Coronary CT Angiography Report (CAD-RADS)

Exam: Coronary CT Angiography [with / without] Coronary Artery Calcium Scoring

Date/Time: [Exam date and time]

Patient: [Patient identifiers per institutional standard]

Referring Clinician: [Name, credentials]

Interpreting Physician: [Name, credentials]

Clinical History

Indication: [Clinical question] (If not provided, state "Clinical history: Not provided")

Symptom context: [Acute / Stable / Asymptomatic / Not documented] (Only include if explicitly documented)

Prior coronary history: [Known CAD, prior PCI/stents, prior CABG, or none reported] (Only include elements explicitly documented)

Comparison: [Prior study modality and date, or none]

Technique

Scanner: [Scanner type and detector configuration]

Acquisition: [Prospective / Retrospective] ECG-gated; [heart rate range if documented]

Contrast: [Agent], [volume] mL at [rate] mL/s

Medications: [Beta-blocker and/or nitroglycerin with doses, or none]

Radiation dose: CTDIvol [value] mGy; DLP [value] mGy·cm

Image quality: [Excellent / Good / Acceptable / Poor]; [reason for limitation and affected segments if applicable] (Identify nondiagnostic segments explicitly as this drives the N modifier)

Findings

CAC: Total Agatston score [value]; [percentile if available] (Omit if not performed)

Plaque burden: [P1 / P2 / P3 / P4] by [CAC-based / SIS / visual estimation] (Omit for CAD-RADS 0)

Dominance: [Right / Left / Co-dominant]

Anomalies: [Anomalous origin or significant variant] (Only include if present)

Coronary arteries:

• Most significant lesion: [Vessel/segment] — [stenosis category: 1–24% / 25–49% / 50–69% / 70–99% / 100%]; [calcified / non-calcified / mixed] plaque
• LM: [Stenosis category and plaque description, or no plaque]
• LAD: [Stenosis category by segment, plaque type, branch involvement if present]
• LCx: [Stenosis category by segment, plaque type, branch involvement if present]
• RCA: [Stenosis category by segment, plaque type, branch involvement if present]

High-risk plaque: [Low attenuation plaque / Positive remodeling / Napkin-ring sign / Spotty calcification] in [segment] (Only include if HRP criteria met)

Stents: [Vessel/segment]: [Evaluable / Non-evaluable]; [in-stent stenosis category] (Only include if stents present; state reason if non-evaluable)

Grafts: [Graft type and target]: [Patent / Occluded]; [stenosis at anastomosis/body if present] (Only include if grafts present)

CT-FFR: [Value] at [location] — [I+ / I− / I±] (Only include if performed)

Non-coronary findings: [Significant cardiac findings; significant extracardiac findings] (Note if not assessed due to protocol limitations)

Impression

CAD-RADS: [0 / 1 / 2 / 3 / 4A / 4B / 5 / N]/[P1 / P2 / P3 / P4]/[N]/[HRP]/[I+ / I− / I±]/[S]/[G]/[E] (Include only applicable modifiers in this order; omit P for CAD-RADS 0; use 4B for LM ≥50% or 3-vessel ≥70%)

• [Most significant lesion location and severity]
• [Left main or multivessel disease if present]
• [Plaque burden in plain language]
• [Nondiagnostic segments with statement that obstructive disease cannot be excluded, if applicable]

Recommendations

• [Category-matched management guidance] (Use conditional phrasing; direct to local pathways if clinical context not provided)
• [HRP statement: elevated risk irrespective of stenosis severity; consider risk optimization] (Only if HRP present)
• [Ischemia-driven escalation recommendation] (Only if I+ present)
• [Additional evaluation may be warranted for nondiagnostic segments] (Only if N modifier applies)

Critical result communication: [Person contacted], [method], [date/time], [information conveyed] (Only include if critical/urgent findings identified)