Cardiac CT: calcium scoring, CTCA and TAVI planning

• This page covers coronary artery calcium (CAC) scoring, CT coronary angiography (CCTA, which the 2025 Australian ACS guideline calls CTCA), FFR-CT, CT before and after valve intervention, the aorta, endocarditis and CT pulmonary angiography, each as the named guideline states it.^[32]
• The full chronic coronary syndrome pathway lives in Chronic coronary syndromes: pre-test likelihood, the CCTA pathway and treatment, risk scores in Cardiovascular risk prediction and when to treat: SCORE2, PREVENT and the Australian calculator, and cardiac MRI in Cardiac MRI: LGE patterns and clinical questions.

What cardiac CT measures

Start with what each kind of scan shows.^[1]

• The first is a non-contrast scan: ESC 2024 says coronary artery calcification (CAC) can be measured using the coronary artery calcium score (CACS), derived from an ECG-gated non-contrast-enhanced CT scan.^[1]
• The second is CCTA: ESC 2024 says that, through the intravenous injection of contrast agent, CCTA allows direct anatomical visualization of the coronary artery lumen and wall.^[1]

Cardiac CT tests and what they show (selected)

^{[1] [6] [5] [1] [6]}

How CCTA defines a stenosis, and why anatomy is not physiology

ESC 2024 says obstructive coronary stenoses have typically been defined using visual thresholds of either 50% or 70% diameter reduction.^[1]

• ESC 2024 adds that not all anatomical stenoses above such thresholds, especially those of moderate (50%–69%) severity, are haemodynamically or functionally significant or induce myocardial ischaemia.^[1]
• Depending on the clinical context, CCTA may need to be complemented with functional data from non-invasive imaging or from invasive angiography with FFR when the haemodynamic consequence of a stenosis is deemed questionable for management options (ESC 2024).^[1]

Getting a diagnostic scan

• ESC 2024: generally, a slow and regular heart rate and compliance with breath-holding instructions are necessary to achieve good image quality, including suitability to receive pre-medication (typically oral or i.v. beta-blockers) when needed.^[1]

• ESC 2024: kidney function and allergy to contrast agents should be assessed prior to referral.^[1]

• ESC 2024: temporal and spatial resolution remain technical limitations and can hinder precision in adjudicating coronary stenosis severity; this is most problematic in older patients with heavily calcified coronary arteries, in whom functional testing may be more appropriate than CCTA.^[1]

• ESC 2024: contemporary CT technology (64-slice technology or above) and a well-trained imaging team can help mitigate these limitations and must be considered a pre-requisite for CCTA.^[1]

• ESC 2024 Recommendation Table 8 carries the formal "do not" row: CCTA is not recommended in patients with severe renal failure (eGFR <30 mL/min/1.73 m²), decompensated heart failure, extensive coronary calcification, fast irregular heart rate, severe obesity, inability to cooperate with breath-hold commands, or any other conditions that can make obtaining good imaging quality unlikely (Class III, Level C).^[1]

Suspected chronic coronary syndrome: where CCTA and the calcium score fit

The question is always the same: how likely is obstructive CAD before you test, and which test suits this patient?^[1]

• ESC 2024 recommends selecting the initial non-invasive diagnostic test based on pre-test likelihood of obstructive CAD, other patient characteristics that influence the performance of non-invasive tests, and local expertise and availability (Class I, Level C).^[1]

The row's footnote lists those characteristics as ability to exercise, likelihood of good image quality, expected radiation exposure, and risks or contraindications.^[1]

ESC 2024 Recommendation Table 13: selection of initial diagnostic tests in suspected chronic coronary syndrome (all seven rows)

^[1]

ESC 2024 by likelihood band

ESC 2024 rows by likelihood band (selected rows from Recommendation Tables 3, 8, 9, 10 and 11)

^{[1] [1]}

Why does CCTA fall away as likelihood rises?^[1]

• ESC 2024 says that in the moderate likelihood group, except older men with all three CCS symptom characteristics, the likelihood of obstructive CAD is around 20%, and anatomical and functional testing will each give an intermediate positive predictive value with eventually many false positives, especially with CCTA easily overestimating stenosis severity.^[1]

• Sequential testing (functional testing after CCTA, or vice versa) will therefore be needed in many individuals to establish an accurate diagnosis of obstructive, ischaemia-inducing CAD.^[1]

• ESC 2024 also says functional imaging tests overcome the limitations of CCTA in certain groups (older patients with more extensive coronary calcifications, AF and other situations with an irregular or fast heart rate, renal insufficiency, or iodinated contrast allergy), and avoid exposure to ionizing radiation in young individuals and in those suspected of ANOCA/INOCA.^[1]

The ESC 2024 key messages put it plainly: CCTA is preferred to rule out obstructive CAD and detect non-obstructive CAD.^[1] Beyond ruling out CAD, ESC 2024 says CCTA offers direct visualization of non-obstructive CAD, which may trigger intensification of preventive measures.^[1]

The calcium score in a patient with symptoms

ESC 2024 says the absence of CAC (CACS = 0) has a very high negative predictive value for obstructive CAD.^[1]

• Do not over-trust it in the young: ESC 2024 notes that in younger patients obstructive CAD is rare, but when present a higher percentage (58% of those younger than 40 years) have a CACS of 0, compared with 9% among those aged 60 to 69 years with obstructive CAD.^[1]

• ESC 2024 reports that small, randomized studies have shown that further testing can safely be deferred in patients without CAC, without increased event rates during follow-up.^[1]

• The ESC tool is the CACS-weighted clinical likelihood (CACS-CL), the combination of CACS with the Risk Factor-weighted Clinical Likelihood (RF-CL) model, which ESC 2024 says showed the strongest potential to effectively defer cardiac testing compared with other clinical prediction models or CACS alone.^[1]

• In the external validation cohorts, the CACS-CL model categorised substantially more individuals (54%) than the RF-CL model (38%) as having a very low clinical likelihood of obstructive CAD.^[1]

Further diagnostic testing can also be deferred in patients reclassified based on CACS from a low to a very low (<5%) likelihood (ESC 2024).^[1]

• Conversely, ESC 2024 says that if CACS is high and there are clinical findings indicating that the RF-CL model may be underestimating the likelihood of obstructive CAD, further diagnostic testing should be selected based on the adjusted clinical likelihood and coronary calcium burden.^[1]

• ESC 2024 Recommendation Table 10 also says that in patients selected for PET or SPECT myocardial perfusion imaging, it is recommended to measure CACS from unenhanced chest CT imaging (used for attenuation correction) to improve detection of both non-obstructive and obstructive CAD (Class I, Level B).^[1]

• ESC 2024 also recommends using additional clinical data, including the presence of vascular calcifications on previously performed imaging tests, to adjust the RF-CL estimate (Recommendation Table 3, Class I, Level C).^[1]

