What is the approach to managing patients with abnormal coronary computed tomography (CT) scan findings?

From the Guidelines

The management of patients with abnormal coronary CT findings should be tailored to the specific abnormality detected and the patient's clinical presentation, with a focus on preventing plaque progression and reducing the risk of acute coronary events, as recommended by the 2024 ESC guidelines for the management of chronic coronary syndromes 1.

Approach to Managing Patients with Abnormal Coronary CT Scan Findings

The approach to managing patients with abnormal coronary CT scan findings involves several key steps:

• Estimating the pre-test likelihood of obstructive epicardial CAD using the Risk Factor-weighted Clinical Likelihood model, as recommended by the 2024 ESC guidelines 1
• Using additional clinical data to adjust the estimate yielded by the Risk Factor-weighted Clinical Likelihood model, such as examination of peripheral arteries, resting ECG, resting echocardiography, and presence of vascular calcifications on previously performed imaging tests 1
• Considering non-invasive anatomical imaging tests, such as coronary computed tomography angiography (CCTA), to diagnose obstructive CAD and estimate the risk of major adverse cardiovascular events (MACE) in individuals with suspected chronic coronary syndrome and low or moderate pre-test likelihood of obstructive CAD 1

Management Strategies

Management strategies for patients with abnormal coronary CT findings include:

• Optimal medical therapy for non-obstructive coronary artery disease (stenosis <50%), including aspirin, moderate to high-intensity statin therapy, and risk factor modification
• Functional testing, such as stress testing, for moderate stenosis (50-70%) to assess for ischemia
• Referral for invasive coronary angiography with possible revascularization for patients with severe stenosis (>70%) or high-risk plaque features
• Guideline-directed medical therapy, including blood pressure control, diabetes management, smoking cessation, and lifestyle modifications, for all patients

Importance of Regular Follow-up

Regular follow-up is essential for patients with abnormal coronary CT findings, with repeat imaging based on the severity of findings, as recommended by the 2024 ESC guidelines 1. This approach is justified by the strong correlation between CT-detected coronary stenosis severity and adverse cardiovascular outcomes, with management strategies aimed at preventing plaque progression and reducing the risk of acute coronary events. In individuals with suspected CCS and moderate or high (>15%–85%) pre-test likelihood of obstructive CAD, stress echocardiography is recommended to diagnose myocardial ischaemia and to estimate the risk of MACE, as well as SPECT or, preferably, PET myocardial perfusion imaging, and CMR perfusion imaging 1.

From the Research

Approach to Managing Patients with Abnormal Coronary Computed Tomography (CT) Scan Findings

The management of patients with abnormal coronary CT scan findings involves a comprehensive approach that includes accurate interpretation of the scan results, identification of coronary artery disease (CAD) severity, and appropriate therapeutic interventions.

• Accurate interpretation of coronary CT angiography (CTCA) scans is crucial to avoid mistakes when assessing for coronary stenoses, as significant stenosis in a coronary artery can be easily missed or a moderate stenosis overcalled as significant 2.
• The use of structured reporting can improve referring clinicians' comprehension of coronary CT angiography reports, particularly with regard to the number of vessels with significant stenosis 3.

Clinical Indications and Therapeutic Implications

Coronary CT angiography is a valuable tool in the assessment of suspected CAD, and its results can guide therapeutic decisions.

• The presence and extent of nonobstructive CAD predicted mortality, and baseline statin therapy was associated with a significant reduction in mortality for individuals with nonobstructive CAD but not for individuals without CAD 4.
• Statins were associated with slower progression of overall coronary atherosclerosis volume, with increased plaque calcification and reduction of high-risk plaque features 5.

Examination and Interpretation

The examination and interpretation of coronary CT angiography require a high level of skill and expertise.

• Coronary CT angiography permits direct visualization of nonobstructive CAD, and its results can be used to stratify disease and plan potential interventional or surgical therapy 6.
• The learning curve of reading coronary CT angiography scans is steep, and access to conventional coronary catheterization results is essential for feedback and to improve the reader's results 2.