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While CT coronary angiography (CTCA) has been validated, the potential of CT to evaluate perfusion has not been explored. We sought to: (1) develop and test a technique for quantitative assessment of myocardial perfusion from CT images, (2) identify the underlying causes of perfusion abnormalities detected by CT, (3) determine the added diagnostic value of CT perfusion. We studied 84 consecutive patients undergoing clinical CTCA. Accuracy of automated detection of perfusion abnormalities was determined against invasive coronary angiography findings combined with known prior myocardial infarction (MI). Perfusion abnormalities were detected in 29/64 patients in 47 vascular territories, of which 36 were confirmed as abnormal. Of these 36, 10 were associated with prior MI, while 26 corresponded to significant stenosis. The addition of perfusion to CTCA improved its diagnostic accuracy. In conclusion, myocardial perfusion is a potentially valuable addition to CT tools for the evaluation of coronary artery disease without additional cost in radiation dose or contrast load.