Coronary computed tomography angiography: modern capabilities of the technique and place in everyday clinical practice
V. Yu. Kozulin,
Daria Аlekseeva,
I. V. Basek,
Y. A. Kudaev,
L. E. Galyautdinova,
G. E. Trufanov,
A. V. Panov https://doi.org/10.18705/2311-4495-2025-12-3-225-237
EDN: SNYVEQ
Abstract
Coronary artery disease (CAD) remains the leading cause of death worldwide. While invasive coronary angiography is the gold standard for lumen visualization, it falls short in morphological assessment of atherosclerotic plaque. Coronary computed tomography angiography (CCTA) offers a non-invasive alternative, enabling detailed analysis of coronary artery anatomy and structural plaque characteristics crucial for determining instability and rupture risk. Modern computed tomography (CT) technologies, including dynamic CT perfusion and CT-fractional flow reserve (FFRCT), further enhance CCTA by providing functional assessment of coronary atherosclerosis. Current clinical guidelines position CCTA as a primary non-invasive method for CAD verification, particularly for patients with suspected stable CAD and intermediate pre-test probability. This comprehensive review elucidates the contemporary diagnostic capabilities of CCTA, including its role in assessing anatomical severity and plaque morphology. It details the standardized CAD-RADS reporting system, discusses the utility of FFRCT and CT perfusion for functional stenosis evaluation, and addresses technical limitations and their mitigation. The article emphasizes CCTA’s growing importance in personalized medicine and optimizing patient management pathways.
Keywords
atherosclerotic plaque,
coronary artery disease,
coronary computed tomography angiography,
coronary imaging,
fractional flow reserve,
myocardial perfusion
Supporting agencies: The work was carried out within the framework of the state assignment of the Ministry of Health of the Russian Federation No. 123021000146-8.
About the Authors
V. Yu. Kozulin
Almazov National Medical Research Centre
Russian Federation
Competing Interests:
Russian Federation
Vikenty Yu. Kozulin, PhD, doctor in X-ray endovascular diagnostics and treatment of the Department of X-ray surgical methods of diagnosis and treatment, Associate Professor of the Cardiology Department
Saint Petersburg
Competing Interests:
The authors declare no conflict of interest
Daria Аlekseeva
Almazov National Medical Research Centre
Russian Federation
Competing Interests:
Russian Federation
Daria V. Аlekseeva, assistant, Radiology and Medical Visualisation Department, radiologist, Head of the Radiology Department No 1
Saint Petersburg
Competing Interests:
The authors declare no conflict of interest
I. V. Basek
Almazov National Medical Research Centre
Russian Federation
Competing Interests:
Russian Federation
Ilona V. Basek, PhD, Associate Professor of the Radiology and Medical Visualisation Department, radiologist, Head of the Department of Radiolody
Saint Petersburg
Competing Interests:
The authors declare no conflict of interest
Y. A. Kudaev
Almazov National Medical Research Centre
Russian Federation
Competing Interests:
Russian Federation
Yuriy A. Kudaev, PhD, Researcher Department of Ischemic Heart Disease
Akkuratova str., 2, Saint Petersburg, 197341
Competing Interests:
The authors declare no conflict of interest
L. E. Galyautdinova
Almazov National Medical Research Centre
Russian Federation
Competing Interests:
Russian Federation
Lina E. Galyautdinova, resident, Radiology and Medical Visualization Department
Saint Petersburg
Competing Interests:
The authors declare no conflict of interest
G. E. Trufanov
Almazov National Medical Research Centre
Russian Federation
Competing Interests:
Russian Federation
Gennady E. Trufanov, MD, Professor, Head of the Radiology and Medical Visualisation Department
Saint Petersburg
Competing Interests:
The authors declare no conflict of interest
A. V. Panov
Almazov National Medical Research Centre
Russian Federation
Competing Interests:
Russian Federation
Aleksey V. Panov, MD, Professor, Chief Researcher Department of Ischemic Heart Disease
Saint Petersburg
Competing Interests:
The authors declare no conflict of interest
References
1. Chazov EI. Guide to Cardiology. In 4 vols. Moscow: Izdatel`skij dom “Praktika”. 2014. In Russian
2. Alekyan BG, Staferov AV, Zakaryan NV. In. Bokeria LA, Golukhova EZ. Clinical cardiology: diagnosis and treatment. Moscow: NTsSSKh im. Bakuleva AN, 2011. In Russian
3. Tonino PA, Fearon WF, De Bruyne B, et al. Angiographic versus functional severity of coronary artery stenoses in the FAME study fractional flow reserve versus angiography in multivessel evaluation. J Am Coll Cardiol. 2010;55(25):2816–2821. DOI:10.1016/j.jacc.2009.11.096.
