CCTA scan at conference gives cardiologist a wake-up call

He said the scan was a wake-up call to do more to protect his heart. 

A lifelong focus on prevention

McMullan was not a typical screening patient. He has a strong family history of coronary artery disease and has monitored his cardiovascular health for decades.

"My father at age 61 had six-vessel coronary artery bypass surgery," he explained. Now that he is his 60s, he was interested to see the actual extent of soft plaque on CCTA.

He had previous calcium scoring CT scans and knew about the calcified plaque in the proximal left anterior descending (LAD) artery. He said the calcium score findings prompted aggressive risk-factor modification, including the initiation of statin therapy more than 25 years ago.

Subsequent scans showed a progression of calcified plaque. About 13 years ago, his calcium score had risen from 5 to roughly 250, with extensive involvement of the LAD. Since then, he has maintained intensive lipid-lowering therapy, titrating treatment to achieve LDL cholesterol levels consistent with evolving preventive cardiology guidelines.

He said his current LDL cholesterol level is within normal range at 46 mg/dL as he takes high-intensity rosuvastatin therapy.

Unexpected plaque burden on CCTA raised concerns

The scan revealed a coronary artery calcium score of 1,232, with nearly 1,200 of those points located in the LAD artery. However, the advanced FFR-CT analysis provided important context that would not have been available from a calcium score alone.

While the plaque burden was extensive, the disease remained non-obstructive. HeartFlow's FFR-CT analysis showed an LAD FFR value of 0.91, indicating no significant flow-limiting blockage. The remaining major coronary arteries demonstrated normal findings.

But he said the artificial intelligence-based plaque composition analysis was even more revealing. According to McMullan, approximately two-thirds of his plaque burden consisted of soft, non-calcified plaque that cannot be seen on calcium scoring exams, and only one-third was calcified.

"I would've certainly expected that ratio to be reversed," he said.

Looking beyond calcium scoring to soft plaques

The findings highlight a growing interest among preventive cardiologists and cardiac imaging specialists in evaluating plaque composition rather than relying solely on calcium scoring or traditional risk calculators. Calcium is often just the tip of the iceberg, where soft plaques have traditionally gone unseen and unmeasured. But newer AI technology now makes this readily available. Soft plaque is often considered more biologically active and may be associated with higher cardiovascular risk, making it more informative on patient risk than calcium.

McMullan said the scan provided information that will influence his own treatment strategy, despite already receiving guideline-directed therapy.

"It was reassuring from the standpoint that I didn't have obstructive disease," he said. "However, it's less reassuring from the standpoint of the plaque characterization, knowing that I still have a lot of room for improvement."

The results have prompted him to reevaluate his preventive regimen, including potential additional lipid-lowering therapies and further lifestyle modifications.

"I certainly need to work on my diet and reducing processed foods and inflammatory foods," he said. "I think this is going to be motivating for me."

CCTA implications for patient care

McMullan's case underscores ongoing discussions within cardiology about how advanced imaging may complement traditional guideline-based risk assessment. Many cardiology experts believe CCTA with plaque assessment and FFR-CT could be a paradigm shift in preventive cardiology, detecting disease years before a patient becomes symptomatic and seeks treatment.

McMullan noted that some colleagues questioned whether the scan would provide actionable information because he was already receiving optimal medical therapy. But he said the advanced imaging technologies revealed disease characteristics that population-based risk models cannot capture.

"I think it's very useful in people who have additional risk factors that aren't necessarily covered in the guidelines to put them at a higher risk," McMullan said.

He acknowledged concerns about over testing with expensive CT scans, but argued that imaging can provide valuable insights when used appropriately.

"I'm a big believer in information," he said. "I realize that we can over test and I don't want to go there, but I think it's very useful in people who have additional risk factors."

A glimpse into the future of prevention

Heartflow worked with ACC to provide the truck-based CT scanner on the expo hall floor. The company said interest was so high that they had to turn many people away who wanted to undergo a scan.

Several preventive cardiologists and cardiac CT experts have suggested that serial CCTA plaque imaging and characterization could eventually become a more personalized method of tracking cardiovascular risk and response to therapy. It also may be able to better select patients for the newer, more expensive lip-lowering drug therapies now available.

"We have more options than ever before to be even more aggressive than just statin and a baby aspirin," McMullan said.