Wk 3, Case 2 - Review

Patient History
A 65-year-old male presents with a history of hyperlipidemia and tobacco use and complains of new onset of chest pain with exertion. Family history of early coronary artery disease.

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 of sublingual nitroglycerin
Contrast: 85mL Isovue 370 injected at 7mL/sec.
QC (signal/noise): Good
Artifacts: None
Complications: None
Heart rate: 53 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 large amount of calcified plaque with a severe (70-99%) stenosis of the 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 medium amount of partially calcified plaque with minimal (1-24%) stenosis in the proximal LAD, mild (25-49%) stenosis of the mid-LAD and distal LAD.

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 partially calcified plaque with minimal (1-24%) stenosis in the proximal LCX, distal LCX, and a mild (25-49%) stenosis of the third branching OM. 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 small amount of partially calcified plaque with minimal (1-24%) stenosis of the proximal RCA, mid-RCA, and PLB.

NON-CORONARY CARDIAC FINDINGS:
Chambers: Left atrial size is normal with no left atrial appendage filling defect. The left and right ventricular cavity size are 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 dilated, measuring 3.8 x 4.0 x 4.0 cm at the Sinuses of Valsalva. There is no aortic rupture, aneurysm, dissection, or 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 a medium amount of partially calcified plaque in a multivessel distribution
2. Obstructive coronary artery disease with severe (70-99%) stenosis of the distal left main. There is mild (25-49%) stenosis of the mid-LAD, OM3, and minimal (1-24%) stenosis of the proximal LAD, distal LAD, pLCX, distal LCX, proximal RCA, mid-RCA and PLB.
3. The aorta is dilated at the sinuses of Valsalva.

RECOMMENDATIONS:
CAD-RADS: 4B(Left main ≥50%, severe stenosis). Aggressive risk factor modification and preventive medical therapy. Anti-anginal therapy is recommended. Recommend ICA, revascularization is recommended.
Modifier: None
Plaque: P2- Moderate amount of plaque
Final diagnosis: I25.10 CAD, native