Q2 2026 Earnings Call — March 18, 2026
Analyst Robbie Marcus (JPM): Thanks for taking the questions. Congrats on a good closing quarter. Two questions from me. I wanted to start first with 2026 guidance came in above the street, and I believe that plaque number is also above where consensus sits. Love to just hear the confidence in the building blocks, particularly any extra commentary you have on PLAC so far in first quarter and feedback on the launch and the assumptions underpinning FFRCT, and then I have a follow-up.
Executive: Yeah, sure. Thanks, Robbie. Great to hear your voice. So, yeah, so thinking about 26, I mean, I'll start by saying I've never been more confident in this business and what we're setting up to deliver here. I think there is fundamental demand out there, and I could not be happier with our team's track record of execution. The way I would kind of categorize this guide is I'd put it as a healthy starting point, and we've talked about our guidance philosophy previously, uh, we want to provide very high conviction guides, uh, that set us up well, uh, you know, for quarters down the road.
Okay. So that's a high level. Um, you know, first, uh, around FFRCT, uh, and the base business, uh, I've got, uh, great confidence here. Okay. Um, and there's really kind of three drivers, uh, underwriting it. You know, we have, um, We have proven our ability to go out into the market and sign up new accounts. We just did the biggest year ever. We did 340 last year, as you're aware of. And I think our go-to-market model has proven our ability to go get it. And that number, incidentally, grows. The number of accounts we can go get grows by about 300 every year.
So, one, we can go get the account. Two, once they're in, we've got very predictable performance relative to utilization. We see physicians ramping and using our FFRCT technology very predictably. So they become healthy in that regard. And then lastly, there's this kind of underlying factor out there relative to CCTA in and of itself. And that, I like to think of that, that genie is not going to get put back in the bottle. CCTA as a frontline test for diagnosing coronary artery disease is in the guidelines, not just in the U.S., but around the world. And I think we're on the right side of history here, and that's going to continue to sort of fuel growth moving forward.
So that's the core business. And then what makes 26 really exciting is plaque. And I think we did a great job last year. We signed up close to 500 accounts by the end of 25. We're well into Q1 here right now, and we've had some strong activations that have continued. I have visibility, obviously, into the funnel. So I've got high confidence that by the end of this year, we'll be in 1,000 accounts. And again, just as frame of reference, it took us eight years to get into 1,000 accounts with our FFRCT business. We'll do it in less than two with FLAC. And then the accounts that are live now, the early trends are very positive relative to volume. So I'm very happy about that.
Now, I will say I don't think this is going to be a light switch moment. I still think, as Vikram mentioned, the material volume is going to come in the back half. We've got some catalysts out there. We've got the one-year decide data reading out in the second half of this year. Physicians really need to experience it. experience outcomes with their individual patients to get into a more kind of higher utilization rate. But all that being said, very confident. And again, I'd say this is a high conviction forecast that we're giving you.
Yeah, I'll probably add some commentary to that. Again, this is a high confidence baseline that really sets a solid foundation to allow for quarterly progression. Additionally, there's, you know, pockets of, you know, incremental pockets of potential upside. I'll start with FFRCT. Again, a high-conviction guide, but not factored in. Any utilization tailwinds from the navigator launch, so that will be upside. The feedback from the physician community has been incredibly positive.
Now, focusing on FLAC, and, you know, you had a very specific question there, Robbie. We'll point out that, again, this is highly de-risked given the early volume data that we're seeing in Q1. If the adoption curve were to steepen more quickly, it provides an additional catalyst for growth. Second, we referenced 1,000 accounts by the end of the year. We've got strong funnel with good visibility, so any outperformance there would also be beyond the range we provided for guidance. Stepping back, the framework here is straightforward. We've been conservative around optionality and realistic around execution assumptions. So the overall skew in our view is to the upside.
