Noninvasive cardiac imaging plays a critical role in the diagnosis and risk stratification of cardiovascular disease in older adults, a population marked by clinical heterogeneity, multimorbidity, and age-related physiologic changes. This review outlines the strengths and limitations of commonly used imaging modalities including echocardiography, transesophageal echocardiography, cardiac computed tomography, nuclear imaging tests, and cardiac magnetic resonance imaging in the context of aging. We highlight diagnostic challenges such as limited exercise capacity, image quality artifacts, reduced specificity in the setting of multivessel, or microvascular disease and intolerance to longer scan protocols. Advances in imaging technology, including artificial intelligence and hybrid protocols, offer opportunities to improve accuracy, access, and individualized decision-making. The review emphasizes the importance of tailoring test selection to patient comorbidities and goals of care. Addressing current evidence gaps through trials inclusive of older adults and geriatric-focused imaging guidelines is essential to delivering equitable, high-value cardiovascular care to older adults.

Background: Cardiovascular risk assessment relies heavily on coronary calcium scoring. With an emphasis on varying slice increments, this study investigates the effectiveness of true and virtual non-contrast reconstructions on photon-counting CT. Reconstruction methods’ effects on calcium severity classifications are critical to the improvement in imaging techniques. Methods: This study comprised 77 participants (mean age: 63 ± 10 years, 43% female), of whom 0 had a coronary artery calcium score (CACS) of zero. In contrast to true non-contrast (TNC) 3 × 3 mm, the reconstructions included TNC 3 × 1.5 mm, virtual non-contrast (VNC) 3 × 3 mm, and VNC 3 × 1.5 mm. Agatston units served as the basis for classifications into standard clinical diagnostic categories. Results: High concordance between acquisition types was revealed by interclass correlation values (0.97–0.99). Comparing TNC 3 × 1.5 mm reconstructions to their VNC counterparts, misclassifications were less common (Cohen Kappa = 0.94). (K = 0.83–0.85). Significant differences in the average calcium scores and rates of misclassification highlighted the impact of reconstruction methods on precise evaluations. Conclusions: VNC methods demonstrated high agreement; however, with a small rate of misclassifications as compared to the gold standard method. VNC CACS may help optimize workflows but may need differing cutoffs as compared to traditional methods.