Diagnostic Performance and Clinical Impact of Photon-Counting Detector Computed Tomography in Coronary Artery Disease

BACKGROUND Photon-counting detector-computed tomography (PCD-CT) has emerged as a promising technology, offering improved spatial resolution. OBJECTIVES This study aimed to evaluate the clinical impact and diagnostic performance of PCD-CT vs conventional energy-integrating detector computed tomography (EID-CT) for obstructive coronary artery disease (CAD). METHODS From 2022 to 2023, we retrospectively identified 7,833 consecutive patients who underwent clinically indicated coronary computed tomography angiography (CCTA) at a single center, with either PCD-CT (n = 3,876; NAEOTOM Alpha [Siemens Healthineers]) or EID-CT (n = 3,957; Revolution Apex 256 [GE HealthCare] or Aquilion ONE ViSION 320 [Canon Medical Systems]) scanners. Subsequent invasive coronary angiography (ICA) and percutaneous or surgical revascularization were performed as part of routine clinical care. Among those referred for ICA after coronary CTA, the presence of obstructive CAD in each vessel was determined by coronary CTA (severe stenosis on visual assessment per the Coronary Artery Disease Reporting and Data System) and ICA (>= 50% diameter stenosis on quantitative coronary angiography) in a blinded fashion. The diagnostic performance of EID-CT and PCD-CT was compared by using quantitative coronary angiography as the reference standard. RESULTS Patients who underwent PCD-CT were less frequently referred to subsequent ICA than those undergoing EID-CT (9.9% vs 13.1%; P < 0.001). Among those who underwent ICA, revascularization was more frequently performed in the PCD-CT group than in the EID-CT group (43.4% vs 35.5%; P = 0.02). In the vessel-level analysis (n = 1,686), specificity (98.0% vs 93.0%; P < 0.001), positive predictive value (83.3% vs 63.0%; P = 0.002), and diagnostic accuracy (97.2% vs 92.8%; P < 0.001) were improved by PCD-CT. Sensitivity (90.9% vs 90.7%; P = 0.95) and negative predictive value (98.9% vs 98.7%; P = 0.83) for obstructive CAD were similar between the PCD-CT and EID-CT groups, respectively. CONCLUSIONS PCD-CT exhibited excellent diagnostic performance for detecting obstructive CAD. Compared with patients undergoing conventional EID-CT, fewer patients were referred to ICA after PCD-CT, but those referred were more likely to undergo revascularization. (JACC. 2025;85:339-348) (c) 2025 by the American College of Cardiology Foundation.