Analyst Robbie Marcus (JPM): Then just as a follow-up, you know, a lot of software companies have come under pressure from fears around AI that they could, you know, do it better and faster. And obviously there's a lot of moats you have with your data and tech and med tech are very different sectors for a reason. I'd love to get just on record your view of your moat around the business versus some of the AI companies that are hitting software and how you've feel your defenses and things you're doing to, you know, stay ahead of all the competition. Appreciate it.
Executive: Yeah, sure, Robbie. And I think that question makes a lot of sense given some of the recent, you know, headlines. You know, I'll say, I mean, I would characterize our moat as highly defensible, okay? And I think there's a couple of components that sort of, you know, to make it up here. The first is, I think as everybody's aware, an AI model is only as good as the training set and the data that that model is trained on. And we have, and we're very proud of it, what we believe to be the world's largest proprietary CT database of annotated CT images. We've got over 160 million images. This data is effectively ground truth data and it does not exist in the public domain. So there's no large data set out there that somebody very quickly could go acquire and start training a model on.
We've been training this model and we've been building this data set for over 10 years. So not only is it very large at 160 million annotated CT images, it's also super diverse because it's got all sorts of different types of anatomy and types of CT capital feeding into it. The last thing I'll say on it is right now, we're already connected, and this is sort of at the end or the start of this year, we're connected to 60% of the market's CCTAs. So every day as the category grows, we're growing disproportionately with it. So this would be a very difficult catch-up game if somebody were to try to start a race here.
So that's the data that the algorithms are trained on, but that works hand-in-hand with clinical evidence. And we like to say you can't code your way into clinical trust. Clinical trust with a physician comes by delivering high-quality clinical data. And HeartGlo as a company has been investing in this regard for over 10 years. We have over 600 peer-reviewed publications. We've got a couple randomized controlled trials. This is high-quality clinical data, and you can't fast-forward that. There's no way to rush that. And so this is an incredible lead that we have, and we'll continue to invest and build on that.
Now, that clinical data works hand-in-hand with the fact that we're MedTech, and in MedTech, you can't have an AI hallucination the way you can in consumer technology. We are a regulated medical device. You need clinical data first to get FDA clearance, but then you need to operate within a regulated quality system. And we have just that, and of course we have our human in the loop that ensures our accuracy remains incredibly high. And then the last thing I'll say is, you know, we are software. And, you know, software is useless if it's not integrated into a doctor's everyday practice. And we are effectively the proven operating system, if you will, in over 15 hospitals and clinics right now.
Okay. So we work really hard to integrate in and meet our physicians where they are so we help them do their job easier. We don't ask them to adapt and do it with us. That can be a tough road to sort of hoe. Initially, it takes over a year to get into some of these hospitals. But once you're in, we're pretty sticky. And being the kind of operating system of choice, we think is a great advantage for us. And then lastly, underscoring all this, we've got a great, strong global patent portfolio that we think is very defensible as well. Appreciate it. Thanks a lot.
Analyst William Plovnik (Canaccord Genuity): Hey, great, thanks for taking my questions, and good evening. I'd like to ask just on the product itself. I mean, you guys are innovating rather quickly, and so you've had significant changes to both FFRCT and PLEC, I think, over the last three to six months. I was wondering if you could just kind of maybe highlight some of those changes and how they've impacted the workflow to help us understand. And then my follow-up is on the PCI Navigator. Just initial feedback, future data, product innovations. You know, we saw the first patient go into the registry. Just love to hear more on that. It sounds like, you know, you're using that as one of your competitive modes as well. Thanks.
Executive: Yeah, sure. So good to hear your voice, Bill. So on kind of the product innovation piece, you know, last year we introduced our next generation plaque algorithm, okay? And that was, again, we're going into this proprietary database that we have. We're training the algorithms to get smarter and we took what was already a really good plaque algorithm and we enhanced it. From a customer standpoint, there's no changes to the workflow per se. We're always doing behind the scenes work that I don't think is really, it's not material enough for a call such as this to take out steps and improve functionality of our product.
