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However, calcification occurs late in atherosclerosis. Coronary CT angiography (CCTA) can detect non-calcific plaque and inflammation before calcification develops, but impact on clinical management is not well documented. We compare coronary artery disease (CAD) detection and grading between CCS and CCTA, impact on management, and explore CCTA-derived inflammation biomarker (pericoronary fat attenuation index [FAI]) in the lipid clinic. Exploratory analysis of a prospectively maintained database of lipid clinic patients with CCS and CCTA (2018\u20132020). CCS grade was compared with CCTA stenosis, presence of high-risk plaque (HRP) and FAI-score analysis. UK Consultant Lipidologists completed an anonymised survey, documenting lipid target and management after sequential unblinding of CCS and CCTA data. In 45 asymptomatic patients (49% female, mean age 55\u2009\u00b1\u20099), CCTA re-classified CAD presence in 22% (\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.002) and severity in 62% (\n                    <jats:italic>p<\/jats:italic>\n                    \u2009=\u20090.005) vs. CCS. HRP was observed in 20% (9\/45), including 56% with CCS\u2009\u2264\u2009100. Median LDL target with clinical vignette was 101\u00a0mg\/dL (IQR 77\u2013120), reducing to 89\u00a0mg\/dL (77\u2013120) after CCS, and 77\u00a0mg\/dL (70\u2013116) after CCTA unblinding. CCS altered LDL target in 12%, and CCTA a further 19% (\u03c72 57.0,\n                    <jats:italic>p<\/jats:italic>\n                    \u2009&lt;\u20090.005). High FAI-score was demonstrated in 20%, including 22% of those with CCS\u2009\u2264\u2009100 and 75% of those with \u2264\u2009mild CAD on CCTA. CCTA increased CAD prevalence and re-classified severity versus CCS, altering hypothetical management. High FAI-scores were observed across CCS and CCTA severity grades, including patients with no overt CAD.\n                  <\/jats:p>","DOI":"10.1007\/s10554-025-03526-3","type":"journal-article","created":{"date-parts":[[2025,10,9]],"date-time":"2025-10-09T03:30:47Z","timestamp":1759980647000},"page":"2205-2217","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["CT coronary angiography in the lipid clinic: a pilot study and lipidologist survey"],"prefix":"10.1007","volume":"41","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-8753-1343","authenticated-orcid":false,"given":"John","family":"Graby","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"James","family":"Sellek","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6374-3782","authenticated-orcid":false,"given":"Ali","family":"Khavandi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6312-1518","authenticated-orcid":false,"given":"Dylan","family":"Thompson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9208-5122","authenticated-orcid":false,"given":"Will W.","family":"Loughborough","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7005-5088","authenticated-orcid":false,"given":"Benjamin J.","family":"Hudson","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tony","family":"Avades","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wycliffe","family":"Mbagaya","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8508-2209","authenticated-orcid":false,"given":"Ahai","family":"Luva","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nigel","family":"Capps","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6463-1838","authenticated-orcid":false,"given":"Cheerag","family":"Shirodaria","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Graham","family":"Bayly","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6983-5423","authenticated-orcid":false,"given":"Charalambos","family":"Antoniades","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8467-1175","authenticated-orcid":false,"given":"Paul F.","family":"Downie","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2744-3509","authenticated-orcid":false,"given":"Jonathan C. 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CA and CS are founders, shareholders, and directors of Caristo Diagnostics, a CT image analysis company that provided the perivascular fat attenuation index analysis used in the study. CS is a full-time employee of Caristo diagnostics. FAI is subject to patent US10,695,023B2 and patent applications PCT\/GB2017\/053262, GB2018\/1818049.7, GR20180100490, and GR20180100510, licensed through exclusive license to Caristo Diagnostics.","order":2,"name":"Ethics","group":{"name":"EthicsHeading","label":"Competing interests"}}]}}