Should CTCA Be Used for Heart Screening in Asymptomatic People?
CTCA has an important role in modern cardiology. In the right patient, it can be an excellent anatomical investigation. But that is not the same as saying it is an appropriate wellness screening tool for people who feel well, and it is certainly not the same as saying it should be pushed to asymptomatic people through a commercial screening pipeline. In Australian practice, cardiovascular imaging sits within a structured clinical pathway: risk assessment first, imaging second. The 2023 Australian CVD risk guideline recommends formal risk estimation with the Aus CVD Risk Calculator in people without known cardiovascular disease, classifying 5-year risk as low if <5%, intermediate if 5% to <10%, and high if ≥10%.[1] The 2025 Australian ACS guideline likewise begins with clinician assessment and structured risk stratification in people with symptoms suggestive of acute coronary syndromes, and states that when patients are defined as low risk using a high-sensitivity troponin strategy, further testing to exclude acute myocardial infarction is not required.[2]
That distinction matters because the public understanding of “screening” is usually simple: a sensible check-up for someone who feels well, with little downside beyond time and cost. CTCA does not fit that description. It is diagnostic imaging, not a harmless wellness scan. It involves iodinated contrast, ionising radiation, the possibility of incidental findings, and the cascade of follow-up tests that may follow. Those burdens may be justified in a properly selected patient. They are much harder to justify in an asymptomatic person who has not first undergone proper medical assessment. A typical adult CTCA dose is often in the low single-digit mSv range, although actual dose varies substantially with scanner, protocol, patient size, and imaging practice.[4]
That is why CTCA should not be marketed as a consumer wellness check. It is a clinician-selected test used in an appropriate diagnostic context after history-taking, symptom assessment, contraindication review, and formal risk stratification.
This is where commercial wellness models can become unsafe. They may present themselves as streamlined, digital, even “multidisciplinary.” But if the actual gatekeeping is being done by AI triage, online forms, and survey responses rather than genuine clinician assessment, the process has been inverted. A questionnaire can collect data. It cannot perform medical judgement.
How Wellness Screening Programs Turn CTCA Into a Consumer Product
Below is a screenshot from a commercial wellness screening provider that presents itself as multidisciplinary, while still allowing the patient to “design” or shape a testing pathway that may include advanced cardiac imaging. Used properly, this image is not decoration. It is evidence. It shows the exact structural problem this article is describing: a diagnostic test being placed inside a consumer-choice framework. That matters because diagnostic imaging should follow clinical judgement, not precede it.
Figure 1 – Example of consumer-facing workflow in which advanced cardiac imaging can be selected within a wellness-style program. The concern is not branding; it is the substitution of consumer choice architecture for clinician-led diagnostic selection
Patients are not doctors. They can fill in a survey in good faith and still get important details wrong. They may misunderstand symptoms, minimise chest discomfort, forget prior reactions, under-report kidney disease, omit medications, or fail to appreciate which facts are clinically important. That is not a criticism of patients. It is exactly why clinician-led assessment exists. The safeguard is not the form. The safeguard is the doctor.
The coronial findings in the Hickey case underscore this point. The Court noted that the questionnaire stated it was important to complete it so the radiologist could decide suitability for the test, and that the patient signed a declaration that she had completed it accurately.[3] But the Court also found that this kind of routine questionnaire process was insufficient in the absence of proper assessment and discussion.
What Are the Risks of CTCA in Asymptomatic Screening?
The risk issue is central. Modern iodinated contrast is much safer than older agents, and that should be stated plainly. But “safer” is not the same as “risk-free.” The ACR Manual on Contrast Media states that allergic-like reactions to modern iodinated contrast are uncommon, with an aggregate rate of about 0.6% and a severe reaction rate of about 0.04%. It also notes that nearly all life-threatening reactions occur within the first 20 minutes after injection.[5] The RANZCR iodinated contrast guideline similarly emphasises that while most reactions are minor, life-threatening and fatal reactions may occur without warning and that the risk must always be weighed against expected benefit.[6]
That means the decision to expose an asymptomatic person to contrast is not an administrative step. It is a clinical decision that requires justification, preparation, and informed consent.
So the honest question is not, “Is CTCA safe?” Usually, yes. The real question is: What Are the Risks of CTCA in Asymptomatic Screening? In a properly assessed, higher-risk or symptomatic patient, the answer may be excellent. In an asymptomatic person moved through a commercial screening funnel, the answer is often much weaker.
