Coronary CTA

and CAD-RADS 2.0

WARIT TARATHIPMON, M.D.
THAMMASAT UNIVERSITY HOSPITAL
10 JAN 2024
CONTENTS
• Principles and techniques
• Coronary artery calcium (CAC) scores
• Coronary CTA
• CAD-RADS 2.0
Principles and
Techniques
Indications
• Evaluation of coronary arteries for atherosclerosis or anomalies
• Evaluation of non-coronary pathology including the great vessels,
chambers, myocardium, valves, or pericardium
• Evaluation of cardiac chamber function, including ejection fraction
and chamber volumes
• Evaluation of low-to-intermediate risk symptomatic patients
presenting with symptoms of stable angina or acute chest pain
• Discordant or inconclusive stress tests
Contraindications
• History of severe and/or anaphylactic contrast reaction
• Inability to cooperate with scan acquisition and/or breath-hold
instructions
• Pregnancy
• Clinical instability (e.g. acute myocardial infarction, decompensated
heart failure, severe hypotension)
• Renal impairment
Case-by-case basis
Patient preparation
• No food for 3-4 hours prior to exam
• No caffeine products for 12 hours prior to exam
• May drink water or clear fluids (without caffeine)
• Take all regular medications the day of exam
• Take pre-medications for contrast allergy
• Suspend metformin for at least 48 hours after contrast administration
(If CIN -> metformin induce lactic acidosis)
• Pediatric patient requires anesthesia
Heart rate control
• Target HR ≤ 60 bpm
• Higher HR may be acceptable if a target HR cannot be reached

1. Beta-blockers (first-line) – oral, IV or both

• Metoprolol; most commonly used, safety and low costs
• Oral dose: 50-100 mg given 1 hr prior to CT scan
• If the target HR is not achieved -> IV doses immediately prior to CT scan
• IV dose: 5 mg (can repeat q 5 mins, max. dose 20-25 mg)
• Atenolol; in patients with hepatic dysfunction (clearance by kidneys)
• Slow-release forms of beta-blockers should NOT be used
Heart rate control
2. Ivabradine (in addition or alternative to BBs) – oral or IV
• Mechanism: direct I(f) current inhibitor (in SA node cells)
• Approval for use in CHF
• Lowers HR without affecting myocardial contractility, impulse
conduction or blood pressure
• Ineffective in patients that are not in sinus rhythm
• Oral dose: 15 mg or 7.5 mg, 1-2 hr before scanning
Nitrates
• Coronary vasodilatation -> enhance coronary evaluation
• Regimens
• Sublingual nitroglycerin (400-800 mcg)
• Metered lingual spray (1-2 sprays)
• Onset: 5 mins
• Duration: 20-30 mins
• Side effects: hypotension, temporary headache
• Contraindication: taken with phosphodiesterase inhibitor (e.g. sildenafil,
vardenafil, or tadalafil) for Tx erectile dysfunction or pulmonary HT
Patient positioning
• Supine
• Arms raised above the head
• The heart centered within the gantry
• Special attention
• Ensure proper positioning and firm contact of ECG leads
• Ensure a high R-peak amplitude and low baseline noise
CM injection and imaging techniques
• High iodine concentrations (270-400 mg Iodine/cc)
• 18-20 gauge IV catheter placed in right upper extremity venous access
• Injection rate 5-7 mL/s
• Biphasic protocols
• Undiluted CM bolus 50-120 mL -> Followed by a 20–30 mL saline (RV is almost entirely void
of CM at the time of scan acquisition)
• High contrast in Lt chambers, ascending Ao and CoA
• Triphasic protocols
• Undiluted CM bolus -> followed by a diluted contrast -> finally, the saline
• Dilution of CM can be varied (e.g., 20% iodine with 80% saline)
• Either bolus tracking or a test bolus protocol is acceptable
Scan range
• Native coronary arteries
• Below tracheal bifurcation or the mid-level
of left PA
• Extends to just below lower cardiac border

