Non-invasive Imaging Tests Research Articles

Diagnosing hilar cholangiocarcinoma: ERCP with cholangioscopy.

Cholangiocarcinoma of the hepatic hilum represents a challenge in its diagnosis, in the palliation of the frequently associated jaundice, and in its treatment. Noninvasive imaging tests can offer a fairly accurate diagnostic approximation, but very often a histopathological diagnosis is necessary to exclude the so-called Klatskin-mimicking lesions, which can reach up to 20% in surgical series. ERCP is the most commonly used endoscopic procedure, both for tissue acquisition and for palliation of jaundice. Although probably underused, intraductal ultrasonography performed during ERCP can provide valuable information for the diagnosis of hilar cholangiocarcinoma. During ERCP, brush cytology and biopsy are performed to acquire tissue for histopathological confirmation of cholangiocarcinoma. The sensitivity of both methods alone is less than 50%. When biopsies are taken through a cholangioscope, the sensitivity is significantly increased. In this editorial we discuss a study by Alonso-Lárraga et al. published in the Spanish Journal of Gastroenterology. The highest sensitivity (77.4%) was obtained when 4 to 6 biopsies were taken with the SpyGlass cholangioscope. Direct visualization of lesions and the higher diagnostic yield of biopsies make ERCP with cholangioscopy the standard approach for patients with suspected perihilar cholangiocarcinoma.

ANMCO/GISE/SICOA Consensus document: Role of coronary computed tomography angiography in chronic coronary syndromes

Chronic coronary syndromes (CCS) are the most common clinical manifestation of coronary atherosclerosis. Coronary computed tomography angiography (CCTA) is a recent innovation in non-invasive cardiac imaging. It is the only anatomical imaging method that allows direct visualization of the coronary lumen, vessel walls, and atherosclerotic plaques, offering high sensitivity and a strong negative predictive value. CCTA is particularly useful in identifying or ruling out coronary atherosclerosis in the context of CCS and serves as an excellent filter for invasive coronary angiography. Compared to other non-invasive functional imaging tests (stress echocardiography, single photon emission computed tomography, magnetic resonance imaging, positron emission tomography), CCTA provides detailed characterization of both obstructive and non-obstructive plaques, enabling accurate risk stratification and guiding therapy. Recent advances in computed tomography technology and imaging techniques further extend the use of CCTA beyond plaque and stenosis evaluation, offering also functional lesion information. This consensus document aims to detail the technical aspects of CCTA and illustrate its role in optimizing CCS diagnostic and therapeutic management, enhancing precision medicine and personalized patient care.

Cardiovascular-Liver-Metabolic Health: Recommendations in Screening, Diagnosis, and Management of Metabolic Dysfunction-Associated Steatotic Liver Disease in Cardiovascular Disease via Modified Delphi Approach.

There is a new awareness of the widespread nature of metabolic dysfunction-associated steatotic liver disease (MASLD) and its connection to cardiovascular disease (CVD). This has catalyzed collaboration between cardiologists, hepatologists, endocrinologists, and the wider multidisciplinary team to address the need for earlier identification of those with MASLD who are at increased risk for CVD. The overlap in the pathophysiologic processes and parallel prevalence of CVD, metabolic syndrome, and MASLD highlight the multisystem consequences of poor cardiovascular-liver-metabolic health. Metabolic dysfunction and associated insulin resistance, together with the predilection for ectopic fat deposition in the liver and surrounding tissues, are associated with elevated risk of endothelial dysfunction, systemic inflammatory response, and ectopic fat deposition in the epicardium. This complex pathophysiology can accelerate atherogenic dyslipidemia, atherogenesis, diastolic dysfunction, valvular calcification, and cardiac arrhythmias. Despite the mounting evidence of mechanistic pathways underpinning MASLD and CVD, current recommendations have not clearly focused upon MASLD as a risk factor or target for intervention in CVD. We have brought together a diverse range of international experts committed to promoting cardiovascular-liver-metabolic health and related outcomes across the globe. The overarching goal of this document is to offer a construct for clinicians in the cardiovascular field with regards to (1) diagnosis and screening of MASLD through the use of noninvasive serum and imaging tests; (2) screening for CVD in all individuals with MASLD regardless of established atherosclerotic risk factors; and (3) the approach to management of MASLD with respect to prevention of CVD through lifestyle, as well as pharmacologic and surgical strategies. To achieve this, the modified Delphi method was applied and a series of evidence-based quality standard recommendations have been identified.

