Heartflow’s Plaque Revenue Timeline and FFRct Growth Signals Clash in 2026 Guidance

Date of Call: Mar 18, 2026

Financials Results

• Revenue: $49.1 million, up 40% year-over-year
• EPS: Non-GAAP loss of $0.12 per share, compared to loss of $3.15 per share in Q4 2024
• Gross Margin: Nearly 80%, compared to 75.3% in Q4 2024
• Operating Margin: Operating loss was $12.5 million, compared to $13.5 million loss in Q4 2024

Guidance:

• Full year 2026 revenue guidance of $218 million-$222 million, representing 24%-26% year-over-year growth.
• Full year 2026 non-GAAP gross margin guidance of 80%-81%, representing 300-400 basis points of expansion year-over-year.
• Plaque revenue expected to be approximately $15 million-$17 million in 2026, weighted towards the back half.
• Increased midterm non-GAAP gross margin target to 85%, up from prior target of 80%.

Business Commentary:

Record Revenue and Growth:

• HeartFlow reported total fourth quarter revenue of $49.1 million, representing more than 40% year-over-year growth.
• The company's global cases grew nearly 53% year-over-year.
• The growth was driven by record installed base growth, consistent FFRct utilization, and strong CCTA market growth.

Plaque Revenue and Market Expansion:

• HeartFlow achieved record non-GAAP gross margin of nearly 80%.
• The company's plaque revenue is expected to reach approximately $15 million-$17 million in 2026.
• The increase in plaque revenue is attributed to strong installed base expansion, favorable reimbursement changes, and increasing coverage by major insurers.

Innovation and Product Development:

• HeartFlow introduced its next-generation plaque algorithm and launched PCI Navigator ahead of schedule in April 2026.
• The innovation efforts are supported by a proprietary database of 160 million annotated CT images.
• These advancements aim to enhance product precision and expand the company's AI platform into the interventional suite.

Clinical Evidence and Leadership:

• The company published over 600 peer-reviewed publications and conducted several randomized controlled trials.
• HeartFlow's DECIDE registry demonstrated that its Plaque Analysis changed physician management plans 51% of the time.
• The strong clinical evidence base is crucial for building trust with physicians and establishing clinical leadership.

Strategic Market Expansion:

• HeartFlow sees an incremental $6 billion opportunity in the high-risk asymptomatic population, expanding its total market opportunity to $11 billion.
• The company plans to initiate three randomized controlled trials targeting specific subpopulations over the next 12 months.
• This strategic expansion aims to de-risk the approach by focusing on patients already within the healthcare system.

Sentiment Analysis:

Overall Tone: Positive

• "We’re pleased to host our fourth quarter call and close out a record year for HeartFlow. We’ve achieved outstanding financial performance..." "I’ve never been more confident in this business and what we’re setting up to deliver here." "Our conviction is high that plaque will be a strong contributor..." "We believe we can achieve our clinical objectives with approximately 1,400 total patients combined across all three trials."

Q&A:

• Question from Robbie Marcus (JPMorgan Chase): Two questions: 1) Confidence in 2026 guidance and plaque assumptions; 2) View on competitive moat vs. AI companies.
  Response: CEO expressed high confidence in FFRCT drivers (new account growth, predictable utilization, CCTA market trend) and plaque early volume, expecting ~1,000 accounts by year-end faster than FFRCT took. CFO added guidance is a high-confidence baseline with upside potential from FFRCT tailwinds and plaque outperformance. On moat, CEO highlighted defensible advantages: proprietary 160M+ annotated CT database, extensive clinical evidence, FDA-regulated medtech quality system, strong physician integration, and global patent portfolio.

• Question from William Plovanic (Canaccord Genuity): 1) Summary of recent product changes and impact; 2) Details on PCI Navigator feedback and future data.
  Response: CEO mentioned next-gen plaque algorithm (no workflow change) and new UI integrating plaque/FFRCT/risk profile. Excited about PCI Navigator launch (pulled forward to April 2026), which helps interventional cardiologists plan PCI procedures. Navigator is viewed as a longer-duration growth vector, not a near-term financial driver; current forecast includes no incremental upside from it.

• Question from William Plovanic (Canaccord Genuity): Follow-up on Q1 2026 expectations given consensus of $46.9M.
  Response: CFO stated Q1 2026 revenue is expected to grow in excess of 30% year-over-year, with sequential improvement of 1%-2%. Plaque contribution is expected to become more meaningful in the back half, providing upside if it outperforms.