• CABG or congenital heart disease

• Extended scan range may be required
Modes of data acquisition
1. Prospective ECG-gated acquisition
2. Retrospective ECG-gated acquisition
 Modes of data acquisition
Prospective ECG-gating
 Part of cardiac cycle
 2-4 mSv
 Arrhythmia sensitive
(Prefer: NSR + HR ≤ 60-65bpm)
 Cannot measure cardiac function
 Calcium scoring
Retrospective ECG-gating
 Entire cardiac cycle
 8-15 mSv
 Less sensitive
 Can measure cardiac function
 Provide ‘backup’ data
Scan protocols
1. Overview image
• AP projection (scout, topogram, topographic scout image, etc.)
• Allows prescription of the scan range
2. Coronary calcium scan
• 120 kV at 2.5–3 mm slice thickness
• Prospectively ECG-triggered axial acquisition
• 65 and 80% of R-R interval
3. Coronary CT angiography
• HR and its variability -> planning the scan
• Patient's weight -> optimized tube voltage and tube current
Image post-processing formats
1. Transaxial images
2. Multiplanar reformation (MPR)
3. Maximum Intensity projection (MIP)
4. Curved Multiplanar Reformation (cMPR)
5. Volume-rendering technique (VRT)
Coronary artery calcium
(CAC) scores
CAC scores
• To detect coronary artery calcification (CAC)
• Vascular calcification -> strongly correlate with degree of atherosclerosis
(both calcified and noncalcified)
• ↑CAC are more likely to have non-calcified plaque -> prone to rupture
CAC scores
The Agatston score
• CAC must reach a threshold of 130 HU + at least 1 mm2
• Calcifications that are lower in attenuation or smaller in size are not included in
the score
• Vessel score = Sum of all CAC scores of the vessel
• Total calcium score = All CAC scores from all vessels

CAC scores = plaque area x attenuation weighting factor

e.g. A maximum attenuation value = 400 HU, occupies 8 mm2 area

CAC score = 4x8 = 32
 CAC scores
Methods Strengths Weaknesses
Agatston score Most validated and widely used Affected by small variations in image noise
(plaque area x method (reference standard) Strict adherence to original published
attenuation weighting Simple postprocessing protocol is necessary
factor) Limited interscan reproducibility
Volume score Relatively resistant to small variations in Does not account for plaque attenuation
(plaque area x section image noise Less validated compared with Agatston
thickness) Simple postprocessing method
Greater interscan reproducibility
Mass score Measure of true calcium hydroxyapatite Complex postprocessing
(plaque volume x mass in plaque Least validated method with very limited
calibration factor x mean Relatively resistant to small variations in supporting data
attenuation of plaque) image noise
Greater interscan reproducibility
CV Risk Assessment in Asymptomatic Patients

Multi-Ethnic Study of
Atherosclerosis (MESA)
• Synthesis of traditional risk factors
+ CAC score to estimate 10-year
CHD risk
To Guide Statin Therapy

Current recommendation
The CAC score as a decision-making tool to reclassify risk and
guide statin therapy in patients older than 40 years who have
borderline to intermediate (5%–20%) 10-year ASCVD risk.
To Guide Statin Therapy
CAC Progression and Follow-up
• Low interscan variability in CAC scoring
• Unclear how CAC progression compares with baseline CAC score in terms of prognostic value

Society of Cardiovascular Computed Tomography (SCCT) guidelines

F/U at 5 years for patients with an initial CAC score of 0
F/U at 3–5 years for patients with a CAC score higher than 0

“Double zero” Best prognosis

- CAC score = 0 at baseline and 5 years later
- A very low 10-year risk (1.4%)
- A new-onset CAC risk at 5 years of 1.8%
Interpretation 2022
Interpretation 2018
Coronary CTA
American Heart Association (AHA) coronary segmentation
1/2

1/2 pRCA

mRCA
Acute margin of heart

dRCA
American Heart Association (AHA) coronary segmentation

dLAD

Bifurcation 1/2

mLAD

pLAD 1/2
LM

First large septal or D1

American Heart Association (AHA) coronary segmentation

Bifurcation

LM

First obtuse marginal

pCx

LCx
American Heart Association (AHA) coronary segmentation
American Heart Association (AHA) coronary segmentation

Coronary segments

Myocardial segments
Plaque Characterization
1. Noncalcified plaque (fibrotic, fatty)
2. Calcified plaque
3. Mixed/partly calcified plaque

Noncalcified plaque Partly calcified focal plaque Partly calcified focal plaque
Minimal luminal stenosis Moderate luminal narrowing Severe luminal narrowing
Coronary Stenosis
A% = 1 – (B / C)

