Evolving Role of Coronary Computed Tomography Angiography (CCTA) in Quantifying Atherosclerotic Coronary Artery Disease: A Narrative Review

TL;DR

This review discusses how coronary CT scans can assess heart disease by measuring plaque buildup and its implications for predicting heart attacks.

Contribution

The paper highlights a staging system for atherosclerotic coronary artery disease using CCTA, emphasizing preconception and protective factors.

Findings

CCTA can quantify plaque burden and type, aiding in predicting myocardial infarction risk.

Non-calcified fatty plaque is a stronger predictor of MI risk than stable calcified plaque.

A randomized trial showed fewer CAD-related deaths and non-fatal MIs in the CCTA group over 10 years.

Abstract

Background: There have been 20.5 million deaths due to cardiovascular diseases (CVDs), including atherosclerotic coronary artery disease (CAD) and stroke, so far in 2025. Atherosclerosis, which begins in newborns, may be influenced by preconception factors and continues to develop in adults, requiring a proper assessment of the burden of atherosclerotic plaque, as it is the direct cause of CAD. This review aims to emphasize the role of a staging system proposed by the Lancet Commission for the quantification of atherosclerotic coronary artery disease (ACAD) with an emphasis on preconception risk factors and protective factors, based on coronary computed tomography angiography (CCTA). Methods: It is suggested that the use of CCTA scanning makes it possible to quantify the atherosclerotic plaque burden into four stages. Results: CCTA enables us to see how much plaque has built up, as well as the type of plaque, but not the biochemistry of the plaque, to determine its vulnerability. However, if the plaque is a non-calcified fatty plaque, it is considered to be a strong predictor of the risk of myocardial infarction (MI), whereas a more stable calcified plaque is known to be protective against MI. There are several risk factors and protective factors which may influence the process of the rupture or vulnerability of the plaque. A randomized trial revealed that, after a median follow-up of 10·0 years, deaths due to CAD or non-fatal MI were less frequent in the CCTA group compared with a control group. Conclusions: Despite a few gaps in knowledge about the value of a staging system of ACAD, the available evidence indicates that it is helpful in decreasing morbidity and mortality with available therapies.

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