Atrial fibrillation (AF) is a growing global health burden and a leading cause of morbidity and mortality. A significant proportion of AF episodes are asymptomatic or subclinical, leading to underdiagnosis and delayed tr...Atrial fibrillation (AF) is a growing global health burden and a leading cause of morbidity and mortality. A significant proportion of AF episodes are asymptomatic or subclinical, leading to underdiagnosis and delayed treatment. Despite traditionally reserving rhythm control-particularly catheter ablation-for symptomatic patients, emerging evidence suggests that asymptomatic individuals face similar risks of stroke, heart failure, and AF progression. Recent data challenge the assumption that asymptomatic AF represents a benign phenotype. Meta-analyses and registry studies show comparable rates of adverse outcomes between symptomatic and asymptomatic patients and highlight AF progression as more frequent in the latter group, if left untreated. Randomized trials such as EAST-AFNET 4 and multiple ablation-first studies (e.g., EARLY-AF, Cryo-FIRST) support early rhythm control, with a growing rationale to consider it even in the absence of symptoms. Furthermore, pulsed field ablation (PFA) represents a transformative innovation, offering tissue-selective, non-thermal lesion creation with promising early clinical data. While routine ablation for all asymptomatic patients is not yet guideline-recommended, evolving evidence and improved safety profiles support a more proactive rhythm control strategy in selected individuals. Shared decision-making, grounded in risk stratification and patient-specific factors, is essential. As new data emerge, the case for expanding ablation indications to include asymptomatic AF continues to strengthen.
Cardiac amyloidosis is increasingly recognized as an underdiagnosed cause of heart failure. This review article provides an overview of the role of multimodality cardiovascular imaging in raising the suspicion of cardiac...Cardiac amyloidosis is increasingly recognized as an underdiagnosed cause of heart failure. This review article provides an overview of the role of multimodality cardiovascular imaging in raising the suspicion of cardiac amyloidosis, confirming the diagnosis, providing risk assessment and detection of myocardial changes in response to therapy. The clinical use of multimodality imaging in diagnosing cardiac amyloidosis is illustrated through a case-based approach. Finally, the emerging role of cardiac positron emission tomography as well as artificial intelligence in cardiac amyloidosis is discussed.
AIMS: Data on cardiac myosin inhibitors (CMIs) in obstructive hypertrophic cardiomyopathy (oHCM) are rapidly emerging. This systematic review and meta-analysis evaluated the efficacy and safety of CMIs in randomized plac...AIMS: Data on cardiac myosin inhibitors (CMIs) in obstructive hypertrophic cardiomyopathy (oHCM) are rapidly emerging. This systematic review and meta-analysis evaluated the efficacy and safety of CMIs in randomized placebo-controlled trials. METHODS: Phase 3 randomized placebo-controlled trials published up to 22-Apr-2025 were included. Outcomes extracted included symptoms, cardiopulmonary exercise testing (CPET), biomarkers, transthoracic echocardiography (TTE), cardiovascular magnetic resonance (CMR), and safety data. Frequentist (common/fixed effect, random) and Bayesian meta-analyses were performed using trial-level data to pool estimates of effects. RESULTS: Four randomized placebo-controlled trials involving 726 patients with oHCM were included (444 mavacamten/placebo, 282 aficamten/placebo). Trial follow-up durations ranged from 16 to 30 weeks. In common/fixed effects meta-analyses, CMIs were associated with a greater proportion achieving ≥1 NYHA improvement [difference 36 % (95 % CI 29, 43)] and an increase in KCCQ-CSS [8.4 (6.6, 10.2) points] versus placebo. CMIs significantly improved several CPET parameters including increased peak oxygen consumption [1.6 (1.0, 2.1) mL/kg/min] and reduced VE/VCO [-2.0 (-2.7, -1.3)]. CMIs significantly reduced NT-proBNP [-79 % (-81 %, -77 %)] and hs-cTnI [-50 % (-54 %, -46 %)]. CMIs led to significant reductions in resting LVOT-G [-40 (-45, -35) mmHg] and favourable cardiac remodelling in other TTE and CMR parameters. Although CMIs increased the likelihood of LVEF <50 %, consistent with its known mechanism of action, none of these patients developed heart failure. No significant differences were seen in safety outcomes. CONCLUSIONS: Mavacamten and aficamten significantly improve symptoms, enhance exercise performance, improve cardiac biomarkers, reduce LVOT obstruction, and promote favourable cardiac remodelling. These findings suggest a class effect of CMIs. PROSPERO REGISTRATION: CRD42024582096.
