CAD-RADS – a new clinical decision support tool for coronary computed tomography angiography

  • Borek Foldyna
  • Bálint Szilveszter
  • Jan-Erik Scholtz
  • Dahlia Banerji
  • Pál Maurovich-Horvat
  • Udo Hoffmann
Cardiac
  • 144 Downloads

Abstract

Coronary computed tomography angiography (CTA) has been established as an accurate method to non-invasively assess coronary artery disease (CAD). The proposed ‘Coronary Artery Disease Reporting and Data System’ (CAD-RADS) may enable standardised reporting of the broad spectrum of coronary CTA findings related to the presence, extent and composition of coronary atherosclerosis. The CAD-RADS classification is a comprehensive tool for summarising findings on a per-patient-basis dependent on the highest-grade coronary artery lesion, ranging from CAD-RADS 0 (absence of CAD) to CAD-RADS 5 (total occlusion of a coronary artery). In addition, it provides suggestions for clinical management for each classification, including further testing and therapeutic options. Despite some limitations, CAD-RADS may facilitate improved communication between imagers and patient caregivers. As such, CAD-RADS may enable a more efficient use of coronary CTA leading to more accurate utilisation of invasive coronary angiograms. Furthermore, widespread use of CAD-RADS may facilitate registry-based research of diagnostic and prognostic aspects of CTA.

Key points

• CAD-RADS is a tool for standardising coronary CTA reports.

• CAD-RADS includes clinical treatment recommendations based on CTA findings.

• CAD-RADS has the potential to reduce variability of CTA reports.

Keywords

Coronary artery disease Computed tomography angiography Coronary stenosis Classification Percutaneous coronary intervention 

Abbreviations and acronyms

ACS

Acute coronary syndrome

AHA

American HeartAssociation

CABG

Coronary artery bypass graft

CAD

Coronary artery disease

CAD-RADS

Coronary artery disease – Reporting and Data System

CT

Computed tomography

CTA

Computed tomography angiography

FFR

Fractional flow reserve

HU

Hounsfield units

LAD

Left anterior descending

LM

Left main

NICE

National Institute for Health and Care Excellence

RCA

Right coronary artery

SCCT

Society of Cardiovascular Computed Tomography

TIMI

Thrombolysis in myocardial infarction

Notes

Acknowledgements

Borek Foldyna received funding from the German Research Foundation (DFG), project 290004377 (FO 993/1).

Compliance with ethical standards

Guarantor

The scientific guarantor of this publication is Borek Foldyna, MD.

Conflict of interest

The authors of this manuscript declare no relationships with any companies whose products or services may be related to the subject matter of the article.

Statistics and biometry

No complex statistical methods were necessary for this paper.

Informed consent

Written informed consent was obtained from all three patients for the anonymised image data use.

Ethical approval

Institutional Review Board approval was not required for this special report.

