Cardiac CT — structured viva

Stem

Practice viva. The examiner shows you a calcium score report, a CCTA report and a TAVI planning CT, then asks about chest pain in the emergency department, endocarditis and pulmonary embolism.^{[1][6][4][8][11]}

Branch A — The calcium score in an asymptomatic patient

Examiner: A 55-year-old man without ASCVD is at intermediate risk and unsure about a statin. Where does a calcium score fit?^[5]

Strong answer:

• ACC/AHA 2026: in adults at intermediate risk and select adults at borderline risk with no prior ASCVD, if the decision regarding LLT remains uncertain, a CAC score should be used for further risk stratification and to guide the decision to withhold, postpone, or initiate therapy (COR 1, LOE B-R).^[5]
• If the score is >0 AU, it is recommended to initiate LLT, particularly if the CAC score is ≥100 AU or ≥75th standardized percentile, to reduce ASCVD risk (COR 1, LOE B-NR); if it is 0 AU and there is preference to avoid LLT and focus on lifestyle management, and no higher risk conditions are present, it is reasonable to defer therapy and reassess with repeat CAC testing in 3 to 7 years to personalize management (COR 2a, LOE B-NR).^[5]
• ESC 2024: CACS may be considered to improve risk classification around treatment decision thresholds (Recommendation Table 27, Class IIb, Level C); the newer ESC/EAS 2025 Recommendation Table 1 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).^[1][30]

Follow-up: The radiologist mentions coronary calcification on a lung CT done last year. Does that count?^[1][5]

• ESC 2024: when coronary artery calcification findings are available from previous chest CT scans, using these findings to enhance risk stratification and guide treatment of modifiable risk factors should be considered (Class IIa, Level C).^[1]
• ACC/AHA 2026: in adults with no prior ASCVD, if incidental CAC is identified on noncardiac CT scans, the presence of coronary atherosclerosis should be considered during decision-making about initiation or intensification of LLT to reduce ASCVD risk (COR 1, LOE B-NR).^[5]

Branch B — Reading the CCTA

Examiner: The CCTA in a symptomatic patient shows a 50% left main stenosis. What now, and what if it had shown only an intermediate mid-vessel lesion?^[1]

Strong answer:

• ESC 2024 Recommendation Table 14 lists left main disease with ≥50% stenosis on CCTA among the results identifying high risk of adverse events (Class I, Level B), and 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 (Class I, Level A).^[1]
• For a known intermediate stenosis (typically around 40%–90% by visual estimate) in a proximal or mid segment on CCTA, ESC 2024 says CT-based FFR may be considered (Class IIb, Level B).^[1]
• ESC 2024 says FFR-CT needs no pharmacological stress, additional contrast or radiation, but is not ubiquitous and depends on image quality.^[1]

Branch C — The emergency department

Examiner: A patient with acute chest pain, suspected ACS and no known CAD is in the emergency department with non-elevated hs-cTn, no ECG changes and no recurrence of pain. After this negative evaluation for ACS you judge him at intermediate risk and eligible for diagnostic testing. Would you order CCTA?^[4][2]

Strong answer:

• ESC 2023: in patients with suspected ACS, non-elevated (or uncertain) hs-cTn levels, no ECG changes and no recurrence of pain, incorporating CCTA or a non-invasive stress imaging test as part of the initial workup should be considered (Class IIa, Level A), but routine, early CCTA in patients with suspected ACS is not recommended (Class III, Level B).^[4]
• ESC 2023 says 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]
• AHA/ACC 2021: for intermediate-risk patients with acute chest pain and no known CAD eligible for diagnostic testing after a negative or inconclusive evaluation for ACS, CCTA is useful for exclusion of atherosclerotic plaque and obstructive CAD (COR 1, LOE A).^[2]

Branch D — Endocarditis and pulmonary embolism

Examiner: When does CT earn its place in endocarditis, and how do you act on a normal CTPA?^[8][11]

Strong answer:

• ESC 2023: cardiac CTA is recommended in NVE and PVE to diagnose paravalvular or periprosthetic complications if echocardiography is inconclusive (Class I, Level B); cardiac CT is more accurate than TOE for perivalvular and periprosthetic complications, while echocardiography remains superior for small vegetations.^[8]
• ESC 2023: in haemodynamically stable patients with aortic valve vegetations who require cardiac surgery and are high risk for CAD, a high-resolution multislice coronary CTA is recommended (Class I, Level B).^[8]
• ESC 2019: it is recommended to reject 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); with high clinical probability or PE-likely, rejecting it after a normal CTPA should be considered (Class IIa, Level B).^[11]
• AHA/ACC 2026: in patients undergoing imaging evaluation, a CTPA is recommended in preference to a V/Q scan to confirm the diagnosis of acute PE (COR 1, LOE B-R); in patients with suspected PE and a negative CTPA or normal V/Q SPECT, venous duplex ultrasonography is not useful for further PE diagnostic evaluation (COR 3: No Benefit, LOE B-NR).^[12]