Purpose: To assess the efficacy of coronary computed tomographic (CT) angiography for therapeutic decision making in patients with high likelihood of coronary artery disease (CAD)-specifically the ability of coronary CT angiography to help differentiate patients without and patients with a need for revascularization and determine the appropriate revascularization procedure. Materials and Methods: The study protocol was approved by institutional review board, with written informed consent from all patients. The study was conducted in compliance with HIPAA. One hundred eighty-five consecutive symptomatic patients (121 men; mean age, 59.4 years ± 9.7) with a positive single photon emission computed tomography (SPECT) myocardial perfusion study underwent coronary CT angiography and conventional cardiac angiography (hereafter, cardiac catheterization). The management strategy (conservative treatment vs revascularization) and revascularization procedure (percutaneous coronary intervention [PCI] vs coronary artery bypass graft surgery [CABG]) were prospectively selected on the basis of a combination of coronary CT angiography and SPECT. In addition, the authors calculated the accuracy, sensitivity, specificity, and negative and positive predictive values of coronary CT angiography in the detection of obstructive CAD and the selection of a revascularization strategy. Cardiac catheterization was used as the standard of reference. Results: Of the 185 patients, 113 (61%) did not undergo revascularization and 42 (23%) were free of CAD. In 178 patients (96%), the same therapeutic strategy (conservative treatment vs revascularization) was chosen on the basis of coronary CT angiography and catheterization. All patients in need of revascularization were identified with coronary CT angiography. When revascularization was indicated, the same procedure (PCI vs CABG) was chosen in 66 of 72 patients (92%). Conclusion: In patients with high likelihood of CAD, the performance of coronary CT angiography in the differentiation of patients without and patients with a need for revascularization and the selection of a revascularization strategy was similar to that of cardiac catheterization; accordingly, coronary CT angiography has the potential to limit the number of patients without obstructive CAD who undergo cardiac catheterization and to inform decision making regarding revascularization. © RSNA, 2012 Supplemental material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.12112426/-/DC1.