CTPA-detected coronary artery calcification as a prognostic marker in acute pulmonary embolism: a narrative review

Abstract

Acute pulmonary embolism (PE) is a major cause of cardiovascular morbidity and mortality. Coronary artery calcification (CAC) is often visible on routine contrast-enhanced, non-ECG-gated CT pulmonary angiography (CTPA), offering potential refinement of risk assessment in confirmed PE and opportunistic identification of underlying coronary atherosclerosis. To review the evidence for CTPA-detected CAC in confirmed acute PE, distinguish this from contextual evidence in suspected PE and other thoracic CT populations, clarify appropriate CAC assessment on contrast-enhanced CTPA, and consider implications for prognostication and cardiovascular risk assessment. PubMed, Scopus, and Web of Science were searched from inception to 3 May 2026 using terms relating to CAC, CTPA, PE, prognosis, mortality, cardiovascular events, and risk stratification. Reference lists of relevant studies, reviews, and consensus statements were screened. Original CTPA studies reporting CAC and clinical outcomes were classified as confirmed acute PE or contextual CTPA populations. Findings were narratively synthesised without formal risk-of-bias assessment or meta-analysis. In confirmed acute PE cohorts, CAC has been associated with short-term mortality, although the strength and independence of associations vary between studies. Longer-term prognostic evidence is similarly heterogeneous. Differences in CAC definition, population characteristics, and covariate adjustment contribute to this variability, with fuller adjustment attenuating significance in some analyses. Most studies assessed CAC on contrast-enhanced, non-ECG-gated CTPA, which may underdetect very low-burden calcification and introduce additional acquisition- and scoring-related heterogeneity. Overall, CAC has potential prognostic relevance, but its independent and incremental value and generalisability remain uncertain without standardised assessment and prospective validation. CTPA-detected CAC is a marker of coronary atherosclerosis with a clinically relevant opportunistic reporting role, but its incremental value for acute PE risk stratification beyond established clinical, biomarker, and RV strain measures remains unproven. On routine contrast-enhanced, non-ECG-gated CTPA, whole-patient visual ordinal grading is the most practical current approach; “no CAC seen” should not be equated with a definitive Agatston score of zero.