Noninvasive Imaging Test to Assess Liver Fibrosis: Vibration-controlled Transient Elastography

Liver fibrosis refers to the formation of scar tissue in the liver when inflammation persists over a long period. Assessing liver fibrosis is crucial for predicting the prognosis of chronic liver disease and managing patients with these conditions. Although a liver biopsy remains the gold standard for assessing liver fibrosis, it is limited by its invasive nature. Consequently, continuous efforts have been made to develop non-invasive methods for evaluating liver fibrosis, including imaging techniques and serum biomarkers. Vibration-controlled transient elastography (VCTE), a representative non-invasive imaging technique, has been used widely for liver fibrosis assessment since its introduction in 2003. This paper discusses the principles and methods of measurement, the advantages and disadvantages, and the considerations for interpreting VCTE based on the 2024 KASL Clinical Practice Guidelines for Non-invasive Tests to Assess Liver Fibrosis in Chronic Liver Disease. In addition, the diagnostic utility of VCTE in chronic viral hepatitis is reviewed.

NAFLD No More: A Review of Current Guidelines in the Diagnosis and Evaluation of Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD).

Provide a concise update on metabolic dysfunction-associated steatotic liver disease (MASLD), formerly known as non-alcoholic fatty liver disease (NAFLD), as well as a practical approach to screening and initial evaluation. Nomenclature changes have placed a greater focus on cardiometabolic risk factors in the definition of MASLD. Screening for MASLD is by stepwise noninvasive serum and imaging tests which can identify patients at risk for advanced fibrosis and liver-related complications. MASLD has been increasing in prevalence and disease burden but is underrecognized in primary care and endocrinology clinics. Multiple society guidelines, synthesized here, provide a framework for the initial approach in the diagnosis and evaluation of MASLD. Recent advances in pharmacologic treatment underline the importance of screening for patients who are at risk for advanced fibrosis as they are most likely to benefit from new drug classes, such as the liver-directed thyroid receptor agonist resmiterom.

The ability of changes in oct angiography values to predict visual field and retinal nerve layer tomography progression in patients with glaucoma progression: A prospective study

To investigate whether changes in optical coherence tomography angiography (OCTA) values can predict progression in the visual field (VF) and retinal nerve fiber layer (RNFL) in patients with glaucoma progression. All patients in the glaucoma outpatient clinic of SBU Gulhane Medicine Faculty between 2021 and 2023 underwent RNFL, 24:2 VF, and simultaneous peripapillary OCTA. 130 eyes that progressed were included in the study. Thinning of more than 5 μ in any quadrant in the RNFL or a decrease of more than 1 dB in the MD value in the visual field within 6 months was accepted as a progression criterion. The ability of changes in OCTA thickness values and OCTA radial peripapillary capillary plexus (RPCP) analysis to predict progression in RNFL and VF was prospectively investigated. The mean age of the patients was 66.9 ± 11.8 years. There was progression in VF in 70 eyes and RNFL in 89 eyes between baseline and 6-month controls. The change in OCTA thickness values had insufficient ability to predict the progression of RNFL in the superior, inferior, nasal, temporal and total quadrants (p = 0.55, 0.40, 0.84, 0.91, 0.39, respectively). The changes in OCTA thickness values failed to predict VF MD progression in the superior, inferior,nasal,temporal,and total quadrants (p = 0.40, 0.11, 0.24, 0.44, 0.10, respectively). The changes in OCTA RPCP values ​​did not show superiority in the ability to predict RNFL progression in superior, inferior, nasal, temporal, and total quadrants (p = 0.21, 0.53, 0.39, 0.39, 0.29, respectively). The changes in OCTA RPCP values ​​did not show superiority in the ability to predict VF progression in superior, inferior, nasal, temporal, and total quadrants (p = 0.96, 0.29, 0.77, 0.42, 0.21, respectively). Although OCTA is a non-invasive imaging test whose use and popularity have been increasing in recent years, our study could not show superiority compared to RNFL and VF tests in demonstrating glaucoma progression.

A Case of the Uncommon Cause of Chronic Coronary Syndrome: Coronary Fistula and Coronary Stenosis, Which One to Intervene?