That is why CTCA should not be a default first step. It puts the scan before the judgement. It gives the patient contrast, radiation, incidental findings, downstream testing, cost, and anxiety before a clinician has established whether anatomy-first imaging is actually warranted. That sequence is backwards.
The Peta Hickey case shows what happens when the safeguards are removed
The most sobering Australian example shows what can happen when CTCA is used as a screening test without proper safeguards. An asymptomatic patient died after a contrast reaction following a scan ordered through a commercial screening pathway. The Coroner found that the safeguards had not been followed, that appropriate pre-scan assessment had not occurred, and that the program had prioritised commercial workflow over patient protection — describing it as an industry “putting profits over patients.”[3] That is the warning: once CTCA is pulled out of a clinician-led diagnostic pathway and sold as screening, the safety system can fail.
That is not a marginal administrative criticism. It is a direct warning about what happens when commercial workflow outruns clinical governance.
This is why “multidisciplinary” is not enough
That is the central criticism of commercial wellness programs: they can strip out the safeguards that make advanced imaging safe and appropriate. A proper CTCA pathway should begin with clinician assessment, not scan access. It should establish who assessed the patient, whether symptoms are present, what the pre-test likelihood of disease is, whether CTCA is truly the best first test, whether renal function and contrast risk have been checked, and whether the patient has had a real discussion about harms, alternatives, and downstream consequences. Branding a program as “multidisciplinary” does not solve the problem if the commercial model is still steering the patient toward the scan and the actual gatekeeping is being performed by surveys, algorithms, or consumer choice rather than independent medical review.
In symptomatic patients, Australian guidance does support CTCA as a first-line investigation in a defined setting: people without previously known coronary artery disease who present with intermediate-risk ACS, provided no contraindications exist.[2] That is very different from asymptomatic wellness screening. It is selective use inside a medical pathway, not consumer-led access to diagnostic imaging.[2]
There is also a regulatory dimension
Under AHPRA’s advertising guidance and section 133 of the National Law, advertising for a regulated health service must not be false, misleading or deceptive, create unreasonable expectations of beneficial treatment, or directly or indirectly encourage the indiscriminate or unnecessary use of regulated health services.[7] That does not mean every wellness program offering CTCA is automatically unlawful. But it does mean that marketing a diagnostic test to asymptomatic consumers as though it were a routine wellness check raises real concerns if the message downplays risk, oversimplifies benefit, or bypasses proper clinical selection.[7]
Bottom line
CTCA is an excellent test. It is just not a generic asymptomatic wellness screen.
It is a diagnostic investigation with low-frequency but potentially serious harms, and its value depends on proper selection. In appropriately chosen higher-risk patients, often under specialist guidance, it may be extremely useful. In asymptomatic commercial screening pipelines driven by AI interpretation of survey answers, it is much harder to defend.
A scanner can detect plaque. It cannot replace judgement. And when judgement is replaced by process, what is lost is not bureaucracy. What is lost is the safety system.
References
1. Nelson MR, Banks E, Brown A, Chow CK, Peiris DP, Stocks NP, et al. 2023 Australian guideline for assessing and managing cardiovascular disease risk. Med J Aust. 2024;220(9). doi:10.5694/mja2.52280.
2. Brieger D, Cullen L, Briffa T, Zaman S, Scott I, Papendick C, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Comprehensive Australian Clinical Guideline for Diagnosing and Managing Acute Coronary Syndromes 2025. Heart Lung Circ. 2025;34(4):309-397. doi:10.1016/j.hlc.2025.02.102.
3. Coroners Court of Victoria. Finding into Death with Inquest: Inquest into the death of Peta Hickey. COR 2019 2336 [Internet]. Melbourne: Coroners Court of Victoria; 2021 Nov 22 [cited 2026 Apr 2].
4. Radiological Society of North America, American College of Radiology. Radiation dose from X-ray and CT exams [Internet]. Oak Brook (IL): RSNA/ACR; 2025 [cited 2026 Apr 2].
5. American College of Radiology Committee on Drugs and Contrast Media. ACR Manual on Contrast Media [Internet]. Reston (VA): American College of Radiology; 2024 [cited 2026 Apr 2].
6. The Royal Australian and New Zealand College of Radiologists. Iodinated Contrast Media Guideline [Internet]. Sydney: RANZCR; [cited 2026 Apr 2].
7. Australian Health Practitioner Regulation Agency. Guidelines for advertising a regulated health service [Internet]. Melbourne: Ahpra; [cited 2026 Apr 2].
Author: Dr Kirralee Sherif (PhD)
