Debates in cardiac CT: Coronary CT angiography is the best test in asymptomatic patients

Cardiovascular disease remains a major cause of mortality, accounting for a third of all global deaths annually. Although there have been major improvements in our ability to detect and to treat patients with coronary heart disease, most myocardial infarctions occur in previously asymptomatic individuals. Identification of individuals at risk of myocardial infarction remains challenging and primary prevention guidelines rely on the use of cardiovascular risk scores that can be supplemented by coronary artery calcium scores. Coronary artery calcium scores provide a simple surrogate late marker of atherosclerosis but is unable to identify the early high risk non-calcified plaque which can be particularly problematic in younger individuals. Coronary computed tomography angiography is increasingly being used as the imaging strategy of choice in patients with symptoms of coronary heart disease. As an anatomical test, it can non-invasively detect the presence of coronary atherosclerosis, providing clinicians with a strong mandate to commence symptom relieving and preventative therapies. For asymptomatic individuals, it allows precise targeting of therapies to those with coronary heart disease rather than those at risk of disease. Moreover, our ability to calculate risk using coronary computed tomography angiography is rapidly improving with the use of techniques, such as plaque quantification and characterisation. These techniques have the potential to provide clinicians with tools to target cardiovascular disease prevention in a precision medicine approach. We here debate the ways in which coronary computed tomography angiography could improve the selection of asymptomatic individuals for preventative therapies over and above risk calculators and calcium scoring.

Automated summary

Cardiovascular disease is a major global cause of death, with most myocardial infarctions occurring in asymptomatic individuals. Current methods for identifying individuals at risk of myocardial infarction face challenges, and rely on cardiovascular risk scores and coronary artery calcium scores for prevention. However, these scores are unable to detect early high risk non-calcified plaque. Coronary computed tomography angiography is increasingly being used as an imaging strategy for detecting coronary atherosclerosis in symptomatic patients, allowing for timely treatment. For asymptomatic individuals, it can accurately target treatment for coronary heart disease, surpassing the effectiveness of risk calculators and calcium scoring. The development of techniques such as plaque quantification and characterization in coronary computed tomography angiography has the potential to provide precise cardiovascular disease prevention tools for clinicians.