Novel developments of CT: myocardial perfusion, hemodynamic assessment derived from anatomy, infarct characterization, and role of microvascular function

Cardiac computed tomography (CT) has grown mainly based on the ability to offer a non-invasive alternative for the assessment of coronary artery stenosis, with an excellent negative predictive value for ruling out obstructive coronary artery disease (CAD). Thereafter, the technique has dramatically evolved to evaluate almost every aspect of the broad CAD spectra. Interestingly, understanding of the pathophysiology of coronary atherosclerosis has simultaneously progressed during the past decades, and CT coronary angiography (CTCA) has played a role in such development. Particularly, CTCA has contributed to change longstanding paradigms beyond ischemia detection: from a simple discrimination between patients with or without obstructive CAD; to a relatively more complex scenario consisting of patients with or without coronary atherosclerosis, patients with non-obstructive extensive/non-extensive CAD, or patients with obstructive extensive/non-extensive CAD. Furthermore, following the leading seminal role of PET-CT, dynamic perfusion CT shows promise to assess myocardial perfusion reserve comparably, being this increasingly relevant among symptomatic patients without evidence of epicardial disease.