Coronary CT imaging is reshaping cardiovascular prevention
Coronary computed tomography angiography (CCTA) and CT coronary artery calcium (CAC) scoring are rapidly transforming cardiovascular prevention by allowing clinicians to identify atherosclerosis years before patients experience a heart attack.
These technologies could create a paradigm shift in cardiology prevention efforts, which was a major topic of discussion at SCCT2026, the Society of Cardiovascular Computed Tomography (SCCT) annual meeting. The details were outlined in a keynote talk by Ron Blankstein, MD, associate director of the cardiovascular imaging program and director of cardiac CT at Brigham and Women's Hospital, professor of medicine for cardiology and radiology at Harvard Medical School and a former SCCT president.
Blankstein described how coronary imaging has evolved over the past two decades from a controversial research tool into a central component of personalized preventive cardiology. He said the field is now moving beyond simply detecting obstructive coronary artery disease toward identifying and treating atherosclerosis before symptoms or cardiovascular events occur.
"There's no better way to assess risk than to know the actual presence of disease," Blankstein explained in the closing session of the meeting.
Risk scores miss younger patients that would be caught using imaging
Blankstein highlighted findings from the Young Myocardial Infarction Registry, which examined patients who experienced heart attacks before age 50. While approximately 90% had traditional cardiovascular risk factors before their heart attack, most would have been categorized as low risk by conventional risk calculators because of their younger age. He said only one in 10 patients was receiving lipid-lowering therapy when they presented with myocardial infarction.
Traditional prevention has relied on estimating future cardiovascular risk using age, cholesterol levels and clinical population-based risk calculators. Coronary imaging instead directly identifies the presence of atherosclerosis by specifically looking for it rather than making educated guesses.
Population studies including SCAPIS, the Miami Heart Study, MESA and PESA have shown that roughly half of adults have detectable coronary atherosclerosis by age 50, he said. Because imaging reveals actual plaque rather than predicting its likelihood, Blankstein said it provides substantially stronger risk stratification for individuals than population-based clinical scores, genetic testing or biomarker combinations.
The visual evidence also changes behavior
Blankstein cited a recent multicenter Australian study published in JACC: Cardiovascular Imaging. Patients with subclinical atherosclerosis and a family history of cardiovascular disease were shown images of their coronary plaque. Compared with usual care, patients who saw their imaging results achieved a 51 mg/dL reduction in LDL cholesterol and experienced significantly less plaque progression over three years.
"There's no better way to assess risk than to know the actual presence of disease," Blankstein said. "And importantly, this impacts physician behavior and patient behavior. Patients in their 30s do not want to be on lipid-lowering therapies. Patients that do not want to be treated with lifelong pharmacological therapy. But it turns out that when we use imaging, we can impact outcomes. When patients were shown the images and informed about their plaque, this led to a 51-point reduction in LDL cholesterol."
New guidelines elevate calcium scoring
Blankstein said the recently released 2026 dyslipidemia guidelines represent a milestone for preventive imaging. For the first time, CAC scoring has received a Class I recommendation when decisions about lipid-lowering therapy remain uncertain, upgrading its previous Class IIa status.
The guidelines also introduce a Class IIa recommendation supporting the use of calcium scoring to determine how aggressively patients should be treated, rather than simply deciding whether treatment is appropriate. The new recommendations establish LDL cholesterol targets based on plaque burden, with progressively lower LDL goals for patients with higher calcium scores.
"This is the first time in any guideline anywhere in the world that the amount of plaque dictates the intensity of therapy," Blankstein said.
This may have major implications as more data is gathered in the area of artificial intelligence (AI)-enabled CCTA soft plaque assessments, which Blankstein and other cardiac imaging experts say is an even better risk assessment tool than calcium.
The guidelines also include the first Class I recommendation to consider incidental coronary calcium identified on routine non-cardiac chest CT scans when making treatment decisions, recognizing the growing role of opportunistic screening.
