Beyond the Calcium Score: What Additional Information from a CT Scan Can Assist in Cardiovascular Risk Assessment?

Coronary artery disease (CAD) still represents a leading cause of mortality worldwide. Early identification of patients at the highest risk of CAD is crucial to prevent acute adverse events and reduce morbidity and mortality. The coronary artery calcium (CAC) score is a reliable cardiovascular (CV) risk index with an independent prognostic value. Guidelines recommend using it as a risk enhancer in individuals with low or moderate CV risk. However, other computed tomography (CT) measurable parameters have recently been proposed as CV risk markers. Increasing evidence demonstrates the association between epicardial fat volume and coronary atherosclerosis in chronic and acute coronary syndromes. Furthermore, other parameters obtainable from CT, such as aortic stiffness, liver fat, aortic calcium, and myocardial scarring, are under investigation. This review aims to describe all CT potential in atherosclerosis detection and cardiovascular risk assessment beyond the CAC, trying to understand how to integrate CT parameters with traditional risk factors and to improve clinicians' ability to detect CAD early, allowing appropriate therapies promptly.