Acute chest pain is one of the most common reasons for emergency department (ED) visits, yet only a small fraction of cases are due to acute coronary syndrome (ACS), creating a diagnostic challenge. Traditional evaluation methods including clinical assessment, electrocardiography, cardiac biomarkers, and risk scores, lack early sensitivity and fail to directly visualize coronary anatomy, often leading to prolonged observation and unnecessary admissions. Coronary computed tomography angiography (CCTA) offers a rapid, noninvasive solution by providing high-resolution visualization of coronary arteries and atherosclerotic plaque, achieving sensitivity above 95% and negative predictive value exceeding 99% for ruling out obstructive coronary artery disease (CAD). Advances in scanner technology, dose reduction, and workflow integration have established CCTA as a feasible, safe, and efficient ED diagnostic tool. Randomized trials demonstrate that CCTA-guided pathways reduce length of stay, hospital admissions, and healthcare costs without compromising safety, while improving triage and enabling early discharge of low-to-intermediate-risk patients. Beyond acute rule-out, CCTA provides valuable prognostic insight through plaque characterization and risk stratification, guiding preventive therapy. Despite challenges such as motion artifacts, heavy calcification, and incidental f indings, optimized protocols and guideline-based patient selection ensure high diagnostic accuracy and safety. Emerging innovations, including CT-derived fractional flow reserve, AI-assisted plaque quantification, and photon-counting CT, promise further gains in precision and efficiency. Major cardiology societies now recommend CCTA as a first-line imaging modality for selected chest-pain patients. Collectively, evidence supports CCTA as a transformative, rapid, and comprehensive approach for ruling out ACS, improving patient outcomes, and enhancing resource stewardship in the emergency department.

• Coronary CT angiography

• Acute coronary syndrome

• Emergency department

• Chest pain evaluation

• Diagnostic accuracy

?AH?N MM, KALÇIK M, YET?M M, ÇEL?K MC, BEKAR L, et al. (2025) Integrating Coronary CT Angiography into the Emergency Department for Rapid Evaluation of Acute Chest Pain. J Radiol Radiat Ther 13(2): 1115.

Acute chest pain remains one of the most frequent reasons for presentation to emergency departments (EDs) worldwide, accounting for approximately 5–10% of all visits [1]. Despite this high prevalence, only a small proportion of patients are ultimately diagnosed with an acute coronary syndrome (ACS) or other life threatening condition [2]. This diagnostic uncertainty poses a major challenge for emergency physicians, who must promptly identify those needing urgent intervention while minimizing unnecessary admissions and resource utilization.

Traditional evaluation of chest pain integrates clinical assessment, electrocardiography (ECG), serial cardiac biomarkers, particularly high-sensitivity troponin, and validated clinical risk scores such as the TIMI and HEART scores [3,4]. While these tools have improved early diagnosis and risk stratification, they remain limited in sensitivity during the early phase of myocardial injury and do not provide direct visualization of coronary anatomy [5]. Consequently, many low-to-intermediate risk patients undergo prolonged observation and downstream stress testing, resulting in extended ED stays and increased healthcare costs [6,7].

Given these limitations, there is an increasing demand for rapid, noninvasive diagnostic approaches with high sensitivity and negative predictive value (NPV) that can confidently exclude obstructive coronary artery disease (CAD). Coronary computed tomography angiography (CCTA) meets these requirements by providing direct visualization of both the coronary lumen and atherosclerotic plaque. Large multicenter studies have demonstrated that CCTA achieves sensitivity >95% and NPV >99% for ruling out significant CAD [8-10]. Improvements in scanner technology, radiation-dose reduction, and workflow optimization have further enhanced its feasibility and safety in the ED setting.

Multiple randomized controlled trials have shown that incorporating CCTA into ED chest pain protocols accelerates diagnostic decision-making, reduces hospital admissions, and allows safe discharge of low-risk patients [8,11,12]. Consequently, major cardiology societies now endorse CCTA as a first-line imaging modality for selected low-to-intermediate risk patients presenting with acute chest pain [13,14].

The aim of this review is to summarize the evidence supporting CCTA for the rapid rule-out of ACS in the emergency department, covering its pathophysiologic basis, technical aspects, diagnostic accuracy, clinical and prognostic implications, limitations, and future directions including artificial intelligence and guideline-based implementation.

Pathophysiologic Basis and Diagnostic Rationale

ACS is precipitated by dynamic coronary obstruction, most commonly plaque rupture with superimposed thrombosis; plaque erosion and, less frequently, calcified nodules may produce similar clinical syndromes [15,16]. These events stem from lipid-rich necrotic cores, thin fibrous caps, inflammation, and adverse shear stress, culminating in abrupt luminal compromise and downstream ischemia [15,16]. Because these mechanisms are fundamentally anatomic and microstructural, diagnostic strategies that directly depict coronary arteries and plaque biology enable early and confident rule-out.

