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Article History

Received: 14 April 2025

Revised: 6 October 2025

Accepted: 27 October 2025

First Online: 13 February 2026

Compliance with ethical standards

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: The scientific guarantor of this publication is Balint Szilveszter.

: Balint Szilveszter: received funding from the EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). He was supported by the János Bolyai Research Scholarship of the Hungarian Academy of Sciences. Federico Biavati: MD/PhD student in the BIOQIC graduate program (GRK 2260/1) financed by the German Research Foundation (DFG). Charlotte Sørum received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Theodora Benedek: received funding from the EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Received grants from the Romanian Ministry of European Funds of the Romanian Government and the European Union (increasing the research capacity in the field of vulnerable plaque imaging, based on advanced nanoparticles, fusion imaging and computational simulation—“PlaqueImage” nt no. 103544/2016, contract number 26/01.09.2016). Patrick Donnelly: received funding from the EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). José Rodriguez-Palomares: received funding from the EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Andrejs Erglis: received funding from the EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Cyril Štěchovský: received funding from the EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Gintarė Šakalytė: received funding from the EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266); received payment or honoraria for lectures from Amgen (Clinical Financial Service), AstraZeneca (Novartis Baltics), Bayer (Sanofi Aventis), Berlin Chemie Menarini, Baltic (Servier Pharma) and IQVIA; reported support from servier; reported participation on a DSMB in Boehringer Ingelheim; Nada Čemerlić Ađić: None. Matthias Gutberlet: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266); received payment or honoraria for lectures from Bayer (Institution), Siemens (Institution), Bracco (Institution) and the German Roentgen Society (DRG) (Institution); Reported to be a member of the ESCR Scientific Committee ESCR (unpaid), and a member of the Committee of the Working Group on Cardiovascular Imaging of the German Roentgen Society (DRG) (unpaid). Jonathan D. Dodd: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266); is an Associate Editor for Radiology , a member of the Editorial Board for Radiology Cardiothoracic Imaging , and an Associate Editor for the Quarterly Journal of Medicine and Rrespirology (all non-paid); and receives royalties as a co-author of book chapters in the Stat-Dx book Series Diagnostic Imaging—Cardiovascular and the textbook CT and MRI in Cardiology, Elsevier. Ignacio Diez: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Gershan Davis: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Elke Zimmermann: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266) and grants from Deutsche Forschungsgemeinschaft (Grant: Radiomics in SPP 2177/1). Cezary Kępka: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Radosav Vidakovic: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Marco Francone: Member of the Scientific Editorial Board of European Radiology (section editor: Cardiac), and as such did not participate in the selection nor review processes for this article. Małgorzata Ilnicka-Suckiel: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Fabian Plank: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Juhani Knuuti: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266); received grants from AstraZeneca (Personal Fees: Study protocol review) and from GE Healthcare (Personal Fees: Study protocol review); received payment or honoraria for lectures from GE Healthcare, Merck, Lundbeck, Bayer, Boehringer-Ingelheim, Pfizer and Siemens (speaker’s fee); and reported other financial or non-financial interests for the European Society of Cardiology (Dr. Knuuti is Chair of the European Society of Cardiology guidelines on chronic coronary syndrome. The work is on a voluntary basis and only remuneration of travel expenses occurs). Rita Faria: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Stephen Schröder: None. Colin Berry: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266); received grants from AstraZeneca (grant and other: The University of Glasgow has received funding for research and consultancy work in the field of ischemic heart disease undertaken by Colin Berry in the course of his employment), Abbott Vascular (other: The University of Glasgow has received funding for research and consultancy work in the field of ischemic heart disease undertaken by Colin Berry in the course of his employment), GSK (grant and other: The University of Glasgow has received funding for research and consultancy work in the field of ischemic heart disease undertaken by Colin Berry in the course of his employment), HeartFlow (grant and other: The University of Glasgow has received funding for research and consultancy work in the field of ischemic heart disease undertaken by Colin Berry in the course of his employment), Menarini (grant and other: The University of Glasgow has received funding for research and consultancy work in the field of ischemic heart disease undertaken by Colin Berry in the course of his employment), Novartis (grant and other: The University of Glasgow has received funding for research and consultancy work in the field of ischemic heart disease undertaken by Colin Berry in the course of his employment), Siemens (other: The University of Glasgow has research agreements in the field of ischemic heart disease for work undertaken by Colin Berry in the course of his employment); and reported that the University of Glasgow received research funding from The British Heart Foundation (RE/18/6134217). Luca Saba: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Balazs Ruzsics: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Nina Rieckmann: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266) and a grant from the German Ministry of Education and Research (NAVICARE 01GY1911; PI of Grant (no own salary)). Christine Kubiak: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Kristian Schultz Hansen: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Jacqueline Müller-Nordhorn: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Pál Maurovich-Horvat: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266) and