The identification of coronary artery calcification (CAC) detected coincidentally on chest CT exams could assist in cardiovascular risk assessment but may not be reported consistently on clinical studies. Cardiovascular risk factor stratification is important to predict short term cardiac events during cancer therapy and long term cardiac event free survival in cancer patients. We sought to determine the prevalence of CAC and clinical reporting rates in a cohort of cancer patients at high risk of cancer therapy related cardiac events. 408 Breast cancer patients who were referred to a cardiac oncology clinic were screened. Inclusion criteria included having had a CT chest and the absence of known coronary disease. Among those screened 263 patients were included in the study. CAC was identified in 70 patients (26%). CAC was reported in 18% of studies. The reporting rates of CAC increased with the extent of coronary calcification (p < 0.01) and increased during the period of the study (p < 0.05). CAC was commonly detected on chest CT studies in this observational study of breast cancer patients at high risk of cardiac oncology events. The presence of CAC was often not reported clinically but reporting rates have increased over time. Recent SCCT/STR guidelines recommend reporting the presence of CAC on routine chest CT scans in recognition of the importance of CAC as a predictor of cardiovascular events. Reporting of CAC on chest CTs may help to further risk stratify breast cancer patients and improve cardiovascular outcomes in this vulnerable population.

Cardiac imaging techniques that use ionizing radiation have become an integral part of current cardiology practice. However, concern has arisen that ionizing radiation exposure, even at the low levels used for medical imaging, is associated with the risk of cancer. From a single diagnostic cardiac imaging procedure, such risks are low. On a population basis, however, malignancies become more likely on account of stochastic effects being more probable as the number of procedures performed increases. In light of this, and owing to professional and industrial commitment to the as low as reasonably achievable (ALARA) principle, over the last decade major strides have been made to reduce radiation dose in cardiac imaging. Dose-reduction strategies have been most pronounced in cardiac computed tomography. This was important since computed tomography has rapidly become a widely used diagnostic alternative to invasive coronary angiography, and initial protocols were associated with relatively high radiation exposures. Advances have also been made in nuclear cardiology and in invasive coronary angiography, and these reductions in patient exposure have all been achieved with maintenance of image quality and accuracy. Improvements in imaging camera technology, image acquisition protocols and image processing have lead to reductions in patient radiation exposure without compromising imaging diagnostic accuracy.

The goals of primary prevention in coronary atherosclerosis are to avoid sudden cardiac death, myocardial infarction or the need for revascularization procedures. Successful prevention will rely on accurate identification, effective therapy and monitoring of those at risk. Identification and potential monitoring can be achieved using cardiac computed tomography (CT). Cardiac CT can determine coronary artery calcification (CAC), a useful surrogate of coronary atherosclerosis burden. Cardiac CT can also assess coronary CT angiography (CCTA). CCTA can identify arterial lumen narrowing and highlight mural atherosclerosis hitherto hidden from other anatomical approaches. Herein we consider the role of CCTA and CAC-scoring in subclinical atherosclerosis. We explore the use of these modalities in screening and discuss data that has used CCTA for guiding primary prevention. We examine therapeutic trials using CCTA to determine the effects of plaque-modifying therapies. Finally, we address the role of CCTA and CAC to guide therapy as defined in current primary prevention documents. CCTA has emerged as an essential tool in the detection and management of clinical coronary artery disease. To date, its role in subclinical atherosclerosis is less well defined, yet with modern CT scanners and continued pharmacotherapy development, CCTA is likely to achieve a more prominent place in the primary prevention of coronary atherosclerosis.