CCTA provides noninvasive, high-resolution visualization of the coronary lumen and atherosclerotic plaque, including high-risk features such as positive remodeling and low-attenuation components that are linked to subsequent ACS [17,18]. In low-to-intermediate risk chest pain cohorts, this anatomic vantage translates into excellent sensitivity and NPV for excluding obstructive CAD, supporting safe early discharge when CCTA is negative [8-10]. Beyond binary stenosis assessment, CCTA’s ability to reveal non-obstructive plaque clarifies alternative explanations for symptoms and guides preventive therapy, advantages that purely functional or biomarker-based approaches cannot consistently provide [15,17].

Importantly, when clinically appropriate, “triple-rule out” CT protocols can evaluate major non-coronary, life threatening causes of chest pain, acute aortic syndrome and pulmonary embolism, within a single ECG-gated acquisition, improving efficiency in selected ED patients [19,20]. Collectively, these pathophysiologic and diagnostic considerations justify CCTA as a rapid, noninvasive test with high NPV for ruling out obstructive CAD while broadening the differential to critical non-coronary etiologies in the emergency department [8,19,20].

Technical Aspects and Protocol Optimization

CCTA has undergone a remarkable technological evolution, progressing from 64-slice multidetector scanners to advanced dual-source, wide-detector, and photon-counting systems that provide sub-millimeter spatial and sub-100 ms temporal resolution [21,22]. These advances have significantly improved image quality at higher heart rates, minimized motion artifacts, and enabled comprehensive coronary assessment in a single heartbeat, critical for rapid evaluation in the ED setting [23]. Dual-source and 320-detector-row scanners offer near-complete cardiac coverage per rotation, reducing motion misregistration and achieving scan times below 10 seconds [24] (Table 1)

Table 1: Technical Optimization and Advances in Contemporary CCTA Protocols.

Abbreviations: AI: artificial intelligence; bpm: beats per minute; CT: computed tomography; ECG: electrocardiogram; mSv: millisievert; CCTA: coronary computed tomography angiography.

Successful CCTA acquisition in acute chest pain evaluation requires optimization of heart rate control, contrast injection, and ECG synchronization. Beta-blockers remain essential to achieve motion-free imaging, although next-generation scanners can yield diagnostic images at rates up to 80 beats per minute [25]. Administration of sublingual nitroglycerin before scanning improves coronary vasodilation and enhances distal vessel visualization [26]. ECG-gated acquisition, either retrospective or prospective, synchronizes scanning with the cardiac cycle; prospective “step-and-shoot” modes have become the standard in ED protocols due to their marked radiation dose reduction without compromising diagnostic quality [27].

Radiation dose minimization remains a cornerstone of modern CCTA practice. The PROTECTION studies demonstrated the feasibility of achieving mean effective doses <3 mSv through strategies including tube current modulation, low kilovoltage settings, and iterative reconstruction [28,29]. The transition from filtered back projection to model-based and AI-assisted iterative reconstruction has further enhanced image quality and dose efficiency, representing one of the most transformative technical advances in CT imaging [29]. In parallel, the emergence of photon-counting CT promises superior contrast-to-noise ratios, reduced artifacts, and further radiation savings [30].

Integrating CCTA into ED workflows requires standardized protocols, automated image reconstruction pipelines, and structured reporting. With current generation technology, scan acquisition and preliminary interpretation can be completed within 10–15 minutes of patient arrival, supporting rapid triage and safe discharge of low-to-intermediate risk patients [8,9,24]. Collectively, these technical refinements have positioned CCTA as a rapid, accurate, and low-dose diagnostic modality for early exclusion of obstructive coronary artery disease in the ED [8,9,28].

Diagnostic Accuracy and Clinical Performance

Across randomized and prospective trials in ED chest pain pathways, CCTA consistently demonstrates high diagnostic accuracy, rapid time-to-decision, and excellent safety for early discharge. In ROMICAT-II, a multicenter randomized trial of low-to-intermediate risk patients, integrating CCTA into ED care accelerated evaluation, reduced hospital admissions, and safely identified candidates for early discharge without increasing missed ACS events [8]. CT-STAT randomized CCTA against myocardial perfusion imaging and showed shorter length of stay and faster diagnostic decisions with CCTA while maintaining clinical safety [9]. The ACRIN-PA trial established that a CCTA-first strategy enables safe discharge of patients with possible ACS, with no increase in major adverse cardiovascular events at 30 days [10] (Table 2).

