Cleerly CTA Analysis: AI Plaque Imaging in Philadelphia

For 50 years, cardiology has been guessing. We measure cholesterol, the fuel, and blood pressure, the pressure, but we rarely look at the pipe (the artery itself) until it is clogged. Cleerly changes that. The standard screening tool, the coronary calcium score (CAC), is good but limited. It only sees calcified plaque, the old, stable scars of past damage. It misses the soft plaque, the active, inflamed, lipid-rich material that actually ruptures and causes most heart attacks. Cleerly is an AI analysis applied to a standard coronary CT angiogram (CCTA). It visualizes, quantifies, and phenotypes every millimeter of plaque in your arteries. It moves us from "risk factors" to "disease measurement."

How does Cleerly's AI plaque phenotyping work?

Cleerly's AI plaque phenotyping works by segmenting the coronary artery wall on a standard CCTA and analyzing tissue density at every voxel. The algorithm distinguishes between different plaque types so we can see not only how much plaque exists but what kind it is.

The tool: CCTA plus AI

We typically order a coronary CT angiogram with iodine contrast. Cleerly's algorithm then processes the images and produces a quantitative report on plaque burden, composition, and stenosis at each artery segment.

The PERFECT registry data

Cleerly separates plaque into:

1. Calcified (white) plaque: Stable, old news. The mark of past damage. Low risk of rupture.
2. Low-density non-calcified plaque (LD-NCP, red/yellow): Dangerous, vulnerable plaque. Thin cap and lipid core. If it bursts, it forms a clot instantly.

Key insight: You can have a calcium score of zero and still have meaningful soft plaque. This is the "widowmaker" scenario, and it is exactly the gap a Cleerly CCTA closes.

Why do we order a Cleerly CTA?

We order a Cleerly CTA for two main reasons: to settle close-call decisions about treatment and to track plaque change over time.

1. The "statins vs. lifestyle" decision

You have an LDL of 130 mg/dL. You do not want to take a statin.

• Without Cleerly: We guess. We argue about risk calculators.
• With Cleerly: We look.
  • Scenario A: Your arteries are pristine. Conclusion: your endothelium is resilient. We can wait on meds and double down on lifestyle.
  • Scenario B: You have 200 mm³ of soft plaque. Conclusion: you have active heart disease today. The debate is over. We treat thoroughly to stabilize the plaque.

2. Tracking regression

Unlike calcium, which rarely goes down, soft plaque can be reversed. We can scan you today, prescribe a PCSK9 inhibitor like Repatha plus metformin and Zone 2 cardio, and rescan in 18 months. We can see the plaque shrink. This is the holy grail of preventive cardiology.

Who is Cleerly CTA for?

Cleerly CTA is for patients in specific clinical situations:

The "family history" phenotype

Your dad had a heart attack at 48. His cholesterol was "fine." You are worried. Cleerly tells you whether you inherited his anatomy or only his risk profile.

The "lipid-independent" risk

You have high Lp(a). This is a genetic risk factor that drives plaque thoroughly. Cleerly tells us if the Lp(a) is actually biting the artery wall.

The data-driven executive

You want a baseline at age 40. You want to know your "vascular age" versus your chronological age, and you want measurable proof that your prevention plan is working.

Who is Cleerly CTA NOT for?

Cleerly CTA is not for everyone. We avoid it in:

The radiation-sensitive patient

A CCTA involves radiation, about 3 to 5 mSv, similar to roughly 100 chest X-rays or one year of background radiation. It is safe, but we do not order it lightly. We do not repeat it every year.

The contrast-reactive patient

It requires iodine contrast dye. If you have severe kidney disease (eGFR under 30) or a severe iodine allergy, we cannot do this scan and may pursue calcium scoring or stress imaging instead.

Very young (under 35)

Unless you have familial hypercholesterolemia (FH) or another major genetic risk, finding soft plaque before age 35 is rare. The radiation cost likely outweighs the benefit at that age.

What is the strategic roadmap for a Cleerly scan?

The strategic roadmap for a Cleerly scan covers ordering, prep, and follow-through:

1. The order: We order a "CCTA with Cleerly Analysis" at a partnered imaging center.
2. The prep: You may need a beta-blocker like metoprolol on the morning of the scan to lower your heart rate below 60 bpm for clear images. You will fast for 4 hours, hold caffeine the morning of, and avoid Viagra-class drugs for 48 hours since nitroglycerin is sometimes used.
3. The result:

• Normal: Less than 100 mm³ plaque volume.
• Mild: Greater than 100 mm³.
• Severe: Greater than 300 mm³ or significant stenosis.

4. The action plan:

• If soft plaque is greater than zero, we lower inflammation (hsCRP) and lower ApoB (under 50 mg/dL for high-risk patients).
• We rescan in 2 to 3 years to verify regression.

Your arteries are not a mystery. They are a plumbing system. Let's send the camera down the drain.

Scientific References

1. Min JK, et al. "Coronary CTA-derived plaque characteristics and the prediction of major adverse cardiovascular events." JACC: Cardiovascular Imaging. 2022.
2. Williams MC, et al. "Coronary Atherosclerosis Imaging by Coronary CT Angiography." Circulation: Cardiovascular Imaging. 2020.
3. Gulati M, et al. "2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR Guideline for the Evaluation and Diagnosis of Chest Pain." Journal of the American College of Cardiology. 2021.
4. Stone GW, et al. "A Prospective Natural-History Study of Coronary Atherosclerosis (PROSPECT)." New England Journal of Medicine. 2011.

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Dr. Ash is a board-certified internal medicine physician at Fishtown Medicine in Philadelphia. He practices Medicine 3.0 preventive cardiology so your heart lasts as long as your ambition.

Medical Disclaimer: This resource provides clinical context for educational purposes. In the world of Precision Medicine, there is no "one size fits all", the right plan must be matched to your unique lab work, physiology, and goals. Consult Dr. Ash to determine if this approach is right for you, especially if you have chronic health conditions or are taking prescription medications.