Seeking advice on 69% RCA narrowing – Asymptomatic 74M

Height: 180 cm, Weight 89 Kg, non-smoker

I'm looking for some perspective on my recent heart scan results. I am a 74-year-old male. I feel great, I'm active (regular walking and moderate exercise), and I have no chest pain or shortness of breath/

Key CCTA Findings (Jan 2025):

·       Anatomy: Left Dominant coronary system.

·       RCA: Calcified lesions along the artery. Maximum stenosis of up to 69% in the distal segment. Note: PDA and PLA show no evidence of atherosclerotic disease.

·       LAD: Partially calcified lesions along the proximal and medial segments; proximal stenosis up to 49%.

·       Circumflex (CX): Calcified proximal lesion, stenosis up to 24%.

·       Calcium Score: 221 (Agatston).

·       Labs: LDL 53 mg/dL (on statins), Lp(a) 26.3 mg/dL.

·       Aorta: Normal ascending diameter (36 mm).

My Questions:

1.     Given the Left Dominant anatomy and the fact that the PDA/PLA are clear, how significant is the 69% distal RCA lesion? Does it supply a meaningful territory in this setup?

2.     My cardiologist suggested a stress test. Is a Stress Echo preferred over SPECT/Nuclear to avoid potential diaphragmatic artifacts common with the RCA?

3.     With an LDL of 53, low Lp(a), and no symptoms, is this a profile that typically requires invasive intervention, or is it managed conservatively with Optimal Medical Therapy (OMT)?