Table 2: Comparison Between Conventional Diagnostic Strategies and Coronary CT Angiography (CCTA).

Abbreviations: ACS: acute coronary syndrome; CAD: coronary artery disease; CCTA: coronary computed tomography angiography; ECG: electrocardiogram; NPV: negative predictive value.

Comparative effectiveness versus functional testing has also been evaluated beyond the ED. In PROMISE, an anatomic strategy using CCTA versus functional testing in stable symptomatic patients yielded similar clinical outcomes while providing clearer anatomic delineation and fewer inconclusive tests, findings directionally consistent with the superior rule-out efficiency observed in acute pathways [31].

Pooled evidence aligns with these trial-level results. Meta-analytic data in acute chest pain cohorts show sensitivity >95% and NPV ≈99% for obstructive CAD,enabling confident rule-out in the ED [11]. A contemporary living systematic review further confirms that CCTA guided pathways shorten ED length of stay and reduce immediate resource use without compromising short term safety [32].

Subgroup analyses indicate that diagnostic performance is robust in low-to-intermediate risk populations, including women and younger patients, in whom non obstructive disease is prevalent and functional tests may be nondiagnostic. Trials and meta-analyses report preserved sensitivity/NPV and safe early discharge when strict inclusion criteria and high-quality image acquisition are maintained [8,10,11]. Overall, the cumulative evidence demonstrates that CCTA delivers high sensitivity and NPV for obstructive CAD, accelerates ED decision-making, reduces admissions and downstream testing, and enables safe early discharge in carefully selected patients [8,11,31].

Impact on Clinical Workflow and Outcomes

Implementing CCTA early in ED pathways reliably accelerates decision-making and improves patient flow. Across landmark randomized trials, CCTA shortened ED length of stay and increased direct discharge rates without compromising safety. In ROMICAT-II, CCTA reduced mean hospital stay by ≈7–8 hours and enabled more discharges from the ED, with no excess missed acute coronary syndromes (ACS) or short-term adverse events [8]. Similar operational gains were observed when CCTA was compared with myocardial perfusion imaging in CT STAT, which showed faster time-to-diagnosis and shorter overall length of stay [9]. ACRIN-PA confirmed the safety of expedited discharge following a negative CCTA among low-to-intermediate-risk patients [10] (Table 3).

Table 3: Key Randomized Trials Evaluating CCTA in Emergency Chest Pain Pathways.

Abbreviations: ACS: acute coronary syndrome; CAD: coronary artery disease; CCTA: coronary computed tomography angiography; CHD: coronary heart disease; ECG: electrocardiogram; ED: emergency department; MACE: major adverse cardiovascular events; MI: myocardial infarction.

These workflow advantages translate into fewer unnecessary admissions and observation stays, allowing earlier triage of low-risk patients and improved bed availability, key levers for ED crowding relief [8–10]. In parallel, guideline bodies now explicitly integrate CCTA within structured chest-pain pathways for appropriate low-to-intermediate-risk cohorts, reinforcing its role as a first-line, rapid rule-out tool [13].

Economic outcomes generally mirror these operational benefits. A meta-analysis of randomized trials reported reduced ED costs and shorter stays with CCTA-guided strategies compared with usual care, albeit with a modest increase in invasive angiography and revascularization when disease was detected, findings that underscore the importance of standardized post-CCTA triage [11]. Decision-analytic models and economic evaluations further suggest that CCTA is cost-effective (and often cost saving) across a wide range of assumptions, particularly when applied to low-risk populations and coupled with selective downstream testing [33,34]. Contemporary living systematic reviews corroborate lower near-term costs with CCTA versus standard care, consistent with reduced time in the ED and fewer inconclusive tests [32].

Downstream testing after CCTA tends to decrease when the index scan is normal or shows only non-obstructive disease, supporting early discharge and outpatient prevention rather than inpatient escalation [8-10]. Conversely, when CCTA reveals obstructive or high-risk anatomy, earlier targeted referral to invasive angiography or revascularization can occur, an effect that likely explains the small increases in invasive procedures noted in some pooled analyses and highlights how CCTA re-allocates testing toward those most likely to benefit [11]. From a health-system perspective, the combination of faster disposition, fewer low-yield admissions, and targeted downstream care yields measurable gains in throughput and resource utilization, especially in high-volume EDs adopting standardized scan-to-report workflows [8 10,13].

Overall, integrating CCTA into ED chest-pain pathways reduces length of stay and unnecessary admissions, and supports safe early discharge [8–10]; it is economically favorable in most scenarios when image quality, risk selection, and post-test management are tightly protocolized [11,33,34], consistent with contemporary guideline recommendations [13].

