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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

Related references

CAD-RADS 2.0 calculator · Coronary calcium score percentile · Fleischner pulmonary nodule follow-up

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This is a reference implementation of a published guideline, for use by qualified clinicians. It does not account for patient-specific factors and is not a substitute for clinical judgment or a formal radiology consultation. Templates are generic scaffolds for licensed radiologists; verify wording against your own practice standards. See our full disclaimer.