The RF-CL model itself is taught in Chronic coronary syndromes: pre-test likelihood, the CCTA pathway and treatment.^[1]

AHA/ACC 2021: the same question, different risk language

• The 2021 AHA/ACC chest pain guideline groups patients with stable chest pain and no known CAD as low risk or intermediate-high risk; the note to its Figure 11 (pretest probabilities of obstructive CAD by age, sex and symptoms) says noninvasive testing is most beneficial when the pretest probability is >15%, and that if CAC is available it can also be used to estimate the pretest probability based on CAC score.^[2]

AHA/ACC 2021 recommendations for low-risk patients with stable chest pain and no known CAD (all three rows)

^[2]

• AHA/ACC 2021 says a CAC score of zero identifies a low-risk cohort of symptomatic patients who may not require additional diagnostic testing, and that most events occur among patients with detectable CAC (e.g., 84% in the PROMISE trial, which randomly assigned 10,003 symptomatic patients to initial coronary CTA or to functional testing).^[2][35]

AHA/ACC 2021 recommendations for intermediate-high risk patients with stable chest pain and no known CAD (selected rows)

^[2]

• Which first test? AHA/ACC 2021 says CCTA is preferable in those <65 years of age and not on optimal preventive therapies, while stress testing may be advantageous in those ≥65 years of age, because they have a higher likelihood of ischemia and obstructive CAD.^[2]
• AHA/ACC 2021 says clinical trials report a higher diagnostic sensitivity for CCTA compared with stress testing for detecting obstructive CAD on ICA, and that in PROMISE (10,003 symptomatic patients randomly assigned to initial coronary CTA or to functional testing) the 3-year CAD event rate for negative test findings was 0.9% for CCTA versus 2.1% for stress testing.^[2][35]

FFR-CT and high-risk anatomy on CCTA

CCTA shows the stenosis; FFR-CT adds a computed estimate of whether it matters.^[1]

• ESC 2024 says FFR-CT can complement CCTA by providing values of model-based computational FFR along the coronary tree, has shown good agreement with invasive FFR, and has clinical utility by reducing the number of unnecessary ICA procedures.^[1]

However, in patients with severe disease at CCTA, FFR-CT has less impact on patient management (ESC 2024).^[1] AHA/ACC 2021 and AHA/ACC 2023 both state that diagnostic sensitivity of FFR-CT compared with invasive FFR is high.^[2][3]

FFR-CT and FFR rows after CCTA, by body and year

^{[1] [2]}

What counts as high-risk anatomy

• ESC 2024 Recommendation Table 14 recommends using one or more listed test results to identify individuals at high risk of adverse events (Class I, Level B).^[1]
• For CCTA, the listed results are left main disease with ≥50% stenosis, three-vessel disease with ≥70 stenosis, or two-vessel disease with ≥70% stenosis, including the proximal LAD, or one-vessel disease of the proximal LAD with ≥70% stenosis and FFR-CT ≤0.8.^[1]

The same row lists exercise ECG, stress SPECT or PET perfusion imaging, stress echocardiography and stress CMR thresholds.^[1]

• In individuals at high risk of adverse events (regardless of symptoms), ICA, complemented by invasive coronary pressure (FFR/iFR) when appropriate, is recommended, with the aim of refining risk stratification and improving symptoms and cardiovascular outcomes by revascularization (ESC 2024, Class I, Level A).^[1]

• AHA/ACC 2021 has its own row: for symptomatic patients with obstructive CAD who have stable chest pain with CCTA-defined ≥50% stenosis in the left main coronary artery, obstructive CAD with FFR with CT ≤0.80, or severe stenosis (≥70%) in all 3 main vessels, ICA is effective for guiding therapeutic decision-making (COR 1, LOE B-R).^[2]

• The legend of AHA/ACC 2021 Figure 12 (clinical decision pathway for stable chest pain and no known CAD) defines high-risk CAD as left main stenosis ≥50% or anatomically significant 3-vessel disease (≥70% stenosis).^[2]

^{[2] [1]}

• Beyond the lumen, AHA/ACC 2023 Table 5 lists potential CCTA features associated with a higher risk of MACE among patients with established chronic coronary disease: total plaque burden, high-risk plaque (positive remodeling [remodeling index >1.1], low attenuation [mean CT number <30 HU], or napkin-ring sign), and reduced CT-fractional flow reserve; the same table lists a higher calcium score, alone and in addition to functional imaging.^[3]

Known CAD, grafts and stents, and follow-up

CCTA rows in known coronary disease, by body and year

^{[1] [2] [3]}

Both bodies give CCTA a IIa/2a row for graft and stent patency (for stents ≥3 mm); their supporting text follows.^[1][3]

• AHA/ACC 2021 says CCTA has been shown to be accurate for native vessel CAD and bypass graft patency with high accuracy (∼96%) and concordance (82%–>93%) to ICA, and it may also be useful to assess patency of proximal large stents (≥3 mm) if such information is known at the time of presentation.^[2]
• ESC 2024 text adds that, although CCTA can detect CABG graft patency and exclude in-stent restenosis in broad lumen arteries, functional imaging is preferred for assessing patients with prior revascularization because of the high frequency of extensive CAD in these patients.^[1]
• For known non-obstructive CAD, ESC 2024 says CCTA can help detect new obstructive stenoses, evaluate atherosclerotic disease progression and identify high-risk plaque features, while functional imaging is reasonable for detecting myocardial ischaemia and guiding further management.^[1]

Acute chest pain and suspected ACS

In the emergency department the question changes from "is there CAD?" to "is this an acute coronary syndrome, and who can go home?" ESC 2023 Recommendation Table 2 gives two CCTA rows.^[4]

ESC 2023 CCTA rows in suspected ACS (selected rows of Recommendation Table 2)

^[4]

• History, dated: ESC 2023 Table 5 (revised recommendations) shows that the 2017 and 2020 ESC versions rated a non-invasive stress test (preferably with imaging) or CCTA as recommended (Class I, Level B) before deciding on an invasive approach in this troponin-negative group; the 2023 row above replaces it, so no mark here rests on the older row.^[4]

• ESC 2023 reports that in the RAPID-CTCA (Rapid Assessment of Potential Ischaemic Heart Disease with CTCA) trial, a default approach using early non-invasive CCTA in patients with suspected NSTE-ACS did not improve clinical outcomes at 1 year and was associated with a modest increase in the duration and cost of the hospital stay.^[4]

A default approach using CCTA as the first-line imaging investigation in patients with suspected NSTE-ACS is therefore not recommended (ESC 2023).^[4]

• ESC 2023 adds that CCTA may provide added value for patients in the observe zone in whom cTn and ECG results remain inconclusive, and that a normal CCTA (ruling out both obstructive and non-obstructive plaque) has a high NPV to exclude ACS and is associated with excellent clinical outcomes.^[4]

