Heart Health Awareness: Understanding Plaque Buildup Before Symptoms Start

Most heart attacks strike suddenly, seemingly without warning. Yet cardiovascular disease rarely appears overnight—it develops silently over decades. By the time chest pain, shortness of breath, or fatigue emerge, arterial plaque has often progressed to dangerous levels. The paradox of heart disease is that feeling fine doesn’t mean you are fine.

At Central Park Advanced Imaging, we partner with Cleerly and HeartFlow to provide Advanced Cardiac Imaging that detects and quantifies plaque buildup years before symptoms develop. Understanding how plaque forms, why it stays hidden, and when to screen can literally save your life.

How Plaque Develops: A Decades-Long Process

Atherosclerotic plaque doesn’t form overnight. It accumulates gradually through a complex biological process beginning decades before symptoms appear—sometimes starting in adolescence or early adulthood. Damage to the arterial lining occurs from high blood pressure, smoking, diabetes, or elevated cholesterol, allowing LDL cholesterol particles to infiltrate the vessel wall.

Over time, immune cells attempt to clear this cholesterol, but the inflammatory response actually worsens the problem. The body walls off plaque with fibrous tissue, creating lesions that narrow arteries while remaining completely asymptomatic. Some plaques develop thin fibrous caps over large lipid cores—becoming vulnerable to rupture and sudden thrombosis.

Throughout this timeline, most people feel perfectly normal. The heart compensates remarkably well until blockages reach 70-80%—and dangerous plaque can rupture even when stenosis is minimal.

Types of Plaque: Not All Are Equal

Plaque composition matters more than size alone. Understanding plaque types explains why some lesions cause heart attacks while others remain stable for decades.

Calcified Plaque: The Stable Marker

• Characteristics: Hardened deposits containing calcium crystals—easily visible on coronary calcium scoring.
• Risk Profile: Generally more stable than soft plaque—less prone to sudden rupture but indicates significant atherosclerotic burden.
• Limitation: Zero calcium doesn’t mean zero risk—non-calcified plaque remains invisible on calcium scoring alone.

Non-Calcified Plaque: The Hidden Threat

• Characteristics: Soft deposits primarily composed of cholesterol and inflammatory cells—invisible on calcium scoring.
• Risk Profile: More prone to progression than calcified plaque—actively inflamed and evolving.
• Detection Challenge: Requires coronary CT angiography with AI analysis to identify.

Low-Density Non-Calcified Plaque: The Vulnerable Lesion

• Characteristics: Large lipid-rich core with thin fibrous cap—most dangerous plaque type.
• Risk Profile: Prone to rupture causing sudden heart attack—often in arteries with minimal narrowing.
• Clinical Importance: Identifying this plaque type triggers intensive medical therapy and changes management strategy.
• Detection: Requires advanced AI analysis (Cleerly/HeartFlow) to distinguish from other plaque types.

Why Symptoms Appear Late: The Compensation Paradox

Understanding why heart disease remains silent for decades reveals the importance of proactive screening rather than waiting for symptoms. Arteries expand outward as plaque accumulates, maintaining luminal diameter despite growing disease burden. The heart develops alternate blood flow pathways around blockages, compensating for reduced flow through diseased vessels.

Slow plaque growth allows the heart to adjust oxygen delivery—symptoms only emerge when compensation fails. Studies show 50-60% of plaque ruptures heal spontaneously without symptoms, contributing to episodic disease progression. This silent advancement explains why 50% of people with heart disease experience heart attack or sudden death as their first symptom.

Risk Factors: Who Should Be Concerned?

While cardiovascular disease can affect anyone, certain factors dramatically increase risk. Understanding your personal risk profile guides screening decisions.

Key Risk Factors

• Age: Men over 45, women over 55—age remains the strongest single predictor of coronary disease.
• Family History: First-degree relative with heart disease before age 55 (men) or 65 (women)—genetic predisposition significantly elevates risk.
• High Blood Pressure: Sustained elevation above 130/80 mmHg—damages arterial lining and accelerates plaque formation.
• High Cholesterol: LDL above 100 mg/dL or total cholesterol above 200 mg/dL—drives plaque accumulation over time.
• Diabetes: Elevated blood sugar damages vessels and promotes inflammation—doubles or triples cardiovascular risk.
• Smoking: Any tobacco use—directly damages endothelium and promotes thrombosis.
• Obesity: BMI over 30, especially with abdominal fat—associated with inflammation and metabolic syndrome.
• Sleep Apnea: Untreated obstructive sleep apnea—causes hypertension, inflammation, and arrhythmias.
• Sedentary Lifestyle: Less than 150 minutes weekly moderate activity—associated with multiple cardiovascular risk factors.