Prognostic and Long-Term Implications

Beyond rapid rule-out, CCTA provides prognostic information that shapes long-term management. In SCOT HEART, adding CCTA to standard care reduced coronary heart disease death or nonfatal myocardial infarction at 5 years, an effect attributed to better targeting of preventive therapies and more precise anatomic diagnosis [35]. Prognostic value derives not only from stenosis grading but also from plaque burden and phenotype. High-risk plaque features on CCTA, such as low attenuation and positive remodeling, predict future major adverse cardiovascular events (MACE) independent of traditional risk factors and obstructive disease, enhancing risk stratification particularly in patients with nonobstructive CAD [17,36].

Large observational registries corroborate these findings. In CONFIRM, absence of CAD on CCTA portended an excellent prognosis, whereas both nonobstructive and obstructive CAD were associated with graded increases in mortality, underscoring that “nonobstructive” does not equate to “benign” [37]. More granular quantitative assessments further refine risk: in a post hoc analysis, low-attenuation plaque burden emerged as the strongest predictor of myocardial infarction, outperforming stenosis severity and coronary calcium score [38]. Collectively, these data support the use of CCTA-derived anatomic and plaque metrics to reclassify risk beyond clinical scores and biomarkers.

The prognostic signal also translates actionable care pathways. Knowledge of CCTA-defined atherosclerosis increases initiation and intensification of evidence-based prevention (e.g., statins, antiplatelet therapy where appropriate), and mediation analyses from SCOT-HEART suggest that improved outcomes are largely driven by such targeted therapy optimization [35,39]. Thus, for ED patients safely discharged after a negative or nonobstructive CCTA, the scan offers a roadmap for outpatient prevention, identifying individuals who merit aggressive risk factor control despite the absence of flow limiting stenosis [36,37].

In summary, CCTA augments long-term risk assessment by integrating stenosis, plaque burden, and high-risk features, with robust associations to MACE and evidence that imaging-guided preventive strategies can improve outcomes [35-39].

Consensus Guidelines and Clinical Implementation

Major societies now endorse a CCTA-first strategy in appropriately selected chest-pain patients, emphasizing rapid rule-out with high negative predictive value while reserving invasive strategies for high-risk presentations. The 2021 AHA/ACC Chest Pain Guideline recommends CCTA for low-to-intermediate-risk patients with non ischemic ECG and negative initial troponin to expedite diagnosis and disposition in both ED and outpatient settings [13]. The 2020 ESC NSTE-ACS guideline similarly supports CCTA to exclude obstructive CAD when ACS probability is not high and initial testing is inconclusive, while directing high-risk features (ischemic ECG, dynamic troponin rise, hemodynamic/arrhythmic instability) to early invasive management [40].

NICE updates moved CCTA to the front line for stable recent-onset chest pain when CAD is suspected, a policy that has influenced many ED pathways by clarifying downstream testing once life-threatening causes are excluded [41]. SCCT consensus documents reinforce these positions, detailing technical standards, quality metrics, and reporting elements that facilitate safe implementation and reproducible performance across institutions [42].Practical integration hinges on clear inclusion criteria (low–intermediate risk; non-ischemic ECG; negative/ unchanged high-sensitivity troponin), protocolized scanner access, nitroglycerin and heart-rate control, prospective ECG-gated low-dose acquisition, and structured reporting with actionable follow-up for non obstructive disease [13,42]. Embedding these criteria into electronic triage tools and accelerated diagnostic pathways enables consistent early discharge when CCTA is negative and targeted referral when obstructive or high-risk anatomy is identified [13,40].

Despite its advantages, CCTA has important limitations in the emergency setting. Severe coronary calcification remains a key technical hurdle: calcium-related blooming and beam-hardening can exaggerate stenosis and reduce specificity, especially in the left anterior descending and circumflex arteries [43]. Even in patients with very high calcium burden (Agatston >1000), per-patient negative predictive value remains >90% for excluding significant stenosis, but overestimation and nondiagnostic segments are more common and require cautious interpretation [44]. Moreover, in hemodynamically unstable or high pretest-probability presentations, guideline pathways favor urgent alternative strategies rather than ED CCTA [13].

Safety considerations also shape use. Contemporary evidence and consensus statements indicate that the risk of contrast-associated acute kidney injury is lower than historically feared with modern low-osmolar agents; individualized risk assessment, periprocedural hydration, and avoidance in active kidney injury remain prudent [45,46]. Radiation exposure has fallen with prospective ECG-gating, low-kVp selection, and iterative reconstruction, but dose stewardship and patient-specific optimization remain essential, particularly for younger patients and those requiring repeat imaging [28,29].

