THE STANDARD NORMAL CARDIAC CT REPORT: BACKGROUND, RATIONALE & BASICS

Modern Cardiac CT reports, especially Cardiac CT Angiography (CCTA), should follow established guidelines and criteria that ensure accurate and standardized reporting. These criteria focus on evaluating coronary artery disease (CAD), cardiac morphology, and any incidental findings that may impact patient management.

Here’s an outline of the key criteria for a comprehensive and modern Cardiac CT report with references to guidelines from professional societies:

?1. Indications for Cardiac CT:

Since it is becoming a huge field I put here the link to my article on contemporary indications for Cardiac CT:

https://www.dhirubhai.net/pulse/cardiac-ct-central-tool-cardiovascular-medicine-cademartiri-mzedf/?trackingId=STrlosB1SDei5z3lgy4YcQ%3D%3D

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2. Coronary Artery Evaluation:

???????????????????????????????? Plaque Characterization:

???????????????????????????????? Calcified, non-calcified, or mixed plaques.

???????????????????????????????? Location and distribution in the coronary tree (proximal, mid, distal).

???????????????????????????????? Assessment of stenosis severity:

???????????????????????????????? Non-significant stenosis: <25% luminal narrowing or <50% luminal narrowing.

???????????????????????????????? Moderate stenosis: 50-70% luminal narrowing.

???????????????????????????????? Severe stenosis: >70% luminal narrowing.

???????????????????????????????? Quantification of coronary artery calcium (CAC) score (if performed):

???????????????????????????????? CAC score of 0 indicates no detectable calcified plaque, suggesting low risk of coronary events in the short term.

???????????????????????????????? Higher scores correlate with greater risk of CAD.

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3. Cardiac Chamber and Valve Assessment:

???????????????????????????????? Chamber sizes (left atrium, right atrium, left ventricle, right ventricle) should be reported as normal or abnormal (dilated, hypertrophied, or atrophic).

???????????????????????????????? Valvular morphology: Assessment of aortic, mitral, tricuspid, and pulmonic valves, noting any calcifications, thickening, or prolapse.

???????????????????????????????? Left ventricular function (optional if a comprehensive cardiac function assessment is needed):

???????????????????????????????? Estimation of left ventricular ejection fraction (LVEF).

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4. Aorta and Great Vessels:

???????????????????????????????? Assessment of thoracic aorta for aneurysm, dissection, and atherosclerosis.

???????????????????????????????? Evaluation of pulmonary arteries for embolism or other vascular abnormalities.

5. Pericardium and Surrounding Structures:

???????????????????????????????? Evaluation of the pericardium for thickening, effusion, or masses.

???????????????????????????????? Incidental findings in the lungs, mediastinum, and adjacent structures should be noted if they impact clinical management.

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6. Report Structure and Standardization:

???????????????????????????????? Structured reports are highly recommended to ensure clarity and completeness.

???????????????????????????????? Include sections for clinical indication, technique, findings, and conclusion/impression.

???????????????????????????????? Clearly define the coronary segments using a standard anatomical classification system (e.g., SCCT 17-segment model).

???????????????????????????????? Ensure quantitative measures are provided when available (e.g., dimensions of vessels, degree of stenosis).

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7. Radiation Dose Reporting:

???????????????????????????????? Indicate radiation dose metrics, such as dose-length product (DLP) and effective dose (mSv), in adherence to ALARA (As Low As Reasonably Achievable) principles.

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8. Clinical Recommendations:

???????????????????????????????? Provide clear recommendations for follow-up or further testing based on the findings.

???????????????????????????????? If significant stenosis is present, consider further functional testing (e.g., stress testing, invasive coronary angiography).

???????????????????????????????? For patients with incidental findings (e.g., lung nodules, mediastinal masses), recommend appropriate follow-up imaging or referral.

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As additional tool to summarize and classify findings we can use the CADRADS 2.0 system

The CAD-RADS 2.0 (Coronary Artery Disease - Reporting and Data System) is a standardized system for reporting coronary artery disease (CAD) severity based on coronary CT angiography (CCTA). It was updated in 2022 to further enhance clinical decision-making and communication between radiologists and cardiologists.