4. Patel P, Rao R, Sethi P, et al. Functional Assessment of Coronary Artery Lesions-Old and New Kids on the Block. Int J Angiol. 2021;30(1):40–47. DOI:10.1055/s-0041-1723942.
5. Knuuti J, Wijns W, Saraste A, et al. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020;41(3):407–477. DOI:10.1093/eurheartj/ehz425.
6. Barbarash OL, Karpov YuA, Panov AV, et al. 2024 Clinical practice guidelines for Stable coronary artery disease. Russian Journal of Cardiology. 2024;29(9):6110. In Russian DOI:10.15829/1560-4071-2024-6110.
7. Vrints C, Andreotti F, Koskinas KC, et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024;45(36):3415–3537. DOI:10.1093/eurheartj/ehae177.
8. Becker LM, Peper J, van Nes SH, et al. Non-invasive physiological assessment of coronary artery obstruction on coronary computed tomography angiography. Neth Heart J. 2024;32(11):397–404. DOI:10.1007/s12471-024-01902-7.
9. Yoshida K, Tanabe Y, Hosokawa T, et al. Coronary computed tomography angiography for clinical practice. Jpn J Radiol. 2024;42(6):555–580. DOI:10.1007/s11604-024-01543-1.
10. Andreini D, Conte E, Serruys PW. Coronary plaque features on CTA can identify patients at increased risk of cardiovascular events. Curr Opin Cardiol. 2021;36(6):784– 792. DOI:10.1097/HCO.0000000000000917.
11. Blaha MJ, Whelton SP, Al Rifai M, et al. Comparing Risk Scores in the Prediction of Coronary and Cardiovascular Deaths: Coronary Artery Calcium Consortium. JACC Cardiovasc Imaging. 2021;14(2):411–21. DOI:10.1016/j.jcmg.2019.12.010.
12. Maurovich-Horvat P, Bosserdt M, Kofoed KF, et al. CT or invasive coronary angiography in stable chest pain. N Engl J Med. 2022;386:1591–602. DOI:10.1056/NEJMoa2200963.
13. Serruys PW, Kotoku N, Nørgaard BL, et al. Computed tomographic angiography in coronary artery disease. EuroIntervention. 2023;18(16):e1307–e1327. DOI:10.4244/EIJ-D-22-00776.
14. Yang J, Shan D, Wang X, et al. On-Site Computed Tomography-Derived Fractional Flow Reserve to Guide Management of Patients with Stable Coronary Artery Disease: The TARGET Randomized Trial. Circulation. 2023;147:1369–81. DOI:10.1161/CIRCULATIONAHA.123.063996.
15. Serruys PW, Hara H, Garg S, et al. Coronary Computed Tomographic Angiography for Complete Assessment of Coronary Artery Disease: JACC State-ofthe-Art Review. J Am Coll Cardiol. 2021;78(7):713–736. DOI:10.1016/j.jacc.2021.06.019.
16. Douglas PS, Nanna MG, Kelsey MD, et al. Comparison of an Initial Risk-Based Testing Strategy vs Usual Testing in Stable Symptomatic Patients With Suspected Coronary Artery Disease: The PRECISE Randomized Clinical Trial. JAMA Cardiol. 2023;8(10):904– 914. DOI:10.1001/jamacardio.2023.2595.
