Coronary Dominance on Coronary CT Angiography: Prevalence and Potential Implications for Electrocardiographic Correlation

Background/Objectives: Coronary dominance is a key anatomical variant in the interpretation of coronary artery disease and its correlation with electrocardiographic (ECG) findings. While right dominance is the most common pattern, left dominance may influence clinical and ECG presentations. This study aimed to determine the prevalence of coronary dominance using coronary CT angiography (CCTA) and evaluate its association with disease severity, gender, and ECG findings. Methods: A retrospective observational analytical study was conducted including 677 patients who underwent CCTA. Coronary dominance was classified as right, left, or codominant. Disease severity was assessed using CAD-RADS. Demographic, clinical, anatomical, and ECG variables were analyzed. Statistical analysis included descriptive statistics, chi-square tests, and multivariable logistic regression analysis. Results: Right coronary dominance was predominant (89.7%), followed by left dominance (8%) and codominance (2.3%). No significant association was found between coronary dominance and disease severity or gender (p = 0.32). Male gender was significantly associated with severe disease (CAD-RADS 4–5) (p < 0.005). The left anterior descending (LAD) artery was the most frequently affected vessel. In the left dominance subgroup, 72.2% of patients had a normal ECG, with a low prevalence of ischemic findings (3%). Cases of left dominance with severe disease and confirmed acute coronary syndrome were identified. Conclusions: Coronary dominance is not associated with disease severity or gender; however, left dominance represents a clinically relevant finding due to its association with atypical or normal ECG presentations. Its systematic inclusion in CCTA reports is recommended to improve clinical correlation and decision-making.