How should I explain CAD‑RADS 3 findings (moderate 60‑70% stenoses in the mid circumflex and mid right coronary arteries, mild stenosis in the proximal left anterior descending artery, patent left main, and possible partial fusion of the right‑left coronary cusp of the aortic valve) to the patient, and should I refer them to cardiology if they develop shortness of breath on exertion?

CAD-RADS 3/P2: Patient Communication and Cardiology Referral

Yes, refer this patient to cardiology immediately, especially if they develop shortness of breath with exertion, as CAD-RADS 3 indicates moderate stenoses (50-69%) in two vessels that require functional assessment or stress testing to determine if these lesions are causing ischemia. 1

How to Explain to the Patient

Tell the patient in plain language:

• "Your CT scan shows moderate narrowing in two of your heart arteries—about 60-70% blockage in the circumflex artery and moderate narrowing in the right coronary artery."
• "You also have mild narrowing in a third artery (the LAD) and moderate overall plaque buildup (P2)."
• "The good news is your main left artery is completely open, and we're waiting on additional computer analysis (FFR-CT) to tell us if these blockages are restricting blood flow to your heart muscle."
• "There's also a possible minor valve abnormality that needs an ultrasound of your heart to clarify."

Clinical Management Algorithm

Immediate Actions:

1. Await pending FFR-CT results - This will determine if the moderate stenoses are hemodynamically significant 1

2. If FFR-CT shows ischemia (I+):

   • Refer to cardiology urgently for consideration of invasive coronary angiography (ICA)
   • The presence of lesion-specific ischemia in CAD-RADS 3 warrants further evaluation, particularly given two-vessel involvement 1

3. If FFR-CT is negative (I-) or borderline (I±):

   • Still refer to cardiology for:
     • Optimization of guideline-directed medical therapy
     • Risk stratification based on symptoms
     • Consideration of alternative stress testing if FFR-CT is borderline 1

Symptom-Based Decision Points:

If the patient develops shortness of breath with exertion:

• This is anginal equivalent and mandates cardiology referral regardless of FFR-CT results 1
• The 2022 CAD-RADS guidelines specifically state that further testing should be considered "in the presence of stable or acute chest pain, if the patient has persistent symptoms despite adequate medical therapy" 1
• Two-vessel moderate disease with symptoms increases risk and may warrant ICA even without documented ischemia

If the patient remains asymptomatic:

• Cardiology referral is still appropriate for:
  • Initiation of aggressive preventive therapy (high-intensity statin, aspirin, blood pressure control)
  • Serial monitoring
  • Lifestyle modification counseling
  • The research shows significant statin underutilization in CAD-RADS 3 patients (only 53.1% on statins pre-ICA) 2

Key Clinical Considerations

The CAD-RADS 3 Dilemma:

CAD-RADS 3 represents a critical decision point. The 2022 guidelines emphasize that "there is an option to consider the use of CT-FFR, CTP, or stress testing to document or exclude the presence of ischemia" 1. Your pending FFR-CT is exactly the right next step.

Two-Vessel Involvement Matters:

While this patient doesn't meet CAD-RADS 4B criteria (which requires three-vessel disease >70% or left main >50%), having moderate stenoses in two vessels (circumflex and RCA) plus mild disease in a third (LAD) with moderate overall plaque burden (P2) represents significant atherosclerotic disease that requires specialist management.

The Aortic Valve Finding:

The possible partial fusion of coronary cusps needs echocardiographic correlation. This is classified under modifier "E" (exceptions) in CAD-RADS terminology and represents a non-atherosclerotic finding that requires separate evaluation 1.

Common Pitfalls to Avoid

1. Don't wait for symptoms to develop before referring - Research shows that 58% of CAD-RADS 3 patients underwent catheterization within 30 days, and many were either asymptomatic or not on antianginal therapy 3. Proactive management is key.

2. Don't dismiss exertional dyspnea as "just deconditioning" - In the context of documented two-vessel moderate CAD, shortness of breath with exertion is an anginal equivalent until proven otherwise.

3. Don't delay preventive therapy - Start high-intensity statin therapy now if not already initiated. The research demonstrates significant gaps in preventive care for CAD-RADS 3 patients 2.

4. Don't forget the echocardiogram - The valve finding needs correlation and shouldn't be lost in the focus on coronary disease.

Bottom Line

Cardiology referral is indicated now, not just "if" symptoms develop. The combination of two-vessel moderate stenoses, moderate plaque burden, pending functional assessment, and a valve abnormality requiring further evaluation makes specialist involvement essential for optimal risk stratification and management. If exertional dyspnea develops before the cardiology appointment, this should trigger urgent (not routine) referral.