January/February 2026 Issue
Heart Strategies
By Beth W. Orenstein
Radiology Today
Vol. 27 No. 1 P. 10
CT-First Approach Enables Earlier CAD Interventions
Someone dies of cardiovascular disease every 34 seconds in the United States, according to the CDC. Of the 700,000 to more than 900,000 deaths annually from all cardiovascular causes, a large portion (around 370,000 to 450,000) are specifically due to coronary artery disease (CAD). Plaque buildup in the arterial walls (atherosclerosis) is the primary cause of CAD.
For decades, the health care system has relied heavily on cholesterol levels, blood pressure, and blood sugar to determine who, when, and how to treat cardiovascular disease, including CAD. The results of these blood tests, blood pressure readings, and other measures combined with a patient’s family history and lifestyle habits (ie, smoking and exercise) help physicians estimate who might be at risk.
“But while all those measurements are important, they don’t show who actually has plaque in their arteries and how advanced their disease might be,” says Jeffrey Boone, MD, cardiologist and founder of the Boone Heart Institute in Greenwood Village, Colorado. Boone steadfastly believes “you don’t know who to treat unless you measure the actual disease.” Boone is one of a growing number of cardiologists who believe that cardiac CT could change this paradigm and allow the medical community to focus more on preventing heart disease before it’s too late.
Cardiac CT is not a new technology. It has been around since the early 2000s when 64-slice scanners debuted. Originally a niche tool, cardiac CT has been gaining prominence and is on its way to becoming a standard of care for evaluating and even predicting chest pain, thanks to major technological advancements and updated clinical guidelines. AI also is making cardiac CT more of a go-to technology for diagnosing, triaging, and treating chest pain. The prospect of cardiac CT becoming a routine screening modality—akin to mammography for breast cancer and colonoscopy for colon cancer—was talked about at the 2025 annual RSNA meeting in Chicago and created much buzz.
AI Analyzes CTA
Dhiraj Carumbaya is senior vice president and general manager of ConcertAI’s Tera-Recon business, which specializes in AI and advanced visualization solutions for medical imaging. Carumbaya says rapid advances in scanning technology, AI, and reimbursement policy are accelerating the adoption of CT, particularly cardiac CT, and reshaping clinical workflows. Traditional CT technology produces a series of 2D “slices” based on X-ray detection of anatomical structures such as blockages, organ size, or tumors. Recent innovations, especially photon-counting CT, offer clearer, higher resolution images, he says.
“These scanners reduce blooming artifacts—bright distortions that obscure detail—allowing for much more precise visualization of plaque and vessel lumen,” Carumbaya says. The improvement is especially significant for cardiac CT, allowing it to find strong clinical traction, Carumbaya says.
A pivotal moment came in the fall of 2024, when CMS agreed to substantially increase the reimbursement amount for cardiac CT angiography (CTA)—about $335 more per scan—for outpatient hospital services, Carumbaya notes. This shift meant cardiology groups could justify investing in their own CT scanners. Additional reimbursement changes are expected and will include AI-assisted plaque analysis and fractional flow reserve, which evaluates bloodflow dynamics to determine the functional significance of blockages, he says. For cases with greater than 39% stenosis, these AI additions can generate up to $1,500 in supplemental reimbursements, depending on whether the study is done on an inpatient or outpatient basis.
Carumbaya says the combination of higher base reimbursement and new, AI-eligible payments greatly shortens the return on investment for practices acquiring CT scanners. He says ConcertAI’s new product, TeraRecon DETECT, automates plaque detection, flags studies that qualify for AI reimbursement, and incorporates patient-specific risk factors into standardized reporting formats such as CAD-RADS (Reporting and Data System). Carumbaya believes the increased speed, accuracy, and cost-support of cardiac CT is moving it toward standard-of-care status for evaluating chest pain and assessing cardiovascular risk. Ultimately, he expects cardiac CT will be used to differentiate between high-risk patients presenting in the emergency department (ED) with chest pain who need treatment and those who can safely be discharged. Eventually, he believes CTA could replace angiography in most cases.