The utility of CCTA may be limited in patients with tachycardia, established CAD, previous stents, or extensive coronary calcification (ESC 2023).^[4]

• Where does CCTA sit once NSTE-ACS is the working diagnosis? ESC 2023 recommends a selective invasive approach in patients without very high- or high-risk NSTE-ACS criteria and with a low index of suspicion for NSTE-ACS (Recommendation Table 4, Class I, Level A).^[4]

ESC 2023 text describes that selective approach as following appropriate ischaemia testing or detection of obstructive CAD by CCTA.^[4]

AHA/ACC 2021 recommendations for intermediate-risk patients with acute chest pain and no known CAD (selected rows)

^[2]

• AHA/ACC 2021 says that in the ED evaluation of acute chest pain, CCTA contributes to a reduced time to diagnosis and prompt discharge, without impacting safety (no difference in death, repeat ED visits, or ACS over 1 to 6 months of follow-up) compared with a standard evaluation including stress testing.^[2]

• AHA/ACC 2021: for intermediate-risk patients with acute chest pain and known nonobstructive CAD, CCTA can be useful to determine progression of atherosclerotic plaque and obstructive CAD (COR 2a, LOE B-NR); the AHA/ACC 2021 synopsis says that with known nonobstructive CAD (a luminal stenosis 1% to 49% on CCTA or ICA, or calcified plaque on chest CT), repeat CCTA is recommended unless there is a large enough plaque burden where ischemia is suspected.^[2]

• AHA/ACC 2021 (acute chest pain in patients with prior CABG surgery): in patients with prior CABG surgery presenting with acute chest pain who do not have ACS, performing stress imaging is effective to evaluate for myocardial ischemia, or CCTA for graft stenosis or occlusion (COR 1, LOE C-LD).^[2]

• The 2025 ACC/AHA ACS guideline focuses on type 1 AMI and says the diagnostic evaluation of chest pain and the management of type 2 MI, SCAD and MINOCA are covered in separate documents.^[29]

• The ACC/AHA 2025 text says some low-risk patients, particularly those who have normal cardiac biomarkers in whom a diagnosis of an ACS is suspect, may have improved outcomes with a selective invasive approach, and that these patients should preferentially undergo noninvasive stress testing or coronary CT angiography prior to hospital discharge to help determine the need for coronary angiography, while patients with suspected ongoing ischemic symptoms should be considered for coronary angiography.^[29]

• The 2026 Fifth Universal Definition of MI says that although current clinical guidelines do not recommend routine CCTA for suspected myocardial infarction in intermediate- and high-risk patients, it may be used to aid the diagnosis and has been found to offer prognostic information comparable to invasive coronary angiography in low-risk NSTEMI patients.^[28]

Calcium scoring in people without symptoms

• In people without symptoms, the calcium-score rows of ESC 2024, the newer ESC/EAS 2025 dyslipidaemia focused update and ACC/AHA 2026 follow, each with its own population and purpose.^[1][30][5]
• ACC/AHA 2026 says assessment of subclinical coronary atherosclerosis provides valuable prognostic information in asymptomatic adults without known clinical ASCVD and is generally recommended for use in men ≥40 years and women ≥45 years of age.^[5]
• The risk calculators that put a patient "near the threshold" are in Cardiovascular risk prediction and when to treat: SCORE2, PREVENT and the Australian calculator.

ACC/AHA 2026 recommendations for selective imaging of subclinical atherosclerosis (men ≥40 or women ≥45 years; all six rows)

^[5]

• ACC/AHA 2026 explains the zero: CAC=0 is strongly associated with a low 10-year risk of ASCVD, so it is reasonable to defer statin therapy among intermediate- or lower-risk adults with CAC=0, although important exceptions include people with FH or severe hypercholesterolemia >190 mg/dL, diabetes, current tobacco use, and those with a strong family history of premature ASCVD.^[5]
• At the other end, observational studies have consistently shown that among adults with CAC ≥100 the incident ASCVD event rate is >7.5%, the threshold (using the PCE) above which statin therapy has been shown to be beneficial, and adults with CAC ≥300 experience ASCVD event rates similar to adults with established, treated ASCVD (ACC/AHA 2026).^[5]

ACC/AHA 2026 recommendations for management of adults with subclinical coronary atherosclerosis (men ≥40 or women ≥45 years; all six rows)

^{[5] [5]}

• Other ACC/AHA 2026 rows also use the score, including this one: in adults aged >75 years with an estimated life expectancy of at least 2.5 years, and for whom the decision regarding LLT is uncertain, it may be reasonable to measure CAC to reclassify those with minimal (1-10) or no CAC to avoid LLT (COR 2b, LOE B-NR).^[5]
• ACC/AHA 2026 also says that in adults without clinical ASCVD who have statin-attributed muscle symptoms on the recommended statin intensity (secondary causes excluded), at borderline to intermediate risk (PREVENT-ASCVD 3% to <10%), and in whom the decision to treat with ezetimibe and/or bempedoic acid is uncertain, coronary calcium scoring may be reasonable to aid in ASCVD risk stratification to inform decision-making about add-on therapy (COR 2b, LOE B-R).^[5]

The European rows

ESC 2024 CCS Recommendation Table 27: screening for coronary artery disease in asymptomatic individuals (all four rows)

^{[1] [30]}

• ESC 2024 adds that opportunistic screening of the burden of calcified atherosclerotic CAD can be accurately assessed with non-ECG-gated chest CT performed for other reasons, that reporting the visual interpretation of coronary plaque burden on a simple four-category score (none, mild, moderate, severe) is recommended, but that there is no current evidence to support further diagnostic imaging in asymptomatic individuals on the basis of calcified plaque alone.^[1]

• ESC 2024 reports that two randomized screening studies have indicated that statin therapy impacts outcomes when guided by CACS in younger patients with high CACS.^[1]

• Two ESC 2024 hypertension rows name CAC (each Class IIb, Level B): in Recommendation Table 4, after assessing 10-year predicted CVD risk and non-traditional CVD risk modifiers, if a risk-based BP-lowering treatment decision remains uncertain for individuals with elevated BP, measuring CAC score, carotid or femoral plaque using ultrasound, high-sensitivity cardiac troponin or B-type natriuretic peptide biomarkers, or arterial stiffness using pulse wave velocity, may be considered to improve risk stratification among patients with borderline increased 10-year CVD risk (5% to <10% risk) after shared decision-making and considering costs.^[24]

• In ESC 2024 hypertension Recommendation Table 10, coronary artery calcium scoring may be considered in patients with elevated BP or hypertension when it is likely to change patient management.^[24]

