Imaging Biomarkers Advance Early ASCVD Detection
Emerging imaging tools complement traditional cardiovascular risk measures
In concert with the RadioGraphics monograph, RSNA News shares the latest on the role of imaging in disease screening.
Imaging biomarkers can detect and quantify atherosclerotic cardiovascular disease (ASCVD) in its early stages, complementing standard risk-prediction models and addressing some of their limitations. This approach offers an opportunity for earlier detection and more personalized prevention of ASCVD, a major cause of morbidity and mortality worldwide.
“Atherosclerosis often develops silently for years. The goal is to identify subclinical disease in appropriately selected patients before symptoms or an acute event occur and then connect the finding to an effective preventive strategy,” said Prabhakar Rajiah, MBBS, MD, a cardiovascular radiologist at the Mayo Clinic in Rochester, MN.
Cardiovascular disease accounted for approximately one-third of all deaths worldwide in 2023, causing an estimated 19.2 million deaths, with ASCVD representing a major contributor.
“For some patients, the first manifestation of ASCVD is a heart attack or stroke. Earlier, more accurate risk assessment will allow us to intensify prevention before that happens,” Dr. Rajiah said.
In a recently published article in RadioGraphics, Dr. Rajiah and his co-authors reviewed the imaging biomarkers available for detecting and assessing ASCVD, from established tools such as coronary artery calcium (CAC) scoring and coronary CT angiography to a growing range of newer approaches.
The authors examine emerging coronary biomarkers, including quantitative plaque analysis and pericoronary and epicardial adipose tissue assessment as well as extracoronary markers such as carotid plaque imaging, aortic plaque and wall imaging, and arterial stiffness. They also highlight opportunistic biomarkers identifiable on routine imaging, including incidental coronary and extracoronary arterial calcification and breast arterial calcification.
Providing a More Complete Picture of Disease Risk
According to Dr. Rajiah and colleagues, traditional ASCVD risk-prediction models may overestimate or underestimate an individual patient’s risk, particularly among those at borderline or intermediate risk. These models may underestimate ASCVD risk in people with chronic inflammatory conditions, including rheumatoid arthritis and HIV infection.
“Short-term estimates may understate lifetime risk in younger adults and may not fully capture risk in some populations, including people of South Asian ancestry,” Dr. Rajiah observed.
Imaging can detect and measure signs of ASCVD, including plaque burden and composition, vascular inflammation and arterial remodeling. When integrated with traditional risk factors, these biomarkers can provide a comprehensive assessment of risk and allow for earlier detection.
They can also enable more personalized care when the appropriate imaging test is selected. “There is no one-size-fits-all imaging test,” Dr. Rajiah said. “Selection should be guided by the patient’s clinical profile, the specific question being asked and whether the result is likely to change management.”
He cited a recent encounter with an asymptomatic patient who appeared to be at low risk and had a CAC score of 0. However, the patient had a strong family history, which prompted coronary CT angiography (CCTA). CCTA revealed substantial non-calcified coronary plaque with high-risk features associated with plaque rupture and myocardial infarction.
“The CCTA findings materially changed the patient’s risk assessment and prompted intensification of preventive therapy,” Dr. Rajiah explained.
Dr. Rajiah also emphasized the importance of residual inflammatory risk. “Even after lipid levels and traditional cardiovascular risk factors are well controlled, some patients may remain at increased risk because of ongoing vascular inflammation,” he said. “Emerging biomarkers of coronary inflammation may help identify this residual risk, although their role in guiding therapy is still evolving.”
AI-based QCPA. Schematic illustration shows AI-based CT analysis of coronary plaque burden and composition. The AI algorithm defines the lumen, vessel wall, and plaque boundaries, classifies plaque on the basis of specific attenuation thresholds, and performs circumferential segmentation around the vessel centerline.
https://doi.org/10.1148/rg.260068 ©RSNA 2026
Radiologists Help Personalize ASCVD Risk Assessment
Imaging biomarkers can provide a more complete risk assessment and help physicians choose among an expanding range of preventive therapies. “Imaging can help identify patients who may benefit from treatment intensification while avoiding unnecessary testing or treatment in others,” Dr. Rajiah said.
He recommends that radiologists collaborate with cardiologists and primary care physicians to select the appropriate test. “Radiologists should review the source images and automated segmentations and interpret quantitative results in the full clinical context. AI can support interpretation, but it does not replace expert review,” he advised. “For example, automated software may misclassify motion artifact or adjacent non-coronary calcification as coronary calcium or plaque unless the source images are carefully reviewed.”
Radiologists can also contribute to prevention by recognizing and reporting coronary calcification on chest CT examinations performed for other indications, creating an opportunity for cardiovascular risk assessment without an additional scan.
The rapid growth of AI-assisted imaging analysis presents both a challenge and an opportunity for radiologists. Automated plaque quantification is already gaining traction, and Dr. Rajiah expects it to become widely adopted within the next five years. He believes that pericoronary adipose tissue assessment, particularly the fat attenuation index as an imaging marker of coronary inflammation, will be the next emerging imaging biomarker to gain broad clinical interest.
Dr. Rajiah expects AI to increasingly integrate clinical risk factors with CAC, plaque burden, and markers of inflammation to generate more individualized risk estimates. Some platforms already provide integrated scores, although standardization, external validation and clinician oversight remain essential.
The expanding options for testing and treating ASCVD illustrate the complexity of the disease. Dr. Rajiah identified this complexity as one of the main reasons ASCVD remains a leading global health challenge despite decades of prevention efforts.
“Two patients with a similar plaque burden may have very different risk because of differences in plaque composition, inflammation and clinical factors,” he said. “As these tools mature, cardiovascular risk assessment may begin earlier and become more individualized, with the goal of reducing heart attacks, strokes and cardiovascular deaths.”
For More Information
Access the RadioGraphics article, “State-of-the-art Imaging Biomarkers in Screening of Atherosclerotic Cardiovascular Disease.”
Read previous RSNA News stories on cardiovascular imaging: