Role of CT and CMR in the Management of Chronic Coronary Syndrome

Chronic coronary syndrome (CCS), encompassing a wide range of phenotypes and clinical scenarios, remains the leading global cause of disability and premature death. Advanced non-invasive imaging modalities, such as coronary computed tomography angiography (CCTA) and cardiac magnetic resonance (CMR), play a pivotal role in enhancing diagnostic accuracy and guiding tailored management strategies for CCS patients. CCTA offers detailed insights into the presence, extent, and severity of coronary atherosclerotic plaques. In addition to detecting coronary stenoses, it enables the characterization of plaque phenotypes and the evaluation of additional prognostic biomarkers, such as perivascular adipose tissue (PVAT) attenuation, allowing for more comprehensive risk stratification. Recent technological advancements have further expanded CCTA's capabilities, enabling the integration of anatomical assessment with hemodynamic evaluation through non-invasive fractional flow reserve computation (FFR-CT) or stress myocardial perfusion analysis. With its superior three-dimensional spatial resolution, CCTA enhances pre-procedural planning for complex coronary revascularization, enabling the selection of optimal interventional strategies and improving patient selection. CMR is considered the gold standard for functional assessment of cardiac function, myocardial viability, quantitative flow evaluation, and tissue characterization, offering excellent soft-tissue contrast. CMR perfusion imaging can accurately assess myocardial ischemia, quantify myocardial blood flow (MBF), and detect microvascular dysfunction, thanks to its high temporal and spatial resolution with the advantage of no radiation exposure. This review highlights the evolving role of CCTA and CMR in managing patients with CCS, focusing on their current applications according to the most recent 2024 ESC guidelines, prognostic value, and recent technological advancements.