How to Report a Coronary Artery CT
A cardiac CT report is designed to report the findings of a patient's cardiac CT scan to all interested parties, from their primary care doctor, to a cardiologist. Due to increasing pressure for radiology reports to be more systematic,and less subjective the Society of Cardiovascular Computed Tomography has developed "SCCT Guidelines for the Interpretation and Reporting of Coronary Computed Tomographic Angiography (CCTA)." In these guidelines, the SCCT offers suggestions as to what should be included in each CCTA report.
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Things You'll Need
- Medical history of the patient
- Clinical data on the CT performed
- Details of the diagnostic lab's/hospital's equipment
- Details of the diagnostic lab's/hospital's CCTA protocols
- Images from the CT scan (film, digital, paper)
- A copy of the SCCT stenosis severity classification
- A copy of the SCCT axial coronary segmentation model
- A computer
- A blank standardized reporting form (paper or digital template on computer) (optional)
- 2 copies of your final report, one for the files, one for the referring doctor
- Copies of any follow-up correspondence with the referring doctor
Instructions
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Coronary artery CT reporting
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Enter the clinical data on the report. Note down the following: date; patient name; date of birth; gender; referring doctor; patient's height, weight; symptoms; risk factors; relevant previous diagnostic tests; reason for the CCTA to be performed.
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Next write up the procedure data. Describe the tests performed (eg, CCTA, calcium scoring, etc.). Give the details of the equipment type, and the acquisition gating method, as well as the tube voltage, and dose modulation, if used. State the reconstruction slice thickness. Note down all the medications given during the test, such as the contrast type, beta blockers, nitroglycerin, etc, and the reason for administration, as well as the patient's response during the CCTA.
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3
Add a section entitled "key results" to the report. These should include the technical quality and overall quality of the images, and the presence and type of artifact, with any effect it might have on your interpretation.
State any coronary anomalies you might have found, as well as any uninterpretable/inaccessible areas. IF seen, state the stenosis location, severity, plaque type, and extent. Use the SCCT stenosis severity classification chart to describe your findings. Use the SCCT axial coronary segmentation model chart to describe your findings also. -
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Indicate any other important findings during the CCTA, such as abnormalities of the cardiac chambers; left ventricular size and volume; left atrial volume; right ventricular size and volume; and the left ventricular wall thickness and motion. Note any abnormalities of the pericardium, non-coronary vessels, pulmonary veins or lung tissue. State the left ventricular ejection fraction if it was recorded during the CCTA. Report any abnormalities of the valves, such as abnormal aortic and mitral valve calcification.
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Note down your impressions and conclusions, summarizing the key findings of the report. Give your overall assessement of the CCTA findings. Summarize the abnormal non-coronary cardiac findings, abnormal non-cardiac findings, and non-coronary cardiac interpretation. State any correlation to prior cardiac studies, such as confirmation or ruling out of any stenosis or blockage. State your clinical recommendations based on any findings.
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Print out two copies of the report, and send one the referring doctor. Keep a record of any communication you have with them.
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Tips & Warnings
It is a good idea to provide images of any representative coronary segments if you wish to support your report findings and conclusions, or feel that your interpretation might not be correct.
Make sure to keep to keep a record of any correspondence outside the radiology department, and any follow up with the referring doctor as needed. Each imaging center's protocols will be different; if there is anything unusual about yours, indicate it on the report.