Prog Cardiovasc Dis
· 2025 · PMID 41043646
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This review highlights the evolving role of positron emission tomography (PET) in quantifying myocardial blood flow (MBF) and myocardial flow reserve (MFR) and its expanding clinical impact. The relative nature of perfus...This review highlights the evolving role of positron emission tomography (PET) in quantifying myocardial blood flow (MBF) and myocardial flow reserve (MFR) and its expanding clinical impact. The relative nature of perfusion assessment with single photon emission computed tomography often underestimates disease in patients with multivessel or microvascular involvement. Positron emission tomography (PET) enables absolute quantification of myocardial blood flow (MBF) and myocardial flow reserve (MFR), which provides deeper insights into coronary physiology. PET-derived MBF and MFR have shown clear diagnostic and prognostic value across a broad spectrum of conditions, including obstructive coronary artery disease, ischemia and angina without obstructive coronary artery disease, post-heart transplant cardiac allograft vasculopathy surveillance, diabetes, hypertension, and systemic inflammatory diseases. Impaired flow reserve consistently predicts adverse outcomes, even in the absence of visible perfusion defects. Newer tracers such as F-flurpiridaz, with their favorable kinetics and logistical advantages, are poised to expand clinical accessibility. At the same time, innovations such as artificial intelligence-driven analysis and total-body PET promise greater reproducibility and efficiency, further integrating flow assessment into everyday practice. Professional society guidelines now recommend routine incorporation of flow quantification into stress PET imaging, yet barriers remain, including limited access, heterogeneity in protocols, and a need for outcome-driven trials. As technology and evidence evolve, PET-based flow quantification is positioned to become an essential tool in precision cardiovascular care, bridging the gap between physiology and clinical decision-making.
OBJECTIVE: To examine the association between handgrip strength asymmetry and the risk of all-cause and cardiovascular mortality. METHODS: This cohort study analyzed participants aged 50 years and older from the SHARE st...OBJECTIVE: To examine the association between handgrip strength asymmetry and the risk of all-cause and cardiovascular mortality. METHODS: This cohort study analyzed participants aged 50 years and older from the SHARE study (2004-2022) across 28 countries. Handgrip strength asymmetry was assessed using a dynamometer, and mortality outcomes (all-cause and cardiovascular) were determined through proxy interviews. Using time-varying Cox regression models, we examined the association between handgrip asymmetry and mortality risk, adjusting for multiple covariates. RESULTS: The study included 107,256 participants (54.9 % women, 45.1 % men). Over a mean follow-up of 7.3 years, 11,574 deaths (10.8 %) from all causes and 4274 (3.98 %) from cardiovascular causes were recorded. The analysis revealed a non-linear relationship. For handgrip strength asymmetries of 4-5 kg, both all-cause mortality risk (HR: 1.06; 95 % CI: 1.01-1.10) and cardiovascular mortality risk (HR: 1.15; 95 % CI: 1.07-1.24) increased significantly. A more pronounced increase was observed from 10 kg of asymmetry, with a 32 % increased risk of all-cause mortality (HR: 1.32; 95 % CI: 1.22-1.43) and a 39 % increased risk of cardiovascular mortality (HR: 1.39; 95 % CI: 1.22-1.59). For asymmetries ≥15 kg, the risk of all-cause mortality increased by 39 % (HR: 1.39; 95 % CI: 1.19-1.61) and by 58 % for cardiovascular mortality (HR: 1.58; 95 % CI: 1.24-2.02). CONCLUSIONS: Even minor handgrip strength asymmetry is significantly linked to higher mortality. This finding suggests that handgrip strength asymmetry may have potential clinical relevance as an additional marker for mortality risk assessment, though further research is needed to evaluate its discriminative value beyond established risk factors.