CCTA frequently reveals extracardiac or incidental coronary findings that, while occasionally actionable, can trigger additional testing and anxiety; structured triage and reporting help mitigate overdiagnosis and low-yield follow-up [47]. Widespread adoption also depends on operational capacity, round-the-clock scanner access, rapid reconstruction pipelines, and experienced readers, with competency frameworks outlining training standards for independent interpretation [48].

Certain patient subgroups present unique challenges for CCTA interpretation and applicability. Patients with chronic kidney disease or borderline renal function require cautious contrast administration, and the balance between diagnostic yield and nephrotoxicity risk should be individualized. Individuals with very high coronary calcium scores may experience decreased specificity due to blooming artifacts, potentially leading to overestimation of stenosis. Obesity can degrade image quality through photon attenuation, occasionally necessitating higher tube currents or dual-energy protocols to maintain diagnostic confidence. Additionally, patients with atrial fibrillation or frequent ectopy introduce motion artifacts that compromise image reconstruction, limiting CCTA’s reliability in this subset. Tailored acquisition protocols, advanced motion-correction algorithms, and strict selection criteria are necessary to optimize outcomes in these real-world populations [49].

From an operational standpoint, the integration of CCTA into emergency department workflows imposes logistical and interpretative demands. Emergency physicians often face increased workload and must coordinate closely with radiology or cardiology specialists for interpretation, potentially delaying real-time decision making if expert readers are unavailable. Limited scanner access, particularly in smaller centers, constrains adoption and creates bottlenecks during peak hours. Interpretation of CCTA remains operator-dependent, and variability in reader expertise can affect diagnostic accuracy. Structured reporting systems and automated AI-based reconstruction tools may help reduce variability and expedite workflow, but reliance on subspecialty interpretation remains a practical limitation in many institutions [50].

In sum, CCTA’s effectiveness hinges on appropriate patient selection and meticulous protocol optimization. Awareness of key limitations, including calcification related specificity loss [43,44], contrast/radiation stewardship [28,45], and incidental findings [47], supports safe ED integration. Adherence to guideline-based selection and training standards further optimizes implementation [13,48] (Table 4).

Table 4: Strengths, Limitations, and Future Directions of CCTA.

Abbreviations: AI: artificial intelligence; AKI: acute kidney injury; CAD: coronary artery disease; CCTA: coronary computed tomography angiography; CT: computed tomography; ED: emergency department; FFR-CT: fractional flow reserve derived from CT; mSv: millisievert; NPV: negative predictive value.

Artificial Intelligence and Future Directions

Artificial intelligence (AI) is shifting CCTA from a purely anatomic test toward an integrated decision support platform for ED. Coupling anatomy with physiology via CT-derived fractional flow reserve (FFR CT) provides robust diagnostic performance against invasive reference standards and strengthens rule-out confidence in appropriate patients [51]. Building on this, machine-learning (ML)–based FFR-CT methods have shown higher diagnostic accuracy than CCTA alone, with practical computation timelines that suit time-sensitive ED workflows [52]. Pragmatic studies suggest that FFR CT–guided strategies can reduce low-yield invasive angiography without compromising clinical outcomes, translating anatomic-physiologic integration into tangible workflow and resource benefits [53].

Beyond physiology, AI-assisted coronary segmentation and quantitative plaque analytics enable automated measurement of plaque volume and high-risk features, enhancing risk stratification beyond stenosis severity and supporting targeted prevention after ED discharge [54,55]. These tools can standardize reporting and reduce interobserver variability while surfacing phenotypes, such as low-attenuation plaque, that anticipate near-term events even in non-obstructive disease [54].

Emerging radiomic biomarkers, including perivascular fat attenuation indices that reflect coronary inflammation, further reclassify risk independently of luminal stenosis and conventional scores [54]. When combined with quantitative plaque metrics and, where appropriate, CT-based functional data, these methods point toward a unified “one-stop” ED evaluation that rapidly excludes obstructive disease while identifying patients who merit intensified prevention [51,54,55]. In parallel, advances in hardware, most notably photon-counting CT, promise improved contrast-to-noise, spectral characterization, and dose efficiency, providing an enabling substrate for AI models trained on richer data [30].

In sum, AI-enabled CCTA is evolving from image interpretation to outcome-oriented triage: adding physiology via FFR-CT, automating plaque quantification, and incorporating inflammation-related biomarkers to deliver faster, safer, and more individualized ED care (51 55).

CCTA has matured into a rapid, accurate, and safe first-line test for evaluating low-to-intermediate risk patients with acute chest pain in ED. Across randomized trials, CCTA accelerates clinical decision-making, reduces hospital admissions and length of stay, and enables safe early discharge when the scan is negative. Meta-analytic data corroborate its high sensitivity and near-perfect negative predictive value for obstructive coronary artery disease, supporting confident rule-out in appropriately selected cohorts.

