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Wk 7, Case 4 - Review

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Patient History

59-year-old male with a history of hyperlipidemia, hypertension tobacco use, and diabetes mellitus type 2, with new onset of acute chest pain with exertion. An acute coronary syndrome is ruled out with negative cardiac biomarkers and no evidence of ischemia on ECG. Request for CCTA for further risk stratification and patient disposition from the Emergency Department.

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: 100 mg Lopressor, 800 mcg sublingual nitroglycerin

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

QC (signal/noise): Good

Artifacts: mild stairstep artifact

Complications: None

Heart rate: 50 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, and a left circumflex artery. There is a small amount of partially calcified plaque with minimal (1-24%) stenosis in the proximal and 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 large amount of partially calcified plaque with mild (25-49%) stenosis in the proximal LAD, and 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 non-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 medium amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal RCA, mid RCA and 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: The aorta is at the upper limits of normal measuring 3.8 x 3.5 x 3.3 cm at the Sinuses of Valsalva. 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 medium amount of partially calcified and non-calcified plaque in a multivessel distribution

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

3. The aorta is at the upper limits of normal at the sinuses of Valsalva.

RECOMMENDATIONS:

CAD-RADS: 2 (mild stenosis). Consider non atherosclerotic causes of symptoms. Aggressive risk factor modification and preventive medical therapy.

Modifier: None

Plaque: P2- Moderate 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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