• Newer than the ESC 2024 row: ESC/EAS 2025 Recommendation Table 1 (recommendations for cardiovascular risk estimation in persons without known cardiovascular disease) says presence of subclinical coronary atherosclerosis by imaging or increased CAC score by CT should be considered as risk modifiers in individuals at moderate risk or individuals around treatment decision thresholds to improve risk classification (Class IIa, Level B).^[30]

The same 2025 ESC/EAS focused update says coronary imaging or CAC measurement are not indicated as broad screening tests for CV risk estimation.^[30]

• The ESC/EAS 2025 update also notes there are no randomized trials showing that using CAC to classify CV risk and guide management improves CV outcomes, although considering CAC improves both discrimination and reclassification.^[30]

The cardiovascular-kidney-metabolic guideline

• The 2026 AHA/ACC/ADA/ASN cardiovascular-kidney-metabolic guideline uses CAC too: among adults at intermediate 10-year ASCVD risk (PREVENT-ASCVD 5% to <10%) or select adults at borderline risk (3% to <5%) for whom decisions about preventive therapies remain uncertain, subclinical coronary atherosclerosis identified via CAC can be beneficial for informing optimal CVD prevention (COR 2a, LOE B-NR).^[14]
• The same CKM guideline (Recommendation for Use of Markers of Subclinical Atherosclerosis): in adults with CKM syndrome stage 3 due to clinically significant CAC (CAC score >100 or moderate to severe CAC on qualitative assessment), initiation or intensification of preventive therapies indicated for CKM syndrome can be beneficial to reduce cardiovascular events (COR 2a, LOE B-NR).^[14]
• The CKM guideline points back to the dyslipidemia rows: it says CAC assessments can be considered as per the 2026 ACC/AHA dyslipidemia guideline among individuals with borderline-intermediate 10-year risk (PREVENT-ASCVD 3% to 10%) when decisions regarding preventive therapies are uncertain, and refers to that guideline for specific dyslipidemia management recommendations.^[14]

TAVI planning and valve disease

Before TAVI, CT answers three questions: will the valve fit, can we get there, and what are the coronaries doing?^[6]

• ESC/EACTS 2025 says cardiac CT is key to determining suitability for TAVI and planning the procedure, and is the preferred imaging tool to assess aortic valve anatomy including annulus size, dimensions of the aortic root and ascending aorta, the extent and distribution of valve and LVOT calcification, the distance of coronary ostia from the annular plane, optimal fluoroscopic projections for transcatheter valve deployment, and the feasibility of vascular access.^[6]
• TOE (more operator-dependent and without coronary or peripheral vascular anatomy) or CMR may be considered when CCT is difficult to interpret or relatively contraindicated (ESC/EACTS 2025).^[6]
• ESC 2024 peripheral arterial and aortic diseases notes that PAD frequently accompanies symptomatic AS, especially among patients not eligible for surgical aortic valve replacement (20%–30%), and that in these patients pre-procedural CCT/CTA or CMR of the aorta and major peripheral arteries is mandatory to evaluate the TAVI access site and plan a closure strategy for the access site.^[9]
• ACC/AHA 2020 says CT imaging is also used for procedural planning in patients undergoing TAVI, for measurement of annulus area, leaflet length and the annular-to-coronary ostial distance.^[7]

^[6]

Coronary assessment before valve intervention

Coronary CT before valve intervention, by body and year (selected rows)

^{[6] [7]}

• Why is CCTA weaker in TAVI candidates? ESC/EACTS 2025 reports that several studies of CCT angiography for CAD screening in elderly TAVI candidates found high sensitivity for obstructive CAD (95%–97%) but modest specificity (68%–73%), mainly explained by the high prevalence of coronary artery calcification and AF in patients with severe AS, which limit imaging resolution and interpretability.^[6]

ACC/AHA 2020 says that in patients with a low pretest probability of CAD, contrast-enhanced coronary CT angiography has an excellent negative predictive value.^[7]

• History, dated: ESC/EACTS 2025 Table 4 (revised recommendations) shows the 2021 row, in which CCTA should be considered as an alternative to coronary angiography before valve surgery in severe VHD and low probability of CAD (Class IIa, Level C), revised into the 2025 Class I row above.^[6]
• ESC 2024 CCS text also says that in valvular heart disease with a risk for associated CAD, in patients who require surgery or in whom a decision of a percutaneous or surgical approach is still pending, ICA or CCTA is recommended to determine the need for coronary revascularization.^[1]

Aortic valve calcium score: when the gradient does not fit the area

The aortic valve calcium score earns its place in low-flow, low-gradient aortic stenosis.^[6][7]

• ESC/EACTS 2025 says that in low-flow, low-gradient AS with reduced LVEF, CCT aortic valve calcium scoring and DSE provide complementary information, and that in symptomatic patients with low-flow, low-gradient AS and reduced LVEF, intervention is recommended when severe AS is confirmed by CCT (calcium scoring) or stress echocardiography.^[6]
• ACC/AHA 2020: in patients with suspected low-flow, low-gradient severe AS with normal or reduced LVEF (Stages D2 and D3), measurement of aortic valve calcium score by CT imaging is reasonable to further define severity (COR 2a, LOE B-NR).^[7]
• ESC/EACTS 2025 says cardiac CT calcium AV scoring is readily available and provides important adjunctive information in patients with low-flow, low-gradient AS because it correlates with haemodynamic severity, progression, and clinical outcomes, and gives the thresholds below in that setting.^[6]

Aortic valve calcium thresholds by body and year (low-flow, low-gradient AS)

^{[6] [7]}

Note the women's cut-point differs between the two documents, so name the guideline when you quote it.^[6][7]

• ESC/EACTS 2025 warns that cautious interpretation is required in patients who can develop severe AS without pronounced AV calcification, such as in BAV, concomitant amyloidosis, and predominantly fibrotic stenosis associated with post-rheumatic, radiation-induced and inflammatory disease.^[6]

Prosthetic valves

CT rows for prosthetic valves, by body and year

^{[6] [7]}

• ESC/EACTS 2025 says hypo-attenuated leaflet thickening (HALT) is detected by CCT in 10%–30% of aortic bioprosthetic valves, depending on antithrombotic management, the definition of HALT, the timepoint of assessment and the type of valve.^[6]

Because its significance for thromboembolic risk and valve durability remains uncertain, routine use of CCT to detect HALT is not indicated.^[6]

• Where gradients rise relevantly and HALT with restricted leaflet motion is confirmed by CCT, elective use of DOACs or VKAs should be considered to resolve leaflet thrombosis (ESC/EACTS 2025).^[6]

The aorta

For a suspected acute aortic syndrome, the AHA/ACC rows put CT first, and ESC 2024 text calls CCT the primary imaging method.^[2][10][9]

