Coronary calcified nodules are an uncommon but important substrate for acute coronary syndromes, stent underexpansion, and recurrent target lesion revascularization. This consensus integrates pathologic, imaging, prognostic, and interventional evidence to guide practical decision-making. Intravascular imaging is essential for diagnosis, mechanism definition, and procedural optimization. Optical coherence tomography provides superior assessment of cap disruption and thrombus, whereas intravascular ultrasound remains valuable when contrast exposure or lesion crossing limits optical coherence tomography. Treatment should be tailored to lesion crossability, calcium distribution, and the need for mechanical scaffolding. No calcium-modification device or drug-eluting stent vs drug-coated balloon strategy has demonstrated consistent superiority. The proposed type IIa/IIb framework is hypothesis-generating and requires prospective validation. Calcified nodule-related target lesion failure should be managed by correcting the dominant mechanical mechanism before antiproliferative therapy. These recommendations emphasize individualized, imaging-guided percutaneous coronary intervention and identify priorities for prospective comparative research.