Imaging and rehabilitation in the management of coronary artery disease

Abstract

Coronary artery disease (CAD) remains a leading cause of morbidity and mortality in the UK. Its management requires substantial healthcare resources and places a burden on patients, families and the healthcare system. Many patients with ‘stable’ forms of CAD continue to suffer from symptoms and remain at risk of future major adverse cardiovascular events (MACE). Computed tomography coronary angiography (CTCA) is now the key test in the diagnostic pathway for CAD. Additional imaging biomarkers have evolved that enable the detection and grading of individualised risk, with prognostic significance.

A significant proportion of CAD burden results from modifiable lifestyle-related cardiovascular risk factors. The risks of both treatment failure and MACE are elevated in patients with combinations of these risk factors. Current treatment algorithms for patients with stable CAD focus on medications and invasive interventions, which are expensive and carry risk. Lifestyle intervention is only available via cardiac rehabilitation for patients with late-stage CAD who have required revascularisation or post- MACE, with the management of earlier CAD relying on generic advice in the passive clinic setting.

The aim of this thesis was to investigate the role for (i) enhanced use of CT in CAD detection earlier in the patient pathway, and (ii) the potential addition of a novel, intensified rehabilitation programme (Super Rehab) in the management of patients with lifestyle-related CAD and high-risk imaging features.

Chapter 2 provides an overview for the current role of cardiac CT in the diagnostic pathway, drawing comparisons between acquisition techniques available, discussing imaging in subclinical populations and evolving CTCA biomarkers. In Chapter 3, the routine grading of coronary artery calcification on non-cardiac chest CT imaging (regardless of scan indication) was found to be reproducible, whilst prognostic and treatment implications of its reporting are maintained in all ages. This offers widescale opportunities to improve CAD outcomes. Subsequent chapters focus on addressing higher risk cohorts. Chapter 4 demonstrates that CTCA re-stratifies CAD presence and severity and alters clinician management vs the standard of care (a calcium score) in a heterogeneous, high-risk lipid clinic cohort.

Chapter 5 provides the protocol and Chapter 6 the results of a multi-centre randomised controlled feasibility study testing ‘Super Rehab’, a novel intensified lifestyle change programme in patients with CAD, metabolic syndrome and coronary inflammation. CTCA was used to track changes in CAD. Feasibility is demonstrated in delivering the study protocol (with in-study modifications). Super Rehab achieved significant, favourable changes in body composition, cardiovascular fitness, diastolic blood pressure and symptoms. The study was not powered to detect clinically relevant changes in CAD on CTCA, however, the application of this technique in this setting provides insight into its potential.

In summary, the work in this thesis has shown the role for enhanced use of CT in the diagnostic pathway for CAD, demonstrated the benefits in cardiovascular risk achieved with Super Rehab, and established the feasibility of a future randomised controlled trial to test its efficacy in the target population.

Date of Award	14 Jan 2026
Original language	English
Awarding Institution	University of Bath
Supervisor	Dylan Thompson (Supervisor), Fiona Gillison (Supervisor), Oliver Peacock (Supervisor), Jonathan Rodrigues (Supervisor) & Ali Khavandi (Supervisor)