• ACC/AHA 2022: in patients with a suspected AAS, CT is recommended for initial diagnostic imaging, given its wide availability, accuracy and speed, as well as the extent of anatomic detail it provides (COR 1, LOE C-LD); TEE and MRI are reasonable alternatives for initial diagnostic imaging (COR 2a, LOE C-LD).^[10]
• History, dated: the older AHA/ACC 2021 chest pain rows said that with acute chest pain and clinical concern for aortic dissection, CTA of the chest, abdomen and pelvis is recommended for diagnosis and treatment planning (COR 1, LOE C-EO), and TEE or CMR should be performed to make the diagnosis if CT is contraindicated or unavailable (COR 1, LOE C-EO); the ACC/AHA 2022 aortic rows above are the newer rows for suspected AAS.^[2][10]

ESC 2024 calls CCT the primary imaging method for aortic disease diagnosis, prognosis and therapy planning (sensitivity 100%, specificity 98% for AAS).^[9]

ACC/AHA 2022 aortic disease rows that name CT (selected rows)

^[10]

• Measure it the same way every time: ESC 2024 says that for accurate assessment you should stick to the same imaging technique, centre, methodology, and side-by-side comparisons.^[9]
• ESC 2024 says that on CCT and CMR, measurements must be performed using the inner-to-inner edge method in end-diastole (fewer motion artefacts), and that CCT or CMR uses the double-oblique technique to measure aortic diameters.^[9]

ESC 2024 adds that changes in aortic diameter require a ≥3 mm increase in echocardiography, which should be confirmed with CCT/CMR.^[9]

• The held publisher (OUP) text of the ESC 2024 aortic guideline prints its recommendation tables as images, and the held PDF copies with row text are a repository mirror and local copies with no recorded source, so no ESC 2024 aortic class is given on this page.

• Before pregnancy, ESC 2025 recommends imaging of the entire aorta (CT or CMR) in women with known or suspected aortic disease (Class I, Level C); in vascular Ehlers–Danlos syndrome and LDS, imaging should encompass the entire aorta, including supra-aortic vessels as well as iliac and femoral arteries.^[23]

• In women with aortic dilatation related to BAV, imaging (with TTE, and CMR/CT if needed) of the aortic root, ascending aorta and descending aorta (to rule out coarctation) is recommended before pregnancy (ESC 2025, Class I, Level C).^[23]

• ACC/AHA 2020: in patients with BAV, CMR angiography or CT angiography is indicated when morphology of the aortic sinuses, sinotubular junction, or ascending aorta cannot be assessed accurately or fully by echocardiography (COR 1, LOE C-LD).^[7]

Infective endocarditis

Echo finds the vegetation; CT finds the abscess around it.^[8]

• ESC 2023 says cardiac CT is more accurate than TOE for diagnosing perivalvular and periprosthetic complications of IE (abscesses, pseudoaneurysms and fistulae) and is recommended in both NVE and PVE if TOE is not conclusive or not feasible, and that cardiac CT can significantly influence subsequent surgical decision-making.^[8]

Echocardiography continues to be superior for detecting valvular lesions, particularly small vegetations (ESC 2023).^[8]

• In the 2023 ESC modified diagnostic criteria, imaging positive for IE is a major criterion: valvular, perivalvular/periprosthetic and foreign material anatomic and metabolic lesions characteristic of IE detected by echocardiography (TTE and TOE), cardiac CT, [18F]-FDG-PET/CT(A) or WBC SPECT/CT.^[8]

ESC 2023 Recommendation Table 6: computed tomography, nuclear imaging and magnetic resonance in infective endocarditis (all seven rows)

^[8]

Other endocarditis rows that name CT, by body and year (selected rows)

^{[8] [7]}

ESC 2023 also calls cardiac CT a valuable alternative for non-invasive assessment of CAD before cardiac surgery in patients with IE.^[8]

Pulmonary embolism: CT pulmonary angiography

Read a CTPA against the clinical probability you had before it.^[11]

• ESC 2019 recommends rejecting the diagnosis of PE without further testing if CTPA is normal in a patient with low or intermediate clinical probability, or who is PE-unlikely (Class I, Level A), and accepting it if CTPA shows a segmental or more proximal filling defect in a patient with intermediate or high clinical probability (Class I, Level B).^[11]

ESC 2019 PE diagnosis rows that name CT (selected rows)

^[11]

AHA/ACC 2026 PE rows that name CT (selected rows)

^[12]

• Older AHA/ACC row: the 2021 chest pain guideline says that in stable patients with acute chest pain with high clinical suspicion for PE, CTA using a PE protocol is recommended (COR 1, LOE B-NR); the 2026 PE rows above are the newer AHA/ACC rows on PE imaging.^[2][12]
• ESC 2019 adds that assessment of the RV by imaging methods (footnote c: transthoracic echocardiography or CTPA) or laboratory biomarkers should be considered, even in the presence of a low PESI or a negative sPESI (Class IIa, Level B).^[11]

Pitfalls

Special populations

• Kidney disease: ESC 2024 says careful assessment of the risk-to-benefit ratio is needed in patients with CKD before considering ICA, CCTA, or non-invasive tests requiring nephrotoxic agents, and that the most important measures to prevent AKI are the lowest necessary total dose of low-osmolality or iso-osmolality contrast medium and sufficient pre- and post-hydration.^[1]
• Atrial fibrillation: ESC 2024 says diagnostic assessment of CAD (CCTA and non-invasive tests) may be difficult in AF with a high ventricular rate.^[1]
• Heart failure: ESC 2024 recommends CCTA or functional imaging in HF patients with LVEF >35% and suspected CCS with low or moderate (>5%–50%) pre-test likelihood (Recommendation Table 24, Class I, Level C).^[1]
• The newer ESC 2026 HF guideline says CTCA should be considered in patients with HFrEF and low-moderate pre-test likelihood (based on cardiovascular risk factors and clinical history) of obstructive CAD (Recommendation Table 4, Class IIa, Level C); for HFrEF that 2026 row is the newer ESC row, and the 2024 row remains the ESC row for other HF patients with LVEF >35%.^[21][1]
• The same ESC 2026 HF table says invasive coronary angiography should be considered in patients with HFrEF and high pre-test likelihood of obstructive CAD, taking into account the risk-to-benefit ratio of the procedures and potential revascularization strategies (Class IIa, Level C); for HFrEF this 2026 row is the newer ESC row.^[21]
• The ESC 2024 CCS row recommends invasive coronary angiography to diagnose obstructive CAD in individuals with a very high (>85%) clinical likelihood of disease, severe symptoms refractory to guideline-directed medical therapy, angina at a low level of exercise, and/or high event risk (Class I, Level C).^[1]
• Pregnancy: ESC 2025 estimates the radiation dose to the foetus from a chest CT or pulmonary CT angiography at 0.02 mGy, recommends keeping the foetal dose as low as possible (preferably <50 mGy), particularly if the foetus is in the field of view (Class I, Level C), and says a CT scan should be considered for PE when clinical benefits outweigh the risks to the mother and foetus (Class IIa, Level C).^[23]
• Pregnancy and suspected PE: ESC 2025 Recommendation Table 11 says that in pregnant women or women in the post-partum period with suspicion of VTE (DVT and/or PE), an immediate formal diagnostic assessment with validated methods is recommended and should not be postponed (Class I, Level B).^[23]
• History, dated: ESC 2019 said perfusion scintigraphy or CTPA (with a low-radiation dose protocol) should be considered to rule out suspected PE in pregnant women, and CTPA should be considered as the first-line option if the chest X-ray is abnormal (Class IIa, Level C); for pregnant women the newer ESC 2025 pregnancy rows above apply.^[11][23]
• Older adults: ACC/AHA 2026 says that in adults aged >75 years with an estimated life expectancy of at least 2.5 years and an uncertain LLT decision, it may be reasonable to measure CAC to reclassify those with minimal (1-10) or no CAC to avoid LLT (COR 2b, LOE B-NR).^[5]
• Before non-cardiac surgery: ESC 2022 says CCTA should be considered to rule out CAD in patients with suspected CCS or biomarker-negative NSTE-ACS with low-to-intermediate clinical likelihood of CAD, or in patients unsuitable for non-invasive functional testing undergoing non-urgent, intermediate- and high-risk NCS (Recommendation Table 10, Class IIa, Level C).^[13]