Methodology

Special report

References

  1. 1.
    Cury RC (2014) President’s page: Ten years of innovation in cardiac CT. J Cardiovasc Comput Tomogr 8:338–339.  https://doi.org/10.1016/j.jcct.2014.07.006 CrossRefPubMedGoogle Scholar
  2. 2.
    Douglas PS, Hoffmann U, Patel MR et al (2015) Outcomes of anatomical versus functional testing for coronary artery disease. N Engl J Med 372:1291–1300.  https://doi.org/10.1056/NEJMoa1415516 CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Hoffmann U, Ferencik M, Udelson JE et al (2017) Prognostic Value of Noninvasive Cardiovascular Testing in Patients with Stable Chest. Insights from the PROMISE Trial. Circulation, Pain.  https://doi.org/10.1161/CIRCULATIONAHA.116.024360 Google Scholar
  4. 4.
    Rybicki FJ, Udelson JE, Peacock WF et al (2016) 2015 ACR/ACC/AHA/AATS/ACEP/ASNC/NASCI/SAEM/SCCT/SCMR/SCPC/SNMMI/STR/STS Appropriate Utilization of Cardiovascular Imaging in Emergency Department Patients With Chest Pain: A Joint Document of the American College of Radiology Appropriateness Criteria Committee and the American College of Cardiology Appropriate Use Criteria Task Force. J Am Coll Cardiol 67:853–879.  https://doi.org/10.1016/j.jacc.2015.09.011 CrossRefPubMedGoogle Scholar
  5. 5.
    Chest pain of recent onset: assessment and diagnosis | Guidance and guidelines | NICE. https://www.nice.org.uk/guidance/cg95. Accessed 19 Apr 2017
  6. 6.
    Leipsic J, Abbara S, Achenbach S et al (2014) SCCT guidelines for the interpretation and reporting of coronary CT angiography: a report of the Society of Cardiovascular Computed Tomography Guidelines Committee. J Cardiovasc Comput Tomogr 8:342–358.  https://doi.org/10.1016/j.jcct.2014.07.003 CrossRefPubMedGoogle Scholar
  7. 7.
    Pelc NJ (2014) Recent and Future Directions in CT Imaging. Ann Biomed Eng 42:260–268.  https://doi.org/10.1007/s10439-014-0974-z CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Abbara S, Blanke P, Maroules CD et al (2016) SCCT guidelines for the performance and acquisition of coronary computed tomographic angiography: A report of the society of Cardiovascular Computed Tomography Guidelines Committee: Endorsed by the North American Society for Cardiovascular Imaging (NASCI). J Cardiovasc Comput Tomogr 10:435–449.  https://doi.org/10.1016/j.jcct.2016.10.002 CrossRefPubMedGoogle Scholar
  9. 9.
    Lu MT, Ferencik M, Roberts RS et al (2017) Noninvasive FFR Derived From Coronary CT. Management and Outcomes in the PROMISE Trial. JACC Cardiovasc Imaging, Angiography.  https://doi.org/10.1016/j.jcmg.2016.11.024 Google Scholar
  10. 10.
    Kim SM, Choi J-H, Chang S-A, Choe YH (2013) Detection of ischaemic myocardial lesions with coronary CT angiography and adenosine-stress dynamic perfusion imaging using a 128-slice dual-source CT: diagnostic performance in comparison with cardiac MRI. Br J Radiol 86:20130481.  https://doi.org/10.1259/bjr.20130481 CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Cury RC, Abbara S, Achenbach S et al (2016) CAD-RADS™: Coronary Artery Disease - Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR) and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology. J Am Coll Radiol JACR 13:1458–1466.e9.  https://doi.org/10.1016/j.jacr.2016.04.024 CrossRefPubMedGoogle Scholar
  12. 12.
    Wolk MJ, Bailey SR, Doherty JU et al (2014) ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease: a report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, American Heart Association, American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Failure Society of America, Heart Rhythm Society, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography, Society for Cardiovascular Magnetic Resonance, and Society of Thoracic Surgeons. J Am Coll Cardiol 63:380–406.  https://doi.org/10.1016/j.jacc.2013.11.009 CrossRefPubMedGoogle Scholar
  13. 13.
    Hecht HS, Cronin P, Blaha MJ et al (2017) 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: A report of the Society of Cardiovascular Computed Tomography and Society of Thoracic Radiology. J Cardiovasc Comput Tomogr 11:74–84.  https://doi.org/10.1016/j.jcct.2016.11.003 CrossRefPubMedGoogle Scholar
  14. 14.