AbstractWe report a case of chronic coronary syndrome (CCS) that had two completely distinct mechanisms in one patient. We applied comprehensive diagnostic tools using noninvasive and invasive physiology and imaging tests before, during, and after the intervention procedure to evaluate the outcome. The patient had previously visited many physicians and was diagnosed with noncardiac chest pain. He was referred to our department due to the increased frequency and intensity of angina pectoris. After a careful diagnosis, we found a nonsignificant stenosis (50%) in the mid-left anterior descending (mid-LAD) artery and an unexpectedly high-flow coronary artery fistula from the LAD to the main pulmonary artery (MPA). We tried a combination therapy with escalation of the anti-ischemic therapy but failed. He was rehospitalized with unstable angina pectoris. After a comprehensive physiology and imaging test, our team decided to perform fistula embolization with detachable coils and defer stenting in the mid-LAD artery. After the intervention procedure, his angina subsided, and his exercise capacity was remarkably improved. Cardiac computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR) evaluation in 3 months revealed all coils in situ and improved cardiac function. We postulate that comprehensive diagnostic tools are required to select appropriate management and prevent unnecessary procedures.

Abstract Mo036: DNA Damage and Repair in Patients Undergoing Myocardial Perfusion Single-Photon Emission Computed Tomography

Background: As medical imaging has continuously grown, patient exposure to ionizing radiation and the risks associated with it are important issues. Myocardial perfusion single-photon emission computed tomography (MP-SPECT) is one of the most frequently performed noninvasive cardiac imaging tests, generating concern about the potentially excessive radiation exposure for patients, including the cumulative doses of lifetime radiation. even though the individual levels of radiation exposure are considered low. Aim: To evaluate DNA damage and DNA repair markers after MP-SPECT. Methods: Thirty-two patients undergoing Tc-99m sestamibi MP-SPECT (mean injected Tc-99m sestamibi dose: 15.1 mCi) were studied. Peripheral blood was collected before radiotracer injection at rest and 60-90 minutes after injection. The comet assay (single-cell gel electrophoresis) was performed with blood lymphocytes to detect DNA strand breaks, which appear as DNA fragmentation (the comet tail; Figure1). Images of fluorescence microscopy were analyzed using the Comet Assay Software Project Lab (CASPLab 1.2.3 beta 2). Three parameters were evaluated: the percentage of DNA in the comet tail, tail length, and tail moment (the measure of migratory DNA and number of fragments). Quantitative PCR (qPCR) was performed to evaluate the expression of five genes related to signaling pathways in response to DNA damage and repair (ATM, ATR, BRCA1, CDKN1A, XPC). Data are expressed as medians, and Wilcoxon or Mann-Whitney tests were employed for statistical analysis. A p-value <0.05 was considered statistically significant. Results: Figure 2 shows pre- and post- radiation exposure comet assay parameters. After radiotracer injection, there was a 10.7% increase of the DNA percentage in the tail (pre-exposure median 2.185 vs post-exposure median 2.418, p<0.0065). Tail length increased 6.7% (15.0 pre-exposure vs 16.0 post-exposure, p<0.0034). Tail moment increased 27.5% (0.3177 pre-exposure vs 0.4050 post-exposure, p<0.0001). qPCR did not reveal increased expression of any gene after radiation exposure. Conclusion: An increase in DNA damage was detected after a single radiotracer injection for MP-SPECT, yet unaccompanied by activation of repair genes. This may suggest that DNA damage is not large enough to trigger intense repair responses and might not result in biologically significant DNA damage.

Use of downstream stress imaging tests for risk stratification of patients presenting to the emergency department with chest pain and low HEART score

BackgroundPatients with low HEART (History, Electrocardiogram, Age, Risk factors, and Troponin level) risk scores who are discharged from the emergency department (ED) may present clinical challenges and diagnostic dilemmas. The...

Quantitative Liver Imaging in Children.

