State-of-the-Art Updates on Cardiac Computed Tomographic Angiography for Assessing Coronary Artery Disease

Cardiac computed tomographic angiography (CCTA) is a noninvasive imaging modality that is increasingly useful for the evaluation of coronary artery disease (CAD). Over the past decade, CCTA has consistently demonstrated an excellent sensitivity for the detection and exclusion of coronary atherosclerosis in patients with stable or acute chest pain symptoms. Large prospective registries have repeatedly demonstrated the prognostic significance of the presence, extent, or absence of CAD by CCTA. In response to initial concerns, technical advances have permitted a dramatic reduction in patient radiation exposure with preserved image quality. For many patients, the radiation dose of CCTA is less than half of that with conventional myocardial perfusion imaging while providing significantly more anatomic information. Furthermore, CCTA's excellent spatial resolution is increasingly being used for noninvasive assessment of coronary plaque, including the detection of higher-risk vulnerable plaque and association between plaque characteristics and ischemia. Finally, new promising techniques that incorporate physiology with anatomy, such as CT-based fractional flow reserve (FFR-CT) and CT perfusion (CTP), are allowing for the noninvasive hemodynamic assessment of coronary stenoses and improvements in the specificity of CCTA findings. Such advances augur a coming transition when CCTA will be a first-line test for the detection, exclusion, and even management of CAD in many patients.