Cardiac CT is a rapidly advancing technology. Non-invasive CT coronary angiography is an established technique for assessing coronary heart disease with accuracy similar to invasive coronary angiography. CT myocardial perfusion imaging can now identify perfusion defects in animal models and humans. MRI is the current 'gold standard' for the assessment of myocardial viability, but it is now also possible to assess delayed enhancement by CT. This has led to the possibility of a 'one-stop shop' for cardiovascular imaging that would provide information on anatomy, function, perfusion and viability in one rapid diagnostic test at a radiation dose equivalent to contemporary nuclear medicine imaging. This review discusses the current status of 'one-stop shop' cardiac CT assessment, clinical utility and directions for future research.

We recently published a commentary on the impact of blood biomarkers in clinical decision-making. In this issue we shift to a similar contemporary debate surrounding over-reliance on imaging technologies to make diagnoses, often without a clinical rationale other than to rule out pathology. This strategy is not without harm to patients as illustrated by both of our experienced contributors. The place and responsibility for missed or irrelevant diagnoses following imaging will often rest on little more than inept clinical targeting, although as McCoubrie points out, the skilled radiologist may have some role in tempering everything from overzealous interpretation to simple error. Given that many techniques are based on (albeit falling) X-ray exposure and involve vastly expensive (and routinely redundant) technologies operating almost continuously, the role of skilled radiological input is more essential than ever for reducing VOMIT. Can we control inadequate imaging request strategies?KeywoRdS Clinical decision-making, medical imaging, 'rule-out' testing, incidentalomas, radiation dose, demise of bedside medicine deClARATion of inTeReSTS No conflicts of interest declared.VOMIT is overstated, preventable and flawed Victim of medical imaging technology isn't a particularly new idea; the term 'incidentaloma' was coined 30 years ago.3 Since this original description of increasingly found incidental adrenal lesions, it has emerged that if one looks closely enough, most organs commonly contain benign masses that are often difficult to distinguish from early malignancies. The principles underlying VOMIT are now considered beyond question. The increasing accuracy brought by advances in imaging technology brings an inevitable flurry of incidental findings. It is a hegemonic assumption that 'red herrings' are an inevitable part of modern medicine. It logically follows that the more modern the imaging technology, the more VOMIT it will produce. Increased availability of modern scanners will merely result in more VOMIT. The ultimate extrapolation of this argument is that expansion of radiological imaging services will not produce population health gains; expansion should be therefore resisted. There are many reasons why this is wrong. In truth, VOMIT is a flawed principle.Why is it flawed? First, incidental isn't always trivial. Second, VOMIT is overstated but not intrinsic to scanning, just usually down to poorly performing radiologists. Third, I will contend the rise in incidental findings is due to defensive medicine driving increasing scanning rates. inCidenTAl iSn'T AlwAyS TRiviAlIt is often forgotten that some 'incidental' findings are not innocuous. For example:• Unexpected malignancies are commonly identified.In a large series of nearly 11,000 patients undergoing bowel cancer screening with computed tomography (CT) colonography (Figure 1), 4 unexpected extracolonic malignancies were discovered in 0.6% of patients. Interestingly, this is over double the rate of colonic malignancies in their series.• Serendipi...