Cardiac CT / Cardiac MRI (beyond calcium scoring)
Coronary CT angiography uses contrast to visualise the coronary lumen along with both calcified and non-calcified “soft” plaque; cardiac MRI assesses structure, function and tissue characteristics such as scar and fibrosis. CCTA’s real advantage over a calcium score is that it detects non-calcified plaque the score misses entirely, including in younger patients who have not yet developed calcification.
CCTA is well validated for evaluating symptomatic chest pain — the SCOT-HEART trial demonstrated improved diagnostic certainty and reduced coronary death or MI at five years when CCTA was added to standard care — and it is increasingly used to refine risk after a borderline or abnormal CAC score. It is not established as a first-line screening tool for asymptomatic, average-risk adults. It carries contrast and, for CT, radiation exposure that calcium scoring does not, and its evidence base sits in symptomatic or higher-risk populations rather than general population screening.