Two years ago, a little over two years ago, we launched our new, another example is we launched our new user interface, which incorporated both plaque and FFRCT co-registered with our risk profile, our nomogram information into a singular user interface. And now physicians can use that to interrogate the entire coronary tree. This year, and we're really excited. We're launching it actually next month. The team did a good job pulling it forward. We're launching our PCI Navigator, and we're really excited about that. And we've talked about the strength of the platform matters, and PCI Navigator expands our platform. And we really think for interventional cardiologists, this can be a pretty attractive tool for their toolkit.
And what allows them to do is really plan ahead before a PCI procedure so they can walk into that procedure knowing the right devices to select, the complexity of the anatomy, et cetera. That's very analogous to what they're already doing with TAVR and Mitral, et cetera. So we're excited to that. We haven't, and Vikram can speak to this if there's interest, we haven't necessarily baked in FFRCT upside as a result of this, but we do think it's possible. We think having an interventional cardiologist, who's an important part of the CV ecosystem, if you will, really advocate strongly for CT and heart flow pathway, that helps us. And certainly using heart flow on every case that comes in helps us as well. We're super excited about that.
Executive Vikram: Yeah, I'll quickly underscore, you know, our current forecast really does not assume any incremental upside from PCI Navigator. To the extent Navigator drives incremental activity, it'll really flow through FFRCT volumes as each case is anchored to an FFRCT order. And then, you know, we're highly encouraged by the early feedback we've received on the product and the early potential we see. But we would frame PCI Navigator as a longer duration growth vector for us than a real near-term driver of financial performance.
Analyst William Plovnik (Canaccord Genuity): And I just wanted to circle up with, you know, just on the consensus on Robbie's question, Q1 consensus, I think it's 46.9 million. That's up 26% year-over-year. You're guiding 24 to 26. How do we think about that first quarter? I mean, you're two weeks away from closing it. Are you extremely comfortable with that current number? Do you think it'll be higher, or how should we think of Q1? Thanks.
Executive: Yeah, in terms of phasing, generally, Bill, what I would say is, you know, our full year guide reflects, you know, a midpoint of 25% year-over-year for the first quarter, and this is specific to your comment there. We expect growth in excess of 30% year-over-year, and that bakes in about a sequential improvement of 1% to 2% full cognizance of where we are, you know, relative to the end of the quarter. Moving into Q2, for what it's worth, we typically benefit from a little bit of seasonality, and we expect that pattern to hold true in 2026 as well. And then as plaque starts to really materialize in 2026 towards the back half of the year, you'll see more sequential growth relative to where consensus is at. And again, plaque, you know, should plaque outperform, that's, you know, the principal upside to the back half phasing assumptions.
Thank you. Bill, just to round out your question on innovation a little bit, obviously Navigator is what we're discussing today. I would describe our pipeline of new products as really strong, and we'll have more news in future quarters of other innovations that are coming.
Analyst Matthew O'Brien (Piper Sandler): All right. Thanks for taking the questions. Just for starters, on the plaque side, should we continue to assume $350 per case for plaque here in 26? And is there any, you know, upward mobility to that revenue per case going forward?
Executive: Yeah, maybe I'll... I'll say a couple comments on plaque, and then Vikram, you can speak to the specificness of the model. I mean, first thing, Matt, I'll say, I mean, I've said this before, but it's worth saying again. I could not be more excited about what plaque is going to mean full stop. I think it's going to mean a lot for patients, most importantly. But I also think it's going to transform this business. Now, over time, we've got to be a little judicious in how we call it, given we're still in the early innings. And as we monitor patients, uptake every quarter we'll be able to adjust going forward. Part of that uptake, to your question, is pricing, and I'll let Vikram speak to that.
Executive Vikram: Yeah, happy to, John. So, Matt, relative to your question, given that we have now commercial pairs coming online, Aetna being the latest one that gets us to about 75% covered lives in the U.S., we now have clearer line of sight to pricing improvements over time. Our contracts with our customers have built-in mechanisms that enable better pricing with broader coverage. And so consequently, in our 2026 base plan, we have underwritten modest ASP upside in the 2026 plan and then more meaningful step-ups in future years.
