CT Angiography in Extreme Coronary Artery Calcium Score: JACC Adv., February 2026

The study's brief report was published in the Journal of the American College of Cardiology (JACC): Advances in February 2026.

Bridging the Calcium Gap in Cardiac Imaging

While extreme Coronary Artery Calcium (CAC) above 1,000 AU denotes significant cardiovascular risk, traditional Coronary Computed Tomography Angiography (CCTA) is frequently hampered by calcium-induced blooming artifacts; therefore, addressing this gap, the study aimed to evaluate whether the PCCT could reliably assess coronary stenosis in this difficult-to-image asymptomatic population.

Study Overview

The retrospective clinical evaluation conducted between February 2024 and March 2025 utilized a PCCT scanner at 0.2 mm slice thickness to evaluate 19 asymptomatic patients with extreme calcium burdens. Excluding those with prior cardiac events or revascularization, the researchers primarily sought to determine the diagnostic yield and the frequency of functionally significant disease via ultra-high-resolution imaging, using the Coronary Artery Disease–Reporting and Data System (CAD-RADS) 2.0 to categorize findings.

Key Findings of the Study Include:

• Universal Clarity: Demonstrating that PCCT achieved 100% diagnostic quality across all segments, the study successfully bypassed the traditional blooming artifacts that typically obscure lumen assessment in high-calcium patients.
• Ischemia Exclusion: Confirming that all seven patients who underwent Fractional Flow Reserve derived from Computed Tomography (FFR-CT) had negative results between 0.80 and 0.93, the study suggests that most extreme calcium cases do not involve functionally significant blockages.
• Anatomic Insight: Categorizing the cohort, the research found that 32% of patients were classified as CAD-RADS 2 and 42% as CAD-RADS 3, providing a detailed map of nonobstructive disease distribution.
• Surgical Necessity: Identifying only one patient who required Coronary Artery Bypass Grafting (CABG) after Invasive Coronary Angiography (ICA) confirmed multivessel disease, the findings highlight PCCT's ability to pinpoint the rare cases needing intervention.
• Reduced Testing: Observing that most participants required no further evaluation following their scan, the data underscores the potential of PCCT to limit redundant and invasive diagnostic procedures.

Potential Clinical Implications

For practicing physicians, PCCT provides a robust, noninvasive pathway to accurately risk-stratify asymptomatic patients with high calcium burdens, potentially sparing many from unnecessary invasive catheterization while precisely identifying those few who require surgical revascularization.

Reference

Shiyovich A, Blair CV, Aun JA, et al. Photon-Counting Coronary CT Angiography in Asymptomatic Patients With Extreme Coronary Artery Calcium Score. JACC Adv. 2026;5(2):102553.