The validity and applicability of CAD-RADS in the management of patients with coronary artery disease

Relationship between pericoronary fat-attenuation values quantified by coronary computed tomography angiography and coronary artery disease severity

AIM

To explore the relationship between pericoronary fat-attenuation index (FAI) values and coronary artery disease (CAD) severity measured using coronary computed tomography angiography (CCTA).

MATERIALS AND METHODS

This study retrospectively included 428 patients with CAD who were eligible and underwent CCTA at our hospital. CAD severity on CCTA images including obstructive stenosis and extensive lesions, and segment stenosis and involvement score (SSS, SIS), and CAD-RADS classification were assessed. FAI values for left anterior descending (LAD), left circumflex (LCX) branches, and right coronary artery (RCA) were quantified using fully automated software. The relationship between FAI values and CAD severity was assessed using univariate and multivariate regression models.

RESULTS

Univariate analyses showed that sex and current smoking were associated with elevated FAILAD and FAILCX values (all P<0.05), whereas CAD severity was not relevant (all P>0.05). Not only clinical factors such as sex, current smoking, and hypertension were associated with elevated FAIRCA, but also indicators to assess CAD severity including obstructive stenosis, SIS, and SSS were related to it (all P<0.05). Multivariate analysis demonstrated that after correcting for the effects of other conventional cardiovascular risk factors and CCTA imaging features, current smoking was an independent risk factor for elevated FAI values (odds ratio [OR] = 0.569, 0.458, and 0.517; all P<0.05), whereas that SSS (OR=1.041, P=0.027) for elevated FAIRCA values.

CONCLUSION

Following correction for conventional cardiovascular risk factors and imaging characteristics, current smoking was an independent clinical risk factor for elevated FAI values, and SSS was an independent risk factor for elevated FAIRCA values.

Dataset for Automatic Region-based Coronary Artery Disease Diagnostics Using X-Ray Angiography Images

X-ray coronary angiography is the most common tool for the diagnosis and treatment of coronary artery disease. It involves the injection of contrast agents into coronary vessels using a catheter to highlight the coronary vessel structure. Typically, multiple 2D X-ray projections are recorded from different angles to improve visualization. Recent advances in the development of deep-learning-based tools promise significant improvement in diagnosing and treating coronary artery disease. However, the limited public availability of annotated X-ray coronary angiography image datasets presents a challenge for objective assessment and comparison of existing tools and the development of novel methods. To address this challenge, we introduce a novel ARCADE dataset with 2 objectives: coronary vessel classification and stenosis detection. Each objective contains 1500 expert-labeled X-ray coronary angiography images representing: i) coronary artery segments; and ii) the locations of stenotic plaques. These datasets will serve as a benchmark for developing new methods and assessing existing approaches for the automated diagnosis and risk assessment of coronary artery disease.

Correlation between TyG index and coronary atherosclerosis assessed by CCTA in elderly male patients: a cross-sectional study

BACKGROUND

Age is a major risk factor associated with the complexity of coronary artery disease (CAD), and the prognosis of elderly patients with coronary heart disease is relatively poor. Metabolic disturbances are prevalent in the elderly population and contribute to CAD morbidity and mortality. This study aimed to investigate the relationship between the triglyceride-glucose (TyG) index and total coronary atherosclerotic burden assessed non-invasively by Coronary Computed Tomography Angiogram (CCTA) in the elderly population.

METHODS

This retrospective cross-sectional study involved 427 patients who underwent CCTA. The patients were divided into two groups based on their Leiden score: ≥5 and < 5. Comparisons between groups were conducted using t-tests or Mann-Whitney U tests for continuous variables and chi-square tests for categorical variables. The correlation between TyG and Leiden score was assessed using Spearman's rank correlation coefficient. Univariable and multivariable logistic regression analyses were performed to assess the role of TyG in atherosclerosis risk, using clinical variables previously shown to independently predict a high Leiden score.

