CAD-RADS: Bringing Clarity to Results
By Scott Jerome, DO, FSCCT
Have you ever gotten a test result back and not really know what it means or what to do with it? As a cardiologist living on the East Coast — where Lyme disease surveillance is ramped up — when I order a Lyme disease test, it comes back with a bazillion antibodies and I really don’t know what they mean. I just want to know: Does the patient have it or not?”
So imagine being a primary care provider (PCP). While you know the correct test for the correct patient, when you order a cardiac CT angiogram, the results come back: “There is spotty calcification with some external remodeling and a moderate stenosis.” The PCP thinks “What does that mean, what am I supposed to do with that?” That’s where CAD-RADS come in.
For years, there has been a push for standard and structured reporting as a major part of quality metrics from the Intersocietal Accreditation Commission (IAC). This is in alignment with many other “RADS” reporting systems (RADS stands for Reporting and Data System, e.g., LUNG-RADS, HI-RADS and many more).
CAD-RADS (Coronary Artery Diseases Reporting and Data System) is SCCT’s standard reporting system; it has been a multisocietal and multidisciplinary effort. Its goal is to improve quality care though standardization of terminology, report organization and minimization of variation. Unique to this document, compared with other reporting systems, is the added dimension of recommending management strategies.
CAD-RADS reporting is broken into two major categories: stable and acute chest pain, represented by Tables 2 and 3 in the document. In Table 3, acute chest pain caveats include a negative first troponin, non-diagnostic ECG and low to intermediate risk (TIMI risk score<4) in the hospital setting or the emergency department.
CAD-RADS scores range from 0 (no plaque or stenosis) to a score of CAD-RADS 5 (100% stenosis). In addition to reporting stenosis there are categories including interpretation (absent disease to severe disease), further cardiac investigation suggested (ranging from none to functional assessment and viability) and management suggestions (reassurance to cardiac angiography). The reporting should be based on the most severe stenosis and in vessels of greater then 1.5 mm. There are four modifier categories as well:
N — non-diagnostic
S — stent
G — graft
V — vulnerability of the plaque
For stable chest pain (Table 2), CAD-RADS 0 has no disease, no further investigations and reassurance and evaluation for non-cardiac chest pain as the management. CAD-RADS 1, 1-24% minimal disease, CAD-RADS 2, 25-49% mild non-obstructive disease and risk factor modification. CAD-RADS 3, 50-69% moderate stenosis, consider functional assessment and symptom/guideline directed care. The fourth category is subdivided into (A) 70-99% severe stenosis with recommendations of consideration of cardiac catheterization as well as guideline directed care and (B) left main greater then 50% or 3 vessel disease of greater then 70%. CAD-RADS 5 is a total occluded vessel.
Table 3 is dealing with acute chest pain considered low to intermediate risk, non-diagnostic EKG and a negative troponin. The scoring system of 0 to 5 is similar, but now the interpretation category begins with acute coronary syndrome highly unlikely with minimal plaque to likely and very likely as the plaque severity progresses. Management strategies again follow standard guidelines.
The bottom line is we’re trying not to be cryptic; rather, we’re trying to be clear and concise. This type of reporting should be implemented universally, as it can only help focus our treatment, improve quality of care and minimize misinterpretation and confusion.
When you report using CAD-RADS, even if you report correctly — such as CAD-RADS 3 — the referring/ordering provider still may not know what you mean. One suggestion is to incorporate Tables 2 and 3 directly into the report. That way the ordering provider can easily look see what CAD-RADS 3 actually means. If you are using electronic medical record and the ordering provider gets the results through their HER, I suggest incorporating a link to the original paper in addition to the final report.