PURPOSE OF REVIEW
Nonobstructive coronary artery disease (NOCA) is now frequently detected by coronary CT angiography (CCTA), but the term compresses biologically distinct patterns into a single anatomic label. This review examines how CT-derived markers can reorganize NOCA around plaque burden, inflammatory activity, clinical expression, and temporal change.
RECENT FINDINGS
Recent work distinguishes three related but distinct tasks in NOCA: identify disease, stratify risk, and define phenotypes that may inform future prevention strategies. CCTA addresses the atherosclerotic and prognostic dimensions by quantifying plaque burden, plaque composition, and high-risk features; CT-derived inflammatory and cardiometabolic markers may further identify active vascular and metabolic phenotypes. In symptomatic patients, CCTA and fractional flow reserve CT can evaluate epicardial anatomy and lesion-specific hemodynamic significance, but normal or nonobstructive findings do not exclude coronary microvascular dysfunction or vasospasm. In asymptomatic patients, coronary artery calcium and CCTA can reveal subclinical atherosclerosis and refine preventive risk assessment. Serial imaging and intervention studies suggest that adverse plaque phenotypes can stabilize or change with intensive prevention, but outcome-proven CCTA-guided treatment algorithms are still lacking.
SUMMARY
CCTA is evolving into a multidimensional phenotyping tool for NOCA. Its immediate value is refined risk stratification; whether these markers will improve outcomes remains unproven and should be tested prospectively.
P. Piña, A. Filtz, Daniel Lorenzatti et al.· Current Opinion in Cardiolog...· 0 citations
Background and Aims: Epicardial adipose tissue (EAT) has emerged as an important cardiovascular biomarker that reflects both inflammatory and cardiometabolic risk. EAT volume and density vary significantly across populations, yet there is a lack of multicenter studies investigating the predictive value of population-specific EAT percentiles. Methods: In this multicenter study, we retrospectively analyzed low-dose computed tomography correction scans from 42,842 patients undergoing myocardial perfusion imaging. A derivation cohort of 15,082 patients was used to establish sex- and age-specific nomograms for EAT density and EAT volume indexed to body surface area. Percentile-based thresholds were tested for outcome prediction in a validation cohort of 27,760 patients. For clinical implementation, we developed an online EAT percentile calculator. Results: Percentile curves demonstrated increased BSA-indexed EAT volume and decreasing EAT density with age. Over a median follow-up of 3.6 years (IQR: 1.83 - 5.14), 4,956 patients experienced a nonfatal myocardial infarction or death. In multivariable Cox models, patients above the 95th sex- and age-specific percentile had significantly worse outcomes for BSA- indexed EAT volume [adjusted hazard ratio 1.30, 95% CI: 1.14 - 1.49, p < 0.001] and EAT density [adjusted hazard ratio 1.7, 95% CI: 1.51 - 1.92, p<0.001] when compared to patients below the 50th percentile (p<0.001). Conclusion: Age- and sex-specific EAT percentiles provide a clinically interpretable framework for contextualizing automated EAT measurements and identifying patients at increased cardiovascular risk. EAT density was a stronger prognostic marker and identified elevated risk even among patients with normal BMI, supporting its potential to provide information beyond conventional anthropometric assessment.
A. Kamagate, A. Shanbhag, M. Buchwald et al.· medRxiv· 0 citations
Peripheral artery disease (PAD) is a prevalent manifestation of systemic atherosclerosis, associated with elevated risks of major adverse cardiovascular events (MACE) and major adverse limb events (MALE). Despite its clinical significance, PAD remains underdiagnosed and undertreated, reflecting substantial gaps in guideline implementation. This review highlights advances in the medical management of PAD, focusing on strategies targeting the metabolic, lipid, immuno-inflammatory, and thrombotic drivers of disease to improve cardiovascular and limb outcomes. Optimal management requires intensive, multifaceted approaches that integrate lifestyle modification (including smoking cessation, a healthy diet, and physical activity), risk factor control, and pharmacologic interventions. Dual pathway antithrombotic therapy with low-dose rivaroxaban and aspirin has emerged as a superior strategy to mitigate both cardiovascular and limb events in patients with high ischaemic risk and non-high bleeding risk. Statins are the first-line lipid-lowering therapy for all patients with PAD, and if low-density lipoprotein cholesterol (LDL-C) goals are not achieved with maximally tolerated doses, adjunctive agents-such as ezetimibe, bempedoic acid, and proprotein convertase subtilisin/kexin type 9 inhibitors (PCSK9i)-should be added. Novel antidiabetic agents, particularly glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and sodium-glucose cotransporter-2 inhibitors (SGLT2is), confer cardiovascular and renal benefits independent of glycaemic control, with emerging data suggesting that GLP-1 RAs may also reduce limb events. To date, semaglutide remains the only anti-obesity pharmacotherapy that has been demonstrated to reduce cardiovascular events in high-risk patients with overweight or obesity in the absence of diabetes. We propose a phenotype-driven approach to enable refined risk stratification across the PAD spectrum, supporting individualized and, when needed, more intensive management.
F. Garagoli, L. Slipczuk, Michael D. Shapiro et al.· European Heart Journal· 0 citations
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