Three late-breaking science studies presented during ESC Congress 2026 provide new insights into the use of coronary computed tomography angiography (CCTA) fractional flow reserve (FFRct) to guide patient selection for invasive coronary angiography (ICA), the use of automated deep learning-quantified total plaque volume (TPV) to improve prediction of first coronary events, and the relationship between epicardial adipose tissue (EAT) volume and long-term major adverse cardiac events (MACE). Each study was simultaneously published in JACC Journals.

FUSION Trial of FFRct

The investigator-initiated, multicenter FUSION trial randomized 528 Dutch patients (median age, 63 years; 41% women) with 50-90% stenosis in at least one coronary artery to either FFRct or usual care. Results published in JACC found that at 90 days, the rate of ICA without obstructive coronary artery disease (CAD) was significantly lower in the FFRct group compared with the usual-care group (48/263; 18% vs. 87/265; 33%; odds ratio, 0.46; p<0.001). In a post hoc exploratory analysis, overall ICA rates were also lower with FFRct (39% vs. 51%; p=0.004), with both differences persisting at one year. Revascularization rates, quality of life, costs and rates of MACE were similar between groups.

“Patients with a 50-90% stenosis on CCTA represent a clinically challenging population, as anatomical stenosis severity alone does not reliably identify flow-limiting lesions and often warrants further functional assessment,” write authors Simran P. Sharma, MD, et al. “FUSION addresses whether FFRct-guided care offers incremental value in patient selection for ICA in an era in which guideline-directed first-line testing has increasingly shifted toward CCTA, alongside greater emphasis on initial medical therapy in the management of patients with CAD.”

SCAPIS Analysis of Plaque Volume

A SCAPIS cohort analysis published in JACC: Cardiovascular Imaging found that automated deep learning-quantified TPV improved prediction of first coronary events – defined as first nonfatal myocardial infarction (MI) or death from coronary heart disease – in 23,314 randomly selected Swedish participants (median age, 57 years; 51% women) without prior atherosclerotic cardiovascular disease, beyond SCORE2, coronary artery calcium score (CACS) and manually derived coronary CTA findings. Compared with a model incorporating SCORE2 and segment involvement score, adding TPV significantly improved discrimination (C-statistic, 0.798 vs. 0.783; p=0.022), with risk of events increasing stepwise as TPV and noncalcified plaque volume (NCPV) increased. Replacing TPV with NCPV yielded similar results.

Noting that the analysis identified small plaque volumes (>0-11 mm3) associated with increased risk of coronary events, investigators Johan Malmqvist, MD, et al., write that “these findings suggest that automated plaque quantification can improve risk stratification beyond CACS and manually read coronary CTA alone, including among individuals traditionally regarded as being at very low risk.”

Epicardial Adipose Tissue in MINOCA

A single-center study led by Lei Chen, MD, et al., and published in JACC: Asia found that among 117 Chinese patients (mean age, 54.1 years; 56% women) with a working diagnosis of MI with nonobstructive coronary arteries (MINOCA), a higher EAT volume index (EATVi) was associated with increased long-term risk of MACE. Over a median follow-up of 48 months, MACE occurred in 28 patients (23.9%), who had significantly higher EATVi (34.1 vs. 23.8 mL/m2; p=0.002). In multivariable analysis, each 10 mL/m2 increase in EATVi was associated with higher risk (hazard ratio, 1.35; p=0.040). Adding EATVi to a clinical model resulted in a modest improvement in discrimination that did not reach statistical significance.

“Risk stratification for secondary prevention in CMR-confirmed MINOCA patients remains grossly inadequate. EAT possesses unique anatomical and metabolic characteristics that distinguish it from other visceral fat depots,” write the authors. “However, given the close relationship between EATVi, visceral adiposity and metabolic dysfunction, residual or combined confounding cannot be fully excluded. Therefore, these findings should be interpreted as supporting a prognostic association rather than establishing an independent or causal effect of EATVi.”

Visit the JACC Journals at ESC Congress 2026 page to see the full list of simultaneous publications, information about editor-in-chief meet and greets, and more!

Clinical Topics: Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging

Keywords: ESC Congress, ESC26, Computed Tomography Angiography, Coronary Angiography, Coronary Artery Disease, Adipose Tissue, Fractional Flow Reserve, Myocardial, Quality of Life