AI-based coronary inflammation imaging detects risk that may have otherwise been missed

"We've been really excited to implement this technology in Australia," Hunyor said. "What this technology has allowed us to do is have a validated method for reliably measuring fat attenuation that gets rid of a lot of the noise and gets you the signal, and it is based on clinical evidence."

Finding hidden residual cardiovascular risk

Hunyor said one of the most valuable applications has been identifying patients whose coronary arteries appear normal on CT scans, but who still have elevated coronary inflammation, which adds additional risk for a plaque rupture, leading to a heart attack.

"Nearly half of those patients with normal coronary CT angiograms have very high coronary inflammation," he explained. "That translates to a substantially increased risk of cardiac death within the next 10 years."

Those findings have prompted physicians in his practice to intensify preventive treatment for patients who otherwise might not have received aggressive therapy based solely on calcium scores or plaque burden.

The additional imaging data has also improved patient engagement, Hunyor said. Rather than discussing statistical risk estimates, physicians can show patients personalized imaging evidence of inflammation and their coronary plaque, leading to better understanding of cardiovascular risk and greater adherence to prescribed therapies.

"You don't need a blockage or a serious plaque volume to have a heart attack. You can have a very small volume of plaque, but if that plaque becomes inflamed it can rupture," he explained. "At least we can potentially detect a signal that would suggest more risk over and above what our standard testing would do."

He noted that while no test can completely eliminate unexpected cardiac events, adding coronary inflammation imaging to CCTA may help detect risk that conventional imaging misses.

Completing the picture beyond plaque

While coronary plaque imaging has become an important component of CCTA, Hunyor said inflammation provides another critical layer of information.

"Plaque assessment is only part of the story. It gives you a picture of what's already there. The damage is done. But what does that mean for the future?" Hunyor explained.

Patients with extensive plaque but low inflammation may already be receiving effective medical therapy, while others with similar plaque burden but high inflammation may have significant residual risk requiring more intensive treatment, he explained.

The approach allows physicians to better tailor treatment using existing therapies, including statins, PCSK9 inhibitors, GLP-1 receptor agonists and lifestyle interventions. Drugs to treat inflammation might also be prescribed, as colchicine.

"We can personalize our treatment much better now than we could before rather than potentially flying blind a little," Hunyor said.

FAI is more specific than CRP biomarkers

Inflammation has long been recognized as a contributor to coronary artery disease, but current blood-based biomarkers such as high-sensitivity C-reactive protein (hs-CRP) lack specificity because they measure inflammation throughout the body. Hunyor said emerging evidence suggests FAI imaging can identify patients specifically with elevated coronary inflammation, even when systemic inflammatory markers remain normal.

"We definitely see patients where there's a discordance," he said. "I think the FAI is more specific."

The imaging biomarker also appears valuable in patients with autoimmune and inflammatory disorders, including psoriasis, who are known to have elevated cardiovascular risk.

Hunyor also sees promise in using inflammation imaging to monitor treatment response over time using serial imaging. Unlike plaque burden, which often changes slowly, coronary inflammation is an active biological process that may respond relatively quickly to therapy and the response can be seen on FAI.

"I think inflammation is an active process where we would expect that anti-inflammatory therapy can knock it down actually quite quickly," he said. "We could consider re-looking at patients to see, 'Has therapy been adequate?'"

The FAI technology is already playing an important role in the development of new anti-inflammatory drugs, where changes in FAI scores is the main endpoint.

Today, colchicine is among the few dedicated anti-inflammatory medications available for cardiovascular prevention. However, Hunyor said FAI imaging may help identify patients most likely to benefit from future targeted therapies and is already being used to enrich patient populations in clinical trials evaluating new anti-inflammatory agents.