In children and adults, quantitative imaging examinations determine the effectiveness of treatment for liver disease. However, pediatric liver disease differs in presentation from liver disease in adults. Children also needed to be followed for a longer period from onset and have less control of their bodies, showing more movement than adults during imaging examinations, which leads to a greater need for sedation. Thus, it is essential to appropriately tailor and accurately perform noninvasive imaging tests in these younger patients. This article is an overview of updated imaging techniques used to assess liver disease quantitatively in children. The common initial imaging study for diffuse liver disease in pediatric patients is ultrasound. In addition to preexisting echo analysis, newly developed attenuation imaging techniques have been introduced to evaluate fatty liver. Ultrasound elastography is also now actively used to evaluate liver conditions, and the broad age spectrum of the pediatric population requires caution to be taken even in the selection of probes. Magnetic resonance imaging (MRI) is another important imaging tool used to evaluate liver disease despite requiring sedation or anesthesia in young children because it allows quantitative analysis with sequences such as fat analysis and MR elastography. In addition to ultrasound and MRI, we review quantitative imaging methods specifically for fatty liver, Wilson disease, biliary atresia, hepatic fibrosis, Fontan-associated liver disease, autoimmune hepatitis, sinusoidal obstruction syndrome, and the transplanted liver. Lastly, concerns such as growth and motion that need to be addressed specifically for children are summarized.

Contemporary algorithms for diagnosing obstructive coronary artery disease in real clinical practice

Background. Despite the high evidence level of the currently existing international recommendations on stable coronary heart disease (CHD) and chronic coronary syndrome, their implementation in domestic clinical practice is insufficient.The aim of the work. To analyze the choice of diagnostic tactics (non-invasive and invasive) in patients with suspected obstructive coronary heart disease in real clinical practice.Methods. The study included outpatients with suspected obstructive CHD, in whom the pre-test probability (PTP) of obstructive CHD was determined; if PTP = 5–15 %, clinical probability was assessed based on CHD risk factors. Based on the results of coronary angiography, the following groups were identified: group I – obstructive lesion of the coronary arteries (≥ 70 %) (n = 50); group II – non-obstructive lesion of the coronary arteries (< 70 %) (n = 32); group III – intact coronary arteries (n = 40). Results. According to the results of coronary angiography, the frequency of detection of obstructive lesion of the coronary arteries was 42 % (in patients without past medical history of myocardial infarction – 31 %). Before performing coronary angiography, non-invasive tests were performed in 2.5 % of cases. Pain in the chest was represented by typical angina in 74 % of patients, with no difference in frequency in all groups. PTP values were statistically significantly higher in the group with obstructive CHD (median – 32 %), however, in the other two groups, PTP values corresponded to a high risk of obstructive CHD (median – 27 % and 21 %, respectively). PTP was an independent predictor for obstructive CHD and subsequent myocardial revascularization.Conclusion. In the cohort of outpatients with suspected coronary heart disease we examined during invasive coronary angiography, the frequency of obstructive lesion of the coronary arteries remains low. Non-invasive tests were performed in isolated cases, while PTP was an independent predictor for obstructive CHD and subsequent myocardial revascularization. To increase the frequency of detection of obstructive coronary heart disease, we should adhere to the diagnostic algorithms of the European Society of Cardiology and make wider use of non-invasive imaging tests.

Multimodality Imaging Diagnosis in Infective Endocarditis.

Imaging is an important tool in the diagnosis and management of infective endocarditis (IE). Echocardiography is an essential examination, especially in native valve endocarditis (NVE), but its diagnostic accuracy is reduced in prosthetic valve endocarditis (PVE). The diagnostic ability is superior for transoesophageal echocardiography (TEE), but a negative test cannot exclude PVE. Both transthoracic echocardiography (TTE) and TEE can provide normal or inconclusive findings in up to 30% of cases, especially in patients with prosthetic devices. New advanced non-invasive imaging tests are increasingly used in the diagnosis of IE. Nuclear medicine imaging techniques have demonstrated their superiority over TEE for the diagnosis of PVE and cardiac implantable electronic device infective endocarditis (CIED-IE). Cardiac computed tomography angiography imaging is useful in PVE cases with inconclusive TTE and TEE investigations and for the evaluation of paravalvular complications. In the present review, imaging tools are described with their values and limitations for improving diagnosis in NVE, PVE and CIED-IE. Current knowledge about multimodality imaging approaches in IE and imaging methods to assess the local and distant complications of IE is also reviewed. Furthermore, a potential diagnostic work-up for different clinical scenarios is described. However, further studies are essential for refining diagnostic and management approaches in infective endocarditis, addressing limitations and optimizing advanced imaging techniques across different clinical scenarios.

