Coronary CTA and the Future of Precision Prevention with Dr Blankenstein

How coronary CTA, plaque analysis and photon-counting CT are reshaping cardiovascular risk assessment and coronary artery disease care.

Cardiac CT Has Become Too Important to Remain Optional

There are moments in cardiology when a diagnostic tool quietly crosses a threshold. It stops being a specialist luxury and becomes part of the grammar of everyday clinical practice. For Professor Ron Blankstein, cardiac CT has clearly crossed that line.

“Cardiac CT is now an absolute essential tool in clinical cardiology,” he says. “It used to be like a luxury that maybe some centres have and some don’t.”

That statement captures the central message of this Parallax discussion: coronary CTA is no longer simply a rule-out test for selected low-risk patients with chest pain. It is becoming a platform for cardiovascular risk assessment, preventive cardiology, procedural planning and, increasingly, precision prevention.

The timing is important. Cardiac CT has matured scientifically, technologically and clinically. The 2021 AHA/ACC Chest Pain Guideline placed coronary CTA firmly in the diagnostic pathway for both stable and acute chest pain, reflecting a body of evidence that has moved the modality from promising to practice-changing.

But what makes the field particularly exciting in 2026 is not merely that CT can detect coronary artery disease. It is that CT can increasingly tell us what kind of disease a patient has, how much plaque is present, whether lesions are likely to be flow-limiting and how aggressively prevention should be intensified.

In that sense, cardiac CT is not just an imaging test. It is becoming a clinical decision tool.

From Stenosis to Plaque: The Real Shift in Coronary CTA

For many years, the clinical question behind coronary CTA was relatively simple: does this patient have obstructive coronary artery disease?

That remains important. But the more profound shift is from stenosis-centred imaging to plaque-centred prevention.

As Professor Blankstein explains, “we’ve learned that the amount of plaque that individuals have may be even more important than whether or not they have stenosis.”

This is one of the most important conceptual changes in contemporary preventive cardiology. A patient does not need to have a flow-limiting stenosis to have clinically meaningful atherosclerosis. Nor does the absence of obstructive disease necessarily mean the absence of risk.

“The vast majority of patients that are referred for coronary CT actually don’t have stenosis,” Blankstein notes. “They have what we call non-obstructive plaque.”

Historically, non-obstructive plaque could be interpreted as reassuring. Today, it is better understood as an opportunity. It identifies atherosclerosis early, before symptoms necessarily declare themselves and before the patient experiences a cardiovascular event.

That changes the conversation in the clinic. Rather than asking only whether a stress test is positive, clinicians can begin asking more precise questions: How much atherosclerosis is present? What type of plaque does the patient have? Does this imaging result justify more intensive lipid lowering, blood pressure management or metabolic risk reduction?

This is where coronary CTA aligns with the wider movement towards precision prevention. As Blankstein puts it, “Why do we need to wait until someone has symptoms to know whether they have coronary disease?”

That question is simple, but it reframes the role of imaging. Coronary CTA is not only about diagnosing disease once it becomes clinically apparent. It can also help identify the substrate of future risk, allowing cardiologists to intervene earlier and more intelligently.

Quantitative Plaque Analysis and the New Language of Risk

The next stage in this evolution is quantitative coronary plaque analysis. If traditional coronary CTA shows whether plaque is present, newer approaches increasingly aim to measure plaque burden and characterise plaque type.

“The new cutting-edge aspect of coronary CTA is the ability to quantify that amount of plaque,” Blankstein says.

This matters because cardiovascular risk is not binary. Patients do not simply have coronary artery disease or not. They exist across a spectrum of plaque burden, plaque phenotype, clinical risk factors and future event probability.

Quantitative plaque analysis may help move clinicians beyond broad categories of risk towards more personalised treatment strategies. For example, a patient with extensive non-calcified plaque may require a different preventive conversation from a patient with minimal calcified plaque and otherwise favourable risk markers.

The clinical value is not just descriptive. It is actionable. If CT can identify higher-risk plaque phenotypes or greater total plaque burden, it may help determine which patients need more aggressive LDL-C lowering, closer follow-up or broader cardiometabolic intervention.

For cardiologists, the implication is clear: coronary CTA is increasingly becoming part of the prevention toolkit, not merely the diagnostic pathway for chest pain.