    Members TF, Montalescot G, Sechtem U et al (2013) 2013 ESC guidelines on the management of stable coronary artery disease: the Task Force on the management of stable coronary artery disease of the European Society of Cardiology. Eur Heart J 34:2949–3003.  https://doi.org/10.1093/eurheartj/eht296 CrossRefGoogle Scholar
  15. 15.
    Maurovich-Horvat P, Ferencik M, Voros S et al (2014) Comprehensive plaque assessment by coronary CT angiography. Nat Rev Cardiol 11:390–402.  https://doi.org/10.1038/nrcardio.2014.60 CrossRefPubMedGoogle Scholar
  16. 16.
    Szilveszter B, Celeng C, Maurovich-Horvat P (2016) Plaque assessment by coronary CT. Int J Cardiovasc Imaging 32:161–172.  https://doi.org/10.1007/s10554-015-0741-8 CrossRefPubMedGoogle Scholar
  17. 17.
    Opolski MP, Ó Hartaigh B, Berman DS, et al (2015) Current trends in patients with chronic total occlusions undergoing coronary CT angiography. Heart heartjnl-2014-306616. doi:  https://doi.org/10.1136/heartjnl-2014-306616
  18. 18.
    Fihn SD, Gardin JM, Abrams J et al (2012) 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 60:e44–e164.  https://doi.org/10.1016/j.jacc.2012.07.013 CrossRefPubMedGoogle Scholar
  19. 19.
    Levine GN, Bates ER, Bittl JA et al (2016) 2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines: An Update of the 2011 ACCF/AHA/SCAI Guideline for Percutaneous Coronary Intervention, 2011 ACCF/AHA Guideline for Coronary Artery Bypass Graft Surgery, 2012 ACC/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease, 2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction, 2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes, and 2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing Noncardiac Surgery. Circulation 134:e123–e155.  https://doi.org/10.1161/CIR.0000000000000404 CrossRefPubMedGoogle Scholar
  20. 20.
    Kolossváry M, Szilveszter B, Édes IF et al (2016) Comparison of Quantity of Coronary Atherosclerotic Plaques Detected by Computed Tomography Versus Angiography. Am J Cardiol 117:1863–1867.  https://doi.org/10.1016/j.amjcard.2016.03.031 CrossRefPubMedGoogle Scholar
  21. 21.
    Puchner SB, Liu T, Mayrhofer T et al (2014) High-risk plaque detected on coronary CT angiography predicts acute coronary syndromes independent of significant stenosis in acute chest pain: results from the ROMICAT-II trial. J Am Coll Cardiol 64:684–692.  https://doi.org/10.1016/j.jacc.2014.05.039 CrossRefPubMedPubMedCentralGoogle Scholar
  22. 22.
    Ferencik M, Mayrhofer T, Puchner SB et al (2015) Computed tomography-based high-risk coronary plaque score to predict acute coronary syndrome among patients with acute chest pain - Results from the ROMICAT II trial. J Cardiovasc Comput Tomogr 9:538–545.  https://doi.org/10.1016/j.jcct.2015.07.003 CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Chandrashekhar Y, Min JK, Hecht H, Narula J (2016) CAD-RADS: A Giant First Step Toward a Common Lexicon? JACC Cardiovasc Imaging 9:1125–1129.  https://doi.org/10.1016/j.jcmg.2016.07.002 CrossRefPubMedGoogle Scholar
  24. 24.
    Bittencourt MS, Hulten E, Ghoshhajra B et al (2014) Prognostic value of nonobstructive and obstructive coronary artery disease detected by coronary computed tomography angiography to identify cardiovascular events. Circ Cardiovasc Imaging 7:282–291.  https://doi.org/10.1161/CIRCIMAGING.113.001047 CrossRefPubMedGoogle Scholar
  25. 25.
    Authors/Task Force members, Windecker S, Kolh P, et al (2014) 2014 ESC/EACTS Guidelines on myocardial revascularization: The Task Force on Myocardial Revascularization of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)Developed with the special contribution of the European Association of Percutaneous Cardiovascular Interventions (EAPCI). Eur Heart J 35:2541–2619. doi:  https://doi.org/10.1093/eurheartj/ehu278
  26. 26.
    SCOT-HEART investigators (2015) CT coronary angiography in patients with suspected angina due to coronary heart disease (SCOT-HEART): an open-label, parallel-group, multicentre trial. Lancet Lond Engl 385:2383–2391. doi:  https://doi.org/10.1016/S0140-6736(15)60291-4
  27. 27.
