Cardiac CT angiography (CTA) is an ideal tool to investigate cardiac and noncardiac causes of acute chest pain. In this case, careful planning of the CTA acquisition and reconstruction limits permitted not only the exclusion of aortic dissection and provided high resolution images of coronary anatomy but also showed a concordant abnormality in myocardial perfusion and ventricular function in the setting of an acute coronary syndrome. Detailed planning of every CTA acquisition reconstruction protocol is essential to obtain the information necessary for clinical decision-making strategies and interventions in the patient with chest pain.