Heart Tests: CAC vs CCTA vs CCTA With Cleerly
Why Your Heart Test Might Be Missing Early Disease and Lying To You About Your Real Risk
Atherosclerotic cardiovascular disease (ASCVD) doesn’t appear suddenly. It evolves quietly and gradually—often beginning in childhood and becoming clinically visible only decades later. In longevity medicine, the challenge is detecting the earliest stages of disease, not waiting for symptoms.
Three imaging tools give us windows into this process:
CAC (Coronary Artery Calcium Score)
CCTA (Coronary CT Angiography)
CCTA with Cleerly analysis
These heart health tests are not interchangeable. They reveal different stages of the same disease. And as two real stories show, the choice of test can completely change a person’s understanding of their cardiovascular risk.
A Personal Story From Dr. Saintsing, Co-Founder of Ikigai Health Institute
When Dr. David Saintsing turned 50, he shared concerns with his primary care doctor. On his paternal side, both men and women had suffered severe vascular disease: strokes, heart attacks, aortic thromboses, premature vascular dementia. ASCVD was common in that branch of his family, and several relatives—including his father—had died from it.
His cholesterol was considered “borderline,” but because he exercised and looked fit, he was reassured: “You’re fine.”
A coronary artery calcium (CAC) score was ordered to reinforce this message.
It came back zero.
The interpretation was simple: no calcified plaque, no risk.
Years later, while building Ikigai, Dr. Saintsing revisited his own prevention strategy with co-founder Dr. Rob Chen. Rob recommended checking Lp(a)—a genetic risk factor that had never been evaluated. It was markedly elevated.
A repeat CAC was obtained.
This time, it showed calcified plaque.
Meaning:
He definitively had soft plaque at age 50, invisible to the original CAC.
Over time, soft plaque had calcified—making it detectable years later.
What looked like a clean bill of health was actually an artifact of the wrong heart test at the wrong stage of disease – coupled with a lack of appropriate risk stratification. LP(a) creates higher risk for plaque formation.
Heart tests are easy, painless ways to get incredibly valuable data about what’s happening on the inside. However, not all tests are the same.
Another Ikigai Example: CCTA with Cleerly When “Normal” Wasn’t Normal
More recently, an Ikigai patient in his 40s decided—after thoughtful discussion—to undergo CCTA with Cleerly. He carried excess body fat, was working hard to lose weight, and wanted a clear picture of his long-term cardiovascular risk. He had requested more advanced preventive testing within his insurance-based system but was turned down.
He eventually came to Ikigai, paying out of pocket for the clarity he felt he couldn’t access elsewhere.
He had never had vascular imaging. Based on his metabolic profile, we suspected his true risk was higher than it appeared.
A CCTA with Cleerly always includes two reports:
A traditional radiologist interpretation
A Cleerly quantitative analysis
The standard CCTA read came back completely normal.
No plaque. No narrowing. No disease.
But the Cleerly analysis told a different story.
It showed mild multivessel atherosclerosis—the exact kind of early, soft plaque that:
CAC cannot detect, and
standard CCTA reports often underestimate or describe as normal.
Had he relied on that traditional read alone, he would have been falsely reassured that his lifestyle patterns had caused no cardiovascular harm.
In reality, he already has early ASCVD. In the absence of knowledge and mitigation he would have been on a path to stroke, heart attack, dementia, and limited quality of life in the back half.
With this information, he is now accurately informed, empowered, and continuing the mitigation work he had already begun before joining Ikigai, and is working alongside his doctor to further mitigate. This is the benefit of early detection.
How Ikigai Uses Modern Tools to Empower Patients
At Ikigai, we believe prevention works best when people can clearly see what’s happening inside their own bodies. Newer technologies—like AI-driven plaque analysis with Cleerly—give us a level of precision that simply wasn’t available a decade ago. These tools let us detect heart disease earlier, measure it more accurately, and personalize treatment long before symptoms develop. But the real value is what it gives patients: insight. When someone can visualize their arteries, understand their metabolic risks, or track changes over time, they become an active participant in protecting their long-term health. Modern technology doesn’t replace clinical judgment—it strengthens it, and it gives patients the clarity and agency needed to make meaningful, lasting change.
How Plaque Really Develops (Soft Plaque → Hard Plaque)
Atherosclerosis begins when the inner lining of the artery—the endothelium—becomes irritated and damaged by factors like high blood pressure, high insulin (due to insulin resistance), smoking or other issues that we will discuss in a more comprehensive ASCVD article.
From there:
LDL particles slip beneath the arterial surface and trigger an immune response.
White blood cells migrate in, transform into macrophages, and become foam cells, forming early fatty streaks—seen even in children and young adults.
Over time, smooth muscle cells build a fibrous cap over a growing lipid-rich core.
This is soft, non-calcified plaque—the earliest and most active stage of disease.
With ongoing injury, some plaques gradually accumulate calcium over 20–30 years. This is the artery’s attempt to stabilize the soft plaque. This late “scarring” process is what CAC detects.
The key:
A CAC of zero does not mean no disease—it means no calcified disease.
Soft plaque can be present for decades before any calcium appears.
What Each Cardiovascular Imaging Test Shows
1. Coronary Artery Calcium (CAC) Score
Shows: Only calcified plaque (late-stage disease)
Misses: All early, soft plaque, plaque composition, vessel-by-vessel burden, progression over time
Best use: Broad population risk stratification (not for precision prevention)
2. Coronary CT Angiography (CCTA)
Shows: Soft plaque with ranges provided, calcified plaque sometimes, degree of narrowing
Limitations: Early, mild plaque is often underreported, interpretations vary widely between radiologists – often broad ranges of disease are provided, plaque isn't quantified consistently
Best use: Better early detection of plaque than CAC, still limited for prevention unless paired with advanced analysis
3. CCTA With Cleerly Analysis: The Best Test for Early Detection
Shows: Total plaque volume, plaque composition (soft plaque, fibrous, fibrofatty, calcified), high-risk plaque features, distribution across all vessels, change over time
Why it matters: This is the only approach that lets us detect heart disease early, measure it accurately, and track whether it’s getting better or worse. It offers the clearest picture of cardiovascular health.
Learn more on Cleerly’s website.
The Pattern We See Again and Again
Anecdotes are not evidence—but in prevention, they highlight the same consistent pattern:
CAC often misses early disease.
Standard CCTA sometimes labels early disease as “normal.”
CCTA with Cleerly finds soft plaque earlier and more reliably.
Our goal is not to alarm people.
It is to avoid false reassurance and replace it with clarity—when there is still time to change the trajectory.
This is precision prevention.
This is why the right heart test matters.
And this is why, at Ikigai, we choose tools that reveal the full story—not just the final chapter.
If you’d like to understand your risk better with best-in-class data and care, please contact us.
