Advanced Cardiovascular Testing: CIMT, echocardiography, and coronary CTA beyond the basics
Beyond the calcium score, three imaging tests come up in prevention discussions: carotid ultrasound (CIMT), echocardiography and coronary CT angiography. Each answers a different question, and the case for using them in people without symptoms is weaker than their marketing suggests. Here is what the trials show.
- Adding carotid intima-media thickness to the Framingham risk score barely improved 10-year prediction of heart attack and stroke in 45,828 people, an improvement the authors judged unlikely to be clinically important.1
- In 4,146 patients with stable chest pain, adding coronary CT angiography to standard care lowered the five-year rate of coronary death or heart attack from 3.9% to 2.3%, and more patients in the CT group started preventive treatment.2
- In 900 people with diabetes but no symptoms of heart disease, screening with coronary CT angiography did not reduce deaths, heart attacks or hospital admissions for unstable angina over four years.3
- For people without symptoms, the imaging test with guideline backing is the coronary artery calcium score, which the 2026 US dyslipidemia guideline, replacing the 2018 cholesterol guideline,5,4 uses selectively when a treatment decision is uncertain.6
- Echocardiography assesses the heart's structure and pumping; it is a test for symptoms or known heart conditions rather than a screening test for healthy adults.
Imaging can show atherosclerosis directly, but showing disease is not the same as improving outcomes. The useful question for any test is whether acting on its result changes decisions or prevents heart attacks and strokes, and the answer differs by test and by whether you have symptoms.
What the Trials Show
Carotid intima-media thickness (CIMT) is the thickness of the inner layers of the carotid artery wall, measured with ultrasound. In an individual-participant meta-analysis of 14 population cohorts with 45,828 people followed for a median of 11 years, adding common CIMT to the Framingham risk score barely changed the prediction of first heart attacks and strokes (C statistic 0.757 versus 0.759; net reclassification improvement 0.8%, or 3.6% among people at intermediate risk). The authors concluded that the improvement was unlikely to be of clinical importance.1
Coronary CT angiography (CTA) images the coronary arteries with CT and an injected contrast agent. Its strongest evidence comes from people with symptoms: in the SCOT-HEART trial, 4,146 patients with stable chest pain referred to a cardiology clinic were randomized to standard care with or without CTA. After a median of 4.8 years, coronary death or non-fatal heart attack had occurred in 2.3% of the CTA group versus 3.9% with standard care. Rates of invasive angiography and revascularization were similar overall at five years, and more preventive therapies were started in the CTA group.2
Clinical Application
Screening people without symptoms is a different question. In the FACTOR-64 trial, 900 adults with type 1 or type 2 diabetes and no symptoms of coronary disease were randomized to CTA screening, with treatment guided by the results, or to standard diabetes care. Over an average of four years, the combined rate of death, heart attack or hospital admission for unstable angina did not differ significantly (6.2% versus 7.6%), and the authors concluded that the findings do not support CTA screening in this group.3
For people without symptoms, the imaging test with guideline backing is the coronary artery calcium score: the 2026 US dyslipidemia guideline, which replaced the 2018 cholesterol guideline,5,4 uses it selectively, when a decision about cholesterol-lowering treatment remains uncertain, rather than as a screening test for everyone.6 Echocardiography uses ultrasound to assess the heart's structure and pumping, and is used to investigate symptoms or known heart conditions. If you have chest pain, breathlessness or other symptoms, which test is right is a decision for your clinician.
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References
- 1Den Ruijter HM, et al. "Common carotid intima-media thickness measurements in cardiovascular risk prediction: a meta-analysis." JAMA. 2012;308(8):796-803. PubMed · DOI
- 2Newby DE, et al. "Coronary CT Angiography and 5-Year Risk of Myocardial Infarction." N Engl J Med. 2018;379(10):924-933. PubMed · DOI
- 3Muhlestein JB, et al. "Effect of screening for coronary artery disease using CT angiography on mortality and cardiac events in high-risk patients with diabetes: the FACTOR-64 randomized clinical trial." JAMA. 2014;312(21):2234-43. PubMed · DOI
- 4Grundy SM, et al. "2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines." Circulation. 2019;139(25):e1082-e1143. PubMed · DOI
- 5Blumenthal RS, et al. "2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Dyslipidemia: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines." Circulation. 2026;153(17):e1154-e1276. PubMed · DOI
- 6Sabouret P, et al. "The 2026 ACC/AHA Dyslipidemia Guideline: A Critical and Transatlantic Perspective on Personalized Lipid Management." Life (Basel). 2026;16(9). PubMed · DOI