Beyond immediate triage, CCTA’s anatomic perspective, encompassing both stenosis and plaque characteristics, adds prognostic insight that can guide preventive therapy after ED discharge, aligning acute care with longer-term risk modification strategies. These strengths are reflected in contemporary professional guidance, which positions CCTA centrally within structured chest-pain pathways while reserving alternative strategies for high-risk or unstable presentations.

Looking ahead, technical and analytical innovations are poised to further expand CCTA’s clinical utility. Photon counting CT promises enhanced contrast-to-noise and dose efficiency, and AI-enabled tools, including FFR-CT and automated plaque quantification, offer streamlined, anatomically and physiologically integrated assessment suited to time-sensitive ED workflows.

When deployed within protocolized pathways and interpreted by trained teams, CCTA delivers fast, reliable exclusion of obstructive CAD, decreases unnecessary admissions and downstream testing, and provides actionable information for personalized prevention, improving care quality and resource stewardship across the ED continuum.

Contributorship

All of the authors contributed planning, conduct, and reporting of the work. All authors had full access to all data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

1. Goodacre S, Cross E, Arnold J, Angelini K, Capewell S, Nicholl J. Thehealth care burden of acute chest pain. Heart. 2005; 91: 229-230.
2. Hsia RY, Hale Z, Tabas JA. Prevalence of life-threatening diagnoses in patients with nontraumatic chest pain. JAMA Intern Med. 2016; 176: 470–477.
3. Amsterdam EA, Wenger NK, Brindis RG. 2014 AHA/ACC guideline for the management of patients with non–ST-elevation acute coronary syndromes. J Am Coll Cardiol. 2014; 64: e139-e228.
4. Backus BE, Six AJ, Kelder JC, Bosschaert MAR, Mast EG, Mosterd A, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013; 168: 2153-2158
5. Than M, Cullen L, Reid CM, Greenslade J, Flaws D, Hammett CJ, et al. 2-hour accelerated diagnostic protocol to assess patients with chest pain symptoms using contemporary troponins as the only biomarker. J Am Coll Cardiol. 2012; 59: 2091-2098.
6. Foy AJ, Liu G, Davidson WR Jr, Sciamanna C, Leslie DL. Comparative effectiveness of diagnostic testing strategies in emergency department patients with chest pain: An analysis of downstream testing, interventions, and outcomes. JAMA Intern Med. 2015; 175: 428-436.
7. Sandhu  AT,  Heidenreich  PA,  Bhattacharya  J,  Bundorf MK. Cardiovascular testing and clinical outcomes in emergency department patients with chest pain. JAMA Intern Med. 2017; 177: 630–637.
8. Hoffmann U, Truong QA, Schoenfeld DA, Chou ET, Woodard PK, Nagurney JT, et al. Coronary CT angiography versus standard evaluation in acute chest pain (ROMICAT-II trial). N Engl J Med. 2012; 367: 299-308.
9. Goldstein JA, Gallagher MJ, O’Neill WW. CT-STAT: Coronary CT angiography versus myocardial perfusion imaging for patients with acute chest pain. J Am Coll Cardiol. 2011; 58: 1414-1422.
10. Litt HI, Gatsonis C, Snyder B. CT angiography for safe discharge of patients with possible acute coronary syndromes (ACRIN-PA trial). N Engl J Med. 2012; 366: 1393-1403.
11. Hulten EA, Carbonaro S, Petrillo SP, Mitchell JD, Villines TC. Meta- analysis of coronary CT angiography in the evaluation of acute chest pain. J Am Coll Cardiol. 2013; 61: 880-892.
12. Newby DE, Adamson PD, Berry C. CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT- HEART trial). N Engl J Med. 2015; 372: 2247-2257.
13. Gulati M, Levy PD, Mukherjee D, Amsterdam E, Bhatt DL, Birtcher KK, et al. 2021 AHA/ACC Chest Pain Guideline: Evaluation and Diagnosis of Chest Pain. J Am Coll Cardiol. 2021; 78: e187-e285.
14. Knuuti J, Wijns W, Saraste A. 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes. Eur Heart J. 2020; 41: 407-477.
15. Libby  P,  Theroux  P.  Pathophysiology  of  coronary  arterydisease. Circulation. 2005; 111: 3481-3488.
