Beyond Angiography: Redefining The Gold Standard for Coronary Atherosclerosis

To examine the evolving paradigm of coronary artery disease [CAD] diagnosis beyond conventional coronary angiography and discuss how contemporary imaging modalities, coronary physiology, and artificial intelligence contribute to a more comprehensive assessment of coronary atherosclerosis. We explore whether the traditional stenosis-centered approach remains sufficient for risk stratification and clinical decision-making.

Recent evidence has demonstrated that coronary risk is determined not only by luminal stenosis but also by plaque burden, plaque phenotype, vascular remodeling, inflammation, endothelial dysfunction, thrombogenicity, coronary physiology, microvascular integrity, and patient-level vulnerability. Intravascular ultrasound and optical coherence tomography provide detailed characterization of plaque morphology and vessel wall pathology, whereas fractional flow reserve and non-hyperemic pressure ratios identify flow-limiting epicardial disease. Coronary computed tomography angiography, combined with CT-derived fractional flow reserve, enables noninvasive evaluation of coronary anatomy, plaque characteristics, perivascular inflammation, and functional significance. Artificial intelligence is emerging as a powerful tool for integrating multimodality imaging and clinical data into individualized risk assessment and therapeutic planning. Coronary angiography remains fundamental for defining coronary anatomy and guiding revascularization but is no longer sufficient as a standalone reference standard for CAD evaluation. Contemporary diagnosis should integrate anatomical, biological, physiological, inflammatory, and patient-specific information to improve risk stratification and personalize treatment. Future advances will likely depend on multimodality imaging supported by artificial intelligence, enabling a precision cardiovascular medicine approach centered on the vulnerable patient rather than stenosis severity alone.