The CAD-RADS 2.0 scoring system assesses the degree of coronary artery stenosis and provides recommendations for management. The system includes categories based on stenosis severity, along with modifiers for special conditions like plaque characteristics and additional findings (e.g., vulnerable plaque, prior coronary interventions, etc.).

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Modifiers:

1.????????? N (Non-Diagnostic):

???????????????????????????????? Used when image quality is insufficient to assess one or more coronary segments.

???????????????????????????????? Example: CAD-RADS 3/N indicates moderate stenosis but poor image quality in some areas.

2.????????? V (Vulnerable Plaque):

???????????????????????????????? Indicating high-risk plaque features (e.g., positive remodeling, low-attenuation plaque, spotty calcification, napkin-ring sign).

???????????????????????????????? Example: CAD-RADS 2/V indicates mild stenosis with high-risk plaque features.

3.????????? S (Stent):

???????????????????????????????? For patients with coronary stents.

???????????????????????????????? Example: CAD-RADS 3/S indicates moderate stenosis in a patient with a prior stent.

4.????????? G (Graft):

???????????????????????????????? For patients with coronary artery bypass grafts (CABG).

???????????????????????????????? Example: CAD-RADS 4A/G indicates severe stenosis in a patient with prior bypass surgery.

5.????????? T (Technical Difficulty):

???????????????????????????????? Indicating cases where the scan is technically difficult due to factors like motion, calcifications, etc.

???????????????????????????????? Example: CAD-RADS 2/T indicates mild stenosis but technical challenges during the scan.

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Detailed Breakdown of Each Category:

1.????????? CAD-RADS 0 (No plaque/stenosis):

???????????????????????????????? Description: No evidence of plaque or stenosis.

???????????????????????????????? Management: Routine follow-up or cardiovascular risk factor management as per primary care recommendations.

2.????????? CAD-RADS 1 (Minimal plaque):

???????????????????????????????? Description: Non-obstructive plaque with less than 25% luminal narrowing.

???????????????????????????????? Management: Reinforce preventive strategies and lifestyle modifications; typically no further testing required.

3.????????? CAD-RADS 2 (Mild stenosis):

???????????????????????????????? Description: Plaque causing 25-49% stenosis.

???????????????????????????????? Management: Medical management for risk factors; low probability of ischemia, so functional testing is generally not required unless symptoms suggest ischemia.

4.????????? CAD-RADS 3 (Moderate stenosis):

???????????????????????????????? Description: 50-69% luminal narrowing.

???????????????????????????????? Management: Consider functional testing (e.g., stress test) to evaluate for ischemia. In symptomatic patients, invasive coronary angiography (ICA) may be warranted.

5.????????? CAD-RADS 4A (Severe stenosis – single vessel):

???????????????????????????????? Description: 70-99% stenosis in a single coronary artery.

???????????????????????????????? Management: Invasive coronary angiography is recommended, especially for symptomatic patients or those with high-risk factors. Revascularization (PCI or CABG) may be necessary based on ICA findings.

6.????????? CAD-RADS 4B (Severe stenosis – multi-vessel or left main):

???????????????????????????????? Description: 70-99% stenosis in multiple vessels or left main artery.

???????????????????????????????? Management: Urgent invasive coronary angiography is typically recommended. There is a high risk of ischemia and myocardial infarction; prompt intervention may be required.

7.????????? CAD-RADS 5 (Total occlusion):

???????????????????????????????? Description: Complete occlusion (100%) of any coronary artery.

???????????????????????????????? Management: Immediate coronary angiography is recommended for revascularization if the patient is symptomatic or at high risk for adverse outcomes.

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Modifiers in Detail:

???????????????????????????????? N (Non-diagnostic):

o??? Used when part of the study is not diagnostic due to poor image quality (e.g., motion artifacts, high coronary calcium score), requiring alternative diagnostic tests or repeat imaging.

???????????????????????????????? V (Vulnerable plaque):

o??? Identifies plaques with high-risk features associated with increased risk for acute coronary syndrome. These plaques may be addressed more aggressively in patient management.

???????????????????????????????? S (Stent):

o??? Denotes patients with previous coronary stenting. The report should comment on in-stent restenosis if detected and assess for patency of stented segments.

