Abstract
Coronary artery calcification (CAC) is a well-known marker of subclinical coronary atherosclerosis, which is always detectable in non ECG-gated routine chest CT examinations, and its visual estimation is correlated to clinical outcomes. Agatston scoring is not routinely performed on these examinations. We sought to validate a visual scoring scheme we derived against ECG-gated CT’s and compare our system with another previously published visual scoring scheme in a different cohort of lung cancer screening participants. 50 COPDGene participants received, regular dose full inspiration (non-gated high mA), and low dose expiration CT (non-gated low mA) and ECG-gated CT’s at the same time. CAC was visually scored by 3 readers using our total visual scoring (TVS) method and compared to the Agatston score. The second portion of the study involved visual and Agatston scoring of a larger sample of 198 lung cancer screening patients, comparing visual scoring described by Shemesh et. al. and our TVS method. For the COPDGene participants, scores were highly correlated among readers (all ICC≥0.92), between the ECG-gated CT, non-gated high mA CT, and the non-gated low dose CT (all p<0.001), and with the Agatston score (all ICC≥0.90). For the cancer screening cohort there was very good agreement of our system and Shemesh scores. Correlations between reader scores, our system, Shemesh scores, and Agatston scores were also very good, ranging from 0.81-0.96. We derived cutoff values corresponding to Agatston risk quartiles for our system and Shemesh. There was excellent correlation of visual scoring with Agatston scoring on ECG-gated and non-gated CT. In lung cancer screening CT’s both ours and Shemesh visual scoring correlated well with Agatston scores and with each other. Visual scoring may predict clinically significant CAC in major Agatston categories.
Highlights
Atherosclerosis is the leading cause of death in the developed nations[1,2,3].Coronary artery calcification (CAC) quantified using electrocardiographically (ECG) gated computed tomography (CT) is well studied as a marker of subclinical coronary artery disease (CAD)
Despite promising advances in lung cancer diagnosis and therapy, we know that more smokers will die from cardiovascular disease than will survive or succumb to lung cancer[3].Agatston scoring performed on low dose non-gated CT for lung cancer screening correlates well with the assessment of the presence or absence of CAC and appropriately categorizes people into major Agatston score ranks[9, 10]
Though prior research has shown that visual scoring of CAC can be predictive of mortality, only one study we are aware of has correlated visual scoring of CAC with Agatston scores, and that was on conventional regular dose CT exams[12]
Summary
Atherosclerosis is the leading cause of death in the developed nations[1,2,3].Coronary artery calcification (CAC) quantified using electrocardiographically (ECG) gated computed tomography (CT) is well studied as a marker of subclinical coronary artery disease (CAD). Visual scoring of CAC on non ECG gated low dose CT scans (LDCT) of the chest performed for lung cancer screening has been demonstrated to be predictive of death from cardiovascular disease in a recent publication[5]. Despite promising advances in lung cancer diagnosis and therapy, we know that more smokers will die from cardiovascular disease than will survive or succumb to lung cancer[3].Agatston scoring performed on low dose non-gated CT for lung cancer screening correlates well with the assessment of the presence or absence of CAC and appropriately categorizes people into major Agatston score ranks[9, 10] This information may be valuable to referring clinicians allowing more appropriate cardiovascular risk stratification as Agatston scores have been shown to add independent and incremental benefits to cardiovascular event prediction above that of Framingham risk scores[11]. We believe that correlation of visual score to the more widely accepted Agatston score can be more readily incorporated in to the familiar coronary artery disease risk stratification and prevention [13]
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