Non-invasive methods of risk assessment in patients with chronic coronary syndrome: which patients will experience an acute event?

Patients with chronic coronary syndrome (CCS) represent a particularly vulnerable group of coronary artery disease (CAD) patients, since predicting the progression of CCS to an acute state and subsequent major cardiovascular events remains challenging despite advances in risk stratification methods. Currently, clinicians implement a multidimensional diagnostic approach and rely on several non-invasive techniques when stratifying risk of major adverse cardiovascular events in CCS patients. Models such as pre-test probability are useful for initial assessment, but their clinical performance remains limited. More advanced modalities such as coronary computed tomography angiography, cardiovascular magnetic resonance, positron emission tomography, and single photon emission computed tomography have demonstrated high diagnostic accuracy and prognostic value. Coronary computed tomography angiography has emerged at the forefront, as it provides a detailed and comprehensive analysis of cardiovascular risk beyond luminal stenosis. Newly developed methods focused on image-derived markers of inflammation, including epicardial adipose tissue, and circulating biomarkers of inflammation provide a broader view of CAD pathology and further enhance the risk evaluation strategies. Nevertheless, the application of these methods in contemporary clinical practice remains limited by high data heterogeneity, lack of standardization, and the lack of expert consensus. This review article aims to critically appraise the strengths and limitations of the current non-invasive strategies and to discuss possible future prospects in this field.