Cardiovascular disease remains a major cause of mortality, accounting for a third of all global deaths annually.
Although there have been major improvements in our ability to detect and to treat patients with coronary heart
disease, most myocardial infarctions occur in previously asymptomatic individuals. Identification of individuals at
risk of myocardial infarction remains challenging and primary prevention guidelines rely on the use of cardiovascular risk scores that can be supplemented by coronary artery calcium scores. Coronary artery calcium scores provide a simple surrogate late marker of atherosclerosis but is unable to identify the early high risk non-calcified plaque which can be particularly problematic in younger individuals. Coronary computed tomography angiography is increasingly being used as the imaging strategy of choice in patients with symptoms of coronary heart
disease. As an anatomical test, it can non-invasively detect the presence of coronary atherosclerosis, providing
clinicians with a strong mandate to commence symptom relieving and preventative therapies. For asymptomatic
individuals, it allows precise targeting of therapies to those with coronary heart disease rather than those “at risk”
of disease. Moreover, our ability to calculate risk using coronary computed tomography angiography is rapidly
improving with the use of techniques, such as plaque quantification and characterisation. These techniques have
the potential to provide clinicians with tools to target cardiovascular disease prevention in a precision medicine
approach. We here debate the ways in which coronary computed tomography angiography could improve the
selection of asymptomatic individuals for preventative therapies over and above risk calculators and calcium
scoring