???????????????????????????????? G (Graft):

o??? Denotes patients with prior CABG. The patency of grafts and native coronary arteries should be assessed.

???????????????????????????????? T (Technical Difficulty):

o??? Indicates a technically challenging exam due to motion, high calcific burden, or suboptimal contrast enhancement. This informs the referring clinician about potential limitations in the report.

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Clinical Management Recommendations:

???????????????????????????????? CAD-RADS 0-2: Typically managed with preventive measures such as lifestyle modifications and medical therapy to control risk factors (e.g., hypertension, dyslipidemia).

???????????????????????????????? CAD-RADS 3-4: Patients may require further functional testing or invasive coronary angiography depending on symptoms and risk factors. Revascularization is considered in appropriate cases.

???????????????????????????????? CAD-RADS 5: Immediate intervention is recommended in most cases due to the high risk of myocardial infarction.

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References:

1.???????????????????????????? Cury, R. C., Abbara, S., Achenbach, S., et al. (2022). CAD-RADS 2.0 - Coronary Artery Disease - Reporting and Data System: An expert consensus document from SCCT, ACR, and NASCI. Journal of Cardiovascular Computed Tomography.

2.???????????????????????????? Ghoshhajra, B., et al. (2022). SCCT Guidelines for Coronary Artery Disease. Society of Cardiovascular Computed Tomography (SCCT).

3.???????????????????????????? Leipsic, J., et al. (2022). Coronary Artery Disease - Reporting and Data System (CAD-RADS 2.0): A Standardized Approach. Radiological Society of North America (RSNA).

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This structured system ensures uniform reporting, helping clinicians make timely and accurate decisions regarding patient management based on the severity of coronary artery disease.

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Conclusion:

A modern Cardiac CT report follows evidence-based guidelines, emphasizing a standardized approach to evaluating coronary artery disease, cardiac structure, and any incidental findings. The report should be structured to provide clear, detailed, and actionable information to assist in patient care.

This approach is endorsed by leading cardiovascular and radiology societies such as the SCCT, AHA, ACC, and ESC, ensuring consistency and clinical relevance.

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References:

1.???????????????????????????? Society of Cardiovascular Computed Tomography (SCCT) Guidelines for the Performance and Acquisition of Coronary CT Angiography.

2.???????????????????????????? American College of Cardiology (ACC)/American Heart Association (AHA) Guidelines for the Management of Stable Ischemic Heart Disease.

3.???????????????????????????? SCCT Guidelines on the Interpretation and Reporting of Coronary CT Angiography.

4.???????????????????????????? ACC/AHA Guidelines for the Assessment of Cardiovascular Risk.

5.???????????????????????????? SCCT Guidelines on Cardiac Structure and Function Assessment.

6.???????????????????????????? European Society of Cardiology (ESC) Guidelines on Cardiac Imaging in Heart Failure.

7.???????????????????????????? AHA/ACC Guidelines for Diseases of the Aorta.

8.???????????????????????????? European Society of Radiology (ESR) Guidelines on Incidental Findings in Cardiac Imaging.

9.???????????????????????????? SCCT Coronary Artery Segmentation Guidelines.

10.??????????????????????? Radiological Society of North America (RSNA) Recommendations on Structured Reporting.

11.??????????????????????? American College of Radiology (ACR) Guidelines on Radiation Dose Reduction in Cardiac CT.

These references ensure that the criteria for a modern Cardiac CT report align with international best practices and safety standards.

See below an example of modern Cardiac CT report

CARDIAC CT ANGIOGRAM REPORT

Patient Information:

? Name: [Patient Name]

? Date of Birth: [DOB]

? Gender: [Male/Female]

? ID/Case Number: [Case ID]

? Date of Study: [Study Date]

? Referring Physician: [Physician Name]

? Indication: there are several (see the other article on this topic linked above)

Technique:

? Imaging Modality: Cardiac Computed Tomography Angiography (CTA)

? Scanner: [CT Scanner Model, e.g., 64-slice or 128-slice CT scanner]

? Contrast:

? Type: [Contrast Agent Type]

? Volume: [mL]

? Injection Rate: [mL/sec]

? Heart Rate Control: [Medication used, e.g., beta-blocker]

? Pre-scan Medications: [Nitroglycerin, Beta-blockers]

? ECG Gating: Yes (retrospective/prospective)

? Radiation Dose: [mSv]

? Post-processing: 3D volume rendering, curved multiplanar reformats, maximum intensity projection (MIP), and coronary artery analysis

Heart Rate During Scan:

? [Heart rate value, e.g., 55 bpm (beats per minute)]

Interpretation Parameters:

? Axial, Coronal, and Sagittal views were evaluated in detail for anatomy and pathology.