A = lesion
B = actual lumen diameter
C = expected lumen diameter (average of
normal proximal and distal arterial lumen)

“Semi-automated stenosis quantification tool”

Arterial Compensatory Remodeling
1. Positive remodeling
• Exophytic growth of the artery wall at the site of coronary plaque
• Unimpressive luminal narrowing

Positively remodeled
lesions are more prone to rupture

2. Negative remodeling
• Endophytic growth of plaque
• Lumen decrease
Collateral Circulation
1. “Intercoronary” artery collateral vessel
- Vascular channels originating from 2 coronary arteries
2. “Intracoronary” (bridging) collateral vessel
- Dilated adventitial arteries that bypass an occlusion in the same coronary artery

Total occlusion

Collateral vessels
CAD-RADS 2.0
CAD-RADS 2.0

1. Stenosis
2. Plaque burden
3. Modifiers (N, HRP, I, S, G, E)
Stable chest pain
CAD-RADS categories
1. The CAD-RADS classification should be applied on a per-patient basis for the clinically most relevant
(usually highest-grade) stenosis.
2. All vessels greater than 1.5 mm in diameter should be graded for stenosis severity. CAD-RADS will
not apply for smaller vessels (<1.5 mm in diameter).
3. CAD-RADS 1 - This category should also include the presence of plaque with positive remodeling
and no evidence of stenosis.
4. Functional assessment : CT-FFR, CTP, stress testing (ETT, stress echocardiogram, SPECT, PET, Cardiac
MRI) or invasive FFR.
5. Further evaluation of CAD-RADS 3 and 4A with functional imaging or invasive coronary angiography
should be considered to identify a target lesion (if unknown) and if the patient has persistent
symptoms despite adequate medical therapy.
6. ICA may be favored if high-grade stenosis (>90%), high-risk plaque features or I+ (presence of lesion
specific ischemia on CT FFR or perfusion defects by CTP) or concordant ischemia by other stress
tests and a candidate for revascularization. It should be clarified that benefit of revascularization
should be confined to patients with persistent symptoms despite optimal medical therapy.
Acute chest pain
Plaque Burden

CAD-RADS 0 = absence of stenosis or plaque,

therefore P0 is not required as a classification

No single method that is used to quantify the

overall amount of plaque

Imagers select the technique which is

considered most appropriate for the individual
patient and according to local practice norms

Multiple different approaches can be

performed to assess plaque burden, the most
severe plaque assessment for the study should
be used.
 Plaque Burden
1. CAC testing – m/c Agatston method
• The CAC score alone lacks the important quantification of non-calcified plaque burden.
• Calcium score should not be used in isolation and should be combined with at least a qualitative
assessment of total plaque burden (calcified and non-calcified) to ensure that non-calcified
plaque is also accounted.
2. Segment involvement score (SIS)
• Assigning a score of 1 for each of the 16 coronary segments with any detectable plaque
3. Visual estimate of overall plaque burden
• Qualitative estimate of the amount of calcified and non-calcified plaque in each coronary vessel
4. Quantitative Assessment of Total Coronary Plaque
• To quantify total coronary plaque volume and plaque type
• Not widely available and not routinely performed
Category “P” should be used with category or modifier “N”
 Modifiers N - non-diagnostic study
Not all segments >1.5 mm diameter can be
Presence of suspected obstructive disease
interpreted with confidence

The study is not fully diagnostic AND stenosis ≥50% is present in a

diagnostic segment (CAD-RADS ≥ 3)

CAD-RADS 3/P2/N
Motion artifact obscuring the mid RCA
Stenosis of the mid LAD with 50–69% luminal narrowing

-Note-
If the LAD lesion were mild (less than 50% diameter stenosis), and
no other stenosis were identified, the patient would be coded as
CAD-RADS N.
 Modifiers S - stent

Indicates the presence of coronary stent anywhere in the coronary system

Category “P” should be added to indicate

the amount of plaque burden.
 Modifiers G - graft

Indicates the presence of at least one coronary-artery bypass graft

Only the grafts and the native coronary
artery segments distal to and including Category “P” should be assessed in both native
the anastomosis should be evaluated for coronary arteries and by-pass grafts
CAD RADS coding.

