From image to action: Evaluating the translation of coronary CT angiography findings into cardiovascular prevention in the emergency department

• This study extends prior evidence by evaluating how CCTA findings influence statin initiation and preventive care at ED discharge in real-world practice. • While CCTA findings strongly predict statin initiation, cardiology referral, and patient education, notable gaps in preventive care continue. • In obstructive CAD, 80% of patients were started on statins, but 1 in 5 remained untreated, reflecting suboptimal adherence to guideline-based care. • In non-obstructive CAD, only ∼10% of patients were initiated on statins, underscoring a critical missed opportunity for timely, personalized prevention despite its established link to elevated ASCVD risk. • Integrating CCTA-guided preventive therapy into standardized ED workflows could close treatment gaps efficiently and reduce ASCVD burden in the current value-based care landscape. Coronary CT angiography (CCTA) is increasingly used in emergency departments (ED) for chest pain evaluation, but its role in directing preventive therapy at discharge remains unclear. We aimed to determine whether CCTA findings were associated with statin initiation at discharge and to identify gaps in preventive care. We conducted a retrospective observational study of adult patients (≥18 years) undergoing CCTA for chest pain in the ED of a large academic hospital. CCTA findings were categorized as no CAD, non-obstructive CAD (<50% stenosis), or obstructive CAD (≥50% stenosis). The primary outcome was statin initiation at discharge among statin-naïve patients. Secondary outcomes included cardiology referral and heart disease education. We applied multivariable Firth logistic regression for the primary outcome and modified Poisson regression with robust variance for secondary outcomes. Of 1410 participants (mean age=53.5±10.9 years; 52.8% female), 723 (51.3%) had no CAD and 687 (48.7%) had CAD (69.3% non-obstructive, 30.7% obstructive). In statin-naïve patients (n=1,120), statin initiation rates were 79.7% for obstructive CAD and 9.5% for non-obstructive CAD. Adjusted models showed higher statin initiation with obstructive CAD (OR=97.0, 95% CI: 22.9–410.5) and non-obstructive CAD (OR=18.2, 95% CI: 4.8–69.1) compared with no CAD. Cardiology referral occurred in 96.2% of obstructive and 83.2% of non-obstructive CAD; education was documented in 83.4% and 52.1%, respectively. CCTA findings strongly predict statin initiation at discharge, yet large treatment gaps persist, especially in non-obstructive CAD. Routine ED CCTA provides a missed but actionable opportunity to initiate guideline-based therapy and reduce ASCVD burden.