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ObjectivesWe evaluated the technical and clinical utility of visual 5-point coronary stenosis grading on coronary computed tomographic angiography (CCTA).BackgroundThe binary approach used to assess coronary stenoses on CCTA does not adequately describe borderline obstructive lesions and limits full expression of clinically useful information.MethodsFrom 84 patients who underwent CCTA and invasive angiography, we identified 278 native coronary segments with ≥25% stenosis on CCTA after excluding all 1 grade in only 4% of grade 2 to grade 5 segments (10 of 278; 2% of CCTA grade 2 segments, 4% of grade 3, 8% of grade 4, 2% of grade 5). Overall quantitative correlation was strong (r = 0.82) with high variability in agreement between CTQCA and IQCA for individual segments (95% of differences between 27.2% and 34.6%).ConclusionsWith current CCTA technology, experienced readers should consider adopting a visually based, multitiered grading approach to evaluate coronary stenoses. A ≤49% lesion on CCTA can be considered virtually exclusive of ≥70% stenosis by invasive angiography.