Circ Cardiovasc Imaging. 2018; 11: e007992. DOI: 10.1161/CIRCIMAGING. 118.007992 July 2018 2 line test for the evaluation of patients with suspected CHD—a reality already in the United Kingdom. 9 Although it is clear that the presence, extent, and location of coronary atherosclerotic disease are critical factors for the prognosis and management of patients with CHD, it remains unclear what level of detail is needed for optimally guiding patient treatment. Our traditional evaluation of CHD, that is, using the number of stenosed vessels with consideration of high-risk locations, for example, left main and proximal left anterior descending artery, is a crude assessment of the coronary atheroma burden. 10 With the availability of noninvasively deriving total coronary atheroma volume and differentiated plaque characteristics—including so called high-risk features—the question arises what information we may add for achieving the most effective risk assessment in patients with stable CHD. In our quest for the optimal CHD assessment, several factors should be considered:(1) cost and efforts in exchange for benefit,(2) ease and clarity in effectively communicating the assessment among providers, and (3) ability to effectively apply the assessment to the available management options. It seems prudent to use our present CHD grading system as benchmark for improvement. Of note, our current management options for improving patient outcome are not infinite and largely confined to (1) risk factor modification only for those at low risk,(2) moderate medical therapy for patients at moderate risk,(3) intensive medical therapy for high-risk patients, and (4) coronary artery revascularization in addition to intensive medical therapy in patients at the highest risk. Given the few present management options, we may not need highly sophisticated tools to categorize which patient will benefit from one of these strategies. With more management options, these requirements may change in the future. In this context, the article by Chang et al in the current issue of this journal is of great interest. The authors studied the outcome of 1345 patients enrolled at 13 international centers who underwent baseline and follow-up CT coronary angiography for the assessment of atherosclerotic plaque burden and high-risk plaque features in addition to traditional stenosis evaluation. 11 In their study, adding coronary atherosclerotic plaque burden assessment, using dedicated vessel contour detection software, to a simple account of coronary artery segments with stenoses increased the test performance for identifying patients with plaque progression and adverse cardiac events at follow-up. Furthermore, adding assessment of high-risk plaque and change in atheroma burden over time to the model further improves prediction of adverse events. The magnitude of incremental risk prediction, however, was small. Whether a change of the area under the receiver operating characteristic curve from 0.75 (model just using segment involvement score) to 0.76 (model also including plaque burden, high-risk plaque, and change in plaque burden) is associated with clinically meaningful impact on patient management appears doubtful. Nevertheless, the study by Chang et al is an important step forward because it recognizes the significance of key factors affecting outcome of patients with suspected CHD, that is, the coronary atheroma burden and plaque progression. The study is limited by the low-risk population, which does not allow evaluating risk stratification over the whole spectrum of CHD. By the same token, the results do not give insights on how advanced coronary atherosclerosis imaging by CT may …