The Calcium Score Consultation: Risk, Reassurance and Action

One of the most practical parts of the discussion concerns the asymptomatic patient with a high coronary artery calcium score. This is an increasingly common scenario: a middle-aged patient, often health-conscious and well-informed, undergoes direct-to-consumer calcium scoring and discovers they are in a high percentile for age and sex.

The first task is interpretation. The absolute calcium score helps estimate near-term risk, while the percentile contextualises relative and lifetime risk. A younger patient may have a modest absolute score but a high percentile, suggesting that their lifetime trajectory deserves attention even if their short-term risk is not extreme.

The second task is action. For Blankstein, the presence of atherosclerosis should lead to systematic preventive intensification — not reflexive invasive testing.

“If someone is truly asymptomatic and has a high calcium score, the most important thing is the preventive therapies,” he says.

That is a crucial message for clinical practice. Coronary calcium scoring should not be treated as a gateway to unnecessary procedures. It should be treated as a gateway to better prevention.

Blankstein is particularly clear on this point: “I’m pretty sure I’ve never referred anyone for an invasive angio based on a calcium score alone.”

That quote is important because it challenges a persistent pattern in community practice. A high calcium score may understandably alarm patients, but it does not automatically mean the patient needs invasive coronary angiography. In asymptomatic individuals, the priority should be aggressive, comprehensive risk reduction.

That includes LDL-C lowering, blood pressure control, assessment of lipoprotein(a), metabolic health, diabetes or pre-diabetes, inflammation, exercise, resistance training, diet, weight management and, in selected patients, antiplatelet therapy.

Blankstein’s prevention philosophy is deliberately broad. “Coronary disease is actually a fairly complex disease,” he says. “It’s not as simple as just controlling your LDL.”

This is where coronary calcium scoring and coronary CTA become clinically powerful. They make risk visible. But once risk is visible, the responsibility is to treat the whole patient, not just the imaging result.

LDL-C Goals, PCSK9 Inhibition and Earlier Intensive Prevention

The discussion also reflects a broader shift in lipid management. Contemporary prevention is increasingly moving towards lower LDL-C goals in patients with greater plaque burden, even if they have not yet experienced a myocardial infarction or stroke.

For patients with high calcium scores or extensive plaque, the treatment question becomes less about whether to start therapy and more about how intensive that therapy should be. High-intensity statins, ezetimibe and PCSK9 inhibitors all become part of the clinician’s therapeutic vocabulary.

The relevance of trials such as VESALIUS-CV lies in this expanding prevention space: patients with atherosclerosis but no previous cardiovascular event may still have risk high enough to justify more intensive LDL-C reduction.

The imaging finding therefore becomes a treatment catalyst. It helps the clinician move from estimated risk to observed disease. That can be especially powerful in patients who appear “healthy” by conventional markers but have a clear burden of coronary atherosclerosis.

The key is not to over-medicalise imaging. The key is to use imaging to personalise prevention.

FFR-CT and the Move from Anatomy to Physiology

One historical criticism of coronary CTA was that it was anatomical but not physiological. It could identify stenosis, but not always clarify whether that stenosis was flow-limiting.

FFR-CT has helped narrow that gap. By applying computational modelling to CT data, clinicians can estimate lesion-specific physiology non-invasively. In the right setting, this can help determine whether an intermediate lesion should lead to invasive angiography or whether invasive testing can safely be deferred.

“The power of FFR-CT is identifying patients in whom we can defer invasive angiography,” Blankstein says.

That is a meaningful clinical advance. It allows coronary CTA to move from “what does the artery look like?” towards “does this lesion matter physiologically?”

The caveat, however, is quality. Blankstein repeatedly emphasises that FFR-CT depends on good image acquisition and appropriate interpretation. It is most useful when applied to the right vessels, in the right clinical context, and with a clear understanding of its limitations.

Used properly, FFR-CT helps avoid unnecessary invasive procedures while preserving diagnostic confidence. It represents the broader direction of travel in cardiac imaging: not anatomy or physiology, but both.

Photon-Counting CT: Why Image Quality Is the Future

If plaque analysis and FFR-CT are changing interpretation, photon-counting CT may change what can be interpreted in the first place.

Blankstein describes the technology with genuine enthusiasm: “It is stunning to see the images from photon-counting CT.”

The promise lies in improved spatial resolution and reduced artefact, particularly in challenging scenarios such as heavily calcified vessels and coronary stents. Traditional CT has struggled with calcium blooming artefact and in-stent assessment. Photon-counting CT may help overcome some of these barriers, expanding the range of patients in whom coronary CTA can be clinically reliable.

