A new classification system was released to standardize the reporting of coronary artery disease (CAD) based on coronary CT angiography.
The Coronary Artery Disease Reporting and Data System (CAD-RADS) features a scale ranging from 0 (no stenosis) to 5 (total occlusion of at least one artery) and corresponds with category-specific recommendations for further imaging or management or both. Modifiers S (stent), G (graft), and V (vulnerable plaque) are used to better describe an artery.
“Decreasing the variation in reporting is one aspect that will contribute to wider dissemination in clinical practice, minimize error and to ultimately improve patient outcome,” Ricardo C. Cury, MD, of Baptist Hospital of Miami, and colleagues wrote in the document released online in the Journal of Cardiovascular Computed Tomography, the Journal of the American College of Radiology, and JACC: Cardiovascular Imaging.
The expert consensus document came from the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology, and the North American Society for Cardiovascular Imaging. It was also endorsed by the American College of Cardiology.
A Common Language
A result of a joint effort between radiologists and cardiologists, “this scoring system provides a clear sense of what coronary CT angiography findings are actionable, and what to do about them,” Pamela S. Douglas, MD, of Duke University School of Medicine, told MedPage Today.
For example, “we have not had any indication of how to manage patients with nonobstructive CAD — no clinical trials or guidelines regarding treatment,” said Douglas, who was not involved in the drafting of CAD-RADS.
Although “CT angiography is enjoying increasingly more widespread use on the heel of large randomized clinical trials such as PROMISE and SCOT-HEART which showed its value relative to standard of care functional testing,” Douglas noted that a noninvasive test like CT angiography hasn’t been around long enough to detect such mild disease.
Consensus document co-author Matthew Budoff, MD, of UCLA School of Medicine, agreed.
“Coronary CT angiography is robust in evaluating plaque (atherosclerosis) and stenosis more accurately than other methods and results in better cardiovascular outcomes,” he told MedPage Today. “However, as a young modality, the data collected and reported is less standardized than other more mature modalities.”
Now with the standardized reporting system, “hopefully this will spur the cardiovascular community to pay more attention to this at-risk group,” Douglas concluded.
Yet James C. Blankenship, MD, of Geisinger Medical Center in Danville, Pa., expressed disagreement with at least one aspect of the document.
“It is odd that a document describing a reporting system is also making recommendations regarding management of patients with the lesions on which they are reporting,” he told MedPage Today, citing the document’s recommendation to “consider hospital admission in high-risk clinical settings” for patients with vulnerable plaque.
With no acute strategies proven effective for vulnerable plaque, to do so because of a visualization seems “over-reaching,” he suggested.
Ultimately, it is “unclear” how the CAD-RADS scale will influence interventional cardiologists, Blankenship said. They will “instantly know the implications of a certain percentage stenosis in an artery, but won’t necessarily remember that at CAD-RADS 3 corresponds to 50% to 69% stenosis,” he added.
Registries should now follow CAD-RADS, Leslee J. Shaw, PhD, of Atlanta’s Emory School of Medicine and president-elect of SCCT, suggested in a press release.
“In addition, CAD-RADS will provide a framework of standardization that may benefit education, research, peer-review and quality assurance with the potential to ultimately result in improved quality of care,” the consensus document suggested.
“Today’s article is the starting point for a very important process. Next, to promote incorporation of CAD-RADS into daily practice, SCCT will partner with other societies and industry to develop tools for every coronary CT angiography facility considering adoption of CAD-RADS,” said Cury.
He and his colleagues emphasized in the document that the positive predictive value of coronary CT angiography is lower in patients with previously known, rather than suspected, CAD. Furthermore, it is also hard to diagnose in-stent restenosis with this tool.
“Thus,” they wrote, “the use of coronary CT angiography in patients with previously known CAD should be carefully considered. Management decisions derived from coronary CT angiography results depend on other clinical findings as well as the patient-specific previous history, and should be made on an individual basis.”
Cury disclosed consulting for GE Healthcare and Novartis, as well as receiving research support from GE Healthcare.
Budoff declared receiving grant support from GE Healthcare.
Other co-authors reported various ties to industry.
Douglas reported receiving research funding from GE Healthcare and HeartFlow.
Blankenship reported no relevant conflicts of interest.
Journal of Cardiovascular Computed Tomography
Cury RC, et al “CAD-RADSTM coronary artery disease — reporting and data system: an expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT), the American College of Radiology (ACR), and the North American Society for Cardiovascular Imaging (NASCI). Endorsed by the American College of Cardiology” J Cardiovasc Comput Tomogr 2016; DOI: 10.1016/j.jcct.2016.04.005.