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Normal Coronary Calcium Score CT Report Template (Agatston 0)
Normal coronary artery calcium scoring CT report template: Agatston score of zero vessel by vessel, MESA percentile wording, CAC-DRS category and the standard zero-score impression, with incidental non-cardiac finding notes.
EXAMINATION: CT coronary artery calcium scoring without intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Cardiovascular risk assessment”] COMPARISON: None available. TECHNIQUE: Prospectively ECG-gated non-contrast axial CT of the heart at [x] mm slice thickness. Coronary artery calcium was quantified by the Agatston method with dedicated scoring software. Dose reduction techniques were used. FINDINGS: Coronary artery calcium (Agatston): Left main coronary artery: 0 Left anterior descending artery: 0 Left circumflex artery: 0 Right coronary artery: 0 Total Agatston score: 0 Risk category: A score of 0 is at the [x]th percentile for age, sex and race/ethnicity by MESA reference data. CAC-DRS: A0 (Agatston 0, no vessels involved). Non-coronary cardiac findings: Normal heart size. No pericardial effusion or pericardial calcification. No aortic valve or mitral annular calcification. Aorta: The visualized thoracic aorta is normal in caliber. No aortic calcification. Lungs: No pulmonary nodule or focal consolidation on the limited field of view. Mediastinum: No lymphadenopathy. The visualized esophagus is normal. Bones and soft tissues: Unremarkable. IMPRESSION: 1. Coronary artery calcium score of 0 (Agatston). No coronary artery calcification identified. CAC-DRS A0. 2. A zero calcium score indicates a very low 10-year risk of atherosclerotic cardiovascular events but does not exclude noncalcified plaque. 3. No significant incidental non-cardiac finding.
Dictation notes
- Report each of the four vessels individually and the total — CAC-DRS (A0-A3 with the number of vessels, or V0-V3 visual) needs the vessel count, and left main calcium carries extra weight.
- Give the MESA percentile with the inputs (age, sex, race/ethnicity) named — a score of 50 is reassuring at 75 and alarming at 45, and the percentile is what the referring cardiologist uses to start or defer a statin.
- A zero score is not a clean coronary tree: the standard qualifier that noncalcified plaque is not excluded belongs in the impression, and in a symptomatic patient the report should say that calcium scoring is not a substitute for coronary CTA.
- Incidental lung nodules, aortic ectasia, aortic valve calcification and coronary anomalies are the extra value of the study — report them under Fleischner or aortic size thresholds rather than leave them in a “non-cardiac findings: see above”.
- A coronary stent, prior CABG or known coronary disease makes the score uninterpretable for risk stratification — state that the Agatston method is not validated in that setting and report the calcium descriptively instead.
Related references
Fleischner pulmonary nodule follow-up
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