title: Scoring of coronary artery calcium scans: history, assumptions, current limitations, and future directions.
abstract: Coronary artery calcium (CAC) scanning is a reliable, noninvasive technique for estimating overall coronary plaque burden and for identifying risk for future cardiac events. Arthur Agatston and Warren Janowitz published the first technique for scoring CAC scans in 1990. Given the lack of available data correlating CAC with burden of coronary atherosclerosis at that time, their scoring algorithm was remarkable, but somewhat arbitrary. Since then, a few other scoring techniques have been proposed for the measurement of CAC including the Volume score and Mass score. Yet despite new data, little in this field has changed in the last 15 years. The main focus of our paper is to review the implications of the current approach to scoring CAC scans in terms of correlation with the central disease - coronary atherosclerosis. We first discuss the methodology of each available scoring system, describing how each of these scores make important indirect assumptions in the way they account (or do not account) for calcium density, location of calcium, spatial distribution of calcium, and microcalcification/emerging calcium that might limit their predictive power. These assumptions require further study in well-designed, large event-driven studies. In general, all of these scores are adequate and are highly correlated with each other. Despite its age, the Agatston score remains the most extensively studied and widely accepted technique in both the clinical and research settings. After discussing CAC scoring in the era of contrast enhanced coronary CT angiography, we discuss suggested potential modifications to current CAC scanning protocols with respect to tube voltage, tube current, and slice thickness which may further improve the value of CAC scoring. We close with a focused discussion of the most important future directions in the field of CAC scoring.
authors.affiliation: Department of Internal Medicine, UPMC Mckeesport Hospital, Mckeesport, PA, USA; The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
authors.forename: Krishna
authors.initials: K
authors.lastname: Alluri
authors.affiliation: The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
authors.forename: Parag H
authors.initials: PH
authors.lastname: Joshi
authors.affiliation: Department of Radiology, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Travis S
authors.initials: TS
authors.lastname: Henry
authors.affiliation: The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA.
authors.forename: Roger S
authors.initials: RS
authors.lastname: Blumenthal
authors.affiliation: The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA; Center for Prevention and Wellness Research, Baptist Health Medical Group, Miami Beach, FL, USA.
authors.forename: Khurram
authors.initials: K
authors.lastname: Nasir
authors.affiliation: The Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD, USA. Electronic address: Mblaha1@jhmi.edu.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Blaha
mesh_terms: D000465:Algorithms; D002114:Calcinosis / Q000503:physiopathology*; D002309:Cardiology / Q000379:methods* / Q000592:standards; D017023:Coronary Angiography; D003324:Coronary Artery Disease / Q000175:diagnosis / Q000000981:diagnostic imaging; D003331:Coronary Vessels / Q000503:physiopathology*; D006801:Humans; D007091:Image Processing, Computer-Assisted; D011857:Radiographic Image Interpretation, Computer-Assisted; D018570:Risk Assessment; D014057:Tomography, X-Ray Computed
keywords: Agatston score; Coronary artery calcium; EBCT; MDCT; Mass score; Volume score