Background and Objectives: Coronary computed tomography angiography (CCTA) has become a central non-invasive imaging modality for the evaluation of suspected chronic coronary syndromes. Nevertheless, referral patterns and sex-related differences in real-world CCTA utilization may vary according to demographic structure, healthcare accessibility, and regional clinical practice. The present study aimed to evaluate age- and sex-related patterns in CCTA referrals and coronary atherosclerotic burden within a real-world Eastern European single-center CCTA referral cohort. Materials and Methods: We performed a retrospective analysis of 2742 consecutive CCTA examinations at a tertiary center in Sibiu, Romania, between March 2019 and January 2025. The demographic profile of the referral cohort was compared with the adult population structure of Sibiu County. Subsequently, an age- and sex-stratified proportional subsample of 397 cases was selected from the CCTA cohort for detailed analysis of sex-related differences regarding coronary artery calcium score (CACS), significant coronary stenoses, and significant cardiovascular event risk. Results: The age distribution of the CCTA referral cohort differed significantly from that of the adult county population (p < 0.01), with referrals concentrated predominantly between 55 and 79 years of age. Female patients were overall more frequently represented within the referral cohort compared with the underlying county population; however, males demonstrated significantly higher coronary artery calcium scores, a greater prevalence of significant coronary stenoses, and higher revascularization risk compared with females-particularly between 50 and 79 years of age-within the stratified proportional subsample. In contrast, patients younger than 40 years demonstrated very low rates of significant coronary disease regardless of sex. Conclusions: This study provides a real-world perspective on age- and sex-related patterns in CCTA utilization and coronary atherosclerotic burden within an Eastern European imaging center. The findings highlight the interaction between demographic structure, guideline-directed diagnostic strategies, and coronary imaging utilization in routine clinical practice.