Analyst Matthew O'Brien (Piper Sandler): Okay. So a little above 350 to start and then maybe going up more in 2027, 2028. Is that fair?
Executive Vikram: Okay. That's right.
Analyst Matthew O'Brien (Piper Sandler): Got it. And then, Vikram, just sticking with the numbers here a little bit, I wanted to get into gross margin because that was so good, but I'm trying to keep it to two here. Was the FFRCT case number per site similar to what you saw in Q3? Because, you know, given the number of hospitals you added, that's really good. And then, you know, I think it's kind of, you know, to the guidance question, if you assume, well, when I'm looking at the FFRCT revenue that's factored in when you think about the plaque growth plus OUS, it's the lowest level that we've seen from you guys or would see from you guys over the last three years. Is there something in there that we should be aware of, again, given all the momentum that we're seeing in the core FFRCT business, or is it just back to kind of what John was saying to start with, like, look, we're trying to be very conditions with how we're guiding early in the year, and then we'll kind of reflect back as things progress. Thanks.
Executive Vikram: Yeah, thanks for the question, Matt, again. You know, relative to cases per site, we did outperform despite the heavy onboard number. We were about 15% higher on a cases per site basis in 4Q25 relative to where consensus came at. And that's really, you know, driven by the strength of that market shift that's happening here with CCTA ultimately on its way to becoming standard of care.
With respect to guidance, you know, I'd say we've, you know, it's part, you know, part law of large numbers as well as a part guidance philosophy. You know, we're lapping an exceptionally strong year in 2025, and when you start with that kind of elevated base the growth rates really start to normalize. And then the second piece, to underscore what John said, this is core to our guidance philosophy. The framework we've put forward for 2026 still assumes very strong underlying demand from a nominal volume perspective with a fair amount of conservatism. So I would really view this guide as an earlier framework that intentionally leads sufficient room for quarterly progression.
Analyst Nathan Trebek (Wells Fargo): Hi, this is Nathan Trebek on for Larry. Thanks for taking the question. Can you talk about the utilization that you're seeing for plaque analysis in your FFRCT accounts? How does the utilization compare to FFRCT, and how do you envision utilization trending throughout 26? Thanks.
Executive: Yeah, thanks, Nathan. So, again, we're at the early innings, but I think what we're seeing so far is positive, okay? Now, you need to remember the total applicability for plaque is 60% of all patients. We're nowhere near 60% right now because we've just kind of got out the gates here. So over time, there's plenty of upside to ramp, but what we've seen is very positive and I think leads to sort of the bullishness that you're hearing from me today.
Relative to FFRCT, FFRCT obviously is a more mature diagnostic. Once an account is up and running, we see FFRCT being utilized pretty close to the full range. So that's the good news, but the full range is about half of what it is on plaque. So FFRCT is about 30% or 33% full utilization, and we get pretty close to that with most of our accounts. So I think over time, there's certainly an opportunity to see plaque really in a material way take off here. I think long-term, I've got really high confidence PLAC is going to be a bigger business than FFRCT. I think where we have to sort of wait and see and kind of measure it every week, every month, is what does that ramp look like? And we're in the early innings there, but again, so far, pretty positive.
Analyst Nathan Trebek (Wells Fargo): Okay, thanks for that. Can you talk about how you're helping your accounts to better understand how to utilize plaque analysis? And I guess what's next for plaque from a clinical data standpoint?
Executive: Yeah, well, we lean very heavily into education. And I think as we talked about before, you know, one important unlock is coverage. And, you know, we're making great progress there. That's super easy to measure, so to speak. Medical education is a little more nuanced. In the FFRCT journey, it was a much simpler story. You just needed to prove accuracy versus invasive FFR, and then everybody knew what to do with whatever .7 FFR value. PLAC is much more nuanced, and we are leaning in very heavily to help physicians understand how to use PLAC with their specific patients.