That matters because the patients who need coronary imaging are not always low-risk or technically straightforward. Many are older, have calcified disease, prior PCI or complex coronary anatomy. The future of CT depends on being able to image these patients accurately.

But technology alone is not enough. “Any technique, if we start using it more and more and the quality goes down, it’s not going to be as useful,” Blankstein cautions.

That may be one of the most important practical messages in the discussion. Coronary CTA is only as good as the system that produces and interprets it. Beta-blockade, scanner quality, acquisition protocols, reconstruction methods and reader expertise all matter.

As adoption expands, quality cannot become optional. It is the condition that makes the entire promise of cardiac CT clinically meaningful.

CT-Guided PCI and Structural Heart Planning

The expanding role of CT is not limited to diagnosis or prevention. It is increasingly becoming a procedural planning tool.

In chronic total occlusion PCI, coronary CTA can define occlusion length, calcification, tortuosity, side branches and proximal and distal caps. This gives interventional cardiologists a clearer roadmap before entering the catheterisation laboratory.

“The more information there is going into the case, the better,” Blankstein says.

That principle applies beyond CTO PCI. In structural heart disease, CT is already central to transcatheter aortic valve replacement planning, valve sizing and access assessment. Its role continues to expand in mitral and tricuspid interventions, where each new device brings new anatomical questions: what should be measured, what complications should be anticipated and how should post-procedural valve function be assessed?

In electrophysiology, cardiac CT can also support anatomical planning for selected procedures. Across subspecialties, the same pattern is emerging: CT is becoming a shared language between imagers, interventionalists, structural operators and electrophysiologists.

That gives cardiac CT a unique position in modern cardiology. It is simultaneously diagnostic, preventive and procedural.

The Training Gap: The Field Needs More Readers

Perhaps the most urgent message in the conversation is not technological but educational.

“Every trainee listening, you have to make sure you have good training in cardiac CT,” Blankstein says.

This matters because the future of coronary CTA depends not only on scanners, software and guidelines, but on clinicians who can acquire, interpret and communicate high-quality studies. It also depends on non-imaging cardiologists understanding when to order CT, what clinical question they are asking and how to act on the result.

Blankstein is direct about the workforce challenge: “The reality is we just don’t have enough good readers.”

That shortage has real implications. If cardiac CT is becoming essential to clinical cardiology, then training pathways need to reflect that. The field needs cardiologists, radiologists and imagers with the time, expertise and judgement to interpret studies well.

Importantly, Blankstein frames this as an inclusive rather than territorial issue. “It doesn’t matter if you’re a cardiologist or a radiologist,” he says. “What matters, if you’re a good CT reader, is your training.”

That is a fitting message for a field built on collaboration. Cardiac CT sits at the intersection of prevention, imaging, intervention and procedural planning. Its success will depend on technical excellence, clinical judgement and cross-specialty fluency.

5. Conclusion

Cardiac CT is reshaping the way cardiologists think about coronary artery disease. It is moving practice from late diagnosis to earlier identification, from binary stenosis assessment to plaque-informed risk stratification, and from generic prevention to precision prevention.

The opportunity is substantial. Coronary CTA can help clinicians see disease earlier, treat risk more intelligently and plan procedures more effectively. But the responsibility is equally clear: the field must protect quality, build training pathways and ensure that imaging findings translate into better decisions for patients.

Perhaps the future of preventive cardiology will not begin with symptoms. Increasingly, it may begin with seeing the plaque before the plaque declares itself — and having the clinical courage to act on it.

References

• Kalra A, Blankstein R. Cardiac CT, Coronary CTA and Precision Prevention. Parallax Podcast. Radcliffe Cardiology, 2026.

• Gulati M et al. 2021 AHA/ACC Chest Pain Guideline. Circulation. 2021.

• Williams MC et al. Low-Attenuation Noncalcified Plaque and Risk of Myocardial Infarction. Circulation. 2020.

• Nørgaard BL et al. CT-Derived Fractional Flow Reserve and Coronary Artery Disease Assessment. Journal of the American College of Cardiology. 2014.

• VESALIUS-CV Investigators. Evolocumab in Patients without Prior Myocardial Infarction or Stroke. 2026.

• SCCT. Guidance on Coronary CT Angiography and Cardiac CT Practice. Society of Cardiovascular Computed Tomography.