Advanced Cardiac Imaging: Seeing the Unseen at CPAI

Modern cardiac imaging moves beyond calcium scoring to provide comprehensive plaque assessment—detecting all plaque types and quantifying total disease burden. At CPAI, we deliver the most advanced non-invasive cardiac assessment available in Manhattan.

Coronary CT Angiography (CCTA)

• Technology: Contrast-enhanced CT imaging of coronary arteries using our uCT Atlas 640-slice scanner—visualizes arterial lumen and wall in exquisite detail.
• Capabilities: Detects calcified, non-calcified, and low-density plaque—provides complete assessment unavailable from calcium scoring alone.
• Speed: Complete scan in 5-10 heartbeats—single breath-hold acquisition with minimal radiation exposure.
• Accuracy: Sensitivity over 95% for detecting significant stenosis—excellent negative predictive value rules out disease.

AI-Powered Plaque Analysis: Cleerly

• Comprehensive Quantification: Measures total plaque volume, calcified volume, non-calcified volume, and dangerous low-density plaque.
• Vessel-by-Vessel Analysis: Assesses each coronary artery separately—identifies regional disease patterns.
• Accuracy: 95% agreement with invasive intravascular ultrasound (IVUS)—validated against gold standard.
• Management Impact: Studies show treatment changes in 50-66% of patients when plaque quantification added to standard CCTA interpretation.

Functional Assessment: HeartFlow FFR-CT

• Technology: Computational fluid dynamics analyzes CCTA images—calculates fractional flow reserve without catheterization.
• Clinical Value: Determines whether plaque causes physiologically significant ischemia—identifies lesions requiring intervention.
• Clinical Impact: Reduces unnecessary cardiac catheterizations by 61%—avoids invasive testing in patients without flow-limiting stenosis.

When to Consider Cardiac Imaging

Proactive screening enables detection before symptoms develop. Consider advanced cardiac imaging if you have:

• Strong Family History: First-degree relative with heart attack before age 55 (men) or 65 (women)—consider imaging by age 40-45.
• Multiple Risk Factors: Two or more traditional risk factors present—imaging clarifies actual disease burden.
• Diabetes: Type 2 diabetes with additional risk factors—high prevalence of silent coronary disease.
• Intermediate Risk Score: 10-year ASCVD risk 7.5-20%—imaging helps decide on statin therapy.
• Zero Calcium Score with Risk Factors: If calcium score zero but strong family history or risk factors—CCTA with AI analysis detects non-calcified plaque.

Red Flags Requiring Immediate Evaluation

• Chest Discomfort: Pressure, squeezing, fullness especially with exertion—classic angina requires urgent assessment.
• Shortness of Breath: New dyspnea with minimal activity—may indicate heart failure or ischemia.
• Unusual Fatigue: Profound tiredness inappropriate to activity level—particularly concerning in women.
• Palpitations: Persistent irregular heartbeat or skipped beats—may indicate arrhythmia requiring evaluation.

The CPAI Advantage: Early Detection Saves Lives

The traditional approach waits for symptoms before investigating heart disease. This reactive strategy means half of people with coronary disease aren’t diagnosed until they suffer heart attack or sudden death. Advanced cardiac imaging with AI analysis shifts the paradigm from reactive to proactive—detecting disease at its earliest, most treatable stages.

At CPAI, our partnership with Cleerly and HeartFlow provides the most comprehensive non-invasive cardiac assessment available. Using our state-of-the-art uCT Atlas 640-slice CT scanner, we deliver rapid, low-dose imaging analyzed by FDA-cleared AI platforms with validated 95% accuracy. Low-density non-calcified plaque—the most dangerous type—requires this advanced technology for detection, since it remains invisible on standard calcium scoring.

If you have risk factors, family history, or simply want to know your true cardiovascular status, advanced cardiac imaging provides answers before symptoms appear. Early detection enables intervention when treatment is most effective, potentially preventing the heart attack that would have been your first symptom.

Contact us to discuss whether cardiac CT with AI analysis is appropriate for your situation, call us at (212) 363-7315, or book your scan online.