Two examples of photon-counting CT highlighting soft coronary plaques with high-risk features. CCTA can now show detailed soft plaque anatomy that can improve patient risk assessments for heart attacks. Photo courtesy of Ron Blankstein
AI expands opportunities for prevention
Artificial intelligence (AI) is expected to play an increasingly important role by automatically identifying coronary calcium and notifying clinicians when unsuspected plaque is found on routine CT scans.
Blankstein highlighted preliminary results from the multicenter AI-INFORM trial presented at the SCCT meeting, which used AI opportunistic imaging to perform calcium scores on patients from prior chest CT scans performed for any reason. Among 660 patients at Brigham and Women's Hospital, automated AI detection of coronary plaque followed by electronic notification to clinicians significantly increased initiation or intensification of lipid-lowering therapy within six months. Investigators found that 42% of patients with detectable plaque had not previously been receiving cholesterol-lowering medication.
He said AI has the potential to help health systems identify high-risk patients who might otherwise go untreated.
Suhny Abbara, MD, senior associate consultant and professor of radiology at Mayo Clinic in Jacksonville, Florida, and editor of the RSNA journal Radiology, also gave high praise for opportunistic AI screenings at SCCT. He said there are more than 20 million chest CTs performed each year in the United States, which holds a massive promise to detect millions of new patients with asymptomatic coronary artery disease the patients are unaware of.
Expanding role for coronary CTA
While calcium scoring remains the primary imaging test for asymptomatic patients, Blankstein said CCTA is beginning to gain a role in primary prevention. The new dyslipidemia guidelines include the first Class IIb recommendation supporting selective use of coronary CTA in asymptomatic patients likely to have a high burden of non-calcified plaque, including individuals with diabetes, HIV infection, systemic inflammatory diseases and elevated lipoprotein(a).
Advances in photon-counting CT and quantitative soft plaque analysis are further improving CTA's ability to characterize plaque composition and identify patients at elevated risk. Blankstein cited emerging data involving more than 14,000 patients showing plaque burden predicts long-term cardiovascular events independently of traditional risk factors and coronary stenosis severity.
Studies also suggest that providing quantitative plaque analysis to physicians leads to medication changes and improved LDL cholesterol reduction in approximately half of patients. SCCT and the American College of Cardiology (ACC) are now developing consensus recommendations defining when plaque analysis should be performed and how it should guide preventive therapy.
CCTA supports increasingly personalized treatment
Blankstein said coronary imaging is becoming a foundation for tailoring preventive therapies, rather than applying identical treatment strategies to every patient based on population health statistics. He said CAC and CCTA are opening up a new era in personalized cardiac medicine, and a greater ability to detect coronary atherosclerosis much earlier, when preventive drug therapies are more effective.
In addition to statins, newer therapies including PCSK9 inhibitors, bempedoic acid, colchicine, GLP-1 receptor agonists and investigational lipoprotein(a)-lowering drugs increasingly enroll patients based on imaging evidence of atherosclerosis. He pointed to results from the VESALIUS trial showing that adding evolocumab (Repatha) to lipid-lowering therapy reduced cardiovascular death, myocardial infarction and ischemic stroke by 25% in patients with imaging-confirmed atherosclerosis before they experienced a cardiovascular event.
Blankstein also emphasized that extensive safety data continue to support aggressive LDL lowering.
"We have not seen any harm from lowering LDL," he said. "The side effect is you live longer."
Rather than recommending calcium scoring or CCTA at a specific age for everyone, future screening decisions will incorporate traditional risk factors, genetic risk scores, incidental imaging findings, and clinical biomarkers to determine when each patient is most likely to benefit from imaging.
He acknowledged that widespread CCTA screening is unlikely because of cost and workforce limitations, making calcium scoring a more practical first-line approach for many patients. Blankstein concluded that the greatest challenge is no longer developing effective preventive therapies, but implementing them before cardiovascular events occur.
"We have the data. We have to implement it," he stressed.
He added that cardiovascular imaging societies are increasingly focused not simply on diagnosing coronary disease, but on preventing heart attacks before they happen by identifying high-risk patients early enough to intervene.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]