The association between CCTA assessment and cardiac symptoms in patients with coronary artery disease: a photon-counting CT study

The correlation between the severity of coronary artery disease (CAD) evaluated by photon-counting coronary computed tomography angiography (CCTA) and patients’ cardiac symptoms remains unclear. The objective of this study is to investigate the correlation between CCTA parameters and specific cardiac symptoms in patients with coronary artery disease. Consecutive CAD patients who underwent Photon-Counting CT angiography (PCCT-CCTA) examination were prospectively enrolled from August 2025 to November 2025. Patients were prospectively classified into five distinct symptom categories (asymptomatic, typical angina, atypical angina, non-anginal chest pain, and dyspnea) through systematic clinical history-taking and structured questionnaire administration. CCTA-derived quantitative parameters, including total plaque volume (TPV), coronary artery calcium score (CACS), CT-derived fractional flow reserve (CT-FFR), and right coronary artery pericoronary fat attenuation index (RCA FAI), were measured. This study prospectively enrolled 889 patients with CAD (mean age 61 ± 11 years; 58% male), of whom 664 were symptomatic. Among the symptomatic patients, 256 (38.6%) had typical angina, 176 (26.5%) had atypical angina, 180 (27.1%) had non-anginal chest pain, and 52 (7.8%) reported dyspnea. In the multivariable multinomial logistic regression model with the asymptomatic group as the reference, adjustment for clinical characteristics revealed that age (OR = 0.96, 95% CI 0.94–0.98, P < 0.001), male sex (OR = 0.46, 95% CI 0.30–0.70, P < 0.001), total plaque volume (TPV) (OR = 1.02 per 10 mm³, 95% CI 1.01–1.03, P = 0.006), coronary artery calcium score (CACS) (OR = 1.08 per 100 AU, 95% CI 1.02–1.15, P = 0.012), and reduced coronary computed tomography angiography–derived fractional flow reserve (CT-FFR) (OR = 0.91 per 0.05, 95% CI 0.83–0.99, P = 0.032) were independently associated with typical angina. TPV (OR = 1.02 per 10 mm³, 95% CI 1.01–1.04, P = 0.001) and elevated right coronary artery pericoronary fat attenuation index (RCA FAI) (OR = 1.35 per 5 HU, 95% CI 1.18–1.54, P < 0.001) were associated with atypical angina (all p < 0.05). TPV, CACS, and reduced CT-FFR were independently associated with typical angina in patients with CAD, whereas TPV and RCA FAI were independently associated with atypical angina. Not applicable.