Preoperative cardiac risk assessment remains essential in patients undergoing intermediate- to high-risk non-cardiac surgery. A prospective multicenter cohort study presented at EuroPCR 2026 evaluated whether coronary computed tomography angiography (CTA) provides incremental prognostic value beyond treadmill testing (TMT) for predicting perioperative cardiac events.

The study included 447 patients undergoing non-cardiac surgery at two tertiary hospitals between January 2018 and April 2025. All patients underwent both TMT and coronary CTA before surgery. The primary endpoint was 30-day major adverse cardiac events (MACE), including cardiac death, nonfatal myocardial infarction, myocardial injury after non-cardiac surgery, pulmonary edema with heart failure, clinically significant arrhythmias requiring urgent intervention, and prophylactic coronary revascularization.

Findings

• Thirty-day MACE occurred in 45 patients (10.1%).
• Significant coronary stenosis (≥50%) and coronary artery calcium score (CACS) ≥203 on CTA were independent predictors of perioperative events.
• Among patients with positive TMT findings, the addition of coronary CTA significantly improved risk prediction.
• CTA also provided meaningful prognostic discrimination among patients with negative TMT findings.
• TMT contributed modest incremental prognostic information in patients with significant coronary stenosis identified on CTA.
• Models integrating both anatomic and functional assessments demonstrated the strongest predictive performance for perioperative MACE.

The analysis suggests that coronary CTA may provide incremental prognostic value beyond TMT in patients undergoing non-cardiac surgery. A combined strategy incorporating both anatomic and functional assessment may improve perioperative risk stratification and support more informed clinical decision-making.