SSFP cine magnetic resonance: Impact of magnetic field strength and parallel imaging

To study the effects of field strength and parallel imaging on image contrast and interstudy reproducibility of right and left ventricular (RV and LV) measurements using steady‐state free precession (SSFP) cardiovascular magnetic resonance (CMR).

CAD-RADS™: Coronary Artery Disease – Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology

The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.

CAD-RADS™: Coronary Artery Disease – Reporting and Data System

The intent of CAD-RADS - Coronary Artery Disease Reporting and Data System is to create a standardized method to communicate findings of coronary CT angiography (coronary CTA) in order to facilitate decision-making regarding further patient management. The suggested CAD-RADS classification is applied on a per-patient basis and represents the highest-grade coronary artery lesion documented by coronary CTA. It ranges from CAD-RADS 0 (Zero) for the complete absence of stenosis and plaque to CAD-RADS 5 for the presence of at least one totally occluded coronary artery and should always be interpreted in conjunction with the impression found in the report. Specific recommendations are provided for further management of patients with stable or acute chest pain based on the CAD-RADS classification. The main goal of CAD-RADS is to standardize reporting of coronary CTA results and to facilitate communication of test results to referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care.

Dynamic Relation of Changes in Weight and Indices of Fat Distribution With Cardiac Structure and Function: The Dallas Heart Study

Background Obesity may increase heart failure risk through cardiac remodeling. Cross‐sectional associations between adiposity and cardiac structure and function have been elucidated, but the impact of longitudinal changes in adiposity on cardiac remodeling is less well understood. Methods and Results Participants in the Dallas Heart Study without cardiovascular disease or left ventricular dysfunction underwent assessment of body weight, anthropometrics, and cardiac magnetic resonance imaging at baseline and 7 years later. Associations between changes in indices of generalized and central adiposity with changes in left ventricular mass, volume, mass/volume ratio (concentricity), wall thickness, and ejection fraction were assessed using multivariable linear regression. The study cohort (n=1262) mean age was 44 years with 57% women, 44% black, and 36% obese participants. At follow‐up, 41% had ≥5% weight gain, and 15% had ≥5% weight loss. Greater weight gain was associated with younger age, lower risk factor burden, and lower body mass index at baseline. In multivariable models adjusting for age, sex, race, comorbid conditions at baseline and follow‐up, baseline adiposity, and cardiac measurement, increasing weight was associated with increases in left ventricular mass (β=0.10, P<0.0001), wall thickness (β=0.10, P<0.0001), and concentricity (β=0.06, P=0.002), with modest effects on end‐diastolic volume (β=0.04, P=0.044) and ejection fraction (β=0.05, P=0.046). Similar results were seen with other adiposity indices. Conclusions Concentric left ventricular remodeling is the predominant phenotype linked to increasing adiposity in middle age. Our findings support the importance of weight management to prevent secular changes in adiposity, concentric remodeling, and eventual heart failure over time.

Association of Concentric Left Ventricular Hypertrophy With Subsequent Change in Left Ventricular End-Diastolic Volume: The Dallas Heart Study

Background In the conventional paradigm of the progression of left ventricular hypertrophy, a thick-walled left ventricle (LV) ultimately transitions to a dilated cardiomyopathy. There are scant data in humans demonstrating whether this transition occurs commonly without an interval myocardial infarction. Methods and Results Participants (n=1282) from the Dallas Heart Study underwent serial cardiac magnetic resonance ≈7 years apart. Those with interval cardiovascular events and a dilated LV (increased LV end-diastolic volume [EDV] indexed to body surface area) at baseline were excluded. Multivariable linear regression models tested the association of concentric hypertrophy (increased LV mass and LV mass/volume0.67) with change in LVEDV. The study cohort had a median age of 44 years, 57% women, 43% black, and 11% (n=142) baseline concentric hypertrophy. The change in LVEDV in those with versus without concentric hypertrophy was 1 mL (−9 to 12) versus −2 mL (−11 to 7), respectively, P<0.01. In multivariable linear regression models, concentric hypertrophy was associated with larger follow-up LVEDV (P⩽0.01). The progression to a dilated LV was uncommon (2%, n=25). Conclusions In the absence of interval myocardial infarction, concentric hypertrophy was associated with a small, but significantly greater, increase in LVEDV after 7-year follow-up. However, the degree of LV enlargement was minimal, and few participants developed a dilated LV. These data suggest that if concentric hypertrophy does progress to a dilated cardiomyopathy, such a transition would occur over a much longer timeframe (eg, decades) and may be less common than previously thought. Clinical Trial Registration URL: http://www.clinicaltrials.gov. Unique identifier: NCT00344903.