Coronary computed tomography angiography (CCTA) has emerged as a pivotal non-invasive imaging modality for detailed assessment of coronary anatomy and plaque characteristics, playing a significant role in diagnosing and managing ischemic heart disease (IHD). Traditional approaches, such as the Segment Stenosis Score, Segment Involvement Score, and Leaman score, offer semi-quantitative evaluations of plaque burden. However, they are limited by their inability to quantify plaque volume precisely. Recent advancements in CCTA software have enabled more accurate, quantitative assessments that strongly correlate with invasive methods like intravascular ultrasonography and optical coherence tomography. These software tools also allow for detailed plaque characterization, categorizing plaques by composition and identifying high-risk features that may predict future cardiovascular events. The emerging photon-counting CT technique further enhances plaque analysis by individually measuring photons to assess plaque structure. Additionally, perfusion CT offers a functional imaging approach to evaluate myocardial blood flow, complementing CCTA by detecting microcirculatory dysfunction and providing insights into myocardial tissue, especially in fibrosis cases. The peri-coronary Fat Attenuation Index (pFAI), a 3D tool analyzing peri-coronary fat, has emerged as a significant prognostic marker, improving risk stratification in IHD. The evaluation of pFAI, particularly in patients with non-obstructive coronary disease, provides valuable information on inflammation and cardiovascular risk, making it a critical component of comprehensive IHD assessment. The advancement of CCTA-derived plaque analysis represents a significant change in cardiovascular imaging, enhancing diagnostic precision and risk assessment. As precision medicine advances, the integration of CCTA plaque analysis is set to transform the treatment of complex cardiovascular diseases.
