Artificial Intelligence in Coronary Computed Tomography: Current Applications, Future Potentials, and Real-world Challenges

Artificial intelligence (AI) is rapidly transforming cardiac computed tomography (CT) imaging by enhancing image acquisition, reconstruction, and analysis to improve diagnostic accuracy and overall clinical workflow. Deep learning reconstruction (DLR) algorithms optimize image quality while reducing radiation and contrast media doses. AI-driven tools for coronary artery segmentation and CAD-RADS classification ensure greater reproducibility and efficiency in coronary artery disease (CAD) assessment. Beyond anatomic evaluation, AI enhances functional imaging with CT-derived fractional flow reserve and myocardial CT perfusion imaging, improving the noninvasive identification of myocardial ischemia associated with flow-limiting coronary lesions. AI also plays a key role in CAD phenotyping through automating quantification and characterization of total plaque burden and identifying rupture-prone plaques and high-risk patients. Radiomics and machine learning models analyzing pericoronary adipose tissue (PCAT) propose new biomarkers of coronary inflammation, refining risk stratification and disease monitoring. Fusion models integrating clinical, imaging, and laboratory data are emerging as powerful tools for comprehensive cardiovascular risk prognostication, surpassing traditional clinical risk scores. Looking ahead, generative AI and large language models (LLMs) could revolutionize radiology workflows by automating report generation and relevant clinical data extraction and integration, while digital twins may enable real-time simulation of patient-specific models that predicts disease progression and treatment response. Despite these advances, challenges like data diversity and standardization, model interpretability, and regulatory approval must be further addressed for AI to reach full integration into clinical practice. As AI-driven technologies continue to evolve, interdisciplinary collaboration will be essential to ensure responsible implementation, ultimately advancing precision medicine in cardiovascular care.