The published literature on the diagnostic accuracy of 64-channel coronary CTA compared with invasive coronary angiography as of June 2009 consists of 3 multicenter cohort studies along with over 45 single-center studies, many of the latter involving fewer than 100 patients. This literature reflects careful selection of study subjects and test interpretation by expert readers, typically with exclusion of patients who would be expected to have lower quality studies, such as those with irregular heart rates (e.g., atrial fibrillation), obesity, or inability to comply with instructions for breath holding. In addition, because the cohorts for these studies were assembled from patients referred for invasive coronary angiography, they do not necessarily reflect, in terms of obstructive CAD prevalence or clinical presentation, the population to which coronary CTA is most likely to be applied in clinical practice. Accepting these caveats, some consistent conclusions emerge from this literature that may be useful in clinical decision making. In these studies, overall sensitivity and specificity on a per-patient basis are both high, and the number of indeterminate studies due to inability to image important coronary segments in the select cohorts represented is less than 5%. In most circumstances, a negative coronary CT angiogram rules out significant obstructive coronary disease with a very high degree of confidence, based on the post-test probabilities obtained in cohorts with a wide range of pretest probabilities. However, post-test probabilities following a positive coronary CT angiogram are more variable, due in part to the tendency to overestimate disease severity, particularly in smaller and more distal coronary segments or in segments with artifacts caused by calcification in the arterial walls. At present, data on the prognostic value of coronary CTA using 64-channel or greater systems remain quite limited. Furthermore, no large-scale studies have yet made a direct comparison of long-term outcomes following conventional diagnostic imaging strategies versus strategies involving coronary CTA.