RESULTS

The levels of age and HbA1c% were significantly higher in patients with Leiden score ≥ 5. Patients with Leiden score ≥ 5 showed no significant difference in TyG index compared to those with Leiden score < 5. Pearson correlation analysis showed that HbA1c% (r = 0.44, p < 0.01), age (r = 0.34, p < 0.01), and FBG (r = 0.15, p = 0.01) were positively correlated with Leiden score, while TyG index had no correlation with Leiden score (r = 0.05, p = 0.42). Multiple linear regression analysis showed that HbA1c% (β = 2.92, 95%CI: 2.25-3.56, P < 0.01) was positively correlated with Leiden score, while TyG index had no correlation with Leiden score (β = 0.73, 95%CI: -3.27-4.72, P < 0.01). HbA1c% was found to be an influential factor for obstructive CVD (β = 1.86, 95%CI: 1.50-2.29, P < 0.01), while TyG index was not an independent risk factor for obstructive CVD (β = 0.39, 95%CI: 0.12-1.32, P = 0.13).

CONCLUSION

The TyG index did not show any significant correlation with the Leiden score and obstructive CVD as a risk factor in elderly male population. On the other hand, HbA1c% was identified as an influential factor for both the Leiden score and obstructive CVD.

Comparison of prognostic value between CAD-RADS 1.0 and CAD-RADS 2.0 evaluated by convolutional neural networks based CCTA

Objectives

The aim of the present study was to investigate the prognostic value of the novel coronary artery disease reporting and data system (CAD-RADS) 2.0 compared with CAD-RADS 1.0 in patients with suspectedcoronary artery disease (CAD) evaluated by convolutional neural networks (CNN) based coronary computed tomography angiography (CCTA).

Methods

A total of 1796 consecutive inpatients with suspected CAD were evaluated by CCTA for CAD-RADS 1.0 and CAD-RADS 2.0 classifications. Kaplan-Meier and multivariate Cox models were used to estimate major adverse cardiovascular events (MACE) inclusive of all-cause mortality or myocardial infarction (MI). The C-statistic was used to assess the discriminatory ability of the two classifications.

Results

In total, 94 (5.2%) MACE occurred over the median follow-up of 45.25 months (interquartile range 43.53-46.63 months). The annualized MACE rate was 0.014 (95% CI: 0.011-0.017). Kaplan-Meier survival curves indicated that the CAD-RADS classification, segment involvement score (SIS) grade, and Computed Tomography Fractional Flow Reserve (CT-FFR) classification were all significantly associated with the increase in the cumulative MACE (all P < 0.001). CAD-RADS classification, SIS grade, and CT-FFR classification were significantly associated with endpoint in univariate and multivariate Cox analysis. CAD-RADS 2.0 showed a further incremental increase in the prognostic value in predicting MACE (c-statistic 0.702, 95% CI: 0.641-0.763, P = 0.047), compared with CAD-RADS 1.0.

Conclusions

The novel CAD-RADS 2.0 evaluated by CNN-based CCTA showed higher prognostic value of MACE than CAD-RADS 1.0 in patients with suspected CAD.

An Egyptian study to assess the accuracy and reliability of CAD-RADS CT coronary angiography algorithm in the evaluation of coronary artery disease

Background

Multidetector computed tomography angiography (MDCT) is a non-invasive examination for coronary artery disease. Coronary artery disease reporting and data system (CAD-RADS) is a structured reporting system that successfully facilitated communication with clinicians. Our study aimed to assess the accuracy as well as the agreement of the CAD-RADS system with the conventional angiography results.

