ACC26: Imaging Redefines Cardiovascular Risk Prevention

“…a picture is worth 1,000 words, and patients who understand they have atherosclerosis, do more – better compliance with both medications and lifestyle changes.”

Cardiovascular prevention is entering a new era of precision, driven by advances in imaging and a sharper focus on individualized risk assessment. From the American College of Cardiology Annual Scientific Session 2026, Dr Matthew Budoff (Lundquist Institute at Harbor-UCLA Medical Center, Torrance, CA, USA) shared his highlights on how emerging data and updated cholesterol guidelines are reshaping the clinical approach to risk stratification and treatment targets. With coronary artery calcium (CAC) scoring now positioned as a central tool in guiding therapy, clinicians are being equipped with more actionable thresholds and clearer pathways for intensifying—or de-escalating—care. Alongside this, new insights into underrecognized drivers of cardiovascular risk, such as secondary causes of hypertension, are challenging traditional assumptions and prompting more comprehensive evaluation strategies. As imaging becomes more integrated into routine practice, these developments signal a shift toward more targeted, patient-engaged prevention, while raising important questions about how best to implement these tools across diverse populations.

The new cholesterol guidelines (2026) were the highlight of the meeting and the discussions around the excitement around better targeting of risk (using coronary artery calcium [CAC] scanning as a Class I indication) and finally acknowledging the 55 mg/dl target. The most important thing is the clear actionable targets for each level of coronary artery calcium; >100 is 70 mg/dl, >300 is 55 mg/dl. CAC of zero is de-escalate therapy and retest in 3–5 years. Of course, the shortcomings of CAC must be noted, and those persons who are under age 45 should undergo coronary computed tomography angiography (CCTA) instead of CAC, as CAC may be a false negative in the young.

Which studies or data presented at the meeting do you think are most likely to influence how clinicians assess and manage cardiovascular risk?

I thought the MOMENTUM study was particularly important, showing that among patients with resistant hypertension, 27% had hypercortisolism and 21% had hyperaldo. We don’t look for these causes enough and they go largely untreated as primary hypertension.

Looking ahead, which areas of imaging and preventive cardiology discussed at the meeting do you feel deserve further investigation or broader clinical adoption?

As CAC scans start getting covered for screening based on the Class I recommendation, broader adoption of this testing will lead to better targeting of treatments and better goal achievements. CAC not only risk stratifies, but also promotes better compliance; a picture is worth 1,000 words, and patients who understand they have atherosclerosis, do more – better compliance with both medications and lifestyle changes.

---