Example
Patient has a graft to LAD
- No significant stenosis in the graft, distal anastomosis and run-off vessel
- Demonstrates non-obstructive lesions (25–49%) in the LCX and RCA
- Moderate plaque burden
“CAD-RADS 2/P2/G”
 Modifiers HRP - High-risk Plaque Features
1. Spotty calcification : punctate calcium within a plaque
2. Napkin ring sign : central area of low attenuation plaque that is apparently in contact with the lumen;
and a ring-like peripheral rim of higher CT attenuation
3. Positive remodeling : ratio of outer vessel diameter at site of plaque divided by average outer
diameter of proximal and distal vessel greater than 1.1, or Av/[(Ap + Ad)/2] >1.1
4. Low attenuation plaque : <30 HU
≥2 high-risk features = modifier “HRP”

Napkin ring
 Modifiers HRP - High-risk Plaque Features
• The potential to develop to plaque rupture/thrombosis.
• Associated with…
- Acute chest pain – a higher risk of ACS
- Stable chest pain – a higher risk of incident adverse cardiovascular events
• Prevalence of these features on CCTA is high (~30% of CCTA, with an even higher
frequency in the presence of stenosis), and thus the positive predictive value for
identifying future events is relatively modest.
 Modifiers I – Ischemia: CT-FFR or CTP
• Indicates that an ischemia test has been performed (either CT-FFR or stress CTP).

Computed tomography fractional-flow reserve (CT-FFR)

• The computation of pressure across the coronary tree through the integration of machine
learning for anatomical data extraction and computational fluid dynamics

Invasive FFR
 Modifiers I – Ischemia: CT-FFR or CTP
Stress myocardial CT perfusion

Steal effect
Autoregulation (coronary flow reverse)
 Modifiers E - Exceptions
Non-atherosclerotic causes of coronary abnormalities
• Coronary dissection
• Anomalous origin of the coronary arteries
• Coronary artery aneurysm or pseudoaneurysm
• Vasculitis
• Coronary artery fistula
• Extrinsic coronary artery compression
• Arterio-venous malformation
• Other causes
• CAD-RADS score for stenosis
• Category “P” for plaque
• Then modifiers should be added, if present.
• The symbol “/” (slash) should follow each modifier in the following order:
i. First: modifier N (non-diagnostic)
ii. Second: modifier HRP (high-risk plaque)
iii. Third: modifier I (ischemia)
iv. Fourth: modifier S (stent)
v. Fifth: modifier G (graft)
vi. Sixth: modifier E (exceptions)
 Examples
1. Non-interpretable coronary stent with moderate amount of plaque burden without
evidence of other obstructive coronary disease.
2. Presence of a stent and at least one moderate stenosis demonstrating severe
amount of plaque burden and high-risk plaque features.
3. Presence of stent, grafts, severe amount of plaque burden and non-evaluable
segments due to metal artifacts.
4. Presence of a patent LIMA graft to the LAD and expected occlusion of the proximal
LAD and extensive amount of plaque burden in the native coronary arteries. Mild
non-obstructive stenosis in the RCA and LCX.
 Examples
5. For a patient with severe stenosis (70–99%) in one segment with severe amount of
plaque burden and a non-diagnostic area in another segment.
6. Presence of moderate stenosis (50–69%) with severe amount of plaque burden and
FFR-CT performed with a value < 0.75.
7. Presence of severe stenosis in the distal RCA (70–99%) with moderate amount of
plaque burden and stress CTP demonstrating no evidence of reversible ischemia.
8. Anomalous left main coronary artery from the right sinus of Valsalva with inter-
arterial course leading to severe compression and stenosis, absence of coronary
plaque and positive stress CTP.
Recommendations: Stable chest pain
Recommendations:
Acute chest pain
Main Changes for 2022 CAD-RADS
 Take Home message
• Principles and techniques • CAD-RADS 2.0
• Patient preparation • Stenosis
• Prospective vs Retrospective ECG-gated • Plaque burden
acquisition • Modifiers (N, HRP, I, S, G, E)
• Coronary artery calcium (CAC) scores
• The Agatston score
• Interpretation
• Coronary CTA
• Coronary segmentation
• Plaque characterization
• Coronary stenosis
• Arterial Compensatory Remodeling
• Collateral circulation
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