Work

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

Year: 2026

Type: article

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.

Source: IJC Heart & Vasculature

DOI: 10.1016/j.ijcha.2026.101875