Year in Review: AI, Business Issues Dominate Cardiac Imaging

Cardiovascular imaging, which continues to evolve alongside interventions and other technologies, made notable strides in the past year with artificial intelligence (AI) seeping into many imaging studies and practice plus other gains. Meanwhile, coronary artery calcium (CAC) remained a cornerstone.

Among the published data on AI: an AI-ECG model led to fewer cath lab activations and more efficiently identified STEMI; both an EchoNet model and one from PanEcho showed promise in automating echocardiography measurements; and data from the DECIDE registry indicated that AI-based coronary plaque analysis can better guide clinical management compared with coronary CT angiography (CCTA) alone in symptomatic patients.

That’s only the tip of the iceberg.

Society of Cardiovascular Computed Tomography (SCCT) President Kavitha Chinnaiyan, MD (Corewell Health, Royal Oak, MI), highlighted the potential for AI tools to identify and analyze coronary plaque, but also the need for standardization across different platforms. “That is going to be the next nut we need to crack,” she told TCTMD. “Does plaque on one platform mean plaque on another?”

There is excitement building, too, around photon-counting CT and it’s potential to solve several shortcomings of traditional cardiac CT imaging. “More and more data are coming out now on its applications and really the technical advantages and then all the different things it can possibly do in the future,” said Chinnaiyan. Some of the limitations of cardiac CT, for instance, include the visualization of the vessel in highly calcified or densely calcified segments or in-stent segments. “The overall spatial resolution is just so much better with photon counting.”

Questions of affordability and the logistics of replacing current scanners remain to be solved, she added.

Additionally, plaque imaging dominated this year, especially in tandem with AI-based tools. “This really blows the clinical assessment or risk factor stratification out of the water,” Chinnaiyan said, adding that calcium scoring—which saw a big win last month in a large study—isn’t going anywhere just yet.

“There is this whole ethical and the environmental concern of doing CT with contrast in large populations versus a calcium score, and I don’t think we have the data to suggest at least definitively that quantitative plaque assessment is better than calcium score for assessing long-term prognosis,” she said.

In fact, the CAUGHT-CAD randomized trial showed just how powerful CAC-guided management can be, especially compared with usual care.

Reimbursement, as ever, has also been a hot topic for cardiovascular imagers in 2025. The SCCT has supported several advocacy efforts designed to protect reimbursement for cardiac CT that will also “drive CT implementation, both as first line for plaque analysis [and] for new CPT codes,” Chinnaiyan said. “That’s a big aspect of cardiac CT—this issue of the business of cardiac CT.”

Similarly, over the summer the American Society of Nuclear Cardiology (ASNC) pushed back on the US Centers for Medicare & Medicaid Services’ proposed 57% cut for pyrophosphate/amyloid imaging.

Other highlights from TCTMD’s 2025 coverage of imaging spanned a wide range of topics. Researchers from the University of Washington Medical Center urged the use of intravascular imaging as a performance metric for PCI, and a few weeks later, the use of IVUS or OCT was given a class 1 recommendation during PCI in the latest American ACS guidelines. Invasive coronary function testing was shown to safely diagnose microvascular dysfunction among patients with nonobstructive coronary artery disease (ANOCA).

In the SONOBIRDIE sham-controlled trial, ultrasound seemed to make carotid endarterectomy safer. And an early look at SCOT-HEART 2 data showed that CCTA is better than risk scores alone at encouraging patients to make lifestyle changes. Similarly, researchers proposed adding annual CCTA to firefighter physicals to better identify CAD even among those with zero CAC.

Some novel techniques made headlines, too, including four-dimensional flow cardiovascular MRI for aortic stenosis as well as calls for more CT-guided PCI. Also in the PCI space, the FLAVOUR trial showed that, for guiding procedures, FFR is noninferior to IVUS over the long-term.

Finally, Chinnaiyan congratulated the SCCT on achieving two decades of innovation this year. “We’ve come a long way,” she said. “Twenty years ago, there was so much skepticism about cardiac CT, and a lot of people thought it was going to be a trend that [would] fizzle out.”

Now, with plenty of data to support the field, “it’s really blossomed and exploded [with] unprecedented growth,” according to Chinnaiyan. Going forward, “we have the very difficult and challenging task of understanding: who do we image, when do we image, why do we image, and is that going to change the management and the course of disease and the natural history of disease?”