Non-Invasive Imaging Modalities for the Evaluation of Coronary Artery Disease among Patients with High Body Mass Index: A Focus on Coronary Computed Tomography Angiography (CCTA)

• CAC score of 0 has 98% NPV for ruling out obstructive CAD in stable chest pain. • CAC = 0 linked to 81% lower MACE risk vs. CAC > 0 in symptomatic patients. • CAC = 0 remains effective in intermediate/high PTP groups with 98% NPV. • Annualized MACE rate: 0.4% for CAC = 0 vs. 1.9% for CAC > 0 (p < 0.01). • CAC testing is cost-effective, simpler, and uses less radiation than CCTA. CAC score of 0 has 98% NPV for ruling out obstructive CAD in stable chest pain. CAC = 0 linked to 81% lower MACE risk vs. CAC > 0 in symptomatic patients. CAC = 0 remains effective in intermediate/high PTP groups with 98% NPV. Annualized MACE rate: 0.4% for CAC = 0 vs. 1.9% for CAC > 0 (p < 0.01). CAC testing is cost-effective, simpler, and uses less radiation than CCTA. Obesity, which is defined as Body Mass Index (BMI) exceeding 30 kg/m 2 is the epidemic of our century. Obesity is estimated to affect more than 40% of the adult population in the United States. Due to the common associations with other prevalent cardiovascular risk factors (diabetes, metabolic syndrome, hypertension, obstructive sleep apnea, hyperlipidemia), obesity is encountered very frequently in patients with established cardiovascular disease or in patients who undergo evaluation for obstructive coronary artery disease. High BMI can be a challenge not only for many of the traditional noninvasive methods used to diagnose coronary artery disease, including treadmill stress test, nuclear imaging, but also coronary computed tomography angiography due to the unique characteristics in those patients, including but not limited to inability to exercise, attenuation artifact, and need for higher radiation dose. With this review, we hope to shed light on the published literature and the gaps for future research.