AimsCT calcium scoring (CTCS) and CT cardiac angiography (CTCA) are widely used in patients with stable chest pain to exclude significant coronary artery disease (CAD). We aimed to resolve uncertainty about the prevalence of obstructive coronary artery disease and long-term outcomes in patients with a zero-calcium score (ZCS).Methods and resultsConsecutive patients with stable cardiac symptoms referred for CTCS or CTCS and CTCA from chest pain clinics to a tertiary cardiothoracic centre were prospectively enrolled. In those with a ZCS, the prevalence of obstructive CAD on CTCA was determined. A follow-up for all-cause mortality was obtained from the NHS tracer service. A total of 3914 patients underwent CTCS of whom 2730 (69.7%) also had a CTCA. Half of the patients were men (50.3%) with a mean age of 56.9 years. Among patients who had both procedures, a ZCS was present in 52.2%, with a negative predictive value of 99.5% for excluding ≥70% stenosis on CTCA. During a mean follow-up of 5.2 years, the annual event rate was 0.3% for those with ZCS compared with 1.2% for CS ≥1. The presence of non-calcified atheroma on CTCA in patients with ZCS did not affect the prognostic value (P = 0.98).ConclusionIn patients with stable symptoms and a ZCS, obstructive CAD is rare, and prognosis over the long-term is excellent, regardless of whether non-calcified atheroma is identified. A ZCS could reliably be used as a ‘gatekeeper’ in this patient cohort, obviating the need for further more expensive tests.

Accurate and timely assessment of suspected acute aortic syndrome is crucial in this life-threatening condition. Imaging with CT plays a central role in the diagnosis to allow expedited management. Diagnosis can be made using locally available expertise with optimized scanning parameters, making full use of recent advances in CT technology. Each imaging centre must optimize their protocols to allow accurate diagnosis, to optimize radiation dose and in particular to reduce the risk of false-positive diagnosis that may simulate disease. This document outlines the principles for the acquisition of motion-free imaging of the aorta in this context.

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SummaryAircrew are responsible for safe and reliable aircraft operations. Cardiovascular disease accounts for 50% of all pilot licences declined or withdrawn for medical reasons in Western Europe and is the most common cases of sudden incapacitation in flight. Aircrew retirement age is increasing (up to age 65) in a growing number of airlines and the burden of subclinical, but potentially significant, coronary atherosclerosis is unknown in qualified pilots above age 40. Safety considerations are paramount in aviation medicine, and the most dreaded cardiovascular complications are thromboembolic events and rhythm disturbances due to their potential for sudden incapacitation. In aviation, the current consensus risk threshold for an acceptable level of controlled risk of acute incapacitation is 1% (for dual pilot commercial operations), a percentage calculated using engineering principles to ensure the incidence of a fatal air accident is no greater than 1 per 107 h of flying. This is known as the ‘1% safety rule’. To fly as a pilot after cardiac surgery is possible; however, special attention to perioperative planning is mandatory. Choice of procedure is crucial for license renewal. Licensing restrictions are likely to apply and the postoperative follow-up requires a tight scheduling. The cardiac surgeon should always liaise and communicate with the pilot’s aviation medicine examiner prior to and following cardiac surgery.