17. Cury RC, Leipsic J, Abbara S, et al. CAD-RADS™ 2.0 - 2022 Coronary Artery Disease-Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr. 2022;16(6):536–557. DOI:10.1016/j.jcct.2022.07.002.
18. Cundari G, Marchitelli L, Pambianchi G, et al. Imaging biomarkers in cardiac CT: moving beyond simple coronary anatomical assessment. Radiol Med. 2024;129(3):380–400. DOI:10.1007/s11547-024-01771-5.
19. Knuuti J, Ballo H, Juarez-Orozco LE, et al. The performance of non-invasive tests to rule-in and rule-out significant coronary artery stenosis in patients with stable angina: a meta-analysis focused on post-test disease probability. Eur Heart J. 2018;39(35):3322–3330. DOI:10.1093/eurheartj/ehy267.
20. Lu MT, Meyersohn NM, Mayrhofer T, et al. Central Core Laboratory versus Site Interpretation of Coronary CT Angiography: Agreement and Association with Cardiovascular Events in the PROMISE Trial. Radiology. 2018;287(1):87–95. DOI:10.1148/radiol.2017172181.
21. Griffin WF, Choi AD, Riess JS, et al. AI Evaluation of Stenosis on Coronary CTA, Comparison With Quantitative Coronary Angiography and Fractional Flow Reserve: A CREDENCE Trial Substudy. JACC Cardiovasc Imaging. 2023;16(2):193–205. DOI:10.1016/j.jcmg.2021.10.020.
22. Virani SS, Newby LK, Arnold SV, et al. 2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines. Circulation. 2023;148:e9–e119. DOI:10.1161/CIR.0000000000001168.
23. Rajiah P, Cummings KW, Williamson E, Young PM. CT Fractional Flow Reserve: A Practical Guide to Application, Interpretation, and Problem Solving. Radiographics. 2022;42(2):340–358. DOI:10.1148/rg.210097.
24. Curzen N, Nicholas Z, Stuart B, et al. Fractional flow reserve derived from computed tomography coronary angiography in the assessment and management of stable chest pain: the FORECAST randomized trial. Eur Heart J. 2021;42(37):3844–3852. DOI:10.1093/eurheartj/ehab444.
25. Patel MR, Nørgaard BL, Fairbairn TA, et al. 1-Year Impact on Medical Practice and Clinical Outcomes of FFRCT: The ADVANCE Registry. JACC Cardiovasc Imaging. 2020;13(1 Pt 1):97–105. DOI:10.1016/j.jcmg.2019.03.003.
26. Ihdayhid AR, Norgaard BL, Gaur S, et al. Prognostic Value and Risk Continuum of Noninvasive Fractional Flow Reserve Derived from Coronary CT Angiography. Radiology. 2019;292(2):343–351. DOI:10.1148/radiol.2019182264.
27. Andreini D, Collet C, Leipsic J, et al. Pre-procedural planning of coronary revascularization by cardiac computed tomography: An expert consensus document of the Society of Cardiovascular Computed Tomography. EuroIntervention. 2022;18(11):e872–e887. DOI:10.4244/EIJ-E-22-00036.
28. Assen MV, Vonder M, Pelgrim GJ, et al. Computed tomography for myocardial characterization in ischemic heart disease: a state-of-the-art review. Eur Radiol Exp. 2020;4(1):36. DOI:10.1186/s41747-020-00158-1.
29. Inacio JR, Srinivasan SB, Ruddy TD, et al. Static CT myocardial perfusion imaging: image quality, artifacts including distribution and diagnostic performance compared to 82Rb PET. Eur J Hybrid Imaging. 2022;6(1):1. DOI:10.1186/s41824-021-00118-x.