Vasculitides are caused by a pathological inflammatory reaction inside the arterial wall that may involve all three layers (endothelium, media and adventitia). They are typically grouped according to the caliber of the v...Vasculitides are caused by a pathological inflammatory reaction inside the arterial wall that may involve all three layers (endothelium, media and adventitia). They are typically grouped according to the caliber of the vessels involved-large, medium or small. The diagnosis of vasculitis should be made rapidly because of the risk of ischemic complications due to vascular occlusion and immunosuppressive treatment initiated without delay. Histological analysis of vascular samples remains the gold standard for the diagnosis but may be inconclusive or not accessible. Non-invasive imaging is playing an increasing role for the diagnosis of vasculitis. Among the different imaging modalities available, F-fluorodeoxyglucose positron-emission tomography (FDG-PET) has demonstrated its interest for the diagnosis of vasculitis. FDG is an analogue of glucose bound to a positron emitter, that accumulates in activated inflammatory cells. FDG-PET imaging provides high sensitivity for the detection of vascular wall inflammation associated with vasculitis. PET imaging has a spatial resolution of only 4-5 mm which is adequate for large vessel vasculitis such as giant cell or Takayasu arteritis, but insufficient for medium or small vessels. FDG-PET has demonstrated high diagnostic performance for the diagnosis of giant cell arteritis and Takayasu arteritis as well as for monitoring the regression of vascular inflammation under immunosuppressive therapy. The role of FDG-PET for the detection and prediction of relapse remains, however, largely discussed. In addition to its role in inflammatory vasculitis, FDG-PET can also help identify vascular complications of sepsis due to septic emboli, such as infectious aortitis or mycotic aneurysms.
Artificial intelligence (AI) is rapidly reshaping cardiovascular imaging, with nuclear cardiology uniquely positioned to benefit. By addressing the technical complexity of image acquisition, reconstruction, and interpret...Artificial intelligence (AI) is rapidly reshaping cardiovascular imaging, with nuclear cardiology uniquely positioned to benefit. By addressing the technical complexity of image acquisition, reconstruction, and interpretation, AI can enhance image quality, reduce radiation exposure, and improve efficiency. Beyond image optimization, AI enables virtual attenuation correction and automated quantification of novel risk markers that are otherwise impractical to assess manually. Machine learning models can also integrate multimodal data, including clinical, stress, and imaging features, to support more accurate diagnosis and to refine risk stratification. Deep learning can be used to provide direct diagnostic or risk stratification estimates from nuclear cardiology images. This review highlights recent advances in AI within nuclear cardiology, outlines their potential to transform clinical workflows, and discusses future directions for integrating these tools into routine practice.
Nuclear cardiology has become an integral component of cardiovascular care in oncology, providing robust tools for the detection, monitoring, and mechanistic assessment of cancer therapy-related cardiac dysfunction. This...Nuclear cardiology has become an integral component of cardiovascular care in oncology, providing robust tools for the detection, monitoring, and mechanistic assessment of cancer therapy-related cardiac dysfunction. This review outlines the evolving applications of nuclear imaging across the cardio-oncology continuum, from reproducible quantification of left ventricular ejection fraction with multigated acquisition to advanced molecular imaging with positron emission tomography for the identification of pathobiology. We discuss the utility of radionuclide techniques for early detection of subclinical cardiotoxicity, including phase analysis, metabolic imaging with F-fluorodeoxyglucose, and emerging tracers targeting inflammation, fibrosis, and immune cell activity. Special considerations are given to their role in differentiating ischemic from non-ischemic injury, evaluating cardiac tumors, and guiding therapeutic decisions. Comparative strengths and limitations relative to other imaging modalities are briefly addressed, along with practical considerations such as access, and modality selection. Looking forward, developments in hybrid imaging, artificial intelligence, and targeted radiotracers are poised to enhance risk stratification and enable personalized, mechanism-based cardioprotection. Nuclear cardiology, when integrated thoughtfully into multimodal strategies, will be essential to advancing precision care in cardio-oncology.