• Question from Matthew O'Brien (Piper Sandler): 1) Should we assume $350 per case for plaque in 2026? 2) Clarification on FFRCT case numbers and guidance conservatism.
  Response: CEO expressed excitement for plaque's potential. CFO confirmed modest ASP upside in 2026 base plan with more meaningful step-ups in future years. On FFRCT, Q4 cases per site were ~15% higher than consensus, driven by strong CCTA market. Guidance for 2026 reflects conservatism and leaves room for quarterly progression, as they are lapping a strong 2025.

• Question from Nathan Treybeck (Wells Fargo): 1) Utilization of Plaque Analysis in FFRct accounts and trend outlook; 2) How you're helping accounts understand Plaque and next clinical data.
  Response: CEO noted early plaque utilization is positive but far below total applicability (60% of patients). Current utilization is lower than mature FFRCT (~33% full utilization). Long-term confidence that plaque will become a bigger business. Company focuses heavily on medical education and unlocking coverage; upcoming one-year DECIDE data in H2 2026 will provide important clinical impact evidence.

• Question from John (Stifel): 1) Update on CCTA adoption and its impact on growth; 2) Competitive positioning and win rates against peers.
  Response: CEO sees durable tailwinds for CCTA adoption (guidelines, reimbursement, reader availability), with U.S. penetration around 10%-12% and potential for significant upside. Company does not compete on price but on data quality and product quality (prospective clinical evidence, continuous innovation like PCI Navigator). Results are very positive.

Contradiction Point 1

Plaque Revenue Materialization Timeline

Contradiction on when significant plaque revenue will begin, impacting financial forecasts and investor expectations.

What did Robbie Marcus discuss in JPMorgan Chase's earnings call? - Robbie Marcus (JPMorgan Chase)

2025Q4: Plaque momentum is strong... expects to reach 1,000 accounts by end of 2026... Early Q1 plaque volume trends are positive, though material ramp expected in second half. - John Farquhar(CEO)

What is the confidence level and key assumptions behind the 2026 guidance for FFRct? - Robbie Marcus (JPMorgan)

2025Q3: Material adoption is not expected until the tail end of 2026, as both coverage and education need to be in place. - John Farquhar(CEO)

Contradiction Point 2

FFRct Case Volume Trends

Contradiction on the current state and outlook for FFRct case volumes, affecting confidence in the core business durability.

Matthew O’Brien (Piper Sandler) - Matthew O’Brien (Piper Sandler)

2025Q4: Q4 2025 FFRct cases per site were ~15% higher than consensus. Growth rates are normalizing after lapping a strong 2025. - Vikram Verghese(CFO)

How should we interpret Q1's performance given your guidance implies >30% growth versus the $46.9M consensus (26% YoY)? - Robbie Marcus (JPMorgan)

2025Q3: The confidence is driven by... 1) Durability of the FFRCT core business... 2) Strong visibility into the sales funnel. - John Farquhar(CEO)

Contradiction Point 3

Guidance Philosophies

Contradiction on the conservative nature of the guidance, affecting how investors interpret future performance baselines.

Robbie Marcus (JPMorgan Chase) - Robbie Marcus (JPMorgan Chase)

2025Q4: Guidance is a high-conviction baseline with upside potential... Plaque guidance is de-risked by early Q1 volume data - Vikram Verghese(CFO)

Can you discuss the confidence in the 2026 guidance, particularly regarding plaque revenue being above the street? - Matthew O’Brien (Piper Sandler)

2025Q3: Given the better-than-expected Q3, the Q4 guidance philosophy embeds a measure of conservatism. The guide is based on a high-conviction forecast, providing a reasonable baseline to overdeliver from. - Vikram Verghese(CFO)

Contradiction Point 4

Market Expansion Strategy

Contradiction on the timing for reaching key adoption milestones for the Plaque product, impacting market strategy and rollout plans.

Robbie Marcus (JPMorgan Chase) - Robbie Marcus (JPMorgan Chase)

2025Q4: Plaque momentum is strong... expects to reach 1,000 accounts by end of 2026. - John Farquhar(CEO)

What is the confidence level and key assumptions behind the 2026 guidance for FFRct? - Robbie Marcus (JPMorgan)

2025Q3: Material adoption is not expected until the tail end of 2026. - John Farquhar(CEO)

Contradiction Point 5

Product Launch Execution

Contradiction on the expected timing of a material revenue ramp for the Plaque product, affecting perceptions of execution and market readiness.

"What were JPMorgan Chase's earnings results for the quarter?" - Robbie Marcus (JPMorgan Chase)

2025Q4: ...though material ramp expected in second half. - John Farquhar(CEO)

What is the confidence level and underlying assumptions for the 2026 guidance related to FFRct? - Robbie Marcus (JPMorgan)

2025Q3: Material adoption is not expected until the tail end of 2026. - John Farquhar(CEO)