Cardiovascular imaging for the detection of asymptomatic coronary artery disease: an updated systematic review of clinical practice guidelines.

Aims: Multiple guidelines provide recommendations for assessing future risk of cardiovascular events in asymptomatic individuals without known coronary artery disease (CAD). We systematically reviewed current national and international guidelines that include imaging strategies for detecting subclinical CAD. Methods and results: MEDLINE and EMBASE were searched for relevant guidelines published between January 2010 and December 2025. Major international guideline repositories and medical society websites were also screened. Two reviewers independently screened records assessed methodological rigour using the AGREE II instrument and extracted recommendations. Of four identified guidelines, three met predefined rigour thresholds and were included in the final analysis. Guidelines discouraged coronary artery calcium (CAC) use as a population-wide screening tool or in high-risk individuals. All three guidelines recommended limited use of scoring as a risk modifier in asymptomatic individuals when cardiovascular risk remains uncertain or near treatment thresholds and highlighted its role in shared decision-making. Differences were observed in the target populations for CAC assessment, recommendation strength, and re-screening intervals. Although CAC scoring was the principal imaging modality evaluated, CT coronary angiography was discussed in one guideline but not recommended due to insufficient evidence of clinical benefit. Conclusion: Cardiovascular imaging for the detection of asymptomatic coronary artery disease is not recommended in the guidelines for population screening or in high-risk patients. CAC use is recommended in specific cases such as where patients are near treatment thresholds for primary prevention. Ongoing randomized studies may provide further outcomes and cost effectiveness driven insights.