reported to be a shareholder of Neumann Medical Ltd. Helena Domínguez: Reported partnership with the private company Cortrium APS jointly related to a grant from Innovation Foundation (Danish Ministry of Science Innovation and Higher Education—Grand Solutions grant CACTH 1061-00046A) 2022–2025. Imre Benedek: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266), a grant from the Romanian Ministry of European Funds, the Romanian Government, and the European Union (for promoting research in the field of vulnerable plaque imaging, based on advanced nanoparticles, fusion imaging and computational simulation—“PlaqueImage” nt no. 103544/2016, contract number 26/01.09.2016). Clare Orr: None. Filipa Xavier Valente: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Ligita Zvaigzne: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Vojtěch Suchánek: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Antanas Jankauskas: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Filip Ađić: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Michael Woinke: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Niall Mulvihill: None. Iñigo Lecumberri: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Erica Thwaite: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Mariusz Kruk: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266) and a grant from National Science Center (Poland) (Payment to the institution) and reported patents for EP3157444B1 (granted); WO2015193847A1 (pending); WO2013060883A4 (pending). Aleksandar N. Neskovic: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Massimo Mancone: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Donata Kuśmierz: None. Gudrun Feuchtner: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Mikko Pietilä: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Vasco Gama Ribeiro: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Tanja Drosch: None. Christian Delles: None. Alberto Boi: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Michael Fisher: None. Bela Merkely: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266), a grant from Biotronik, Medtronic and Abbott (personal fees), and a grant from Boston Scientific. Thomas Fritz Hansen: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Rosca Aurelian: None. Stephanie Kelly: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Bruno Garcia del Blanco: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Ainhoa Rubio: None. Melinda Boussoussou: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Tem Jørgensen: None. Ioana Rodean: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Susan Regan: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Hug Cuéllar Calabria: None. Borbála Vattay: None. Roxana Hodas: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Adriane E. Napp: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Robert Haase: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Sarah Feger: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Mahmoud Mohamed: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Lina M. Serna-Higuita: None. Konrad Neumann: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Henryk Dreger: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Matthias Rief: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Received a grant from Deutsche Forschungsgemeinschaft (Grant: Radiomics in SPP 2177/1). Viktoria Wieske: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Michelle Williams: is supported by the British Heart Foundation (FS/ICRF/20/26002). She has given talks for Canon Medical Systems, Siemens Healthineers and Novartis. Melanie Estrella: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Maria Bosserdt: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Peter Martus: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266). Klaus F. Kofoed: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266), financial support from Rigshospitalet, University of Copenhagen, during the conduct of the study, and grants from AP Møller og hustru Chastine McKinney Møllers Fond, Danish Heart Foundation, The Danish Agency for Science, Technology and Innovation by The Danish Council for Strategic Research, and Health Insurance Company Denmark. He additionally received unrestricted research grants from Canon Medical Corporation and GE Healthcare. Marc Dewey: received funding from EU-FP7 Framework Program (DISCHARGE EU FP EC-GA 603266), grant support from German Research Foundation (DFG) in the Heisenberg Program (DE 1361/14-1, DFG project number: 213705389), the graduate program on quantitative biomedical imaging (BIOQIC, GRK 2260/1, DFG project number: 289347353), for fractal analysis of myocardial perfusion (DE 1361/18-1, DFG project number: 392304398), the DFG Priority Programme Radiomics (DFG project number: 402688427) for the investigation of coronary plaque and coronary flow (DE 1361/19-1 [DFG project number: 428222922] and DE 1361/20-1 [DFG project number: 428223139] in SPP 2177/1), the GUIDE-IT project on data sharing of medical imaging trials (DE 1361/24-1 [DFG project number: 495697118]), the Quantitative Cardiovascular Imaging (QCI) meeting (DE 1361/22-1), and the Future of Medical Imaging meeting (DE 1361/28-1). He also received funding from the Berlin University Alliance (GC_SC_PC 27) and from the Digital Health Accelerator of the Berlin Institute of Health and reported a patent on fractal analysis of perfusion imaging, jointly with Florian Michallek, on dynamic perfusion analysis using fractal analysis (PCT/EP2016/071551 and USPTO 2021 10,991,109 approved). M.D. is European Society of Radiology (ESR) Publications Chair (2022–2025); and the opinions expressed in this article are the author’s own and do not represent the view of ESR. Per the guiding principles of ESR, the work as Publications Chair is on a voluntary basis and only remuneration of travel expenses occurs. He is also the editor of Cardiac CT , published by Springer Nature, and offers hands-on courses on CT imaging ( ).

: Two authors have significant statistical expertise and performed the analyses.

: Written informed consent was obtained from all subjects (patients) in this study.

: Institutional Review Board approval was obtained.

: The primary trial results (10.1056/NEJMoa2200963), the design of the trial (10.1007/s00330-016-4620-z), and the comparative effectiveness of computed tomography and invasive coronary angiography in women and men (10.1136/bmj-2022-071133) were described previously.

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