Evidence, guidelines and regional differences

Three randomized trials frame the CCTA debate; their numbers below are from the trial abstracts.^[34][35][36]

^[34]

• AHA/ACC 2021 reports the same SCOT-HEART result as a reduction in 5-year CAD death or AMI when CCTA was added to standard of care (HR 0.59; 95% CI 0.41-0.84; p=0.004).^[2]

^{[35] [36] [1] [30] [4] [2] [5]}

• The pattern to explain at the viva: in suspected CCS, ESC 2024 frames the choice by pre-test likelihood bands, with CCTA (if available and supported by local expertise) recommended at low or moderate (>5%–50%) likelihood to diagnose obstructive CAD and to estimate the risk of MACE, while for stable chest pain and no known CAD, AHA/ACC 2021 frames it by low versus intermediate-high risk, with CAC testing (for excluding calcified plaque and identifying patients with a low likelihood of obstructive CAD) or exercise testing without imaging (for excluding myocardial ischemia and determining functional capacity in patients with an interpretable ECG) as reasonable first-line tests at low risk, and CCTA effective for diagnosis of CAD, risk stratification and guiding treatment decisions at intermediate-high risk.^[1][2]

Other guideline rows that name CT, by guideline

Other guideline rows that name CT, by guideline

^{[16] [17] [18] [19] [31] [42] [20] [22] [24] [2] [7]}

In Australia and New Zealand

• The 2025 NHFA/CSANZ ACS guideline, through its Med J Aust summary, says invasive or non-invasive inpatient testing is recommended for people at intermediate risk with elevated hs-cTn above the sex-specific 99th percentile, and that if non-invasive testing is selected in these people, the guideline supports CTCA as a first-line investigation for those without previously known CAD presenting with intermediate-risk ACS, if no contraindications exist.^[32]
• For First Nations peoples and those in regional and remote areas, its considerations for non-invasive test selection include a lower threshold for using CTCA when available for definitive early identification of CAD.^[32]
• The 2023 Australian guideline for assessing and managing CVD risk uses the Aus CVD Risk Calculator and lists coronary artery calcium score among the reclassification factors that may be applied to recategorise calculated risk to improve accuracy of risk prediction, particularly in individuals close to a risk threshold.^[33]
• Only the PubMed abstract of the 2023 Australian guideline for assessing and managing cardiovascular disease risk (PMID 38623719) is held; its full text is not held and was not checked for this topic.
• The NHFA/CSANZ 2018 heart failure guideline (PMID 30077227) says either CT coronary angiography or CMR with late gadolinium enhancement (LGE) may be considered in patients with heart failure who have a low-to-intermediate pretest probability of coronary artery disease, to distinguish ischaemic and non-ischaemic causes of ventricular dysfunction (weak recommendation for; low quality of evidence).^[41]

Two ANZ position statements on calcium scoring also exist; they give GRADE ratings or advice without guideline classes.^[39][40]

• The NHFA 2021 position statement (PMID 33960402) is quoted from its Med J Aust version of record (PubMed Central PMC8252756): its full text says the Heart Foundation position is that CAC scoring can have a role in the reclassification of absolute CVD risk for selected, asymptomatic patients in Australia, in conjunction with traditional absolute CVD risk assessment and as part of a shared decision-making approach that considers the preferences and values of individual patients.^[39]

• Its main recommendations, with their GRADE ratings, are quoted from the article abstract: CAC scoring could be considered for selected people with moderate absolute cardiovascular risk, as assessed by the NVDPA absolute cardiovascular risk algorithm, and for whom the findings are likely to influence the intensity of risk management (GRADE evidence certainty low; recommendation strength conditional).^[39]

• NHFA 2021 adds that CAC scoring could be considered for selected people with low absolute cardiovascular risk by the NVDPA algorithm who have additional risk-enhancing factors that may result in the underestimation of risk (low certainty; conditional).^[39]

• If CAC scoring is undertaken, the NHFA statement says a score of 0 AU could reclassify a person to low absolute cardiovascular risk status, and a score >99 AU or ≥75th percentile for age and sex could reclassify a person to high absolute cardiovascular risk status; in each case subsequent management is to be informed by patient-clinician discussion and follow contemporary recommendations for that risk status (very low certainty; conditional).^[39]

• Its full text adds that a CAC score of 0 AU could reclassify a moderate risk person to low absolute risk status, although it does not rule out the presence of non-calcified plaque.^[39]

• The NHFA 2021 risk bands come from the NVDPA algorithm; the 2023 Australian guideline now categorises risk with the Aus CVD Risk Calculator.^[39][33]

• CSANZ 2017 position statement (PMID 28690020): use of CAC for risk stratification is confined to primary prevention and can be considered as "individualised coronary risk scoring" for those not considered to be of high or low risk; it should only be undertaken if an alteration in therapy, including embarking on pharmacotherapy, is being considered based on the result.^[40]

• Only the PubMed abstract of the Cardiac Society of Australia and New Zealand Position Statement: Coronary Artery Calcium Scoring (PMID 28690020) is held; its full text is not held and was not checked for this topic.

• The Noninvasive coronary artery imaging: current clinical applications: Cardiac Society of Australia and New Zealand guidelines (PMID 21530393) is not held as text in the evidence caches, so it was not checked for this topic.

