Summary

CT coronary angiography (CTCA) is increasingly being used to diagnose coronary artery disease (CAD). Recent technological advancements, including dual energy CT and improved gantry times, have led to the ability to image coronary arteries with excellent spatial resolution at low radiation doses. Atheromatous plaques can be identified using CTCA and assessed to establish the risk of acute coronary syndrome from each individual plaque. If CTCA identifies CAD, it should then be used in conjunction with functional testing or invasive angiography with physiological assessment to establish the significance of coronary disease in an individual patient. In this case, the patient was diagnosed with an acute coronary syndrome originating from an atheromatous plaque that had been identified on CTCA 15 months before the acute event. The patient had positive ischaemic testing on myocardial perfusion scan but no symptoms of angina prior to the acute event. This case highlights the increasing difficulties clinicians face when deciding on management for patients with high-risk plaques, as there are little guidelines beyond aggressive secondary prevention.