And we do a lot of medical education. I would say moving forward, and we're at AHA just this next week in New Orleans, and far and away, you know, the lion's share of everything we're talking about there will be plaque. In the second half of this year, the big data that we'll share is the one-year data on DECIDE, where we'll have one-year outcomes there, and that'll be another piece that's really important to bring to our physicians. Ultimately, what we're trying to do is shift it from clinical utility. Question number one is first, how do you use it to actual clinical management? And that's the journey that we're on with our physicians right now.
Analyst John (Stifel): Hi, John and team. This is John on for Rick today. A couple quick questions for me. First, I just wanted to ask about the broader role of CCTA for heart flow and how that's impacted growth today. I remember back in the IPO, you gave a couple metrics about how penetrated and utilized CCTA is for non-invasive coronary tests. I was just hoping for a general update on where CCTA adoption stands, how much are you benefiting from it, and how much more do we have to go in terms of uptake there in your view?
Executive: Yeah, sure. Thanks, John. Appreciate the question. So, again, we're trying to create a new standard of care here, and it's well documented that the existing standard of care is suboptimal. Patients are being misdiagnosed, way too many false positives, way too many false negatives. CT plus heart flow addresses that issue, and we're trying to create a new one. The first piece of that is CCTA being adopted. At the end of 2021, CCTA in the US came in as a level 1A test ahead of all other alternatives.
We like to say we're on the right side of history here, but we have a lot of upside. It's around 10 to 12%, I think, penetrated relative to the whole standard of care. So there's lots of ways to go before we get there. But as I said earlier, I don't think the genie is gonna get put back in the bottle there. I think it's just a matter of time between the guidelines, the stronger reimbursement, more and more readers are raising their hand, becoming CTA readers, plaque is coming on board, so that makes utility even that much greater.
All of those trends in my mind are durable, and there's a high ceiling for us to aspire to go hit. Now, from what I'm seeing in the data, I'm not seeing anything slowing us down. We're seeing more and more accounts join the category, so to speak. At the start of this year, there's 3,200 accounts with active CTA programs. We expect that number will be 3,500 before the year's out. Right now, the majority of volume coming off a CT scanner is not CCTA. It's for another modality. So more and more accounts can start adding slots to it before they even have to tap into kind of a longer uptick of a capital cycle. So there's lots of tailwinds into this story, and we continue to lean into them.
Analyst John (Stifel): That's helpful. And I just wanted to also ask about competition quickly here. I'm just curious what you're seeing in terms of win rates or when you're going up head-to-head against peers. Are you getting any pushback on price if they come below you? And just curious about how the broader HeartFlow ecosystem factors into the competitive positioning when you go up against others. Thanks.
Executive: Yeah, sure. So first thing I'll say, and I remind the team of this often, our competition is the standard of care, okay? When we wake up every morning, we are trying to convert volume from the existing standard of care into CT plus heart flow. And when we do that, we will be successful and patients will be better off. And we're continuing to focus on changing those practice patterns and bringing physicians into kind of a CT plus heart flow pathway.
Now, your question, I think, is more specifically around other AI vendors. This is not a new dynamic. Some of these vendors have been around since 2018, 2017. None of that is slowing us down. I think, if anything, having more competitors or players in the category is actually good for the category. We don't compete on price. We compete on the quality of our data, which we're extremely proud of. We're prospective. We're published. We lean into that. We prove our accuracy. And we compete on the quality of our products, and we continue to improve our product just like we're doing this year and expanding our platform with PCI Navigator.
We don't publish win rates and things like that, but I think our results are very positive, and I feel good about the way the team is competing and how we're winning in the market.
Executive: That's helpful. Thanks for taking my questions.
Executive: And with that, we conclude our Q&A session and conference for today. We want to thank everyone for participating. You may now disconnect.