Results

48 patients were enrolled in this prospective study, all patients underwent MDCT coronary angiography and conventional coronary artery angiography. An excellent inter method agreement between coronary CT angiography (CCTA) and conventional coronary angiography was noted for the left main trunk (LMT) with k = 1 (p < 0.001). An excellent inter method agreement was found for the proximal, mid- and distal segments of the left anterior descending artery (LAD) and the second diagonal segment, with k = 1, 0.842 0.886 and 0.886, respectively (p < 0.001). A good agreement was noted at the first diagonal segment with k = 0.765 (p < 0.001). An excellent inter-method agreement was found for the proximal, mid- and distal segments of the left circumflex artery (LCx) and the obtuse marginal branch, with k = 0.838, 0.846, 1 and 0.846, respectively (p < 0.001). An excellent agreement was found for the proximal and mid-segments of the right coronary artery (RCA) and the posterior descending artery, with k = 1 for all segments (p < 0.001), yet a good agreement was noted at its distal segment with k = 0.782 (p < 0.001). The overall per-patient sensitivity, specificity and accuracy of the CT coronary angiography were 92.9%, 90% and 91.7% respectively.

Conclusions

The CAD-RADS algorithm and invasive coronary angiography agreed perfectly; thus, CT coronary angiography can be used as the first screening test and the invasive coronary angiography can be spared for cases requiring intervention.

CAD-RADS™ 2.0 - 2022 Coronary Artery Disease-Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI)

Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.

CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System.: An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI)

Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.

CAD-RADS™ 2.0 - 2022 Coronary Artery Disease-Reporting and Data System: An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR), and the North America Society of Cardiovascular Imaging (NASCI)

Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care.

CAD-RADS™ 2.0 - 2022 Coronary Artery Disease - Reporting and Data System An Expert Consensus Document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Cardiology (ACC), the American College of Radiology (ACR) and the North America Society of Cardiovascular Imaging (NASCI)

Coronary Artery Disease Reporting and Data System (CAD-RADS) was created to standardize reporting system for patients undergoing coronary CT angiography (CCTA) and to guide possible next steps in patient management. The goal of this updated 2022 CAD-RADS 2.0 is to improve the initial reporting system for CCTA by considering new technical developments in Cardiac CT, including data from recent clinical trials and new clinical guidelines. The updated CAD-RADS classification will follow an established framework of stenosis, plaque burden, and modifiers, which will include assessment of lesion-specific ischemia using CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion (CTP), when performed. Similar to the method used in the original CAD-RADS version, the determinant for stenosis severity classification will be the most severe coronary artery luminal stenosis on a per-patient basis, ranging from CAD-RADS 0 (zero) for absence of any plaque or stenosis to CAD-RADS 5 indicating the presence of at least one totally occluded coronary artery. Given the increasing data supporting the prognostic relevance of coronary plaque burden, this document will provide various methods to estimate and report total plaque burden. The addition of P1 to P4 descriptors are used to denote increasing categories of plaque burden. The main goal of CAD-RADS, which should always be interpreted together with the impression found in the report, remains to facilitate communication of test results with referring physicians along with suggestions for subsequent patient management. In addition, CAD-RADS will continue to provide a framework of standardization that may benefit education, research, peer-review, artificial intelligence development, clinical trial design, population health and quality assurance with the ultimate goal of improving patient care. Keywords: Coronary Artery Disease, Coronary CTA, CAD-RADS, Reporting and Data System, Stenosis Severity, Report Standardization Terminology, Plaque Burden, Ischemia Supplemental material is available for this article. This article is published synchronously in Radiology: Cardiothoracic Imaging, Journal of Cardiovascular Computed Tomography, JACC: Cardiovascular Imaging, Journal of the American College of Radiology, and International Journal for Cardiovascular Imaging. © 2022 Society of Cardiovascular Computed Tomography. Published by RSNA with permission.

Validation of Coronary Artery Disease Reporting and Data System (CAD-RADS) and Application of Coronary Artery Calcium Data and Reporting System (CAC-DRS) as New Standardized Tools in the Management of Coronary Artery Disease Patients

Background and Objectives

The coronary artery disease reporting and data system (CAD-RADS) is intended to standardize the reporting of CCTA and the subsequent management guidelines of CAD. The present study was conducted to investigate the validation of CAD-RADS and the application of coronary calcium grading in CAD management.