Ictal EEG Source Imaging With Supplemental Electrodes.

Noninvasive brain imaging tests play a major role in guiding decision-making and the usage of invasive, costly intracranial electroencephalogram (ICEEG) in the presurgical epilepsy evaluation. This study prospectively examined the concordance in localization between ictal EEG source imaging (ESI) and ICEEG as a reference standard. Between August 2014 and April 2019, patients during video monitoring with scalp EEG were screened for those with intractable focal epilepsy believed to be amenable to surgical treatment. Additional 10-10 electrodes (total = 31-38 per patient, "31+") were placed over suspected regions of seizure onset in 104 patients. Of 42 patients requiring ICEEG, 30 (mean age 30, range 19-59) had sufficiently localized subsequent intracranial studies to allow comparison of localization between tests. ESI was performed using realistic forward boundary element models used in dipole and distributed source analyses. At least partial sublobar concordance between ESI and ICEEG solutions was obtained in 97% of cases, with 73% achieving complete agreement. Median Euclidean distances between ESI and ICEEG solutions ranged from 25 to 30 mm (dipole) and 23 to 38 mm (distributed source). The latter was significantly more accurate with 31+ compared with 21 electrodes (P < 0.01). A difference of ≤25 mm was present in two thirds of the cases. No significant difference was found between dipole and distributed source analyses. A practical method of ictal ESI (nonuniform placement of 31-38 electrodes) yields high accuracy for seizure localization in epilepsy surgery candidates. These results support routine clinical application of ESI in the presurgical evaluation.

Ischemic Cardiomyopathy Evaluation with Coronary Calcium Score and CT Angiogram

Our study aimed to examine the prevalence of atherosclerotic burden in a predominantly non-white cohort of patients from LA County who underwent coronary artery calcium scoring (CACS) and coronary CT angiogram (CCTA) for the evaluation of cardiomyopathy of ischemic origin. Ischemic cardiomyopathy, primarily caused by reduced blood supply to the heart, is the most common type of cardiomyopathy. CCTA is a well-established and non-invasive imaging test used to assess the extent of coronary artery disease (CAD) in individuals suspected of having it. We analyzed data from 131 patients with cardiomyopathy who were referred to Harbor-UCLA Medical Center between August 2016 and September 2020. These patients had no chest pain, no q waves on electrocardiogram (ECG), and exhibited cardiomyopathy with reduced ejection fraction (EF) without wall motion abnormalities on transthoracic echocardiogram. Among the 131 patients included in our study, the average age was 54.6 years, with 93 (71%) being male. The racial distribution was as follows: 71 (54%) Hispanic, 17 (13%) White, 24 (18%) African American, and 10 (8%) Asian. Various risk factors for coronary artery disease were present, including diabetes mellitus (30%), hypertension (75%), hyperlipidemia (45%), and smoking (46%). We assessed CACS using the Agatston score, while atherosclerotic disease burden was evaluated using total plaque score (TPS), total segment stenosis score (TSSS), and segment involvement score (SIS). Of the patients, 55 (42%) had a CACS of zero, 28 (21%) had a CACS below 10, and the median (interquartile range) of TPS was 1 (1, 5). The median TSSS and SIS were both 1 (1, 5) and 0 (1, 4), respectively. A total of 23 patients (18%) exhibited 50% stenosis indicative of obstructive CAD, while 13 patients (10%) had even more severe stenosis of 75% or greater. Our findings revealed that the majority of patients in our cohort had non-obstructive CAD, suggesting that non-ischemic factors were the primary cause of their cardiomyopathy. Additionally, our study demonstrated that CCTA is an effective non-invasive diagnostic tool for cardiomyopathy, allowing for the avoidance of more invasive procedures in a predominantly non-white population receiving care at a public hospital in LA County.

Histopathologic Validation of Stress T1 Mapping in Myocardial Ischemia: Another Step toward Clinical Translation?

Histopathologic Validation of Stress T1 Mapping in Myocardial Ischemia: Another Step toward Clinical Translation?

Isolated pericardial hydatid cyst: a case report.