16. Virmani R, Burke AP, Farb A, Kolodgie FD. Pathology of the vulnerable plaque. J Am Coll Cardiol. 2006; 47: C13-C18.
17. Motoyama S, Ito H, Sarai M, Kondo T, Kawai H, Nagahara Y, et al. Plaque characterization by coronary CTA and the likelihood of acute coronary events in mid-term follow-up. J Am Coll Cardiol. 2015; 66: 337-346.
18. Maurovich-Horvat P, Schlett CL, Alkadhi H, Nakano M, Otsuka F, Stolzmann P, et al. The napkin-ring sign indicates advanced atherosclerotic lesions in coronary CT angiography. JACC Cardiovasc Imaging. 2012; 5: 1243-1252.
19. Halpern EJ. Triple-rule-out CT angiography for evaluation of acute chest pain. Radiology. 2009; 252: 332-345.
20. Stein PD, Fowler SE, Goodman LR, Gottschalk A, Hales CA, Hull RD, et al. Multidetector computed tomography for acute pulmonary embolism (PIOPED II). N Engl J Med. 2006; 354: 2317-2327.
21. Flohr TG, McCollough CH, Bruder H, Petersilka M, Gruber K, Süss C, et al. First performance evaluation of a dual-source CT (DSCT) system. Eur Radiol. 2006; 16: 256-268.
22. Leipsic J, Labounty TM, Heilbron B. Adaptive statistical iterative reconstruction: Assessment of image noise and quality in coronary CT angiography. AJR Am J Roentgenol. 2010; 195: 649-654.
23. Bischoff B, Hein F, Meyer T. Comparison of sequential and helical scanning with 64-section CT in the diagnosis of coronary artery disease (PROTECTION I). AJR Am J Roentgenol. 2010; 194: 865-872.
24. Hausleiter J, Meyer T, Martuscelli E, Pschierer I, Feuchtner GM, Catalán-Sanz P, et al. Image quality and radiation exposure with a low tube voltage protocol for coronary CT angiography (PROTECTION II). JACC Cardiovasc Imaging. 2010; 3: 1113-1123.
25. Achenbach S, Ropers U, Kuettner A, Anders K, Pflederer T, Komatsu S, et al. Randomized comparison of 64-slice single- and dual-source computed tomography coronary angiography for the detection of coronary artery disease. JACC Cardiovasc Imaging. 2008; 1: 177-186.
26. Dewey M, Zimmermann E, Deissenrieder F, Laule M, Dübel HP, Schlattmann P, et al. Noninvasive coronary angiography by 320- row CT with lower radiation exposure and maintained diagnostic accuracy. Eur Heart J. 2009; 30: 594-602.
27. Earls JP, Berman EL, Urban BA, Curry CA, Lane JL, Jennings RS, et al. Prospectively gated transverse coronary CT angiography versus retrospective gating with tube current modulation: Comparison of image quality and patient radiation dose. Radiology. 2008; 246: 742- 753.
28. Hausleiter J, Meyer T, Hermann F, Hadamitzky M, Krebs M, Gerber TC, et al. Estimated radiation dose associated with cardiac CT angiography. JAMA. 2009; 301: 500-507.
29. Willemink MJ, Noël PB. Iterative image reconstruction for CT, From filtered back projection to artificial intelligence. Eur Radiol. 2019; 29: 2185-2195.
30. Willemink MJ, Persson M, Pourmorteza A, Pelc NJ, Fleischmann D. Photon-counting CT: Technical principles and clinical prospects. Radiology. 2018; 289: 293-312.
31. Douglas PS, Hoffmann U, Patel MR. Outcomes of anatomical versus functional testing for coronary artery disease (PROMISE). N Engl J Med. 2015; 372: 1291-1300.
32. Barbosa MF, Cury A, Ahmed S, Xie Y, Kicska F. Comparative Effectiveness of Coronary CT Angiography and Standard of Care for Evaluating Acute Chest Pain: A Living Systematic Review and Meta- Analysis. Radiology: Cardiothoracic Imaging. 2023; 5: e230022.
33. Ladapo JA, Hoffmann U, Bamberg F, Nagurney JT, Cutler DM, Weinstein MC, et al. Cost-effectiveness of coronary MDCT in the triage of patients with acute chest pain. AJR Am J Roentgenol. 2008; 191: 455-463.
34. Branch KR, Bresnahan BW, Veenstra DL, Shuman WP, Weintraub WS, Busey JB, et al. Economic outcome of cardiac CT–based evaluation and standard of care for suspected acute coronary syndrome in the emergency department: A decision analytic model. Acad Radiol. 2012; 19: 265-273.