Patients and Methods

The current study is a single-center prospective study that involved 177 participants with chest pain who were submitted to coronary CT angiography (CCTA). Two reviewers independently assessed CCTA results and gave each patient a CAD-RADS category. The reference standard for determining the clinical utility of CAD-RADS was invasive coronary angiography (ICA). The inter-reviewer agreement (IRA) was tested using the intra-class correlation (ICC).

Results

The study enrolled 111 cases with non-significant CAD and 66 cases with significant CAD based on ICA findings. According to the reviewer, the CAD-RADS had a sensitivity, specificity, and accuracy of 90.9 to 100%, 89.2 to 94.6%, and 93.16 to 93.2%, respectively, for predicting severe CAD. The IRA for CAD-RADS categories was excellent (ICC = 0.960). The best cut-off value for predicting severe CAD was CAD-RADS > 3. Significant relation between Ca and severe CAD (p<0.001) was detected.

Conclusion

The current study provides a good understanding of CAD-RADS as a standard tool with high diagnostic accuracy.

Coronary artery disease imaging reporting and data system (CAD-RADS): what radiologists need to know?

The aim of this work is to review Coronary Artery Disease Imaging Reporting and Data System (CAD-RADS) that was designed to standardize reporting language and improve the communication of data among radiologists and clinicians. Stenotic lesions are graded into 5 grades ranging from 0 (no stenosis) to 5 (total occlusion), where the highest grade represents the final score. The expert consensus platform has added 4 special modifiers (non-diagnostic, stent, graft, and vulnerability) to aid patient management through linking these scores with decision algorithm and treatment plan. Adherence to standard imaging protocol; knowledge of normal, variant, and anomalous anatomy; and skillful evaluation of stenosis are important for proper utilization of this reporting system. Lastly, radiologists should be aware of the inherited benefits, limitations, and common pitfalls of this classification system.

Coronary CT Angiography CAD-RADS versus Coronary Artery Calcium Score in Patients with Acute Chest Pain

Background The Coronary Artery Disease Reporting and Data System (CAD-RADS) was established in 2016 to standardize the reporting of coronary artery disease at coronary CT angiography (CCTA). Purpose To assess the prognostic value of CAD-RADS at CCTA for major adverse cardiovascular events (MACEs) in patients presenting to the emergency department with chest pain. Materials and Methods This multicenter retrospective observational cohort study was conducted at four qualifying university teaching hospitals. Patients presenting to the emergency department with acute chest pain underwent CCTA between January 2010 and December 2017. Multivariable Cox regression analysis was used to evaluate risk factors for MACEs, including clinical factors, coronary artery calcium score (CACS), and CAD-RADS categories. The prognostic value compared with clinical risk factors and CACS was also assessed. Results A total of 1492 patients were evaluated (mean age, 58 years ± 14 years [standard deviation]; 759 men). During a median follow-up period of 31.5 months, 103 of the 1492 patients (7%) experienced MACEs. Multivariable Cox regression analysis showed that a moderate to severe CACS was associated with MACEs after adjusting for clinical risk factors (hazard ratio [HR] range, 2.3-4.4; P value range, <.001 to <.01). CAD-RADS categories from 3 to 4 or 5 (HR range, 3.2-8.5; P < .001) and high-risk plaques (HR = 3.6, P < .001) were also associated with MACEs. The C statistics revealed that the CAD-RADS score improved risk stratification more than that using clinical risk factors alone or combined with CACS (C-index, 0.85 vs 0.63 [P < .001] and 0.76 [P < .01], respectively). Conclusion The Coronary Artery Disease Reporting and Data System classification had an incremental prognostic value compared with the coronary artery calcium score in the prediction of major adverse cardiovascular events in patients presenting to the emergency department with acute chest pain. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Vliegenthart in this issue.