• The NHFA/CSANZ Comprehensive Australian Clinical Guideline for Diagnosing and Managing Acute Coronary Syndromes 2025 (PMID 40180468) is not held as text in its version of record, so it was not checked for this topic. Its Med J Aust summary (PMID 41693087) is quoted instead.^[32]

• No Australian or New Zealand guideline or position statement on CCTA, FFR-CT or TAVI CT newer than those above was found in the census for this topic (PubMed, 2026-10-09); the ANZ sources above are the ones this topic uses.^{[32][33][39][40]}

Guidelines checked for this topic

• Rows on this page come from the ESC 2024 chronic coronary syndromes, ESC 2023 acute coronary syndromes, ESC/EACTS 2025 valvular heart disease, ESC 2023 endocarditis, ESC 2019 pulmonary embolism, ESC 2025 pregnancy, ESC 2024 hypertension, ESC 2023 cardiomyopathies, ESC 2025 myocarditis and pericarditis, ESC 2021 pacing, ESC 2022 ventricular arrhythmias, ESC 2022 non-cardiac surgery and ESC 2026 heart failure guidelines.^{[1][4][6][8][11][23][24][16][18][19][20][13][21]}
• AHA/ACC rows come from the 2021 chest pain, 2023 chronic coronary disease, 2026 dyslipidemia, 2026 cardiovascular-kidney-metabolic, 2020 valvular heart disease, 2022 aortic disease, 2026 pulmonary embolism, 2024 HCM, 2022 heart failure (AHA/ACC/HFSA), 2018 bradycardia (ACC/AHA/HRS) and 2017 syncope (ACC/AHA/HRS) guidelines.^{[2][3][5][14][7][10][12][17][22][31][42]}
• Rows marked "History, dated" or "Older AHA/ACC row", and rows with a note naming a newer row for a subgroup, have a newer row from the same body beside them; among the guidelines named in this section, no same-month or newer guideline of the same body revises any other row (census 2026-10-09).

The 2019 ESC PE guideline is quoted from its Eur Respir J co-publication, which prints the class and level beside each row.^[11] Rows also come from the 2025 ESC/EAS dyslipidaemia focused update, whose Recommendation Table 1 is held as a cell-by-cell transcription of the version-of-record image.^[30]

• Text without rows also comes from the 2024 ESC peripheral arterial and aortic diseases guideline (its publisher text prints the recommendation tables as images), the 2025 ACC/AHA ACS guideline and the 2026 Fifth Universal Definition of MI; the Australian and New Zealand sources, including the NHFA/CSANZ 2018 heart failure recommendation (weak; low quality of evidence), are listed in the section above.^{[9][29][28][32][33][41]}

• The documents in this list are not used; each line gives the held status recorded in the census for this topic.

• The 2018 ESC/EACTS Guidelines on myocardial revascularization (PMID 30165437) are not held as text in the evidence caches, so they were not checked for this topic.

• The 2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization (PMID 34882435) is not held as text in the evidence caches, so it was not checked for this topic.

• The 2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the European Renal Association (ERA) (PMID 42661426) are not held as text in their version of record, so they were not checked for this topic.

• The 2022 ESC Guidelines on cardio-oncology (PMID 36017568) are not held as text in the evidence caches, so they were not checked for this topic.

• The JCS/JPCPHS 2025 Guideline on Pulmonary Hypertension and Pulmonary Embolism/Deep Vein Thrombosis (PMID 42386545) is not held as text in the evidence caches, so it was not checked for this topic.

• The 2024 CSANZ Position Statement on Indications, Assessment and Monitoring of Structural and Valvular Heart Disease With Transthoracic Echocardiography in Adults (PMID 38749800) is not held as text in its version of record, so it was not checked for this topic; only its PubMed abstract is quotable.

• Only the PubMed abstract of the 2026 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery (PMID 42804570) is held; its full text is not held and was not checked for this topic. The held abstract is that of its JACC co-publication (PMID 42813718), and it does not name CT.

• Only the PubMed abstract of the 2024 ACC/AHA/AACVPR/APMA/ABC/SCAI/SVM/SVN/SVS/SIR/VESS Guideline for the Management of Lower Extremity Peripheral Artery Disease (PMID 38743805) is held; its full text is not held and was not checked for this topic. The held abstract does not name CT.

• Only the PubMed abstract of the European Respiratory Society clinical practice guidelines update for the treatment of pulmonary arterial hypertension (PMID 42705705) is held; its full text is not held and was not checked for this topic. The held abstract does not name CT.

• The 2024 AHA/ACC perioperative guideline (39316661) is held, but a newer 2026 edition exists (above), and the held 2024 text prints no recommendation rows (it gives each section's synopsis and recommendation-specific supportive text but not the recommendation tables), so it is not used.

• The CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI) (PMID 36339062) is not held as text in the evidence caches, so it was not checked for this topic.

• The SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography (PMID 33303384) is not held as text in the evidence caches, so it was not checked for this topic.

• The Computed tomography imaging in the context of transcatheter aortic valve implantation (TAVI) / transcatheter aortic valve replacement (TAVR): An expert consensus document of the Society of Cardiovascular Computed Tomography (PMID 30630686) is not held as text in the evidence caches, so it was not checked for this topic.

The held guidelines below were checked, and no row from them is used here; each line gives the reason.^{[25][26][27][38][15][37]}

