Cardiovascular risk stratification by coronary computed tomography angiography imaging: current state-of-the-art

Available toolkit for the detection of the vulnerable patient by non-invasive imaging with computed tomography angiography. (A) Conventional assessment of coronary computed tomography angiography (CCTA) scans relies on the anatomical assessment for the presence of obstructive coronary artery disease and the grading of the anatomical extent of disease (CAD-RADS, SIS/SSS, Duke CAD Index). In asymptomatic patients undergoing computed tomography (CT) imaging, measurement of coronary calcium score (CCS) also contributes to risk stratification for future coronary events. (B) Plaque characterization and identification of high-risk features also provides information on future risk for adverse cardiac events independently of the presence of obstructive disease. (C) Functional assessment of the haemodynamic significance of intermediate coronary stenoses can be performed by CT perfusion imaging or CT-derived fractional flow reserve (FFRCT). Further to anatomical and functional information, perivascular FAI mapping can be measured by the post-processing of standard CCTA images as a metric of coronary inflammation to obtain incremental prognostic and risk classification information. CCS or high-risk plaque features. CAD-RADS, Coronary Artery Disease Reporting and Data System; SIS, segment involvement score; SSS, segment stenosis score. Current cardiovascular risk stratification by use of clinical risk score systems or plasma biomarkers is good but less than satisfactory in identifying patients at residual risk for coronary events. Recent clinical evidence puts now further emphasis on the role of coronary anatomy assessment by coronary computed tomography angiography (CCTA) for the management of patients with stable ischaemic heart disease. Available computed tomography (CT) technology allows the quantification of plaque burden, identification of high-risk plaques, or the functional assessment of coronary lesions for ischaemia detection and revascularization for refractory angina symptoms. The current CT armamentum is also further enhanced by perivascular Fat Attenuation Index (FAI), a non-invasive metric of coronary inflammation, which allows for the first time the direct quantification of the residual vascular inflammatory burden. Machine learning and radiomic features' extraction and spectral CT for tissue characterization are also expected to maximize the diagnostic and prognostic yield of CCTA. The combination of anatomical, functional, and biological information on coronary circulation by CCTA offers a unique toolkit for the risk stratification of patients, and patient selection for targeted aggressive prevention strategies. We hereby provide a review of the current state-of-the art in the field and discuss how integrating the full capacities of CCTA into clinical care pathways opens new opportunities for the tailored management of coronary artery disease.

Automated summary

Computed tomography angiography is a valuable toolkit for detecting vulnerable patients. It allows for risk stratification and selection of targeted aggressive prevention strategies by combining anatomical, functional, and biological information.