    Hoffmann U, Truong QA, Schoenfeld DA et al (2012) Coronary CT angiography versus standard evaluation in acute chest pain. N Engl J Med 367:299–308.  https://doi.org/10.1056/NEJMoa1201161 CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Min JK, Dunning A, Lin FY et al (2011) Rationale and design of the CONFIRM (COronary CT Angiography EvaluatioN For Clinical Outcomes: An InteRnational Multicenter) Registry. J Cardiovasc Comput Tomogr 5:84–92.  https://doi.org/10.1016/j.jcct.2011.01.007 CrossRefPubMedGoogle Scholar
  29. 29.
    Plank F, Burghard P, Friedrich G et al (2016) Quantitative coronary CT angiography: absolute lumen sizing rather than %stenosis predicts hemodynamically relevant stenosis. Eur Radiol 26:3781–3789.  https://doi.org/10.1007/s00330-016-4229-2 CrossRefPubMedPubMedCentralGoogle Scholar
  30. 30.
    Tonino PAL, De Bruyne B, Pijls NHJ et al (2009) Fractional flow reserve versus angiography for guiding percutaneous coronary intervention. N Engl J Med 360:213–224.  https://doi.org/10.1056/NEJMoa0807611 CrossRefPubMedGoogle Scholar
  31. 31.
    Delgado Sánchez-Gracián C, Oca Pernas R, Trinidad López C et al (2016) Quantitative myocardial perfusion with stress dual-energy CT: iodine concentration differences between normal and ischemic or necrotic myocardium. Initial experience. Eur Radiol 26:3199–3207.  https://doi.org/10.1007/s00330-015-4128-y CrossRefPubMedGoogle Scholar
  32. 32.
    Dwivedi G, Liu Y, Tewari S et al (2016) Incremental Prognostic Value of Quantified Vulnerable Plaque by Cardiac Computed Tomography: A Pilot Study. J Thorac Imaging 31:373–379.  https://doi.org/10.1097/RTI.0000000000000236 CrossRefPubMedGoogle Scholar
  33. 33.
    Nadjiri J, Hausleiter J, Jähnichen C et al (2016) Incremental prognostic value of quantitative plaque assessment in coronary CT angiography during 5 years of follow up. J Cardiovasc Comput Tomogr 10:97–104.  https://doi.org/10.1016/j.jcct.2016.01.007 CrossRefPubMedGoogle Scholar
  34. 34.
    Schlett CL, Ferencik M, Kriegel MF et al (2012) Association of pericardial fat and coronary high-risk lesions as determined by cardiac CT. Atherosclerosis 222:129–134.  https://doi.org/10.1016/j.atherosclerosis.2012.02.029 CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Puchner SB, Lu MT, Mayrhofer T et al (2015) High-Risk Coronary Plaque at Coronary CT Angiography Is Associated with Nonalcoholic Fatty Liver Disease, Independent of Coronary Plaque and Stenosis Burden: Results from the ROMICAT II Trial. Radiology 274:693–701.  https://doi.org/10.1148/radiol.14140933 CrossRefPubMedGoogle Scholar
  36. 36.
    Ghoshhajra BB, Lee AM, Ferencik M et al (2013) Interpreting the interpretations: the use of structured reporting improves referring clinicians’ comprehension of coronary CT angiography reports. J Am Coll Radiol JACR 10:432–438.  https://doi.org/10.1016/j.jacr.2012.11.012 CrossRefPubMedGoogle Scholar
  37. 37.
    Marcovici PA, Taylor GA (2014) Journal Club: Structured radiology reports are more complete and more effective than unstructured reports. AJR Am J Roentgenol 203:1265–1271.  https://doi.org/10.2214/AJR.14.12636 CrossRefPubMedGoogle Scholar
  38. 38.
    Stillman AE, Rubin GD, Teague SD et al (2008) Structured reporting: coronary CT angiography: a white paper from the American College of Radiology and the North American Society for Cardiovascular Imaging. J Am Coll Radiol JACR 5:796–800.  https://doi.org/10.1016/j.jacr.2008.04.002 CrossRefPubMedGoogle Scholar
  39. 39.
    MacMahon H, Naidich DP, Goo JM, et al (2017) Guidelines for Management of Incidental Pulmonary Nodules Detected on CT Images: From the Fleischner Society 2017. Radiology 161659. doi:  https://doi.org/10.1148/radiol.2017161659
  40. 40.
    Lung CT Screening Reporting and Data System (Lung-RADSTM) - American College of Radiology. https://www.acr.org/Quality-Safety/Resources/LungRADS. Accessed 28 Apr 2017

Copyright information

© European Society of Radiology 2017

Authors and Affiliations

  1. 1.Cardiac MR PET CT ProgramMassachusetts General Hospital, Harvard Medical SchoolBostonUSA
  2. 2.Department of Diagnostic and Interventional RadiologyUniversity of Leipzig – Heart CenterLeipzigGermany
  3. 3.MTA-SE Cardiovascular Imaging Research Group, Heart and Vascular CenterSemmelweis UniversityBudapestHungary

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