What is the management approach for a patient with mild atheroma on computed tomography coronary angiography (CTCA)?

Management of Mild Atheroma on CTCA

For patients with mild atheroma detected on coronary CT angiography, aggressive risk factor modification and preventive pharmacotherapy are recommended, with no need for further anatomical or functional cardiac testing in the absence of symptoms. 1, 2

Initial Risk Stratification and Assessment

• Confirm the patient is truly asymptomatic by specifically excluding typical angina, anginal equivalents (dyspnea, jaw pain, arm discomfort with exertion), heart failure symptoms (orthopnea, paroxysmal nocturnal dyspnea, exercise intolerance due to dyspnea), or recent changes in exercise tolerance. 2, 3

• Quantify the total atherosclerotic plaque burden using standardized CAD-RADS classification (P1 = minimal, P2 = mild, P3 = moderate, P4 = extensive plaque burden), as mild atheroma typically corresponds to CAD-RADS 1 or 2 with P1-P2 plaque burden. 1

• Document coronary artery calcium score if available from the CTCA study, as this provides additional prognostic information and helps guide intensity of preventive therapy. 1, 3

Medical Management Strategy

Lipid Management

• Initiate high-intensity statin therapy targeting LDL-cholesterol <1.4 mmol/L (55 mg/dL) for patients with documented atherosclerosis, even if mild and non-obstructive. 1, 2

• Consider adding ezetimibe if LDL-cholesterol targets are not achieved with statin monotherapy after 4-6 weeks. 2

Blood Pressure Control

• Target office blood pressure to 120-130 mmHg systolic for most patients under 65 years, or 130-140 mmHg systolic for patients over 65 years. 2

• Preferentially use ACE inhibitors or ARBs as first-line antihypertensive agents, particularly in patients with diabetes or chronic kidney disease. 2

• Avoid combining ACE inhibitors with ARBs due to increased risk of adverse events without additional benefit. 2

Antiplatelet Therapy

• Initiate low-dose aspirin (75-100 mg daily) for secondary prevention in patients with documented atherosclerosis, after assessing bleeding risk. 1, 2

• Single antiplatelet therapy is sufficient; dual antiplatelet therapy is not indicated for stable, non-obstructive atherosclerosis. 1

Diabetes Management (if applicable)

• Optimize glycemic control with HbA1c targets individualized based on patient characteristics. 2

• Consider SGLT2 inhibitors (empagliflozin, canagliflozin, or dapagliflozin) or GLP-1 receptor agonists (liraglutide or semaglutide) for patients with diabetes and documented atherosclerosis, given their cardiovascular benefits. 2

Lifestyle Modifications

• Mandate smoking cessation with pharmacotherapy and counseling support if currently smoking. 2

• Recommend weight management targeting BMI <25 kg/m² through dietary modification and regular physical activity. 2

Follow-Up and Monitoring

• Schedule periodic clinic visits (initially at 3-6 months, then annually) to reassess cardiovascular risk factors, evaluate treatment adherence, monitor for medication side effects, and screen for development of symptoms. 2

• Repeat CCTA is not routinely recommended for asymptomatic patients with mild atheroma, as serial anatomical imaging has not been shown to improve outcomes and carries unnecessary radiation exposure. 3

• Perform functional testing only if symptoms develop, such as stress echocardiography, myocardial perfusion imaging, or exercise stress testing to evaluate for inducible ischemia. 2, 3

When Further Cardiac Evaluation IS Indicated

• If typical anginal symptoms emerge despite optimal medical therapy, proceed with functional imaging (stress testing) or consider invasive coronary angiography based on symptom severity and clinical risk. 1, 2

• If there is clinical suspicion that cardiac disease is limiting exercise capacity despite the patient's perception of non-cardiac symptoms, consider objective functional testing before additional anatomical imaging. 3

• For patients with extremely high calcium scores (>400 Agatston units) detected incidentally, consider screening for silent ischemia with stress imaging, though this remains a Class IIb recommendation. 3

Common Pitfalls to Avoid

• Do not perform invasive coronary angiography solely for risk stratification in asymptomatic patients with mild atheroma, regardless of plaque burden or calcium score—this is explicitly not recommended (Class III). 3

• Do not use CCTA as a screening tool in truly asymptomatic individuals, even with elevated cardiovascular risk factors; imaging should be symptom-driven. 3, 4

• Do not underestimate the prognostic significance of even mild, non-obstructive atherosclerosis—these patients require aggressive preventive therapy, not reassurance alone. 1, 2

• Avoid attributing all exercise limitation to cardiac causes when leg fatigue is the primary symptom; evaluate for peripheral arterial disease, musculoskeletal conditions, or deconditioning before pursuing additional cardiac testing. 3

Special Considerations

• In patients with chronic kidney disease, pay special attention to dose adjustments of renally excreted medications and minimize future use of iodinated contrast agents. 2

• In elderly patients (>75 years), be particularly vigilant for medication side effects, drug interactions, and potential overdosing when intensifying preventive therapies. 2

• Document the presence of high-risk plaque features if reported on CTCA (positive remodeling, low-attenuation plaque, spotty calcification, napkin-ring sign), as these may warrant more aggressive preventive therapy even with mild stenosis. 4