Heart Science Journal 2025.
: 1-3
Contents list available at w.
Editorial Redefining cardiovascular risk stratification: The evolving role of coronary CTA Putri Annisa Kamila1,2,3* 1 Department of Biochemistry and Biomolecular.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia 2 Department of Cardiology.
Universitas Brawijaya Hospital.
Malang.
Indonesia 3 Department of Cardiology.
Leiden University Medical Center.
Netherlands ARTICLE INFO
ABSTRACT
Keyword :
Artificial Intelegence.
Atherosclerosis.
CCTA.
Coronary Artery Disease.
Coronary computed tomography angiography (CCTA) has evolved far beyond its initial role as an anatomical imaging modality.
Today, it serves as a versatile, multiparametric tool for cardiovascular risk assessment.
This progress has been driven by advances in plaque characterization, non-invasive functional assessment, coronary inflammation imaging, and artificial intelligence (AI).
CCTA enables clinicians not only to detect obstructive coronary artery disease but also to evaluate total plaque burden and high-risk plaque characteristics, such as low-attenuation components and positive remodeling.
The addition of fractional flow reserve derived from CCTA (FFR-CT) offers myocardial ischemia assessment without the need for invasive More recently, the perivascular fat attenuation index (FAI) has emerged as a promising marker of coronary inflammation, highlighting patients who may have residual inflammatory risk despite non-obstructive disease.
AI-driven tools, including models like AI-QCTISCHEMIA, now allow for automated and accurate plaque analysis and ischemia prediction.
The advent of photon-counting detector CT (PCD-CT) complements these advancements by improving spatial resolution and visualization of vulnerable plaque.
These developments are reshaping the role of CCTA in clinical practiceAifrom a diagnostic test to an integrated platform for individualized cardiovascular prevention and management.
Over the last decade, coronary computed tomography angiography (CCTA) has progressed from a method primarily used to exclude obstructive coronary artery disease (CAD) into a versatile imaging modality that informs comprehensive cardiovascular risk 1,2 Clinicians have increasingly shifted from focusing solely on luminal narrowing to considering the underlying biology of atherosclerosis and the broader implications of coronary plaque The concept of high-risk plaque (HRP) has emerged from such CCTA can identify HRP features such as low-attenuation plaque (LAP), positive remodeling, and spotty calcification, which are linked to vulnerable plaque biology.
6 In SCOT-HEART, patients exhibiting HRP features had a threefold increased risk of coronary death or myocardial infarction, independent of clinical risk factors.
Notably, those with both obstructive lesions and HRP features had over a tenfold increase in event rates compared to individuals with normal arteries.
This progression has been driven by a confluence of Advances in plaque characterization, developments in non-invasive functional imaging, the ability to visualize coronary inflammation, and the integration of artificial intelligence (AI) have collectively redefined what CCTA can offer in clinical practice.
1 These tools have positioned CCTA as more than just a diagnostic test.
it now serves as an integrative modality for risk stratification and preventive Extending Insight: Hemodynamic and Inflammatory Evaluation Hemodynamic Assessment with FFR-CT While anatomical information remains essential, it does not always capture the physiological significance of a coronary lesion.
The development of fractional flow reserve derived from CCTA (FFR-CT) addressed this limitation of anatomical imaging by enabling assessment of myocardial ischemia.
Using computational fluid dynamics applied to standard CCTA datasets.
FFR-CT non-invasively calculates pressure gradients across coronary lesions, with values of 0.
80 or lower indicating significant ischemia.
Beyond Narrowing: Quantifying Plaque Burden and Vulnerability A foundational advancement was the ability of CCTA to visualize and characterize coronary atherosclerotic plaque beyond simple stenosis measurement.
3 Growing evidence shows that luminal narrowing is an incomplete and often insufficient surrogate for cardiovascular risk.
4 The SCOT-HEART trial was instrumental in supporting this paradigm shift.
In its five-year follow-up, clinicians who received CCTA data, particularly regarding non-obstructive disease, were more likely to initiate appropriate preventive therapies, resulting in a significant reduction in coronary death and non-fatal myocardial The PLATFORM trial provided early clinical validation of this Among patients referred for invasive coronary angiography (ICA), a diagnostic strategy combining CCTA with FFR-CT significantly reduced the proportion of patients undergoing ICA without obstructive disease, from 73% to 12% , without compromising outcomes.
9 The ADVANCE registry further supported these findings, demonstrating that patients with negative FFR-CT results had very low event rates and rarely required revascularization.
10 Collectively, these studies have established * Corresponding author at: Department of Biochemistry and Biomolecular.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia Department of Cardiology Universitas Brawijaya Hospital.
Malang.
Indonesia E-mail address: putriannisa@ub.
id (P.
Kamil.
https://doi.
org/10.
21776/ub.
Received 25 July 2025.
Received in revised form 25 July 2025.
Accepted 28 July 2025.
Available online 31 July 2025 Editorial Heart Science Journal 2025.
: 1-3
FFR-CT as a valuable tool for guiding decisions regarding invasive evaluation and intervention.
individualized strategies guided by detailed imaging biomarkers.
CCTA
now enables clinicians to evaluate not only coronary anatomy but also the biological and functional aspects of atherosclerotic disease.
As a result.
CCTA is emerging not only as a diagnostic modality but also as a prognostic tool, capable of guiding targeted preventive strategies and influencing long-term cardiovascular outcomes.
Imaging Coronary Inflammation: Perivascular Fat Attenuation Indeks One of the most notable recent advancements in coronary imaging is the ability to non-invasively assess vascular inflammation, a critical contributor to plaque destabilization and rupture.
The perivascular fat attenuation index (FAI) serves as a novel biomarker that captures inflammation-induced changes in the adipose tissue surrounding coronary arteries, based on the principle that inflamed vessels influence the phenotype of adjacent perivascular fat through paracrine signaling.
Conflict of Interest There is no conflict of interest.
References