Erasmo DLP

TARGET-CTCA: a negative CTCA trial? Maybe. But look at what was actually tested. Patients were selected mainly by mildly elevated hs-troponin—not by likelihood or burden of coronary atherosclerosis—and CTCA was performed weeks after the acute presentation. More importantly, the enormous amount of information provided by CTCA was reduced essentially to four stenosis categories: no, mild, moderate or obstructive CAD. No plaque burden, quantitative plaque analysis or high-risk plaque phenotype was used to guide treatment. Yet CTCA clearly changed management: at 12 months statin use rose from 27% in patients without CAD to 79%, 92% and 95% in mild, moderate and obstructive CAD. And the trial was designed to detect an ambitious 40% reduction in MI/cardiac death. The per-protocol analysis actually showed HR 0.83 (95% CI 0.63–1.09), still compatible with clinically meaningful benefit. Perhaps TARGET-CTCA does not show that CTCA fails to improve outcomes. It shows that simply detecting CAD and applying a relatively crude stenosis-based treatment algorithm is not enough. The next question should be different: can CTCA-guided precision prevention based on the burden and biology of atherosclerosis improve outcomes?

# Better Images Are Only the Beginning - Photon Counting CT Photon-Counting CT has consistently demonstrated superior image quality over conventional CT. The more important question is: **Does that improvement occur where it actually matters clinically?** This head-to-head intra-patient study (from my good friends in Negrar and Verona) compared **Photon-Counting CT (PCCT)** with a third-generation dual-source EID-CT in **25 patients** undergoing hepato-bilio-pancreatic imaging. Four blinded radiologists independently assessed six clinically relevant anatomical domains. The results were remarkably consistent. PCCT achieved significantly higher scores across all evaluated parameters, including: - Overall image quality (4.82 vs 3.80) - Arterial visualization (4.87 vs 3.98) - Venous visualization (4.84 vs 3.91) - Pancreatic duct visualization (4.83 vs 3.51) - Biliary tree visualization (4.87 vs 3.63) - Peripancreatic lymph node depiction (4.86 vs 3.81) All differences were highly significant (*p*<0.0001). Interestingly, the greatest improvements were observed in the **pancreatic and biliary ductal systems**, where subtle anatomical detail often determines lesion characterization, surgical planning, and resectability. PCCT also showed substantially higher inter-reader agreement, suggesting that improved image quality may translate into more reproducible image interpretation. ## A Critical Point The authors appropriately acknowledge that this is **not a pure detector comparison**. PCCT images were reconstructed at **0.4–0.6 mm**, whereas EID-CT images were reconstructed at **1.0 mm**, and acquisition parameters also differed between scanners. Consequently, part of the observed superiority likely reflects protocol optimization rather than detector technology alone. Moreover, this remains a **qualitative** study. It demonstrates improved visualization—not improved diagnostic accuracy, clinical management, or patient outcomes. ## My Take This paper reinforces an important concept. The value of PCCT should not be judged by sharper images alone, but by its ability to improve visualization of anatomically and clinically critical structures. The next challenge is no longer to demonstrate superior image quality. It is to show that these improvements translate into **earlier diagnosis, more accurate staging, better therapeutic decisions, and ultimately better patient outcomes.** That is where the true clinical value of Photon-Counting CT will be established. #PhotonCountingCT #PCCT #AbdominalImaging #PancreaticImaging #HepatobiliaryImaging #Radiology #MedicalImaging #PrecisionMedicine

🫀🔥 LDL is down. Therapy is optimal. And yet… plaque is still growing. Report from the presentation of the HURRICANE study at the ECR2026 Proud to be part of this study that sheds more light into a very hot contemporary topic. That’s the uncomfortable reality highlighted by new data presented at ECR 2026. 👉 Statins were working. 👉 Guidelines were followed. 👉 LDL was controlled. And still: 📈 Atherosclerosis progressed. 💡 This is the blind spot we’ve been ignoring: 👉 Residual cardiovascular risk Driven by: ✔️ Inflammation ✔️ Metabolic factors ✔️ Genetics 👉 Things LDL alone does NOT capture 🚀 Enter Photon-Counting CT (PCCT) For the first time, we can: ✔ Quantify plaque volume ✔ Differentiate plaque components ✔ Track progression over time 👉 Not just detect disease… 👉 Measure its evolution ⚠️ And this is where it gets disruptive: Patients who are “well-controlled” on paper may still be: 👉 biologically active 👉 progressing silently 🧠 This changes the entire paradigm: ❌ Treat LDL → assume success ➡️ becomes ✅ Treat disease → verify with imaging 🎯 Clinical implication We may need to move from: Lipid targets ➡️ to Plaque targets From: Surrogate biomarkers ➡️ to Direct disease measurement 🚨 Bottom line Statins treat risk. 👉 PCCT shows reality. And sometimes… they don’t match. ⚡ The future is not: “Did we lower cholesterol?” It’s: 👉 “Did we actually stop the disease?”

🧠 We optimized the stent. We forgot the disease. Two major NEJM trials just dropped. Both asked the same question: 👉 Does IVUS-guided PCI improve outcomes vs angiography alone? The answer? ❌ No. 📊 Trial #1 – Complex High-Risk PCI (IVUS-CHIP) IVUS: 13.9% events Angio: 11.1% events HR 1.25 → trending worse 📊 Trial #2 – Left Main PCI (OPTIMAL) IVUS: 33.7% events Angio: 30.9% events HR 1.11 → no difference Let’s be honest. 💡 IVUS did exactly what it’s supposed to do: ✔️ Better sizing ✔️ More post-dilation ✔️ More “optimized” stents And yet… 👉 No clinical benefit. ⚠️ This is the uncomfortable truth: We’ve been chasing procedural perfection, thinking it would translate into patient outcomes. It doesn’t (and yes I know the comparator is highly skilled PCI operators/centers; but does this appears as inclusion criteria?) Because events are NOT driven by: ❌ stent expansion ❌ lumen gain ❌ apposition metrics They are driven by: 🔥 plaque biology 🔥 disease burden 🔥 patient-level risk Even more interesting: 👉 The “inferior” arm (angiography) was already excellent 👉 Modern PCI is already optimized 👉 There’s very little left to gain mechanically 💥 So what did these trials really show? Not that IVUS is useless. But that: 👉 The paradigm is wrong. 🧬 We are: ✔️ optimizing millimeters ✔️ while events come from microns of biology 🚨 The future is NOT: “optimize the stent more” It is: 👉 identify disease earlier 👉 quantify plaque, not stenosis 👉 treat-to-plaque, not treat-the-lumen 💬 Final thought: We spent 20 years perfecting PCI. And almost none of that effort touched the disease that actually kills patients. #Cardiology #PCI #IVUS #CardiacImaging #PhotonCountingCT #PreventiveCardiology #TreatToPlaque