Single-photon emission computed tomography (SPECT) or positron emission tomography (PET) myocardial perfusion scintigraphy (MPS) is a well-established noninvasive imaging modality that is a core element in evaluation of patients with stable chest pain syndromes. Stress SPECT MPS is the most commonly utilized stress imaging technique for patients with suspected or known coronary artery disease (CAD) and has a robust evidence base including the support of numerous clinical guidelines. By comparison, cardiac computed tomography (CT) is a more recently developed method, providing noninvasive approaches for imaging coronary atherosclerosis and coronary artery stenosis. After being in use for well over a decade, noncontrast CT for imaging the extent of coronary artery calcification (CAC) has an extensive evidence base supporting its use in CAD prevention. Contrast-enhanced CT for noninvasive CT coronary angiography (CCTA) is relatively new, but has a rapidly growing evidence base regarding diagnosing obstructive CAD and assessing risk. It is likely that noncontrast CT or CCTA for assessment of extent of atherosclerosis will become an increasing part of mainstream cardiovascular imaging practices as a first-line test. In some patients, further ischemia testing with MPS will be required. Similarly, MPS will continue to be widely used as a first-line test, and, in some patients, further anatomic definition of atherosclerosis with CT will also be appropriate. This review also provides a synopsis of the available literature on imaging that integrates both CT and MPS in strategies for the assessment of asymptomatic patients for their atherosclerotic coronary disease burden and risk as well as symptomatic patients for diagnosis and guiding management. We propose possible risk-based strategies through which imaging might be used to identify asymptomatic candidates for more intensive prevention and risk factor modification strategies as well as symptomatic patients who would benefit from referral to invasive coronary angiography (ICA) for consideration of revascularization.
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