How often should a person over 50 years old get a computed tomography (CT) angiogram?

CT Angiography Screening in Asymptomatic Adults Over 50

CT angiography is not recommended as a routine screening test for asymptomatic individuals over 50 years of age. 1

Evidence-Based Recommendations Against Routine Screening

The major cardiology societies uniformly recommend against CT coronary angiography (CCTA) for screening asymptomatic adults:

• The American College of Cardiology explicitly does not recommend CT coronary angiography as a routine test in asymptomatic individuals. 1
• The American College of Cardiology does not recommend MRI or CT angiography for screening asymptomatic coronary artery disease. 1
• The European Society of Cardiology does not recommend coronary CT angiography or functional imaging for ischemia in low-risk non-diabetic asymptomatic adults (Class III recommendation). 1

Alternative Risk Assessment Strategies

Instead of routine CT angiography, guidelines support targeted risk stratification approaches:

Coronary Artery Calcium Scoring

• The European Society of Cardiology recommends considering coronary artery calcium (CAC) scoring as a risk modifier in cardiovascular risk assessment of asymptomatic individuals at intermediate risk (Class IIb recommendation). 1
• CAC scoring should not be performed in men under 40 years and women under 50 years due to very low prevalence of detectable calcium. 1
• For borderline to intermediate-risk patients (5-19.9% 10-year risk) with CAC = 0, repeat scanning may be warranted in 3-5 years. 2
• High-risk patients (≥20% 10-year ASCVD risk) or diabetic patients warrant repeat CAC scanning at 3 years. 2

Limited Exceptions for High-Risk Asymptomatic Patients

• The European Society of Cardiology recommends considering functional imaging or coronary CTA for cardiovascular risk assessment only in high-risk asymptomatic adults with diabetes, strong family history of CAD, or when previous risk assessment tests suggest high risk (Class IIb recommendation). 1

Clinical Context: When CCTA Has Diagnostic Value

CCTA is appropriate for symptomatic patients with stable chest pain, not asymptomatic screening:

• For intermediate-high risk patients with stable chest pain and no known CAD, CCTA is reasonable as a diagnostic test. 3
• CCTA can be performed in patients with low to intermediate probability of CAD when evaluating chest pain symptoms. 3
• For patients with obstructive CAD who have stable chest pain despite optimal medical therapy, CCTA is reasonable to evaluate bypass graft or stent patency. 3

Important Caveats About CCTA in Older Adults

Age-related limitations significantly reduce CCTA utility in elderly patients:

• In patients over 75 years, only 68% of CCTA scans are interpretable, with 80% of non-interpretable scans due to calcified plaque. 4
• Male gender, age >78 years, diabetes mellitus, and excess motion are associated with non-interpretable CCTA. 4
• The presumption that elderly patients have heavily calcified plaque limiting accurate assessment is often correct. 4

Summary Algorithm

For asymptomatic adults over 50:

1. Do not order routine CT angiography 1
2. Assess cardiovascular risk using traditional risk calculators
3. Consider CAC scoring only if intermediate risk (5-20% 10-year ASCVD risk) 1
4. Reserve CCTA for symptomatic patients or very high-risk asymptomatic patients with diabetes, strong family history, or abnormal prior risk assessment 1
5. In patients >75 years, recognize that CCTA has limited interpretability and should be avoided unless compelling clinical indication exists 4

The answer to "how often" is therefore: never for routine screening, and only when specific high-risk features or symptoms warrant targeted evaluation. 1