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Normal Coronary CTA Report Template (CAD-RADS 0)
Normal coronary CT angiogram report template: dominance, segment-by-segment patency of the left main, LAD, circumflex and RCA, CAD-RADS 0 category, calcium score, cardiac chambers and non-cardiac findings, with notes on CAD-RADS 2.0 modifiers and anomalous origins.
EXAMINATION: CT coronary angiogram with intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Stable chest pain, low to intermediate pretest probability of coronary artery disease”] COMPARISON: None available. TECHNIQUE: Non-contrast ECG-gated calcium scoring acquisition followed by [prospectively / retrospectively] ECG-gated coronary CT angiography after the intravenous administration of [x] mL of iodinated contrast. Heart rate [x] bpm [after oral/intravenous beta blockade]; sublingual nitroglycerin was [administered / not administered]. Multiplanar, curved and 3D reformats were reviewed. Image quality: [excellent / good / adequate], without significant motion or misregistration artifact. FINDINGS: Coronary artery calcium score: Total Agatston score 0. Coronary dominance: [Right] dominant. Coronary origins: The left main and right coronary arteries arise normally from the left and right coronary sinuses respectively. No anomalous origin or course. No myocardial bridging. Left main coronary artery: Normal caliber. No plaque or stenosis. Bifurcates into the LAD and circumflex. [No ramus intermedius.] Left anterior descending artery: Patent to the apex through the proximal, mid and distal segments. No plaque or stenosis. Diagonal branches (D1, D2) are patent. Left circumflex artery: Patent through the proximal and distal segments. No plaque or stenosis. Obtuse marginal branches are patent. Right coronary artery: Patent through the proximal, mid and distal segments. No plaque or stenosis. The posterior descending and posterolateral branches are patent. Overall: No coronary atherosclerotic plaque. No stenosis in any segment. CAD-RADS 0. Cardiac chambers and myocardium: Normal left ventricular size and wall thickness. No myocardial thinning, fatty replacement or subendocardial hypoenhancement. Normal right ventricle and atria. No left atrial appendage thrombus. Valves: No aortic valve calcification. Trileaflet aortic valve. No mitral annular calcification. Pericardium: No pericardial effusion or thickening. Aorta and pulmonary arteries: Normal caliber of the aortic root ([x] mm at the sinuses of Valsalva) and ascending aorta ([x] mm). No dissection. Normal pulmonary artery caliber. Pulmonary veins: Four pulmonary veins drain normally into the left atrium. Non-cardiac findings: No pulmonary nodule or focal consolidation. No mediastinal or hilar lymphadenopathy. The visualized upper abdomen is unremarkable. No acute osseous abnormality. IMPRESSION: 1. Normal coronary CT angiogram. No coronary plaque or stenosis. CAD-RADS 0. 2. Coronary artery calcium score 0 (Agatston). 3. Normal coronary origins and course. Normal cardiac chambers, valves and aortic root. No significant non-cardiac finding.
Dictation notes
- CAD-RADS 2.0 grades the maximal stenosis (0 none, 1 minimal 1-24%, 2 mild 25-49%, 3 moderate 50-69%, 4A severe 70-99%, 4B left main 50%+ or three-vessel 70%+, 5 occluded) with modifiers for plaque burden (P1-P4), stent (S), graft (G), high-risk plaque (HRP), ischemia (I) and nondiagnostic (N); the category and modifiers belong in the impression verbatim.
- A CAD-RADS 0 requires no plaque at all; one small calcified plaque anywhere is CAD-RADS 1 with a P1 burden modifier, and the difference changes whether preventive therapy is recommended.
- Image quality and heart rate are reported in the technique: a segment that is uninterpretable from motion or calcium blooming is called nondiagnostic (modifier N) rather than normal.
- Name the dominance and check every origin — an anomalous interarterial right coronary from the left sinus, with a slit-like ostium and intramural course, is a surgical finding on an otherwise normal study.
- The incidental findings (pulmonary nodules, aortic root and ascending aorta diameter, hiatal hernia, esophageal thickening, breast or thyroid lesions in the field) are reported with the guideline thresholds; a coronary CTA is also a limited chest CT.
Related references
CAD-RADS 2.0 calculator · Coronary calcium score percentile · Fleischner pulmonary nodule follow-up
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