CAD-RADS 2.0: What We Need to Know

Purpose or LearningObjectiveTo describe CAD-RADS 2.0 classification system andhighlight the differences from the first version.Methods or BackgroundCoronary CT angiography (CCTA) is the primary imagingmodality to assess symptomatic patients with stable symptoms, intermediate-riskacute chest pain and intermediate or high pre-test probability of obstructivecoronary disease. Coronary Artery Disease - Reporting and Data System(CAD-RADS) was first released in 2016 to standardize reporting of the CCTA (1).CAD-RADS 2.0 is published in July 2022 and aims to improve the first reportingsystem under the guidance of new guidelines and technical developments .Theupdated 2022 CAD-RADS 2.0 classification will follow a framework of stenosis,plaque burden and modifiers, with the option to also include ischemiaevaluation by CT fractional-flow-reserve (CT-FFR) or myocardial CT perfusion(CTP), if performed. As in the original version, the most severe coronaryartery luminal stenosis defined on a per-patient basis will be the centralcomponent of assessment and will provide the numeric descriptor. In addition,methods to estimate, quantify and report overall plaque burden will beprovided. Collectively, the goal of these additions is intended to enhancepatient management decisions following CCTA.(2).Results or FindingsThe First CAD-RADS classification was focused on the stenosisgrading and 4 complementary modifiers were described: N( non-diagnostic), S(stent), G (graft), and V ( vulnerability).On CAD-RADS 2.0; stenosis grading ,N-S and G modifiers remain the same. Describing a grading scale for plaqueburden is the main addition to the first version. There are also two newmodifiers; I+, I- and I± (ischemia), and E (exceptions). V modifier becomes HRP(high-risk plaque) .Stenosis grading ranges from CAD-RADS 0 ( no visiblestenosis) to CAD-RADS 5 (at least one occluded vessel).Plaque burden can bedetermined by Coronary Artery Calcium testing , Segment İnvolvement Score orvisual estimation and it ranges from P1 (mild) to P4 (extensive). P1 (mild)refers to 1-2 vessels with mild amount of plaque (Fig.1-2). P2 (moderate) isused for 1-2 vessels with moderate or 3 vessels with mild amount of plaque(Fig.3). P3 (severe) refers to 3 vessels with moderate amount or 1 vessel withsevere amount of plaque. P4 (extensive) is known for 2 or 3 vessels with severeamount of plaque (Fig 4,5). “İ" indicates lesion specific ischemia orreversible perfusion defect detected by Computed tomography fractional flowreserve (CT-FFR) or computed tomography perfusion (CTP). “E” is used for non-atherosclerotic causes of coronary abnormalities (Fig.6).