OBJECTIVES: This systematic review was conducted for The New Zealand Ministry of Health to summarise recent evidence pertaining to the clinical effectiveness of 64-slice or higher computed tomography angiography (CTA) in patients with suspected coronary artery disease (CAD). If CTA proves to be a successful diagnostic performance measure, it could prevent the application of invasive diagnostic procedures in some patients. This would provide multiple health and cost benefits, particularly for under resourced District Health Boards where invasive coronary angiography is not always available. METHODS: A systematic method of literature searching and selection was employed with searches limited to December 2006 to March 2009. Included studies were quality assessed using NHMRC diagnostic levels of evidence and a modified QUADAS tool. Individual and pooled diagnostic performance measures (i.e. sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and overall diagnostic accuracy) were calculated at the patient, vessel and segment level. RESULTS: This systematic review included 28 studies. The base case meta-analysis at the patient-level indicated a sensitivity of 98.2%, specificity of 81.6%, PPV of 88.9%, NPV of 96.8%, and diagnostic accuracy of 91.6%. In all vessels, the pooled sensitivity was 95.0%, specificity 85.2%, PPV 69.4%, NPV 97.9%, and diagnostic accuracy 87.7%. At the individual artery level, overall diagnostic accuracy appeared to be slightly higher in the left and right coronary artery and slightly lower in the left anterior descending and circumflex artery. In all segments, the sensitivity was 91.1%, specificity 94.3%, PPV 65.7%, NPV 98.9%, and overall diagnostic accuracy 94.0%. CONCLUSIONS: The high sensitivity observed in this update indicates that CTA can effectively identify the majority of patients with significant coronary artery stenosis. The high NPV at the patient, vessel and segment level establishes CTA as an effective non-invasive alternative to ICA for the exclusion of stenosis.