Integrating Anatomy and Ischemia in Chest Pain Evaluation

Coronary atherosclerosis remains a leading cause of morbidity and mortality, and its optimal evaluation integrates anatomic and physiologic assessment. Noninvasive strategies, including coronary CT angiography with or without CT-derived fractional flow reserve and functional imaging (stress echocardiography, Single positron emission computed tomography, Positron emission tomography myocardial blood flow/coronary flow reserve, stress Cardiac magnetic resonance)-efficiently triage patients and characterize disease. Invasive coronary angiography with physiology (fractional flow reserve/instantaneous wave-free ratio) and intravascular imaging (Intravascular ultrasound, Optical coherance tomography) provides lesion-specific information when revascularization is contemplated. Contemporary pathways begin with anatomy in low-intermediate-risk chest pain, add physiology in intermediate-high risk, and escalate to invasive assessment when decisions hinge on revascularization or discordant findings. Patient-specific factors (renal function, rhythm, calcification, and previous revascularization) also guide modality selection. This review synthesizes current evidence, clinical pathways, and diagnostic performance to inform evidence-aligned practice and improve outcomes.