• ESC 2020 adult congenital heart disease (PMID 32860028), checked, not used: congenital heart disease is outside this topic; in its section on patients after the arterial switch operation, the guideline says CCT is the preferred technique for non-invasive imaging of coronary arteries, including the ostia, when stenosis is suspected, and that the reported low incidence of coronary-related problems makes it questionable whether routine screening for coronary artery pathologies (with whatever modality) can be justified.^[25]
• ACC/AHA 2025 adult congenital heart disease (PMID 41411375), checked, not used: congenital heart disease is outside this topic, although the guideline has CT rows, for example cardiac CT is recommended to determine anatomic suitability in adults with repaired TOF and native RVOT anatomy being considered for transcatheter pulmonary valve replacement (COR 1, LOE B-NR).^[26]
• ESC 2020 sports cardiology (PMID 32860412), checked, not used: sports participation is outside this topic; its text says CAC scoring may be performed in asymptomatic athletes with a moderate atherosclerotic risk profile.^[27]
• AHA/ACC 2025 scientific statement on competitive sports participation (PMID 39976316), checked, not used: it is a scientific statement without classes and sports participation is outside this topic; its Table 14 (clinical considerations for masters athletes with coronary artery disease and other conditions) says low-risk masters athletes should not undergo routine cardiac risk stratification testing, including imaging for CAC, and that clinicians should consider further risk stratification with options including CAC or coronary CT angiography for presumed intermediate and high-risk masters athletes.^[38]
• ESC/ERS 2022 pulmonary hypertension (PMID 36017548), checked, not used: CTEPH work-up is outside this topic; its recommendations for diagnostic strategy (Recommendation Table 2) say CT pulmonary angiography is recommended in the work-up of patients with suspected CTEPH (Class I, Level C), and its text says CTPA is mainly used to detect direct or indirect signs of CTEPH and that its diagnostic accuracy for CTEPH is limited (sensitivity 76%, specificity 96% at the patient level), but was reported to be higher when modern, high-quality multi-detector CT scanners were used and when interpreted by experienced readers.^[15]
• ESC 2023 diabetes (PMID 37622663), checked, not used: no recommendation names CT; its text says there is not enough robust evidence to suggest that assessment of CAC or intima media thickness helps reclassify CV risk in people with type 2 diabetes.^[37]
• ESC 2021 prevention (PMID 34458905), checked, not used: the newer ESC 2024 CCS Recommendation Table 27 row and ESC/EAS 2025 Recommendation Table 1 row on calcium scoring for risk classification are given instead.^[1][30]
• 2019 ESC/EAS dyslipidaemias (PMID 31504418), checked, not used: ESC/EAS 2025 Recommendation Table 1 marks its CAC row as a revised recommendation replacing the recommendation on CAC score for CV risk assessment in the 2019 ESC/EAS Guidelines, so the 2025 row is given instead.^[30]
• Definition, classification and diagnosis of pulmonary hypertension (2024, PMID 39209475), checked, not used: pulmonary hypertension diagnosis is outside this topic.
• ESC 2018 syncope (PMID 29562304), checked, not used: under additional advice and clinical perspectives it says computed tomography or MRI should be considered in selected patients presenting with syncope of suspected cardiac structural origin when echocardiography is not diagnostic (no class or level given); the ACC/AHA/HRS 2017 syncope row is in the table of other rows above.^[43][42]
• The 2026 ESC cardiac rehabilitation (PMID 42661418), 2024 ESC (39210723) and 2023 ACC/AHA/ACCP/HRS (38033089) atrial fibrillation, 2019 ESC SVT (31504425) and 2025 AHA/ACC blood pressure (40811497) guidelines, checked, not used: none has a recommendation row that names cardiac, coronary, aortic or pulmonary vascular CT.

Exam pearls

• ESC 2024 bands of pre-test likelihood of obstructive CAD in suspected CCS (the CCTA, stress echocardiography, SPECT/PET and CMR rows apply if available, and supported by local expertise): very low (≤5%), deferral of further diagnostic tests should be considered (IIa B); low (>5%–15%), CACS should be considered to reclassify subjects and to identify more individuals with very low (≤5%) CACS-weighted clinical likelihood (IIa B); low or moderate (>5%–50%), CCTA is recommended to diagnose obstructive CAD and to estimate the risk of MACE (I A); moderate or high (>15%–85%), stress echocardiography is recommended to diagnose myocardial ischaemia and to estimate the risk of MACE, stress SPECT or, preferably, PET myocardial perfusion imaging is recommended to diagnose and quantify myocardial ischaemia and/or scar, to estimate the risk of MACE and to quantify myocardial blood flow (PET), and stress CMR perfusion imaging is recommended to diagnose and quantify myocardial ischaemia and/or scar and to estimate the risk of MACE (each I B); very high (>85%) clinical likelihood, severe symptoms refractory to guideline-directed medical therapy, angina at a low level of exercise, and/or high event risk, ICA is recommended to diagnose obstructive CAD (I C).^[1]
• CCTA high-risk anatomy (ESC 2024 Recommendation Table 14): left main ≥50%, three-vessel ≥70, two-vessel ≥70% including the proximal LAD, or one-vessel proximal LAD ≥70% with FFR-CT ≤0.8.^[1]
• FFR-CT after CCTA: ESC 2024 says CT-based FFR may be considered for a known intermediate stenosis (typically around 40%–90% by visual estimate) in a proximal or mid coronary segment on CCTA (IIb B); AHA/ACC 2021 says that for intermediate-high risk patients with stable chest pain and known 40% to 90% stenosis in a proximal or middle coronary segment on CCTA, FFR-CT can be useful for diagnosis of vessel-specific ischemia and to guide decision-making regarding the use of coronary revascularization (2a B-NR).^[1][2]
• CAC categories (ACC/AHA 2026): 0 absent, 1-9 minimal, 10-99 mild, 100-299 moderate, 300-999 severe, ≥1000 extensive.^[5]
• Aortic valve calcium for severe AS in low-flow, low-gradient AS: ESC/EACTS 2025 >2000 AU men and >1200 AU women; ACC/AHA 2020 2000 men and 1300 women.^[6][7]
• Endocarditis: cardiac CT is more accurate than TOE for perivalvular and periprosthetic complications; echo is superior for small vegetations (ESC 2023).^[8]
• CTPA: a normal scan rejects PE without further testing when clinical probability is low or intermediate, or the patient is PE-unlikely (ESC 2019, I A); CT venography is not recommended as an adjunct to CTPA (ESC 2019, III B).^[11]

References43ShowHide

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14. [14]Ndumele CE, et al. 2026 AHA/ACC/ADA/ASN Guideline for the Prevention, Detection, Evaluation, and Management of Cardiovascular-Kidney-Metabolic Syndrome: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2026.PMID 42265997
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17. [17]Ommen SR, et al. 2024 AHA/ACC/AMSSM/HRS/PACES/SCMR Guideline for the Management of Hypertrophic Cardiomyopathy: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2024.PMID 38727647
18. [18]Schulz-Menger J, et al. 2025 ESC Guidelines for the management of myocarditis and pericarditis. Eur Heart J, 2025.PMID 40878297
19. [19]Glikson M, et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J, 2021.PMID 34455430
20. [20]Zeppenfeld K, et al. 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death. Eur Heart J, 2022.PMID 36017572
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22. [22]Heidenreich PA, et al. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2022.PMID 35379503
23. [23]De Backer J, et al. 2025 ESC Guidelines for the management of cardiovascular disease and pregnancy. Eur Heart J, 2025.PMID 40878294
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25. [25]Baumgartner H, et al. 2020 ESC Guidelines for the management of adult congenital heart disease. Eur Heart J, 2021.PMID 32860028
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29. [29]Rao SV, et al. 2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol, 2025.PMID 40013746
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31. [31]Kusumoto FM, et al. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. J Am Coll Cardiol, 2019.PMID 30412709
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34. [34]Newby DE, et al. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction. N Engl J Med, 2018.PMID 30145934
35. [35]Douglas PS, et al. Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med, 2015.PMID 25773919
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42. [42]Shen WK, et al. 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients With Syncope: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the Heart Rhythm Society. Circulation, 2017.PMID 28280231
43. [43]Brignole M, et al. 2018 ESC Guidelines for the diagnosis and management of syncope. Eur Heart J, 2018.PMID 29562304