ABSTRACT
Coronary computed tomography angiography (CCTA) has evolved significantly over the past decade, expanding from stable coronary artery disease (CAD) assessment to diverse cardiovascular applications. However, its role in non-ST-elevation acute coronary syndromes (NSTE- ACSs) remains incompletely defined despite excellent diagnostic accuracy. This review synthesizes current evidence on the performance of CCTA in NSTE-ACS, examining diagnostic capabilities, advanced plaque characterization, clinical outcomes, and knowledge gaps requiring future investigation. CCTA demonstrates high negative predictive value (>90%) for ruling out obstructive CAD in NSTE-ACS, particularly in low-to-intermediate risk patients. Despite this diagnostic performance, contemporary evidence reveals a persistent disconnect between anatomical accuracy and clinical benefit, with CCTA-guided strategies failing to demonstrate improvements in major adverse cardiovascular events or reductions in healthcare costs when compared to standard invasive approaches. Advanced plaque characterization techniques offer potential refinement in risk stratification. Pericoronary adipose tissue analysis via fat attenuation index correlates with vulnerable plaque features and inflammatory markers in NSTE-ACS populations. Critical evidence gaps persist regarding optimal patient selection algorithms, timing strategies across risk stratification, and cost-effectiveness analyses. Future research must prioritize outcome-driven investigations demonstrating that CCTA-guided management improves clinical endpoints, prospective validation of advanced imaging biomarkers, and integration into personalized algorithms to bridge the gap between diagnostic capability and meaningful clinical impact.