Successful Strategy
Boone, too, is enthusiastic about using cardiac CT more as a robust tool for disease measurement, enabling quantification of coronary calcium and plaque burden. At his busy cardiology practice, Boone says, they have a CT-first strategy using CTA to determine patients’ heart health early on and how to treat them going forward. “I think within 10 years,” he says, “everybody will get a baseline CTA at age 40, repeat it every five years or so … and it will become a preventive cardiology approach” much like mammography is for breast cancer or colonoscopy is for colon cancer.
CTA is less invasive than angiography, and it can be done in 20 to 25 minutes with minimal radiation, Boone says. Those are significant advantages. Safety is not a concern, he says. Boone also notes that, thanks to AI analysis, doing CTAs in the office with the practice’s Arineta small footprint scanner has not burdened its readers.
Alberto Morales, MD, cardiologist and founder of South Tampa Cardiology in Florida, has found an alarming rate of plaque and early disease in patients as young as their 20s and those with zero calcium scores, since the practice acquired its own CT scanner and adopted a CT-first strategy. Calcium scores have been a go-to assessment for cardiologists to measure risk of CAD for a long time, Morales says. But with innovations in technology available, including Arineta’s small footprint scanner and AI analysis from Cleerly and Elucid, “we see exactly what’s happening inside the arteries that an EKG or calcium score alone can miss.” This CT-first approach, Morales says, “is allowing us to identify risk much earlier and help people change course before a heart attack ever has the chance to strike.”
Jonathon Leipsic, MD, a past president of the Society of Cardiovascular Computed Tomography and chairman of radiology for Providence Health Care in Vancouver, British Columbia, Canada, says patients complaining of chest pain are typically anxious and “they want to know what’s going on as soon as possible.” His practice can quickly assess patients using its compact cardiac CT scanner, which was acquired from the University of British Columbia in 2019. “Our patients appreciate that we give them clarity, often in minutes, and most are relieved to learn they can avoid catheterization unless it’s truly needed,” Leipsic says. “Their experience ends up being quicker and far less disruptive.”
When the CT scan does identify plaque, it gives patients a visual to help them understand their condition, Leipsic says. “That sense of ‘we know what’s happening, and we have a plan’ is powerful.” Having its own dedicated CT scanner “shortens the time spent in the emergency department and lowers cath lab volumes for cases that wouldn’t benefit from [such an] evaluation,” Leipsic adds.
Shifting Standard of Care?
Like Boone, Leipsic believes cardiac CT will become a standard in cath labs and prevention clinics within the next 10 years. “For decades, the industry has relied too heavily on stress testing and symptom-based referrals to cath labs as the first step in detecting cardiovascular disease,” he says.
Chest pain alone is not a strong enough indicator of CAD. “Sending patients in for catheterizations based on those symptoms alone often ends up costing them a lot of unnecessary time, money, and duress, especially when no coronary disease is discovered,” Leipsic says. “CCTA provides an anatomical ‘truth’ about the coronary arteries in one quick exam and, with lower dose radiation, can now provide noninvasive physiology and plaque characterization and quantitation.”
Sujith Kalathiveeti, MD, cardiologist at Duly Health and Care and director of cardiology at Northwestern Medical in Naperville, Illinois, says that CTA is not yet approved by any of the relevant medical societies as a screening tool for asymptomatic individuals. However, like his colleagues, Kalathiveeti anticipates that evolving plaque-based data will eventually support broader preventive use, offering a more comprehensive picture than current methods do. His center uses advanced plaque analysis tools through HeartFlow, including total plaque volume and characterization of calcified, noncalcified, and low-attenuation plaque.
“These metrics help predict long-term risk and may eventually support serial imaging, allowing physicians to monitor plaque stabilization over time,” Kalathiveeti says.
Strong evidence supports the practices’ CTA-first approach, the cardiologists say. One trial in particular, the SCOTHEART trial, published in August 2018 in the New England Journal of Medicine, demonstrated reduced heart attacks and improved mortality among patients evaluated with CTA compared with standard stress testing. “Benefits persisted for 10 years, largely because CTA identifies nonobstructive disease early enough for the initiation of preventive therapy,” Kalathiveeti says. Other studies have shown similar results, he says, but the SCOTHEART trial is the one most often cited.
