What should I do for severe coronary atherosclerosis identified on computed tomography of the chest?

Management of Severe Coronary Atherosclerosis on CT Chest

You need cardiology consultation and likely invasive coronary angiography (ICA), along with immediate initiation of aggressive medical therapy including high-intensity statin, antiplatelet therapy, and risk factor modification. 1

Immediate Next Steps

Determine the Severity Using CAD-RADS Classification

The management pathway depends critically on the degree of stenosis identified on your CT scan 1:

• CAD-RADS 3 (50-69% stenosis): Consider functional assessment with CT-derived fractional flow reserve (CT-FFR), CT perfusion (CTP), or stress testing (exercise ECG, stress echo, SPECT, PET, or cardiac MRI) to document ischemia, especially if symptoms persist despite medical therapy 1

• CAD-RADS 4A (70-99% stenosis in 1-2 vessels): Proceed to ICA or functional assessment, with ICA strongly favored if stenosis exceeds 90%, high-risk plaque features are present, or the patient has persistent angina despite optimal medical therapy 1

• CAD-RADS 4B (≥50% left main stenosis OR 3-vessel disease >70%): ICA with possible revascularization is recommended, particularly for patients with frequent symptoms despite optimal medical therapy 1

• CAD-RADS 5 (total occlusion): ICA is recommended for definitive evaluation and potential intervention 1

Assess for High-Risk Features

Look specifically for these features that mandate more aggressive intervention 1:

• Very high-grade stenosis (>90%)
• High-risk plaque characteristics (positive remodeling, low-attenuation plaque, spotty calcification, napkin-ring sign)
• Evidence of lesion-specific ischemia on CT-FFR or perfusion defects by CTP
• Persistent anginal symptoms despite guideline-directed medical therapy

Cardiology Consultation Timing

• Immediate/urgent consultation: Required for CAD-RADS 4B or 5, or any severe stenosis with ongoing symptoms 1
• Prompt outpatient consultation: Appropriate for CAD-RADS 3 or 4A in stable patients 1

Medical Therapy Initiation (Start Immediately)

Aggressive Risk Factor Modification and Preventive Pharmacotherapy

Lipid Management 1, 2:

• High-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily)
• Target LDL-C levels according to risk category (typically <70 mg/dL for high-risk patients, <55 mg/dL for very high-risk)

Antiplatelet Therapy 2:

• Aspirin for secondary prevention (unless contraindicated)

Blood Pressure Control 1, 2:

• Target office blood pressure 120-130 mmHg systolic for general population
• Target 130-140 mmHg systolic for patients >65 years
• ACE inhibitors or ARBs preferred, especially with diabetes

Diabetes Management (if applicable) 1, 2:

• Optimize glycemic control with HbA1c targets
• Consider SGLT2 inhibitors (empagliflozin, canagliflozin, dapagliflozin) or GLP-1 receptor agonists (liraglutide, semaglutide) for cardiovascular benefit

Lifestyle Modifications 1, 2:

• Smoking cessation (mandatory)
• Weight management
• Regular physical activity

Anti-Anginal Therapy

Consider guideline-directed anti-anginal medications if symptomatic 1:

• Beta-blockers
• Calcium channel blockers
• Long-acting nitrates
• Ranolazine (if symptoms persist)

Common Pitfalls to Avoid

Do not rely solely on stenosis severity 1, 3: Functional significance does not always correlate with anatomic severity. A 70% stenosis may not cause ischemia, while a 50% stenosis with high-risk plaque features may be hemodynamically significant 1, 3.

Do not ignore non-obstructive disease 4, 5: Even CAD-RADS 1-2 (minimal or mild stenosis) with extensive plaque burden (P3 or P4) requires aggressive preventive therapy, as non-obstructive disease carries prognostic significance 1, 4.

Do not overlook image quality issues 1: If the CT scan was non-diagnostic (CAD-RADS N) due to heavy calcification, motion artifact, or other technical factors, additional or alternative evaluation is required 1.

Do not miss non-atherosclerotic causes 1, 3: Consider spontaneous coronary artery dissection, coronary anomalies, vasculitis, or other non-atherosclerotic etiologies that may require specific management 1, 3.

When Revascularization Should Be Considered

Revascularization (PCI or CABG) should be confined to patients with 1:

• Persistent symptoms despite optimal medical therapy
• High-grade stenosis (>90%) with documented ischemia
• Left main disease ≥50%
• Three-vessel disease >70%
• Evidence of significant ischemia on functional testing

The benefit of revascularization is primarily for symptom relief and should not be pursued solely for prognostic benefit in stable patients without significant ischemia 1.

Follow-Up and Monitoring

Periodic reassessment 2:

• Evaluate treatment adherence
• Monitor for development of symptoms or comorbidities
• Repeat risk stratification if symptoms worsen

Do not routinely repeat coronary CTA 1: Coronary CTA is not recommended as a routine follow-up test for patients with established CAD 1.