Nowadays, coronary computed tomography angiography (CCTA) has a role of paramount importance in the diagnostic algorithm of ischemic heart disease (IHD), both in stable coronary artery disease (CAD) and acute chest pain. Alongside the quantification of obstructive coronary artery disease, the recent technologic developments in CCTA provide additional relevant information that can be considered as “novel markers” for risk stratification in different settings, including ischemic heart disease, atrial fibrillation, and myocardial inflammation. These markers include: (i) epicardial adipose tissue (EAT), associated with plaque development and the occurrence of arrhythmias; (ii) late iodine enhancement (LIE), which allows the identification of myocardial fibrosis; and (iii) plaque characterization, which provides data about plaque vulnerability. In the precision medicine era, these emerging markers should be integrated into CCTA evaluation to allow for the bespoke interventional and pharmacological management of each patient.

After almost a decade of stagnation in clinical research for HF treatment, five large randomized trials recently published have supported the use of four new classes of drugs, namely: angiotensin receptor/neprilysin inhibitor, sodium–glucose co-transporters 2 inhibitors, soluble guanylate cyclase modulators, and myosin activators. Each treatment has proved to be beneficial for both long-term outcomes and quality of life. Beside their clinical relevance, all these novel treatments have a different mechanism of action beyond the usual neuro-hormonal blockage. These different pathways, together with the unquestionable clinical evidence, advocate a re-thinking of HF treatment and of the appropriate drug to integrate with the existing standard therapy, according to different characteristics of HFrEF patients. This study aimed to offer a synthetic overview of the mechanisms of action of the new drugs and to propose a more personalized approach, considering patients’ characteristics and safety profiles. To this end, we have identified seven profiles for patients with chronic heart failure with reduced ejection fraction and two for pre-discharge patients.

Background: Little evidence to date has described the feasibility and diagnostic accuracy of coronary computed tomography angiography (CCTA) with noninvasive fractional flow reserve (CT-FFR) in coronary vessels with resorbable magnesium scaffold (RMS). Methods: The SHERPA-MAGIC is a prospective study enrolling patients receiving RMS. The present analysis considered patients undergoing CCTA 18 months after the index procedure. CCTA images were employed to investigate reabsorption status, luminal measurements, and noninvasive FFR. Three-year follow-up was available for all patients. Results: Overall, 26 patients with a total of 29 coronary arteries treated with 35 RMS were considered. The most frequently involved vessel was left anterior descendent (LAD). Median stent length was 25 (20–25) mm, with a median diameter of 3 (3–3.5) mm. At 18-month CCTA, all scaffolded segments were patent. Complete RMS reabsorption was observed in 27 (93%, 95% CI 77–99%) cases. Median minimal lumen diameter (MLD) and area (MLA) of the scaffolded segments were 2.5 [2.1–2.8] mm and 6.4 [4.4–8.4] mm2, respectively. Median CT-FFR was 0.88 [0.81–0.91]. Only one (3.5%) vessel showed a flow-limiting CT-FFR value ≤0.80. During the 3-year follow-up, only one (4%) adverse event was observed. Conclusions: In patients undergoing RMS implantation, CCTA including noninvasive CT-FFR evaluation is feasible and allows investigation of long-term RMS performance.

The aim of this review is to identify possible structural abnormalities of BrS and their potential association with symptoms, risk stratification, and prognosis. (1) Background: BrS has always been considered a purely electrical disease and imaging techniques do not currently play a specific role in the diagnosis of this arrhythmic syndrome. Some authors have recently hypothesized the presence of structural and functional abnormalities. Therefore, several studies investigated the presence of pathological features in echocardiography and cardiac magnetic resonance imaging (MRI) in patients with BrS, but results were controversial. (2) Methods: We performed a systematic review of the literature on the spectrum of features detected by echocardiography and cardiac MRI. Articles were searched in Pubmed, Cochrane Library, and Biomed Central. Only papers published in English and in peer-reviewed journals up to November 2021 were selected. After an initial evaluation, 596 records were screened; the literature search identified 19 relevant articles. (3) Results: The imaging findings associated with BrS were as follows: right ventricular dilation, right ventricular wall motion abnormalities, delayed right ventricular contraction, speckle and feature tracking abnormalities, late gadolinium enhancement, and fat infiltration in the right ventricle. Furthermore, these features emerged more frequently in patients carrying the genetic mutation on the sodium voltage-gated channel α-subunit 5 (SCN5A) gene. (4) Conclusions: Specific imaging features detected by echocardiography and cardiac magnetic resonance are associated with BrS. However, this population appears to be heterogeneous and imaging anomalies emerged to be more frequent in patients carrying genetic mutations of SCN5A. Future studies with an evaluation of BrS patients are needed to identify the specific association linking the Brugada pattern, imaging abnormalities and their possible correlation with prognosis.

Background Cardiac metastases (CM) are rare findings and their diagnosis is often challenging due to the large panel of symptoms they can cause. CM are frequently clinically silent, and their diagnosis is frequently made post-mortem. Even in the rare cases in which they clinically manifest themselves, it's harsh to distinguish them from other (more common) cardiovascular conditions presenting with the same panel of symptoms. The diagnosis could be very challenging, in particular in subjects with occult primary neoplasm. Electrocardiogram, although not specific, is frequently abnormal and imaging tools play a key role in the diagnostic process. Case Report A 75-year-old man went to the emergency room for chest pain and fever. The pain differs from that experienced in previous myocardial infarction. Laboratory tests showed plateau rise in troponins and the electrocardiogram showed diffuse changes in depolarization and repolarization. Transthoracic echocardiographic assessment showed a non-dilated left ventricle (LV) with a huge thickening of the interventricular septum and of the LV apex. The inferior wall was akinetic and the ejection fraction of the left ventricle was 45%; diffuse pericardial effusion was also present. To characterize the nature of this finding, a chest CT scan an a Cardiac Magnetic Resonance were performed. The diagnosis of a cardiac metastasis and its occult primary lung cancer was then made. Discussion In this clinical case, metastases manifest themselves mimicking an acute coronary syndrome, albeit with atypical characteristics; the atypical symptoms and the instrumental findings made us hypothesize that we were not dealing with a myocardial infarction. The peculiarity of this clinical case lies in the fact that the onset of symptoms led to the diagnosis of the cardiac metastasis and, subsequently, of the occult primary lung tumor. Our case report warn us that, sometimes, when you hear the hoofbeats you should also have to think about zebras.