Imaging Guided Treatment of Subclinical Atherosclerosis- We’ve come a long way!

The optimal use of imaging subclinical atherosclerosis to optimize prevention of atherosclerotic cardiovascular disease continues to evolve. The new 2026 ACC/AHA/Multisociety Guideline on the Management of Dyslipidemia builds on the prior National Lipid Association scientific statement on CAC by expanding the use of CAC testing for both initiation of treatment and for informing treatment intensity. Specific algorithms delineate treatment initiation as well as treatment intensity with LDL-C treatment goals based on the amount of coronary plaque. The Guideline also provides a limited role for coronary CT angiography in select individuals who are more likely to have non-calcified plaque, where the amount of disease may be underestimated by coronary calcification. Lastly, the Guideline also recommends that, when available, incidental detection of CAC on non-cardiac chest CT should be used to guide treatment goals and intensity. The sum of the above recommendations highlights the evolving role of imaging in personalized preventive care.