Beyond Coronary Stenosis: Coronary Computed Tomography Angiography and the New Approach to the Coronary Atheroma Assessment

Coronary computed tomography angiography (CCTA) has profoundly changed the diagnostic approach to patients with suspected coronary artery disease (CAD). Originally developed as a non-invasive technique for identifying or ruling out obstructive coronary stenoses, CCTA has progressively evolved into an imaging modality capable of providing a comprehensive assessment of coronary atherosclerosis. A growing body of evidence has demonstrated that the clinical value of CCTA extends far beyond the anatomical evaluation of coronary stenosis. Modern CCTA allows for the quantification of the burden of atherosclerotic plaques, the characterization of plaque composition, the identification of high-risk plaque features, and a more accurate stratification of cardiovascular risk, moving from the concept of ischemia to that of atheroma. In addition to its role in diagnosing CAD and evaluating coronary stents and bypass grafts, CCTA is also becoming increasingly important in procedure planning, cardiovascular prevention, and the personalization of treatment strategies. Overall, this could finally represent a unique opportunity to reduce the cardiovascular burden that still weighs on health care systems. Looking ahead, the growing use of CCTA in clinical practice is creating new diagnostic, interpretive, and organizational challenges. This perspective aims to discuss the evolving role of CCTA and the necessary changes regarding the new competencies required of clinical cardiologists, interventional cardiologists, and cardiovascular radiologists, taking into account the need to redefine technological standards, multidisciplinary training programs, as well as the organization and sustainability of healthcare—including environmental impact and reimbursement models—in order to fully and fairly harness the potential of modern CCTA.