During the past few years CTA has rapidly developed into a versatile non-invasive imaging modality. While imaging of the coronary arteries to determine or rule out the presence of stenosis will... Show moreDuring the past few years CTA has rapidly developed into a versatile non-invasive imaging modality. While imaging of the coronary arteries to determine or rule out the presence of stenosis will remain one of the main indications, additional information on plaque severity and composition can be obtained. The improvements in technology (faster gantry rotation times, an increasing number of detectors, volumetric image acquisition) and consequential improvement in image quality have resulted in advances in the characterization of coronary atherosclerosis and vulnerable plaque. Interestingly, the diagnostic performance of CTA was superior in the evaluation of presence or absence of clinically relevant atherosclerosis as compared to the evaluation of signifi cant stenosis. Regarding plaque observations with the novel 320-row CTA scanner, the results showed good agreement to relative plaque composition on invasive VH IVUS. Moreover, mixed plaques on 320-row CTA paralleled the more vulnerable plaque on VH IVUS. In addition, lesions with spotty calcifi cations and positive remodeling on CTA were associated with a higher percentage necrotic core and a higher prevalence of vulnerable plaques. Accordingly, evaluation of spotty calcifi cations and remodeling on CTA may be valuable markers for plaque vulnerability. The relation between characterization of atherosclerosis on CTA and its effect on clinical management was also evaluated. As a result of rapid developments in coronary CTA technology, high diagnostic accuracies of 320-row CTA for detecting coronary stenosis were obtained in patients with stable chest pain complaints as well as in patients presenting with acute chest pain. In addition, although a zero calcium score has important prognostic value, patients with acute coronary syndrome and zero calcium had increased plaque burden as well as increased vulnerability as compared to patients with stable chest pain. Accordingly, absence of coronary calcifi cation did not exclude the presence of clinically relevant and potentially vulnerable atherosclerotic plaque burden in patients with acute coronary syndrome. Lastly, in addition to the degree of stenosis, CTA variables of atherosclerosis describing plaque extent, composition and location were predictive of the presence of ischemia on myocardial perfusion imaging. Possibly, these results may allow a more refi ned and individualized assessment of patients undergoing CTA imaging and provide the basis for the development of an algorithm to improve identifi cation of patients requiring more aggressive therapy or intervention. Show less