Reliability analysis of visual ranking of coronary artery calcification on low-dose CT of the thorax for lung cancer screening: comparison with ECG-gated calcium scoring CT

  • Yoon Kyung Kim
  • Yon Mi Sung
  • So Hyun Cho
  • Young Nam Park
  • Hye-Young Choi
Original Paper


Coronary artery calcification (CAC) is frequently detected on low-dose CT (LDCT) of the thorax. Concurrent assessment of CAC and lung cancer screening using LDCT is beneficial in terms of cost and radiation dose reduction. The aim of our study was to evaluate the reliability of visual ranking of positive CAC on LDCT compared to Agatston score (AS) on electrocardiogram (ECG)-gated calcium scoring CT. We studied 576 patients who were consecutively registered for health screening and undergoing both LDCT and ECG-gated calcium scoring CT. We excluded subjects with an AS of zero. The final study cohort included 117 patients with CAC (97 men; mean age, 53.4 ± 8.5). AS was used as the gold standard (mean score 166.0; range 0.4–3,719.3). Two board-certified radiologists and two radiology residents participated in an observer performance study. Visual ranking of CAC was performed according to four categories (1–10, 11–100, 101–400, and 401 or higher) for coronary artery disease risk stratification. Weighted kappa statistics were used to measure the degree of reliability on visual ranking of CAC on LDCT. The degree of reliability on visual ranking of CAC on LDCT compared to ECG-gated calcium scoring CT was excellent for board-certified radiologists and good for radiology residents. A high degree of association was observed with 71.6 % of visual rankings in the same category as the Agatston category and 98.9 % varying by no more than one category. Visual ranking of positive CAC on LDCT is reliable for predicting AS rank categorization.


Coronary artery calcification Low-dose CT Lung cancer screening 


  1. 1.
    Greenland P, Bonow RO, Brundage BH et al (2007) ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation Clinical Expert Consensus Task Force (ACCF/AHA Writing Committee to Update the 2000 Expert Consensus Document on Electron Beam Computed Tomography) developed in collaboration with the society of atherosclerosis imaging and prevention and the society of cardiovascular computed tomography. J Am Coll Cardiol 49(3):378–402PubMedCrossRefGoogle Scholar
  2. 2.
    Aberle DR, Adams AM, Berg CD et al (2011) Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med 365(5):395–409PubMedCrossRefGoogle Scholar
  3. 3.
    Shaw LJ, Raggi P, Schisterman E et al (2003) Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiology 228(3):826–833PubMedCrossRefGoogle Scholar
  4. 4.
    Kim SM, Chung MJ, Lee KS et al (2008) Coronary calcium screening using low-dose lung cancer screening: effectiveness of MDCT with retrospective reconstruction. AJR Am J Roentgenol 190(4):917–922PubMedCrossRefGoogle Scholar
  5. 5.
    Wu MT, Yang P, Huang YL et al (2008) Coronary arterial calcification on low-dose ungated MDCT for lung cancer screening: concordance study with dedicated cardiac CT. AJR Am J Roentgenol 190(4):923–928PubMedCrossRefGoogle Scholar
  6. 6.
    Shemesh J, Henschke CI, Farooqi A et al (2006) Frequency of coronary artery calcification on low-dose computed tomography screening for lung cancer. Clin Imaging 30(3):181–185PubMedCrossRefGoogle Scholar
  7. 7.
    Shemesh J, Henschke CI, Shaham D et al (2010) Ordinal scoring of coronary artery calcifications on low-dose CT scans of the chest is predictive of death from cardiovascular disease. Radiology 257(2):541–548PubMedCrossRefGoogle Scholar
  8. 8.
    Agatston AS, Janowitz WR, Hildner FJ et al (1990) Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol 15(4):827–832PubMedCrossRefGoogle Scholar
  9. 9.
    Rosner B (1995) Fundamentals of biostatistics. Duxbury Press, New YorkGoogle Scholar
  10. 10.
    Blaha M, Budoff MJ, Shaw LJ et al (2009) Absence of coronary artery calcification and all-cause mortality. JACC Cardiovasc Imaging 2(6):692–700PubMedCrossRefGoogle Scholar
  11. 11.
    Elias-Smale SE, Proenca RV, Koller MT et al (2010) Coronary calcium score improves classification of coronary heart disease risk in the elderly: the Rotterdam study. J Am Coll Cardiol 56(17):1407–1414PubMedCrossRefGoogle Scholar
  12. 12.
    Budoff MJ, McClelland RL, Nasir K et al (2009) Cardiovascular events with absent or minimal coronary calcification: the multi-ethnic study of atherosclerosis (MESA). Am Heart J 158(4):554–561PubMedCentralPubMedCrossRefGoogle Scholar
  13. 13.
    Yeboah J, McClelland RL, Polonsky TS et al (2012) Comparison of novel risk markers for improvement in cardiovascular risk assessment in intermediate-risk individuals. JAMA 308(8):788–795PubMedCentralPubMedCrossRefGoogle Scholar
  14. 14.
    Kim KP, Einstein AJ, de Gonzalez AB (2009) Coronary artery calcification screening: estimated radiation dose and cancer risk. Arch Intern Med 169(13):1188–1194PubMedCentralPubMedCrossRefGoogle Scholar
  15. 15.
    Naghavi M, Falk E, Hecht HS et al (2006) From vulnerable plaque to vulnerable patient—part III: executive summary of the Screening for Heart Attack Prevention and Education (SHAPE) task force report. Am J Cardiol 98(2A):2H–15HPubMedCrossRefGoogle Scholar
  16. 16.
    Committee to Assess Health Risks from Exposure to Low Levels of Ionizing Radiation (2006) Health risks from exposure to low levels of ionizing radiation: BEIR VII phase 2. National Academies Press, Washington, DCGoogle Scholar
  17. 17.
    Einstein AJ, Johnson LL, Bokhari S et al (2010) Agreement of visual estimation of coronary artery calcium from low-dose CT attenuation correction scans in hybrid PET/CT and SPECT/CT with standard Agatston score. J Am Coll Cardiol 56(23):1914–1921PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    McCollough CH, Ulzheimer S, Halliburton SS et al (2007) Coronary artery calcium: a multi-institutional, multi manufacturer international standard for quantification at cardiac CT. Radiology 243(2):527–538PubMedCrossRefGoogle Scholar
  19. 19.
    Fujioka C, Funama Y, Kiguchi M et al (2012) Coronary artery calcium scoring on different 64-detector scanners using a low-tube voltage (80 kVp). Acad Radiol 19(11):1402–1407PubMedCrossRefGoogle Scholar
  20. 20.
    Yoon HC, Goldin JG, Greaser LE 3rd et al (2000) Interscan variation in coronary artery calcium quantification in a large asymptomatic patient population. AJR Am J Roentgenol 174(3):803–809PubMedCrossRefGoogle Scholar
  21. 21.
    Jacobs PC, Isgum I, Gondrie MJ et al (2010) Coronary artery calcification scoring in low-dose ungated CT screening for lung cancer: interscan agreement. AJR Am J Roentgenol 194(5):1244–1249PubMedCrossRefGoogle Scholar
  22. 22.
    Wood DE, Eapen GA, Ettinger DS et al (2012) Lung cancer screening. J Natl Compr Canc Netw 10(2):240–265PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  • Yoon Kyung Kim
    • 1
  • Yon Mi Sung
    • 1
  • So Hyun Cho
    • 1
  • Young Nam Park
    • 1
  • Hye-Young Choi
    • 1
  1. 1.Department of RadiologyGachon University Gil Medical CenterIncheonRepublic of Korea

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