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CAD-RADS 2.0 calculator

Pick the maximal stenosis in the worst segment, tick left main or three-vessel disease if present, then add the modifiers. The calculator writes the CAD-RADS 2.0 category and modifier string in the order the document specifies, shows the interpretation and the management wording for both the stable and the acute chest pain pathway, and drafts the sentence for the impression. The category table, the plaque burden definitions and the high-risk plaque features are reproduced below.

How the category is chosen. The category is the maximal stenosis in any evaluable segment, with two overrides: left main stenosis ≥ 50% or ≥ 70% stenosis in all three vessels is CAD-RADS 4B whatever the single worst segment shows, and a total occlusion is CAD-RADS 5. A non-diagnostic study is CAD-RADS N. Modifiers follow the category in the order N → P → HRP → I → S → G → E, separated by slashes (e.g. CAD-RADS 4A/P3/HRP/I+/S).

CAD-RADS 2.0 categories

Category	Degree of maximal stenosis	Interpretation	Stable chest pain: further investigation	Acute chest pain
CAD-RADS 0	0% (no plaque or stenosis)	Documented absence of CAD	None.	ACS highly unlikely.
CAD-RADS 1	1-24% — minimal stenosis or plaque with no stenosis	Minimal non-obstructive CAD	None.	ACS highly unlikely.
CAD-RADS 2	25-49% — mild stenosis	Mild non-obstructive CAD	None.	ACS unlikely.
CAD-RADS 3	50-69% — moderate stenosis	Moderate stenosis	Consider functional assessment (stress testing, FFR-CT or CT perfusion); see the I modifier.	ACS possible.
CAD-RADS 4A	70-99% stenosis in 1 or 2 vessels	Severe stenosis	Consider ICA or functional assessment (stress testing, FFR-CT or CT perfusion); see the I modifier.	ACS likely.
CAD-RADS 4B	Left main ≥ 50% stenosis, or 3-vessel obstructive (≥ 70%) disease	Severe stenosis	ICA is recommended.	ACS likely.
CAD-RADS 5	100% — total coronary occlusion	Total coronary occlusion	Consider ICA and/or viability assessment.	ACS very likely.
CAD-RADS N	Non-diagnostic study	Obstructive CAD cannot be excluded	Additional or alternative evaluation is needed.	ACS cannot be excluded.

Management wording

Stable chest pain (Cury et al. 2022, Table 3) and acute chest pain (Table 4). In the acute setting the category is read together with troponin and ECG; CAD-RADS does not replace them.

Category	Stable chest pain	Acute chest pain
CAD-RADS 0	Reassurance. Consider non-atherosclerotic causes of chest pain. Preventive therapy and risk factor modification are not indicated on the basis of the CT; follow primary prevention guidelines.	Consider evaluation of non-ACS etiologies.
CAD-RADS 1	Consider non-atherosclerotic causes of chest pain. Consider preventive therapy and risk factor modification per guideline-directed care.	Consider evaluation of non-ACS etiologies.
CAD-RADS 2	Consider non-atherosclerotic causes of chest pain. Consider preventive therapy and risk factor modification per guideline-directed care; consider antiplatelet therapy.	Consider evaluation of non-ACS etiologies. If high-risk plaque (HRP) is present or there is clinical concern, consider hospital admission with troponin follow-up.
CAD-RADS 3	Consider symptom-guided anti-ischemic and preventive pharmacotherapy as well as risk factor modification per guideline-directed care. Other treatments (including options such as revascularization) should be considered per guideline-directed care.	Consider hospital admission with troponin follow-up and cardiology consultation. Consider functional assessment or ICA.
CAD-RADS 4A	Consider symptom-guided anti-ischemic and preventive pharmacotherapy as well as risk factor modification per guideline-directed care. Other treatments (including options such as revascularization) should be considered per guideline-directed care.	Consider hospital admission with troponin follow-up and cardiology consultation. Consider ICA; revascularization as appropriate.
CAD-RADS 4B	Consider symptom-guided anti-ischemic and preventive pharmacotherapy as well as risk factor modification per guideline-directed care. Other treatments (including options such as revascularization) should be considered per guideline-directed care.	Consider hospital admission with troponin follow-up and cardiology consultation. ICA is recommended; revascularization as appropriate.
CAD-RADS 5	Consider symptom-guided anti-ischemic and preventive pharmacotherapy as well as risk factor modification per guideline-directed care. Other treatments (including options such as revascularization) should be considered per guideline-directed care.	Consider expedited ICA and revascularization if appropriate (an occlusion may be chronic; correlate with ECG and troponin).
CAD-RADS N	Obstructive CAD cannot be excluded; management per the alternative test.	Additional or alternative evaluation is needed.

Plaque burden modifier (P)

CAD-RADS 2.0 grades total plaque burden by either definition. Use the Agatston calcium score when a non-contrast scan was acquired; otherwise use the segment involvement score (SIS, the number of segments in the 18-segment model with any plaque) or a visual estimate. The P modifier applies to CAD-RADS 1-5; CAD-RADS 0 means no plaque.

Modifier	Plaque burden	Agatston score	Segment involvement score
P1	Mild plaque burden	CAC 1-100	SIS 1-2
P2	Moderate plaque burden	CAC 101-300	SIS 3-4
P3	Severe plaque burden	CAC 301-999	SIS 5-7
P4	Extensive plaque burden	CAC ≥ 1000	SIS ≥ 8

High-risk plaque (HRP)

Two or more of the following features in any plaque. The 2016 modifier V (vulnerable plaque) was renamed HRP in 2.0.

Positive remodeling (remodeling index > 1.1)
Low-attenuation plaque (< 30 HU)
Spotty calcification (< 3 mm)
Napkin-ring sign

Ischemia modifier (I)

Used only when FFR-CT or CT perfusion was performed, and only with CAD-RADS 3 and 4 (50-99% stenosis). I+ ischemia present (FFR-CT ≤ 0.75 or a perfusion defect); I− no ischemia (FFR-CT > 0.80); I± borderline (FFR-CT 0.76-0.80). A negative functional result with CAD-RADS 3 or 4A favours medical therapy over ICA; a positive one favours ICA.

Other modifiers

S. Stent — one or more coronary stents are present; stent patency and in-stent restenosis are graded with the native segments.
G. Graft — prior coronary bypass surgery; the category reflects the most severe stenosis in grafts or in native vessels distal to a patent graft.
E. Exception — a non-atherosclerotic cause of stenosis or an important non-stenotic finding (dissection, anomalous origin, aneurysm, vasculitis, fistula, myocardial bridge).

Coronary calcium score interpretation — Agatston bands and the 2018 guideline strata behind the P modifier
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Source. Cury RC, et al. J Cardiovasc Comput Tomogr 2022;16(6):536-557. View on PubMed

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