From measuring stenosis to understanding atherosclerosis.
The publication of the Quantitative Coronary Plaque Analysis in Clinical Practice: 2025 ACC Scientific Statement represents one of the most important developments in cardiovascular imaging in recent years [1]. The statement arrives at a time when artificial intelligence, advanced coronary CT angiography (CCTA), and plaque quantification tools are becoming increasingly integrated into routine cardiac imaging workflows.
The same trend was impossible to ignore during The Society of Cardiovascular Computed Tomography Annual Meeting 2026, where coronary plaque analysis emerged as a central topic across scientific sessions, industry presentations, and discussions on preventive cardiology. The message was consistent: cardiac CT is evolving beyond stenosis assessment toward comprehensive characterization of atherosclerotic disease.
Over the past decade, advances in coronary CT technology and AI-driven image analysis have enabled clinicians to quantify plaque volume, plaque composition, and high-risk plaque features with unprecedented precision. Simultaneously, a growing number of FDA-cleared software solutions have entered clinical practice. Yet despite strong evidence supporting the prognostic value of plaque analysis, important questions remained unanswered:
The ACC Scientific Statement was developed specifically to address these gaps and provide clinicians with a practical framework for implementing QCPA in everyday practice.
For decades, coronary CT interpretation has focused primarily on luminal narrowing.
The key clinical question was:
“How severe is the stenosis?”
The ACC statement introduces a broader perspective:
How extensive and how dangerous is the patient’s atherosclerosis?”
This distinction is critical because of the well-known myocardial infarction paradox: most myocardial infarctions occur at lesions that were previously non-obstructive and would not have been identified as high risk based on stenosis severity alone. Many acute coronary syndromes originate from vulnerable plaques that may cause only mild or moderate luminal narrowing before rupture. As a result, focusing exclusively on the degree of obstruction can underestimate a patient’s true cardiovascular risk. Quantitative plaque assessment shifts the focus from stenosis to the overall atherosclerotic disease burden, enabling physicians to evaluate plaque volume, composition, and high-risk features that are more closely linked to future adverse cardiovascular events.
As emphasized throughout discussions at SCCT 2026, the future of cardiac CT lies in comprehensive plaque characterization, not merely stenosis grading.
According to the ACC statement, Quantitative Coronary Plaque Analysis should primarily be considered in patients with visible coronary plaque identified on CCTA. In these individuals, quantitative analysis can provide additional information for risk stratification and preventive treatment planning.
Particularly valuable use cases include:
One of the most important contributions of these latest scientific statements is the emphasis on standardized plaque characterization. Once a fascinating niche topic for a select few, it is now recommended in… routine clinical practice [2]. Clinicians are encouraged to move beyond visual assessment and evaluate:
1. Total plaque burden
Total plaque volume throughout the coronary tree is increasingly recognized as a strong marker of cardiovascular risk.
3. High-risk plaque features
The ACC identifies several features that should receive particular attention:
These findings have significant prognostic implications and may identify patients at elevated risk despite the absence of severe stenosis.
The ACC Scientific Statement outlines a practical approach that can be incorporated into routine clinical practice.
Step 1: Verify CCTA image quality
Assess image quality, contrast enhancement, motion artifacts, and the evaluability of coronary segments. Reliable plaque quantification requires high-quality datasets.
Step 2: Confirm plaque presence
Conduct a traditional CCTA review and identify patients with coronary atherosclerosis suitable for quantitative evaluation.
Step 3: Quantify total plaque burden
Measure plaque volume and distribution across the coronary tree.
Step 4: Characterize plaque composition
Determine the relative contribution of calcified and non-calcified plaque components.
Step 5: Identify high-risk features
Actively evaluate for imaging markers associated with vulnerable plaque biology.
Step 6: Perform vessel-specific assessment
Analyze disease burden within left main (LM), left anterior descending (LAD), left circumflex (LCx), right coronary artery (RCA) .
Step 7: Compare with prior examinations
When available, serial studies should be reviewed to assess plaque progression or regression.
Step 8: Integrate imaging and clinical risk
Plaque findings should always be interpreted together with traditional risk factors and laboratory data.
Step 9: Guide preventive treatment
QCPA findings can support decisions regarding statin initiation, statin intensification, ezetimibe therapy, PCSK9 inhibitors in selected patients or even more aggressive cardiovascular risk reduction strategies.
Another major focus of the ACC statement is reporting standardization. Reports should include:
The goal is to improve consistency across institutions, imaging specialists, and software vendors while enabling more meaningful clinical decision-making.
A particularly exciting area highlighted by the ACC is serial plaque assessment.
While further validation is needed, the statement acknowledges that repeated QCPA examinations may allow clinicians to monitor:
• Disease progression
• Disease stabilization
• Response to lipid-lowering therapy
• Long-term preventive treatment effectiveness
This concept was frequently discussed during SCCT 2026 as a potential future biomarker for precision prevention and treatment optimization.
The ACC Scientific Statement signals a fundamental evolution in cardiovascular imaging. The future of coronary CT is not simply identifying whether a vessel is narrowed.
As demonstrated both in the ACC guidance and throughout the conversations at SCCT 2026, Quantitative Coronary Plaque Analysis is rapidly becoming a cornerstone of personalized cardiovascular prevention.
The era of asking only “How severe is stenosis?” is ending.
The new question is:
“What is the patient’s true atherosclerotic burden, and how can we use that information to prevent the next cardiovascular event?”
REFERENCES:
[1] Chandrashekhar, Y, Blankstein, R, Shaw, L. et al. Quantitative Coronary Plaque Analysis in Clinical Practice: 2025 ACC Scientific Statement: A Report of the American College of Cardiology. J Am Coll Cardiol Img. 2026 May, 19 (5) 637–652. https://doi.org/10.1016/j.jcmg.2025.11.008
[2] https://graylight-imaging.com/blog/coronary-artery-calcification-and-beyond-calcification/
