Coronary artery anomalies: contemporary approaches to risk stratification and management

The widespread adoption of coronary computed tomography angiography (CCTA) has led to a growing detection of coronary artery anomalies in contemporary clinical practice, often as incidental findings during the evaluation of suspected or known coronary artery disease. Among these, anomalous aortic origin of a coronary artery (AAOCA) represents the most clinically debated entity, historically associated with myocardial ischaemia and sudden cardiac death, yet increasingly identified in asymptomatic or minimally symptomatic adults. Accumulating evidence indicates that most AAOCA diagnosed in adulthood are not associated with functionally relevant ischaemia and frequently follow a benign clinical course, highlighting the limitations of anatomy-based risk stratification alone. In this context, CCTA plays a pivotal role by accurately defining coronary origin and course, characterizing proximal vessel morphology, and assessing concomitant atherosclerotic disease, which often represents the predominant determinant of symptoms and prognosis in adult patients. Recent studies have demonstrated that quantitative CCTA-derived parameters can reliably exclude hemodynamically significant AAOCA and reduce unnecessary downstream testing. In selected cases, invasive functional assessment and intracoronary imaging provide incremental value by clarifying the presence and mechanisms of ischaemia but should be reserved for carefully selected patients. This review summarizes current evidence on coronary artery anomalies with a specific focus on AAOCA and proposes a pragmatic, stepwise approach integrating anatomical and functional assessment to guide clinical decision-making in daily practice.