The following are key points to remember about this Journal of the American College of Cardiology State-of-the-Art Review on coronary computed tomography angiography (CCTA):

1. CCTA is emerging as a first-line diagnostic modality for coronary artery disease (CAD) and shows extraordinary potential for future applications due to its ability to distinguish biopathological changes in stenoses.
2. European countries have led the United States in CCTA use. CCTA was recognized as a first-line modality in evaluation of chest pain in guidelines from the United Kingdom in 2016 and in evaluation of chronic coronary syndromes in guidelines from the European Society of Cardiology in 2019.
3. In the United States, CCTA is used to evaluate acute coronary syndrome (ACS) in the emergency department, for planning before cardiac surgery, and for assessment following abnormal exercise or perfusion study. It can be used to assess cardiac status before liver transplantation.
4. According to several clinical trials, CCTA may predict obstructive CAD better than traditional functional testing.
5. CCTA is an effective, safe, and rapid modality for ruling out CAD in patients at low to intermediate risk presenting with acute chest pain.
6. CCTA offers several advantages over coronary artery calcium scoring. It can identify coronary stenosis severity, distinguish morphology and composition of plaque in calcified or non-calcified lesions, and characterize alterations in plaque structure in response to treatment.
7. CCTA disadvantages include reduced image quality in patients with morbid obesity, dense calcifications, multiple or small-diameter stents, elevated heart rates, or arrhythmia; the need for intravenous contrast, which may be nephrotoxic; and the risk of excess downstream testing.
8. CCTA can accurately characterize and quantify atherosclerosis. A thin fibrous cap is associated with positive remodeling, spotty calcifications, napkin-ring sign, and low attenuation plaque. Macrophage infiltration and necrotic core size are associated with low attenuation plaque.
9. CCTA can assess response to treatment. The PARADIGM (Progression of Atherosclerotic Plaque Determined by Computed Tomographic Angiography Imaging) study showed changes in plaque composition and morphology of patients treated with statins. Another study of patients with recent acute coronary syndrome showed changes in response to optimal medical therapy and colchicine.
10. Inflammation is a significant factor in the biology of atherosclerosis. In patients with chronic inflammatory diseases (human immunodeficiency virus, psoriasis, rheumatoid arthritis, and systemic lupus erythematosus), CCTA has aided in characterizing CAD and its response to treatments that attenuate inflammation (i.e., statins and biologic therapy for psoriasis).
11. Emerging technologies in CCTA include the following:
    • Techniques to reduce radiation exposure
    • Imaging biomarkers such as perivascular fat attenuation index, which identifies and quantifies inflammation
    • Dramatic improvements in stenosis visualization and characterization with software applications
    • Functional assessment with CCTA-derived fractional flow reserve or myocardial perfusion by cardiac computed tomography in conjunction with CCTA
    • Computation of wall shear stress
12. CCTA remains limited in spatial and temporal resolution. Other tests are preferable for patients with multiple stents, extensive calcifications, or lesions of uncertain hemodynamic significance.

Clinical Topics: Acute Coronary Syndromes, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Interventions and ACS, Interventions and Coronary Artery Disease, Interventions and Imaging, Angiography, Computed Tomography, Nuclear Imaging

Keywords: Tomography, X-Ray Computed, Tomography Scanners, X-Ray Computed, Coronary Angiography, Coronary Artery Disease, Chest Pain, Plaque, Atherosclerotic, Acute Coronary Syndrome, Coronary Stenosis, Constriction, Pathologic

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