30. Williams MC, Kwiecinski J, Doris M, et al. Low-Attenuation Noncalcified Plaque on Coronary Computed Tomography Angiography Predicts Myocardial Infarction: Results From the Multicenter SCOT-HEART Trial (Scottish Computed Tomography of the HEART). Circulation. 2020;141(18):1452–1462. DOI:10.1161/CIRCULATIONAHA.119.044720.
31. Gu M, Mao Q, Wang H, et al. Coronary computed tomographic angiography-derived anatomic and hemodynamic plaque characteristics in prediction of cardiovascular events. Int J Cardiovasc Imaging. 2024;40(8):1641–1652. DOI:10.1007/s10554-024-03149-0.
32. Iraqi N, Nørgaard BL, Dey D, et al. Influence of plaque characteristics by coronary computed tomography angiography on lesion-specific ischemia: a systematic review and meta-analysis. Eur Radiol. Published online March 27, 2025. DOI:10.1007/s00330-025-11516-1.
33. Mortensen MB, Dzaye O, Steffensen FH, et al. Impact of Plaque Burden Versus Stenosis on Ischemic Events in Patients With Coronary Atherosclerosis. J Am Coll Cardiol. 2020;76(24):2803–2813. DOI:10.1016/j.jacc.2020.10.021.
34. Reynolds HR, Shaw LJ, Min JK, et al. Outcomes in the ISCHEMIA trial based on coronary artery disease and ischemia severity. Circulation 2021;144:1024–38. DOI:10.1161/CIRCULATIONAHA.120.049755.
35. Maron DJ, Hochman JS, Reynolds HR, et al. Initial Invasive or Conservative Strategy for Stable Coronary Disease. N Engl J Med. 2020;382(15):1395–1407. DOI:10.1056/NEJMoa1915922.
36. Puchner SB, Liu T, Mayrhofer T, et al. High-risk plaque detected on coronary CT angiography predicts acute coronary syndromes independent of significant stenosis in acute chest pain: results from the ROMICAT-II trial. J Am Coll Cardiol. 2014;64(7):684–692. DOI:10.1016/j. jacc.2014.05.039.
37. Stocker TJ, Leipsic J, Chen MY, et al. Influence of Heart Rate on Image Quality and Radiation Dose Exposure in Coronary CT Angiography. Radiology. 2021;300(3):701– 703. DOI:10.1148/radiol.2021210245.
38. Aziz MU, Singh S. Computed tomography of coronary artery atherosclerosis: A review. J Med Imaging Radiat Sci. 2021;52(3S):S19–S39. DOI:10.1016/j.jmir.2021.08.007.
39. Pack JD, Xu M, Wang G, et al. Cardiac CT blooming artifacts: clinical significance, root causes and potential solutions. Vis Comput Ind Biomed Art. 2022;5(1):29. DOI:10.1186/s42492-022-00125-0.
40. Burch RA, Siddiqui TA, Tou LC, et al. The Cost Effectiveness of Coronary CT Angiography and the Effective Utilization of CT-Fractional Flow Reserve in the Diagnosis of Coronary Artery Disease. J Cardiovasc Dev Dis. 2023;10(1):25. DOI:10.3390/jcdd10010025.
41. Tatsugami F, Higaki T, Kawashita I, et al. Improvement of Spatial Resolution on Coronary CT Angiography by Using Super-Resolution Deep Learning Reconstruction. Acad Radiol. 2023;30(11):2497–2504. DOI:10.1016/j.acra.2022.12.044.
Review
For citations:
Kozulin V.Yu., Аlekseeva D., Basek I.V., Kudaev Y.A., Galyautdinova L.E., Trufanov G.E., Panov A.V. Coronary computed tomography angiography: modern capabilities of the technique and place in everyday clinical practice. Translational Medicine. 2025;12(3):225-237. (In Russ.) https://doi.org/10.18705/2311-4495-2025-12-3-225-237. EDN: SNYVEQ
Views:
1
Email this article 