Coronary artery disease (CAD) still represents a leading cause of mortality worldwide. Early identification of patients at the highest risk of CAD is crucial to prevent acute adverse events and reduce morbidity and mortality. The coronary artery calcium (CAC) score is a reliable cardiovascular (CV) risk index with an independent prognostic value. Guidelines recommend using it as a risk enhancer in individuals with low or moderate CV risk. However, other computed tomography (CT) measurable parameters have recently been proposed as CV risk markers. Increasing evidence demonstrates the association between epicardial fat volume and coronary atherosclerosis in chronic and acute coronary syndromes. Furthermore, other parameters obtainable from CT, such as aortic stiffness, liver fat, aortic calcium, and myocardial scarring, are under investigation. This review aims to describe all CT potential in atherosclerosis detection and cardiovascular risk assessment beyond the CAC, trying to understand how to integrate CT parameters with traditional risk factors and to improve clinicians' ability to detect CAD early, allowing appropriate therapies promptly.

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The most common organic etiology of mitral regurgitation is degenerative and consists of mitral valve prolapse (MVP). Volume overload because of mitral regurgitation is the most common complication of MVP. Advocating surgery before the consequences of volume overload become irreparable restores life expectancy, but carries a risk of mortality in patients who are often asymptomatic. On the other hand, the post-surgical outcome of symptomatic patients is dismal and life expectancy is impaired. In the present article, we aim to bridge the gap between these two therapeutic approaches, unifying the concepts of watchful waiting and early surgery in a “watchful surgery approach”.

Aims New onset atrial fibrillation (NOAF) is associated with worse clinical outcomes after acute coronary syndrome (ACS). Identification of patients at risk of NOAF remains challenging, and various clinical scores of varying complexities have been proposed to predict incident AF. We tested the value of the simple C2HEST score for predicting NOAF in patients with ACS. Methods We studied patients from the prospective ongoing multicenter REALE-ACS registry of patients with ACS. NOAF was the primary endpoint of the study. The C2HEST score was calculated as coronary artery disease or chronic obstructive pulmonary disease (1 point each), hypertension (1 point), elderly (age ≥75 years, 2 points), systolic heart failure (2 points), thyroid disease (1 point). We also tested the mC2HEST score. Results We enrolled 555 patients (mean age 65.6±13.3 years; 22.9% women), of which 45 (8.1%) developed NOAF. Patients with NOAF were older (p<0.001) and had more prevalent hypertension (p=0.012), COPD (p<0.001) and hyperthyroidism (p=0.018). Patients with NOAF were more frequently admitted with STEMI (p<0.001), cardiogenic shock (p=0.008), Killip class ≥2 (p<0.001) and had higher mean GRACE score (p<0.001). Patients with NOAF had a higher C2HEST score compared with those without (4.2±1.7 vs 3.0±1.5, p<0.001). A C2HEST score >3 was associated with NOAF occurrence (odds ratio 4.33, 95% confidence interval 2.19-8.59, p<0.001). ROC curve analysis showed good accuracy of the C2HEST score (AUC 0.71, 95%CI 0.67-0.74) and mC2HEST score in predicting NOAF (AUC 0.69, 95%CI 065-0.73). Conclusion The simple C2HEST score may be a useful tool to identify patients at higher risk of developing NOAF after presentation with ACS.