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Wk 1, Case 5 - Review

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Patient History

49-year-old male with a history of hyperlipidemia and family history of early coronary artery disease, with new onset of chest pain with exertion. Request for CCTA for further risk stratification.

Report
PROCEDURE:

1. Cardiac CT Angiography (Computed tomographic angiography, heart, coronary arteries and bypass grafts (when present), with contrast material, including 3D image postprocessing (including evaluation of cardiac structure and morphology, assessment of cardiac function, and evaluation of venous structures, if performed).) (CPT code: 75574)

TECHNIQUE:

Gating: Prospective; data acquisition between 60-80%

Medications: 200 mg Lopressor, 800 mcg sublingual nitroglycerin

Contrast: 85 mL Isovue 370 injected at 7mL/sec.

QC (signal/noise): Good

Artifacts: None

Complications: None

Heart rate: 53 bpm.

Findings:
CORONARY ANGIOGRAPHY:

The left and right coronaries arise from their respective normal anatomic ostia.

The coronary circulation is right dominant.

Left Main (LM):

The left main is a large caliber short vessel that bifurcates to form a left anterior descending, and a left circumflex artery. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis of the distal left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that gives rise to three diagonal branches before wrapping the apex. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis in the proximal LAD and the second diagonal branch. There is a small amount of partially calcified plaque with positive remodeling and spotty calcification with severe (70-99%) stenosis of the mid LAD. There is no plaque or stenosis in the remainder of the vessel.

Left circumflex artery (LCX):

The circumflex is a large caliber, non-dominant vessel that gives rise to three obtuse marginal branches before terminating as a small vessel within the AV groove. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis in the proximal LCX. There is no plaque or stenosis in the remainder of the vessel.

Right coronary artery (RCA):

The right coronary artery is a large caliber, dominant vessel, arising right cusp, that gives rise to acute marginal branches before terminating as the posterior descending artery and postero-lateral branches. There is a large amount of partially calcified plaque with a severe (70-99%) stenosis of the proximal RCA, mild (25-49%) stenosis of the mid RCA and minimal (1-24%) stenosis of the distal RCA.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is normal with no left atrial appendage filling defect. The left and right ventricular cavity size is within normal limits. There are no abnormal filling defects.

Myocardium: Normal thickness. No outpouching or masses.

Valves: Trileaflet aortic valve with normal leaflet thickening and mild calcifications. Normal mitral valve leaflet thickening.

Pericardium: Normal thickness with no significant effusion or calcium present.

Aorta: There is no aortic rupture, aneurysm, dissection, intramural hematoma.

Pulmonary arteries: Normal in size without proximal filling defect. Not fully opacified.

Pulmonary veins: Normal pulmonary venous drainage. There are four pulmonary veins, two on the right and two on the left.

Impressions
1. Overall, there is large amount of partially calcified plaque with high-risk plaque features in a multivessel distribution

2. Obstructive coronary artery disease with severe (70-99%) stenosis of the mid LAD, and proximal RCA. There is mild (25-49%) stenosis of the mid RCA, and minimal (1-24%) stenosis of the distal LM, proximal LAD, D2, pLCX, and dRCA.

3. Aortic valve is mildly calcified.

RECOMMENDATIONS:

CAD-RADS: 4A (Severe 70-99%). Aggressive risk factor modification and preventive medical therapy. Anti-anginal therapy recommended. Consider ICA if symptoms persist despite medical therapy.

Modifier: High Risk Plaque Features.

Plaque: P3- Severe amount of plaque

Final diagnosis: I25.10 CAD, native

Case Discussion

Faculty

Giovanni E. Lorenz, DO

Cardiothoracic Radiologist

San Antonio Military Health System (SAMHS)

Emilio Fentanes, MD

Director of Cardiac Imaging, Department of Cardiology

Brooke Army Medical Center

Tags

Vascular

Coronary arteries

Cardiac CT (SCCT Cat B1 Video Case)

Cardiac CT

Cardiac

Acquired/Developmental

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