Hybrid imaging has transformed nuclear cardiology by integrating anatomical and molecular data. Positron emission tomography (PET) /CT and single-photon emission computed tomography (SPECT)/CT improve diagnostic accuracy...Hybrid imaging has transformed nuclear cardiology by integrating anatomical and molecular data. Positron emission tomography (PET) /CT and single-photon emission computed tomography (SPECT)/CT improve diagnostic accuracy through attenuation correction, coronary artery calcium (CAC) scoring, and precise localization of tracer uptake. These advances enhance risk stratification, differentiate obstructive from microvascular disease, and detect extracardiac pathology. Despite these strengths, adoption remains limited. Misregistration, motion artifacts, and suboptimal CT quality restrict image reliability, while reimbursement gaps, workforce shortages, and training standards may hinder broader adoption. The frequent detection of incidental findings further underscores the need for structured reporting protocols, yet reimbursement pathways remain unclear. PET/magnetic resonance imaging (MRI) offers unique advantages by combining the molecular sensitivity of PET with the superior soft tissue characterization of MRI, without additional radiation. This modality is particularly valuable in myocarditis, sarcoidosis, viability assessment, and cardiac tumors, where multiparametric data refine diagnosis and guide management. Motion correction using real-time MRI tracking adds further potential. However, PET/MRI adoption is constrained by high costs, technical complexity, prolonged scan times, and limited validation outside tertiary centers. The lack of large multicenter outcome studies continues to restrict its role to research settings, where its strengths in tissue characterization and integrated functional assessment are most apparent.
Single photon emission computed tomography (SPECT) remains the most widely used modality for the assessment of coronary artery disease (CAD) owing to its diagnostic and prognostic value, cost-effectiveness, broad availab...Single photon emission computed tomography (SPECT) remains the most widely used modality for the assessment of coronary artery disease (CAD) owing to its diagnostic and prognostic value, cost-effectiveness, broad availability, and ability to be performed with exercise testing. However, major cardiology guidelines recommend positron emission tomography (PET) over SPECT when available, largely due to its superior accuracy and ability to provide absolute myocardial blood flow quantification. A key limitation of SPECT is its reliance on relative perfusion imaging, which may overlook diffuse flow reductions, such as those seen in balanced ischemia, diffuse atherosclerosis, and microvascular dysfunction. With the shifting paradigm of CAD toward non-obstructive disease, the need for absolute quantification has become increasingly critical. This review highlights the strengths and limitations of SPECT and explores strategies to preserve its clinical relevance in the PET era. These include the adoption of CZT-SPECT technology for quantification, the use of hybrid systems for attenuation correction and calcium scoring, the adoption of stress-only protocols, the integration of quantitative data and calcium scoring into reporting, and the emerging applications of artificial intelligence (AI) among others.
BACKGROUND: Cardiopulmonary resuscitation (CPR) is a vital intervention for managing cardiac arrest; however, enhancing survival rates remains a significant challenge. Recent advancements highlight the importance of inte...BACKGROUND: Cardiopulmonary resuscitation (CPR) is a vital intervention for managing cardiac arrest; however, enhancing survival rates remains a significant challenge. Recent advancements highlight the importance of integrating artificial intelligence (AI) to overcome existing limitations in prediction, intervention, and post-resuscitation care. METHODS: A thorough review of contemporary literature regarding AI applications in CPR was undertaken, explicitly examining its role in the early prediction of cardiac arrest, optimization of CPR quality, and enhancement of post-arrest outcomes. The analysis incorporated data from machine learning models, biosignal-responsive robotics, and advanced monitoring systems to showcase advancements and identify future challenges. RESULTS: Innovations driven by AI have significantly transformed CPR practices across multiple areas. Predictive algorithms leveraging electronic health records and continuous electrocardiogram (ECG) monitoring facilitate the early identification of at-risk patients. Additionally, AI-enhanced feedback systems improve the accuracy of chest compressions and minimize variability in manual execution. Integrating AI with automated external defibrillators (AEDs) and real-time ECG analysis increases defibrillation precision and reduces interruptions during CPR. Emerging technologies, including wearable devices, immersive training simulators, and drone-delivered defibrillators, show considerable potential in addressing response time disparities during out-of-hospital cardiac arrests. Nevertheless, ethical considerations, particularly regarding data privacy and equitable access, pose significant challenges. CONCLUSIONS: Integrating AI into CPR practices can enhance prediction accuracy, procedural effectiveness, and survival rates. Addressing the ethical, legal, and technological barriers to successful implementation in clinical settings is crucial.
