Coronary artery disease (CAD) remains the leading cause of death despite advances in diagnostic and therapeutic options. Based on the National Health and Nutrition Examination Survey data for the period 2015 to 2018, it is estimated that more than 20 million adults (>20 years of age) in the United States have CAD and 3% have suffered from a myocardial infarction.1 The 2021 American College of Cardiology (ACC)/American Heart Association (AHA) chest pain guidelines highlight the role of coronary computed tomography angiogram (CCTA) as a test with several class 1 (level of evidence A) indications, favouring CCTA in patients less than the age of 65 years or with low probability of obstructive CAD as well as in those with prior inconclusive or mildly abnormal functional testing.2 Of note, CCTA is the only noninvasive testing modality with a “Class I00 endorsement by the ACC/AHA for patients with acute or stable chest pain, supported by “Level A00 quality of evidence. Other modalities also received a Class I endorsement but “Level B quality of evidence. CCTA may also provide additional benefits compared with functional imaging including the ability to assess other anatomic structures enabling the diagnosis of alternative causes of symptoms (Fig. 1), reliably exclude left main disease, and provide prognostically useful information from plaque extent and high-risk plaque (HRP) features. This is in the context of overall low radiation dose that is now easily achievable with contemporary technological advancements. These advancements in detector rows, gantry rotation speed, dual-source scanners, and photon-counting CTs have also dramatically improved spatial and temporal resolution as well as image quality of CCTA. The protocols vary depending on the institutional workflow, scanner type, and baseline patient heart rate and regularity of the rhythm. The warranty period for CCTA is longer (2 years) than functional imaging (1 year) due to the low number of events in patients with no plaque or stenosis on CT in contrast to functional imaging which cannot evaluate nonobstructive CAD burden.3 In addition to the role of CT in symptomatic CAD, de- cades of evidence support the use of coronary artery calcium (CAC) scoring in select asymptomatic patient populations. Multiple treatment guidelines including the ACC/AHA and the European Atherosclerosis Society/European Society of Cardiology guidelines for the management of atherosclerotic disease endorse the use of CAC scoring in inter- mediate- and borderline-risk patients, thereby providing a more personalized risk assessment for preventative measures. Recent advancements in CT imaging technology including perfusion imaging and fractional flow reserve derived from CCTA (FFR-CT) allow not only assessment of luminal stenosis severity and overall plaque burden but also assessment of lesion-specific ischemia which can improve the diagnosis and management of patients with CAD. In this review, the authors summarize the role of CCTA and CAC scoring in different clinical presentations of chest pain and for preventative care. Following this, the authors discuss future directions and new technologies such as pericoronary fat inflammation and the growing footprint of artificial intelligence (AI) in cardiovascular medicine. <br/
