What are the guidelines for reporting coronary computed tomography (CT) angiography results?

Coronary CT Angiography Reporting Guidelines

The standard for reporting coronary CT angiography (CCTA) results should follow the CAD-RADS (Coronary Artery Disease Reporting and Data System) classification system, which provides a standardized method to communicate findings and guide patient management decisions based on stenosis severity. 1

Core Components of CAD-RADS Reporting

Stenosis Classification

CAD-RADS categorizes coronary stenosis on a per-patient basis, representing the highest-grade lesion:

• CAD-RADS 0: 0% stenosis (no plaque or stenosis)
• CAD-RADS 1: 1-24% stenosis (minimal stenosis or plaque)
• CAD-RADS 2: 25-49% stenosis (mild stenosis)
• CAD-RADS 3: 50-69% stenosis (moderate stenosis)
• CAD-RADS 4A: 70-99% stenosis (severe stenosis)
• CAD-RADS 4B: Left main >50% or 3-vessel disease with ≥70% stenosis
• CAD-RADS 5: 100% stenosis (total occlusion)
• CAD-RADS N: Non-diagnostic study 1

Plaque Burden Modifier (CAD-RADS 2.0)

The 2022 update (CAD-RADS 2.0) added plaque burden assessment:

• P1: Minimal plaque burden
• P2: Mild plaque burden
• P3: Moderate plaque burden
• P4: Severe plaque burden 1

Additional Modifiers

• N: Non-diagnostic study
• S: Presence of stent
• G: Presence of bypass graft
• V: Vulnerable plaque features (≥2 high-risk features) 1

Standardized Report Structure

A complete CCTA report should include:

1. Exam and Technique Section:

   • Scanner type
   • Acquisition method (prospective/retrospective)
   • Medications administered
   • Technical quality assessment 1

2. Findings Section:

   • Calcium score (if performed)
   • Coronary dominance pattern
   • Systematic evaluation of each coronary artery:
     • Left main
     • Left anterior descending (LAD)
     • Left circumflex (LCX)
     • Right coronary artery (RCA)
   • Non-coronary cardiac findings (valves, pericardium)
   • Extra-cardiac findings 1

3. Impression Section:

   • CAD-RADS classification
   • Plaque characterization
   • Overall plaque burden assessment
   • Relevant modifiers 1

4. Recommendation Section:

   • Management suggestions based on CAD-RADS category
   • Further testing recommendations when appropriate 1

Clinical Management Recommendations

Management recommendations should be included based on the CAD-RADS category:

• CAD-RADS 0: Reassurance, consider non-atherosclerotic causes
• CAD-RADS 1-2: Consider non-atherosclerotic causes, risk factor modification
• CAD-RADS 3: Consider functional assessment, aggressive risk factor modification
• CAD-RADS 4: Consider invasive coronary angiography or functional assessment
• CAD-RADS 5: Consider invasive coronary angiography and/or viability assessment 1

Common Pitfalls to Avoid

• Overcalling or undercalling stenosis: Use multiple reconstruction techniques and views to confirm stenosis severity 2
• Misinterpreting artifacts: Motion artifacts, beam hardening from calcifications, and blooming artifacts can mimic stenosis 2
• Incomplete vessel evaluation: Ensure all segments ≥1.5-2mm are assessed 1
• Failing to report non-coronary findings: Include relevant cardiac and extra-cardiac findings 1
• Inconsistent terminology: Use standardized CAD-RADS terminology for clear communication 1, 3

Benefits of Standardized Reporting

• Improved communication with referring physicians
• Consistent recommendations for patient management
• Framework for data collection and research
• Quality improvement and benchmarking
• Reduced variability among practitioners 1

By implementing the CAD-RADS classification system in CCTA reporting, clinicians can ensure standardized communication of findings, facilitate appropriate patient management decisions, and ultimately improve patient outcomes through early identification and management of coronary artery disease.