Here we report a rare case of an isolated pericardial hydatid cyst in a young woman who complained of sternal chest pain, palpitations, and shortness of breath. The diagnosis of pericardial hydatic cyst in our case was confirmed by serologic tests for hydatidosis and the results of echocardiography and tomography. No other localizations were found after realizing a body scan. The patient was started on oral albendazole and then was referred to surgery for the resection of the cardiac mass. Cardiac hydatid cyst represents a rare disease, frequently associated with fatal complications, which makes its early diagnosis and treatment an urgent priority.

CT CORONARY ANGIOGRAPHY AS THE INITIALANATOMIC IMAGING TEST FOR STABLE CHEST PAIN

Coronary artery disease (CAD) is the leading cause of morbidity and mortality in the current scenario. The recommended diagnostic protocols include either exercise treadmill testing (ETT) or noninvasive cardiac imaging tests like, stress echocardiography (SE), myocardial perfusion scintigraphy (MPS), and coronary computed tomographic angiography (CCTA) to diagnose, prognosticate risk and impact therapeutic decision making for patients with an intermediate pre-test likelihood of stable CAD. In comparison with cardiac testing without imaging, non-invasive cardiac testing with imaging has been favoured as an initial test for stable angina patients with at least intermediate pre-test likelihood of obstructive CAD, due to its superior ability to diagnose, reclassify and predict CAD events, guiding the [1] subsequent treatment

Clinical Management of Patients With Stable Ischemic Heart Disease.

Ischemic heart disease is considered stable, if patients are asymptomatic or have well controlled symptoms. Based on the pretest probability, noninvasive imaging tests are performed to rule out the disease, and coronary computed tomography angiography being the first line. Invasive coronary angiography remains the gold standard method for diagnosing coronary artery disease. In patients with stable coronary artery disease, comorbidities such as hyperlipidemia, hypertension, and diabetes should be optimized. For patients with persistent anginal symptoms even with optimized medical therapy, coronary revascularization with percutaneous coronary intervention can be considered. Coronary artery bypass grafting may be more beneficial for patients who has stable coronary artery disease with left main disease and/or left ventricular dysfunction and/or multivessel disease; however, treatment should be individualized to the overall clinical picture.

The diagnostic value of ultrasound and mammography in detection of breast cancer in Albania

Early detection of breast cancer is essential for improving patient survival. However, non-invasive imaging test have different diagnostic value. This study aimed to assess the diagnostic accuracy of mammography and ultrasound to detect breast malignancy in Albania. The 234 patients suspected with breast lesions in Albania during 2018-2022 were subjected to both mammograph and ultrasound and then to core needle biopsy (CNB). The BI-RADS classification was used to evaluate breast lesions. The diagnostic value of ultrasound, mammography and their combination were assessed. Mean age of participants was 55.97 years (96.2% females). Ultrasound detected higher proportions of high-risk patients compared to mammography (79.1% vs. 52.6%, respectively) but the combination of the two increased this figure even further (88.9%). The sensitivity of mammography increased quickly with age, peaking to 93.2% among patients &amp;gt;60 years old, whereas ultrasound has better sensitivity among younger participants (&amp;lt;45 years and 45-60 years); overall, the combined tests had the highest sensitivity (95.1%), followed by ultrasound (87.4%) and mammography (59.3%). In conclusion, the sensitivity of mammography is best among older patients whereas ultrasound seems to be more accurate among younger patients. The combination of mammography and ultrasound seems to increase the diagnostic accuracy of breast tumors among Albanian patients.

Diagnostic and Therapeutic Strategies for Stable Coronary Artery Disease Following the ISCHEMIA Trial.

Until recently, coronary revascularization with coronary artery bypass grafting or percutaneous coronary intervention has been regarded as the standard choice for stable coronary artery disease (CAD), particularly for patients with a significant burden of ischemia. However, in conjunction with remarkable advances in adjunctive medical therapy and a deeper understanding of its long-term prognosis from recent large-scale clinical trials, including ISCHEMIA (International Study of Comparative Health Effectiveness With Medical and Invasive Approaches), the approach to stable CAD has changed drastically. Although the updated evidence from recent randomized clinical trials will likely modify the recommendations for future clinical practice guidelines, there are still unresolved and unmet issues in Asia, where prevalence and practice patterns are markedly different from those in Western countries. Herein, the authors discuss perspectives on: 1) assessing the diagnostic probability of patients with stable CAD; 2) application of noninvasive imaging tests; 3) initiation and titration of medical therapy; and 4) evolution of revascularization procedures in the modern era.