? Coronary Artery Calcium Score: [0 or other value, if performed]

Findings:

1. Coronary Arteries:

? Left Main Coronary Artery (LMCA): No significant atherosclerosis or stenosis. Patent and free of calcified or non-calcified plaques.

? Left Anterior Descending Artery (LAD):

? Proximal, mid, and distal LAD segments appear normal without stenosis or plaques.

? Diagonal branches are free of significant disease or stenosis.

? Left Circumflex Artery (LCX):

? Proximal and distal segments are normal with no evidence of atherosclerotic plaques or luminal narrowing.

? Obtuse marginal branches are patent and free from disease.

? Right Coronary Artery (RCA):

? RCA and its major branches (acute marginal branches, posterior descending artery) are widely patent with no plaques or stenosis.

? Dominance: [Right/Left/Co-dominant]

2. Cardiac Chambers:

? Left Ventricle (LV): Normal in size and configuration. No hypertrophy, dilation, or wall motion abnormalities. LV ejection fraction appears preserved.

? Right Ventricle (RV): Normal in size, no dilation or hypertrophy.

? Left Atrium (LA): Normal size, no enlargement.

? Right Atrium (RA): Normal size, no enlargement.

3. Valves:

? Aortic Valve: Trileaflet, normal in appearance, no calcification or stenosis.

? Mitral Valve: Normal leaflet morphology with no evidence of prolapse or stenosis.

? Tricuspid Valve: No significant abnormalities identified.

? Pulmonic Valve: No abnormalities.

4. Pericardium:

? No pericardial thickening or effusion. Pericardium appears normal in thickness and configuration.

5. Thoracic Aorta:

? Ascending Aorta: Normal diameter, no aneurysm or dissection.

? Aortic Arch: Normal configuration with no evidence of atherosclerosis or stenosis.

? Descending Thoracic Aorta: Unremarkable, no evidence of aortic disease.

6. Pulmonary Arteries:

? Pulmonary arteries are patent without filling defects to suggest pulmonary embolism.

7. Mediastinum and Lungs:

? Mediastinum: No lymphadenopathy or abnormal masses detected.

? Lungs: Clear, no evidence of pulmonary nodules, masses, infiltrates, or effusions.

? Pleura: No pleural thickening or effusion.

8. Bone Structures:

? No lytic or sclerotic lesions observed. Bony thorax appears intact without fractures or abnormalities.

Conclusions:

? No evidence of coronary artery disease (CAD). All coronary arteries, including their major branches, are widely patent with no stenosis or atherosclerotic plaques.

? No significant cardiac or vascular abnormalities were identified. Normal chamber sizes and function.

? No pericardial or valvular disease.

? Thoracic aorta and pulmonary arteries are normal without evidence of aneurysm, dissection, or embolism.

? Mediastinal and pulmonary structures appear normal, with no incidental findings requiring further evaluation.

Impression:

? Normal cardiac CT angiography with no evidence of coronary artery disease or structural cardiac abnormalities.

? No further imaging or immediate intervention required at this time.

Recommendations:

? Routine follow-up based on clinical symptoms or risk factor reassessment.

? Continue with standard cardiovascular risk management (if applicable).

Radiologist:

? Name: [Radiologist’s Name]

? Certification: [Board Certification, if applicable]

? Signature: [Electronic Signature]

? Date of Report: [Date]

This report includes all major aspects of a cardiac CT, providing a detailed overview of the coronary arteries, cardiac chambers, valves, pericardium, thoracic aorta, pulmonary arteries, lungs, and mediastinum. A negative report like this emphasizes the normal findings and the absence of disease, particularly highlighting the coronary artery status, which is crucial in ruling out CAD.