Visual coronary calcium scoring to support opportunistic CAD screening: comparative evaluation of three established systems and introduction of a novel scoring system

IF 2.9 Q2 CARDIAC & CARDIOVASCULAR SYSTEMS

IJC Heart and Vasculature Pub Date : 2026-02-01 Epub Date: 2026-01-19 DOI:10.1016/j.ijcha.2026.101875

Philipp Nicol , Rafael Adolf , Salvatore Cassese , Adnan Kastrati , Michael Joner , Heribert Schunkert , Martin Hadamitzky , Leif-Christopher Engel

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引用次数: 0

Abstract

Background

Coronary artery calcium (CAC) scoring is an established marker of atherosclerotic burden and cardiovascular risk. While the Agatston score is the clinical gold standard, alternative visual scoring methods—including the Visual Ordinal Score, Weston Score, and Vessel-specific extent-based score—are increasingly used, particularly in non-gated or opportunistic CT imaging. This study aimed to compare the diagnostic performance, inter-observer reliability, and correlation of different visual scoring methods against the Agatston score.

Methods

A total of 299 cases were evaluated using ECG-gated CT scans. Each case was independently scored in a blinded fashion by two observers using three visual methods: (1) Visual Ordinal Score (VS), (2) Weston Score (WS) and (3) Vessel-specific extent-based score (VSES). A novel visual CAC score was derived by combining Weston and Vessel-specific extent-based scoring (= Weston Extent Score, WES). Cohen’s Kappa and Intraclass Correlation Coefficients (ICC) were used for inter-observer agreement. Classification performance was assessed against Agatston-based categories (No CAC, Mild, Moderate, Severe), including accuracy, precision, sensitivity, and specificity. Correlation analyses were conducted using Pearson and Spearman coefficients.

Results

All scoring methods showed high correlation with the Agatston score (Spearman ρ > 0.87; p < 0.001). Visual scoring demonstrated the highest inter-observer agreement (Kappa = 0.94, ICC = 0.97), followed by Weston (Kappa = 0.90) and Vessel-Specific scores (Kappa = 0.77). Visual scoring also yielded the highest accuracy (Observer 1: 91.3 %, Observer 2: 90.0 %) The newly derived WES score achieved 80.9 % accuracy, with macro-averaged specificity of 93.8 % and improving diagnostic accuracy compared to WS and VSES.

Discussion

Different visual scoring offers excellent reproducibility and diagnostic accuracy for CAC classification, with strong correlation to the Agatston score. The newly-derived WES score could be useful in providing a practical balance regarding volumetric information (CAC densitiy) and anatomical distribution of CAC. These findings support the implementation of structured visual CAC scoring in clinical and opportunistic CT settings.

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视觉冠状动脉钙评分支持机会性CAD筛查：三种已建立的系统的比较评价和一种新的评分系统的介绍

背景：冠状动脉钙化（CAC）评分是动脉粥样硬化负担和心血管风险的一个既定标志。虽然Agatston评分是临床金标准，但其他视觉评分方法——包括视觉序数评分、Weston评分和血管特异性范围评分——越来越多地被使用，特别是在非门控或机会性CT成像中。本研究旨在比较不同视觉评分方法与Agatston评分的诊断性能、观察者间信度和相关性。方法对299例患者进行心电图门控CT扫描。每个病例由两名观察者以盲法独立评分，采用三种视觉方法：(1)视觉顺序评分（VS），(2)韦斯顿评分（WS）和(3)血管特异性程度评分（VSES）。结合Weston和血管特异性范围评分，得出了一种新的视觉CAC评分（= Weston范围评分，WES）。使用Cohen’s Kappa和class内相关系数（ICC）来衡量观察者间的一致性。根据agatston分类（无CAC、轻度、中度、重度）评估分类效果，包括准确性、精密度、敏感性和特异性。使用Pearson和Spearman系数进行相关分析。结果各评分方法均与Agatston评分高度相关（Spearman ρ > 0.87; p < 0.001）。视觉评分显示出最高的观察者间一致性（Kappa = 0.94, ICC = 0.97），其次是Weston评分（Kappa = 0.90）和Vessel-Specific评分（Kappa = 0.77）。视觉评分的准确率也最高（观察者1:91.3%，观察者2:90.0%）。新得出的WES评分准确率为80.9%，宏观平均特异性为93.8%，与WS和VSES相比，诊断准确率有所提高。不同的视觉评分为CAC分类提供了极好的再现性和诊断准确性，与Agatston评分有很强的相关性。新得出的WES评分可用于提供有关CAC的体积信息（CAC密度）和CAC的解剖分布的实际平衡。这些发现支持在临床和机会性CT设置中实施结构化视觉CAC评分。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

IJC Heart and Vasculature Medicine-Cardiology and Cardiovascular Medicine

CiteScore

4.90

自引率

10.30%

发文量

216

审稿时长

56 days

期刊介绍： IJC Heart & Vasculature is an online-only, open-access journal dedicated to publishing original articles and reviews (also Editorials and Letters to the Editor) which report on structural and functional cardiovascular pathology, with an emphasis on imaging and disease pathophysiology. Articles must be authentic, educational, clinically relevant, and original in their content and scientific approach. IJC Heart & Vasculature requires the highest standards of scientific integrity in order to promote reliable, reproducible and verifiable research findings. All authors are advised to consult the Principles of Ethical Publishing in the International Journal of Cardiology before submitting a manuscript. Submission of a manuscript to this journal gives the publisher the right to publish that paper if it is accepted. Manuscripts may be edited to improve clarity and expression.