At Kalathiveeti’s practice, patients are routed using a nurse-administered triage questionnaire. Patients with signs of potentially dangerous or classic cardiac pain—such as prior bypass with recurrent symptoms, pain rated 8 out of 10 or higher, crushing pain, or a sense of impending doom—are sent directly to the ED. Most others are directed to the practice’s Cardiac Evaluation Center, which is effectively a cardiac urgent care clinic where they can receive same-day CTA. Each visit includes basic lab work, an EKG, and then the scan. Patients typically complete the full process, including interpretation, within two hours, Kalathiveeti says. Cardiologists interpret the cardiac findings while radiologists review the noncardiac findings, he notes.
The practice has found that CTA results generally fall into three categories: normal coronary arteries, nonobstructive disease (<70% blockage), or obstructive disease (>70%). Patients with normal results are reassured and evaluated for noncardiac causes of their pain. Those with nonobstructive disease are counseled about early coronary disease and possibly started on preventive medication and lifestyle interventions. Patients with severe blockages are referred for intensifying medical therapy and often cardiac catheterization. Most patients fall into the nonobstructive category, allowing reassurance while simultaneously detecting early plaque and avoiding unnecessary ED visits or invasive testing, Kalathiveeti says.
Chest X-ray vs CTA
Michael Hood, MD, emergency radiologist in the department of radiology at Massachusetts General Hospital (MGH), agrees that cardiac CT is the best tool for measuring how much calcium is present in a patient’s coronary arteries. However, Hood says, single-exposure, dual-energy chest X-rays can allow doctors to identify coronary calcium in patients even when not looking specifically for it. At RSNA 2025, Hood and Michael Lev, MD, director of emergency radiology at MGH, presented their group’s work comparing single-exposure, dual-energy chest X-ray to CTA.
“Chest X-rays are one of the most common medical tests in the world,” Hood says. “Some patients who get them for routine indications, such as cough and pneumonia, might have heart disease without knowing it. Dual-energy imaging allows us to see calcium that standard X-rays often miss, without adding radiation, cost, or more time.”
Unlike other dual-energy approaches that require two exposures, the single-exposure detector used in this study can be retrofitted into existing X-ray setups, positioning the technology as more accessible and implementable. A positive finding acts as an early warning sign. “It tells clinicians that a patient may need closer attention to heart risk factors or follow-up testing,” Hood says.
Hood adds that CT is still the “confirmatory reference standard test.” In an opportunistic screening workflow, the dual-energy technology acts as a funnel to direct patients who are flagged for coronary calcium on their chest X-ray toward receiving a diagnostic cardiac CT. “By detecting coronary calcium on routine chest X-rays with accuracy close to CT, we can identify hidden heart disease earlier and connect more patients to preventive care like statin treatment before a heart attack happens,” Hood says. In that sense, this approach complements cardiac CT by helping to funnel patients who might otherwise be missed toward further evaluation.
In MGH’s pilot study, they found that single-exposure, dual-energy chest X-ray correctly identified calcium about 85% of the time, compared with approximately 38% for regular X-ray. Overall accuracy improved to a level close to that of routine chest CTs that are not specifically optimized to evaluate the heart, Hood says. “Doctors reading the images were also more confident and more consistent with each other, which matters in everyday clinical practice,” he says. “This turns a routine chest X-ray into something that can reliably flag hidden heart disease.”
Like using CTA for screening, the idea that routine dual-energy X-ray can identify calcium early is a significant shift in thinking about treating heart disease, Hood says. “Larger studies are needed, along with clear guidance and broader access to the technology. Any rollout would have to be considered and gradual.” However, what is encouraging, he says, is that cardiologists and radiologists are working together on this. “Both groups see value in earlier detection and prevention. The concept is exciting, but any implementation must be steady and evidence driven.”
— Beth W. Orenstein of Northampton, Pennsylvania, is a freelance medical writer and regular contributor to Radiology Today.