35. Newby DE, Adamson PD, Berry C, Boon NA, Dweck MR, Flather M, et al. Coronary CT Angiography and 5-Year Risk of Myocardial Infarction (SCOT-HEART). N Engl J Med. 2018; 379: 924-933.
36. Ferencik M, Mayrhofer T, Bittner DO, Emami H, Puchner SB, Lu MT, et al. Use of high-risk coronary atherosclerotic plaque detection for risk stratification: Secondary analysis of the PROMISE trial. JAMA Cardiol. 2018; 3: 144-152.
37. Min JK, Dunning A, Lin FY, Achenbach S, Al-Mallah M, Budoff MJ, et al. Age- and sex-related differences in all-cause mortality risk based on coronary CT angiography findings: CONFIRM registry. J Am Coll Cardiol. 2011; 58: 849-860.
38. Williams MC, Kwiecinski J, Doris M, McElhinney P, D’Souza MS, Cadet S, et al. Low-attenuation noncalcified plaque burden on CCTA predicts myocardial infarction. Circulation. 2020; 141: 1452-1462.
39. Adamson PD, Hunter A, Williams MC, Dweck MR, Mills NL, Boon NA, et al. Guiding therapy by coronary CT angiography improves outcomes by targeting prevention (SCOT-HEART mechanistic analysis). J Am Coll Cardiol. 2019; 74: 2058-2070.
40. Collet JP, Thiele H, Barbato E, Barthélémy O, Bauersachs J, Bhatt DL, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. 2021; 42: 1289-1367.
41. Carrabba N, Parodi G. Old and New NICE Guidelines for the Evaluationof Stable Angina. Biomed Res Int. 2018; 2018: 3762305.
42. Narula J, Chandrashekhar Y, Ahmadi A, Abbara S, Berman DS, Blankstein R, et al. SCCT 2021 Expert Consensus Document on Coronary Computed Tomographic Angiography. J Cardiovasc Comput Tomogr. 2021; 15: 192-217.
43. Chen CC, Chen CC, Hsieh IC, Liu YC, Liu CY, Chan T, et al. The effect of calcium score on the diagnostic accuracy of coronary CT angiography. Int J Cardiovasc Imaging. 2011; 27: 37-42.
44. Kwan AC, Gransar H, Shaw LJ. The accuracy of coronary CT angiography in patients with coronary calcium score >1000 Agatston units: comparison with quantitative coronary angiography. J Cardiovasc Comput Tomogr. 2021; 15: 308-316.
45. Davenport MS, Perazella MA, Yee J. Use of intravenous iodinated contrast media in patients with kidney disease: ACR–NKF consensus statements. Radiology. 2020; 294: 660-668.
46. McDonald RJ, McDonald JS, Bida JP, Carter RE, Fleming CJ, Misra S, et al. Intravenous contrast–induced nephropathy: causal or coincident? Radiology. 2013; 267: 106-118.
47. Lee CI, Tsai EB, Sigal BM. Incidental extracardiac findings at coronary CT: clinical and economic impact. AJR Am J Roentgenol. 2010; 194: 1531-1538.
48. Choi AD, Thomas DM, Lee J. 2020 SCCT guideline for training cardiology and radiology trainees as independent (Level II) and advanced (Level III) practitioners in cardiovascular CT. J Cardiovasc Comput Tomogr. 2021; 15: 2-15.
49. Ghekiere O, Salgado R, Buls N, Leiner T, Mancini I, Vanhoenacker P, et al. Image quality in coronary CT angiography: challenges and technical solutions. Br J Radiol. 2017; 90: 20160567.
50. De Vita A, Covino M, Pontecorvo S, Buonamassa G, Marino AG, Marano R, et al. Coronary CT Angiography in the Emergency Department: State of the Art and Future Perspectives. J Cardiovasc Dev Dis. 2025; 12: 48.
51. Nørgaard BL, Leipsic J, Gaur S. Diagnostic performance of noninvasive fractional flow reserve derived from coronary CT angiography: The NXT trial. J Am Coll Cardiol. 2014; 63: 1145-1155.
52. Coenen A, Kim YH, Kruk M. Diagnostic accuracy of a machine-learning approach to CT-derived fractional flow reserve: A multicenter study. Circ Cardiovasc Imaging. 2018; 11: e007217.
53. Douglas PS, Pontone G, Hlatky MA. Clinical outcomes of FFRCT- guided diagnostic strategies vs usual care: the PLATFORM study. Eur Heart J. 2015; 36: 3359-3367.
54. Oikonomou EK, Desai MY, Marwan M. Perivascular fat attenuation index stratifies cardiac risk associated with high-risk plaques (CRISP- CT). J Am Coll Cardiol. 2020; 76: 755-757.
55. Deseive S, Straub R, Kupke M. Automated quantification of coronary plaque volume from CCTA improves cardiovascular risk prediction at long-term follow-up. JACC Cardiovasc Imaging. 2018; 11: 280-282.