OBJECTIVES: This study explores the impact of lower baseline aortic valve (AV) mean gradients on the clinical outcomes of patients with low-gradient aortic stenosis (LG AS) post-transcatheter aortic valve replacement (TA...OBJECTIVES: This study explores the impact of lower baseline aortic valve (AV) mean gradients on the clinical outcomes of patients with low-gradient aortic stenosis (LG AS) post-transcatheter aortic valve replacement (TAVR). Additionally, the study aims to understand the predictors of a lower baseline AV mean gradient (MG). BACKGROUND: Reduced left ventricular ejection fraction (LVEF) and low-flow states are known to correlate with worse clinical outcomes. Lower mean gradients are also known to correlate with poorer outcomes, but the outcomes of patients with very low-gradient AS compared to low-gradient AS are not well understood. METHODS: This is a retrospective cohort of patients >18 years who underwent TAVR at Cleveland Clinic between 2016 and 2020. Only patients with AV area < 1 cm, and AV MG <40 mmHg were included. Patients who underwent valve-in-valve TAVR were excluded. Patients were classified into 3 tertiles according to their baseline AV MG. Clinical outcomes included mortality and heart failure hospitalization. Survival analysis was used to assess the clinical outcomes between the tertiles. RESULTS: Around 60 % of the patients in this study were males, with a mean age of 80 years. The mean AV MG was 21.8 ± 4.0 mmHg for the first tertile, 30.9 ± 1.9 mmHg for the second tertile, and 37.1 ± 1.6 mmHg for the third tertile. The present study shows that patients with very low-gradient AS (first tertile) have higher mortality rates compared to those with low-gradient AS (third tertile) (hazard ratio: 2.07, 95 % confidence interval (1.2-3.6)), even after stratifying by flow and by LVEF. Lower stroke volume index (SVI), lower LVEF, atrial fibrillation, and moderate to severe TR were associated with lower mean gradients. CONCLUSIONS: Patients with very low-gradient AS have worse outcomes than those with low-gradient AS. Multiple clinical characteristics, including a lower SVI, lower LVEF, and atrial fibrillation, correlate with having very low-gradient AS. Therefore patients with low-gradient AS should undergo earlier intervention to improve their clinical outcomes.
Stankowski K, Volpi B, Balata F
… +12 more, Buonamici L, Biroli M, Figliozzi S, Maltagliati A, Mancini E, Mantegazza V, Pepi M, Muratori M, De Marco F, Fazzari F, Cannata F, Pontone G
Left atrial appendage (LAA) closure has emerged as a critical therapeutic option for stroke prevention in patients with atrial fibrillation who are unsuitable for long-term oral anticoagulation. Multimodality imaging pla...Left atrial appendage (LAA) closure has emerged as a critical therapeutic option for stroke prevention in patients with atrial fibrillation who are unsuitable for long-term oral anticoagulation. Multimodality imaging plays a pivotal role throughout the LAA closure process, from pre-procedural planning to long-term follow-up. This review focuses on the complementary roles of cardiac computed tomography (CCT) and transesophageal echocardiography (TEE), outlining their respective strengths and limitations in various phases of LAA management, while also discussing the roles of intracardiac echocardiography (ICE) and fluoroscopy. Pre-procedurally, CCT and TEE provide detailed anatomical characterization of the LAA, including morphology, ostial dimensions, and adjacent structures, aiding device sizing and selection. TEE, with its real-time imaging capabilities, remains essential intra-procedurally for guiding device deployment, assessing sealing, and identifying complications such as pericardial effusion or device embolization. The role of ICE as a lesser invasive intraprocedural alternative is steadily growing. Post-procedural and long-term follow-up imaging relies on both modalities to evaluate for residual leaks, device-related thrombus, embolization and other potential complications. The integration of CCT and TEE enhances procedural safety, accuracy, and long-term efficacy. This review underscores the importance of a tailored, patient-specific approach to imaging, leveraging the synergistic advantages of CCT and TEE to optimize outcomes in LAA closure.