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Wk 4, Case 2 - Review

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Patient History
56-year-old female with probable cardiac chest pain, with detectable high sensitivity troponin. Request for cardiac CT for further risk stratification.

Report
PROCEDURE:

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 70-75%

Medications: 150 mg Lopressor, 800 mg nitroglycerin

Contrast: 70 mL Visipaque 320 injected at 6 mL/s.

QC (signal/noise): Good

Artifacts: None that are significant

Complications: None

Heart rate: 58 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 vessel that bifurcates to form a left anterior descending artery, and a left circumflex artery. There is no plaque or stenosis of the left main.

Left anterior descending artery (LAD):

The LAD is a large caliber vessel that supplies three diagonal vessels before wrapping the apex. There is a small amount of non-calcified plaque with positive remodeling and low attenuation in the mid LAD with mild (25-49%) stenosis. There is a small amount of non-calcified plaque with minimal (1-24%) stenosis in the second diagonal branch.

Left circumflex artery (LCX):

The circumflex is a medium caliber, non-dominant vessel that gives rise to three obtuse marginal branches before terminating within the AV groove. There is no plaque or stenosis in the left circumflex or its branches.

Right coronary artery (RCA):

The right coronary artery is a medium caliber, dominant vessel, arising from the right cusp, that gives rise to acute marginal branches before terminating as the posterior descending artery and right posterolateral artery. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis in the proximal RCA, and mid RCA.

NON-CORONARY CARDIAC FINDINGS:

Chambers: Left atrial size is normal in size with no left atrial appendage filling defect. The 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. 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.

There is a small amount of non-calcified plaque in the descending aorta.

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

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

EXTRACARDIAC FINDINGS:

Mediastinum: No mediastinal lymphadenopathy or relevant finding.

Lungs: The visualized lung, pleural and airways are unremarkable.

Upper Abdomen: Visualized structures are within normal limits.

Bones/Soft tissues: There are degenerative changes of the spine.

Impressions
1. Overall, there is a small amount of non-calcified and partially calcified plaque with high-risk plaque features in a two vessel distribution lesions.

2. Non obstructive coronary artery disease with mild (25-49%) stenosis of the mid LAD, and minimal (1-24%) stenosis of the proximal RCA, mid RCA, and second diagonal branch.

3. Small amount of non-calcified plaque in the descending aorta

4. No significant extra cardiac findings.

RECOMMENDATIONS:

CAD-RADS: 2 (Mild non-obstructive CAD up to 25-49% stenosis). Consider non-atherosclerotic causes of chest pain, consider aggressive preventive therapy and risk factor modification.

Plaque: P1 mild amount of plaque.

Modifier: High risk plaque features.

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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