Coronary Artery Disease Reporting and Data System (CAD-RADS) Adoption: Analysis of Local Trends in a Large Academic Medical Center

Purpose

To perform a retrospective review of Coronary Artery Disease Reporting and Data System (CAD-RADS) adoption at a high-volume cardiac CT service.

Materials and Methods

In this retrospective study, the adoption of CAD-RADS in 6562 coronary CT angiography (CTA) reports from January 1, 2017, to February 13, 2020, was evaluated. Reports without CAD-RADS were classified as opt-outs or exceptions to CAD-RADS. CAD-RADS classifications were retrospectively assigned to the opt-outs and the clinical indications for coronary CTA.

Results

CAD-RADS scores were reported in 95% (6264 of 6562) of cases. Among the 5% (n = 298) of reports not reported according to CAD-RADS, 58% (n = 172) were considered opt-outs and 42% (n = 126) were exceptions. Cases with higher degree of stenosis, stents, and coronary artery bypass grafts (CABGs) occurred more often in opt-outs versus reports with CAD-RADS (odds ratio [OR], 8.3 [95% CI: 1.6, 42.1]; P < .001). The quarterly opt-out rate decreased over consecutive quarters in the 1st year (OR, 0.77 [95% CI: 0.61, 0.96]; P = .01), then stabilized. Quarterly opt-out rate for patients with stents decreased over time (OR, 0.82 [95% CI: 0.73, 0.92]; P = .008), as did the opt-out rates in patients with CABG (OR, 0.83 [95% CI: 0.76, 0.91]; P < .001). Exceptions (n = 126) included coronary dissections (44%), anomalous coronary arteries (41%), coronary artery aneurysms or pseudoaneurysms (10%), vasculitis (2%), stent complications (2%), and extrinsic compression of grafts (2%).

Conclusion

CAD-RADS was adopted rapidly and widely. Readers opted out of its use most often in complex cases of CAD, and the most common exceptions were coronary dissections and anomalous coronary artery.Keywords: Coronary Arteries, CT Angiography© RSNA, 2021.

Coronary Artery Disease Reporting and Data System: A Comprehensive Review

The Coronary Artery Disease Reporting and Data System (CAD-RADS) is a standardized reporting method for coronary computed tomography angiography (CCTA). It summarizes the findings of CCTA in 6 categories ranging from CAD-RADS 0 (complete absence of coronary artery disease) to CAD-RADS 5 (total occlusion of at least one vessel). It is applied on per patient basis for the highest grade of the stenotic lesion. The CAD-RADS also provides category-specific treatment recommendations, helping patient management. The main objectives of the CAD-RADS are to improve the consistency in reporting, facilitate the communication between interpreting and referring clinicians, recommend the best course of patient management, and produce consistent data for quality improvement, research and education. However, CAD-RADS has many limitations, resulting into the misclassification of the observed findings, misinterpretation of the final category, and misguidance for the treatment based upon the single score. In this review, the authors discuss the CAD-RADS categories and modifiers, along with the strengths and limitations of this new classification system.

Imaging of the aortic root on high-pitch non-gated and ECG-gated CT: awareness is the key!

The aortic pathologies are well recognized on imaging. However, conventionally cardiac and proximal aortic abnormalities were only seen on dedicated cardiac or aortic studies due to need for ECG gating. Advances in CT technology have allowed motionless imaging of the chest and abdomen, leading to an increased visualization of cardiac and aortic root diseases on non-ECG-gated imaging. The advances are mostly driven by high pitch due to faster gantry rotation and table speed. The high-pitch scans are being increasingly used for variety of clinical indications because the images are free of motion artifact (both breathing and pulsation) as well as decreased radiation dose. Recognition of aortic root pathologies may be challenging due to lack of familiarity of radiologists with disease spectrum and their imaging appearance. It is important to recognize some of these conditions as early diagnosis and intervention is key to improving prognosis. We present a comprehensive review of proximal aortic anatomy, pathologies commonly seen at the aortic root, and their imaging appearances to familiarize radiologists with the diseases of this location.