Abstract: Purpose: To evaluate the feasibility of combining photon-counting computed tomography (PCCT) virtual monoenergetic images (VMI) with iterative metal artifact reduction (iMAR) to suppress cardiac pacemaker-related metal artifacts and determine the optimal reconstruction energy level. Methods: This prospective study included patients with implanted cardiac pacemakers who underwent chest PCCT between February and December 2024; a total of 42 patients were enrolled in this study. Images were reconstructed at energy levels ranging from 70 to 150 keV (at 20-keV intervals), with and without iMAR. The artifact index (AIX) and corrected attenuation (ΔHU) were compared using the Friedman test. Interobserver agreement for subjective scoring was evaluated using weighted kappa analysis and subjective scores were compared using one-way repeated-measures ANOVA. Results: Compared with the non-iMAR group, the group subjected to the iMAR technique had significantly reduced AIX values across all artifact types, including the high/low-density muscle, clavicular, vascular, and thyroid regions. The 110 keV+iMAR reconstruction protocol demonstrated the optimal artifact suppression effect: for high-density muscle artifacts, the ΔHU was 29.0 (9.0, 41.0), with an AIX reduction of 28.1 (19.8, 36.4); for low-density muscle artifacts, the ΔHU was 50.0 (23.0, 83.0), with an AIX reduction of 34.1 (7.5, 60.7); for clavicular artifacts, the ΔHU was 35.0 (18.0, 46.0), with an AIX reduction of 45.6 (22.2, 69.0). Vascular and thyroid artifacts showed AIX reductions of 13.0 (8.8, 17.2) and 14.7 (12.3, 17.1), respectively, with corresponding ΔHU values of 5.0 (1.0, 18.0) and 14.0 (7.8, 27.5), respectively. The maximum reduction in ΔHU for artifacts surrounding the cardiac pacemaker reached 68.4%, with a 61.5% decrease in AIX. Interobserver agreement was excellent (kappa values ranging from 0.80 to 0.91), and the subjective scores in the iMAR group were significantly higher than those in the non-iMAR group. Conclusion: VMI at 110k eV combined with application of the iMAR algorithm significantly suppressed cardiac pacemaker-related metal artifacts and achieved an optimal balance between artifact reduction and image quality. This reconstruction protocol is recommended as the preferred parameter for evaluating patients with pacemakers using PCCT and has significant clinical value.