Cardiac CT at 20 Years: From Doubt to Dominance, What’s Next?

 Introduction:

Two decades ago, cardiac computed tomography (CT) stood at the margins of cardiovascular imaging—dismissed by skeptics, mired in technical limitations, and often underestimated. Fast forward to 2025, and the field has not only matured but has transformed into a cornerstone of coronary artery disease assessment. At this year’s Society of Cardiovascular Computed Tomography (SCCT) meeting in Montreal, pioneers in the field gathered to commemorate this extraordinary journey—highlighting major achievements, ongoing challenges, and a future shaped by artificial intelligence, plaque characterization, and preventive cardiology.

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A Diamond Formed Under Pressure

The early 2000s were marked by considerable skepticism toward cardiac CT. Doubts centered on radiation exposure, cost, accuracy, and the perceived lack of clinical impact. Yet as current SCCT leaders emphasized, the intense scrutiny only made the field stronger: “When you put enough pressure on carbon, it becomes a diamond.” That diamond began to shine with the release of landmark trials such as SCOT-HEART and PROMISE, which validated CT’s utility in diagnosing and managing coronary artery disease (CAD).

Cardiac CT's ability to noninvasively assess coronary anatomy, especially nonobstructive plaque, shifted paradigms in primary prevention and risk stratification, and opened the door to precision medicine in cardiovascular care.

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From Niche to Norm: The SCCT’s Expanding Impact

Founded in 2005, the SCCT grew from a modest group of 200 to more than 6,000 members worldwide. This evolution was far from smooth. As past leaders recalled, the society faced “pushback from other imaging societies,” and technological barriers such as high radiation doses and limited spatial resolution. Radiologists and cardiologists were at odds, and false positives in early CT angiograms drew criticism from interventionalists and lipidologists alike.

Despite these hurdles, the field remained resilient, driven by a tight-knit community of innovators and early adopters. Founding members described their early involvement not as a calculated strategy, but as a pursuit of exciting scientific discovery. “We were challenged every step of the way—and I’m glad we were,” one said.

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CT's Clinical Contributions and the AI Boom

In recent years, coronary CT angiography (CCTA) has evolved well beyond lumenography. Advanced tools now enable:

• Plaque morphology and composition analysis

• Quantitative plaque burden measurement

• Functional assessments with CT-derived fractional flow reserve (FFR-CT)

• Perivascular fat analysis and inflammation metrics

• AI-enhanced image interpretation for improved workflow and diagnostic accuracy

These innovations have expanded the modality’s value from diagnosis to risk prediction, and now increasingly toward guiding therapy—particularly in patients with nonobstructive atherosclerosis, a group often missed by conventional stress testing.

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Unanswered Questions and the Road Ahead

Despite the progress, several critical knowledge gaps persist. Experts noted that the prognostic value of CCTA remains under debate. While observational data suggest benefit, a randomized trial evaluating CT angiography in asymptomatic individuals—such as the ongoing SCOT-HEART 2 study—is needed to confirm whether early plaque detection improves outcomes.

Additional unanswered questions include:

• Does plaque regression equate to event reduction?

• Can AI models outperform traditional risk scores?

• How should noncalcified plaque guide therapy in low-to-intermediate risk patients?

Current treatment trials such as EVAPORATE, HEARTS, and ARCHITECT aim to answer whether reducing plaque burden leads to fewer clinical events.

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Charting a Transformative Future

The session’s panelists called for a rethinking of cardiovascular care. They emphasized that acute coronary syndromes should be viewed as preventable failures, not inevitable endpoints. Achieving this vision requires integrating early detection, aggressive risk modification, and personalized therapy—with cardiac CT playing a central role.

Speakers also highlighted the need to address sustainability, equitable access, and appropriate use criteria, along with the development of more effective AI-driven tools. These will define the next chapter in the evolution of cardiac CT.

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Key Takeaways for Clinicians

• Cardiac CT has evolved from a fringe tool to a mainstream modality backed by strong evidence from SCOT-HEART, PROMISE, and real-world practice.

• The SCCT’s growth reflects the modality’s rising relevance in both diagnosis and prevention of CAD.

• Ongoing challenges include the need for prospective outcome trials, better endpoint validation, and cost-effective implementation.

• AI, plaque imaging, and functional CT tools are transforming CCTA into a prognostic and therapeutic guide.

• Future directions emphasize prevention-first strategies, aiming to reduce events before they occur—with CCTA at the helm.

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For further reading on the role of coronary CT in preventive cardiology and AI applications, visit the SCCT website and explore recent publications from JACC: Cardiovascular Imaging.