High-pitch dual-source CT for coronary artery calcium scoring: A head-to-head comparison of non-triggered chest versus triggered cardiac acquisition



      To determine the effect of low-dose, high-pitch non-electrocardiographic (ECG)-triggered chest CT on coronary artery calcium (CAC) detection, quantification and risk stratification, compared to ECG-triggered cardiac CT.


      We selected 1,000 participants from the ImaLife study, 50% with coronary calcification on cardiac CT. All participants underwent non-contrast cardiac CT followed by chest CT using third-generation dual-source technology. Reconstruction settings were equal for both acquisitions. CAC scores were determined by Agatston's method, and divided dichotomously (0, >0), and into risk categories (0, 1–99, 100–399, ≥400). We investigated the influence of heart rate and body mass index (BMI) on risk reclassification.


      Positive CAC scores on cardiac CT ranged from 1 to 6926 (median 39). Compared to cardiac CT, chest CT had sensitivity of 0.96 (95%CI 0.94–0.98) and specificity of 0.99 (95%CI 0.97–0.99) for CAC detection (κ = 0.95). In participants with coronary calcification on cardiac CT, CAC score on chest CT was lower than on cardiac CT (median 30 versus 40, p˂0.001). Agreement in CAC-based risk strata was excellent (weighted κ = 0.95). Sixty-five cases (6.5%) were reclassified by one risk category in chest CT, with fifty-five (84.6%) shifting downward. Higher BMI resulted in higher reclassification rate (13% for BMI ≥30 versus 5.2% for BMI <30, p = 0.001), but there was no effect of heart rate.


      Low-dose, high-pitch chest CT, using third-generation dual-source technology shows almost perfect agreement with cardiac CT in CAC detection and risk stratification. However, low-dose chest CT mainly underestimates the CAC score as compared to cardiac CT, and results in inaccurate risk categorization in BMI ≥30.


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        • Greenland P.
        • Blaha M.J.
        • Budoff M.J.
        • Erbel R.
        • Watson K.E.
        Coronary calcium score and cardiovascular risk.
        J Am Coll Cardiol. 2018; 72: 434-447
        • Arnett D.K.
        • Blumenthal R.S.
        • Albert M.A.
        • et al.
        2019 ACC/AHA guideline on the primary prevention of cardiovascular disease: executive summary: a report of the American College of Cardiology/American heart association task Force on clinical practice guidelines.
        J Am Coll Cardiol. 2019; 140: e596-e646
        • Oudkerk M.
        • Devaraj A.
        • Vliegenthart R.
        • et al.
        European position statement on lung cancer screening.
        Lancet Oncol. 2017; 18: e754-e766
        • Hecht H.S.
        • Henschke C.
        • Yankelevitz D.
        • Fuster V.
        • Narula J.
        Combined detection of coronary artery disease and lung cancer.
        Eur Heart J. 2014; 35: 2792-2796
        • Wu M.-T.
        • Yang P.
        • Huang Y.-L.
        • et al.
        Coronary arterial calcification on low-dose ungated MDCT for lung cancer screening: concordance study with dedicated cardiac CT.
        Am J Roentgenol. 2008; 190: 923-928
        • Kim S.M.
        • Chung M.J.
        • Lee K.S.
        • Choe Y.H.
        • Yi C.A.
        • Choe B.K.
        Coronary calcium screening using low-dose lung cancer screening: effectiveness of MDCT with retrospective reconstruction.
        AJR Am J Roentgenol. 2008; 190: 917-922
        • Budoff M.J.
        • Nasir K.
        • Kinney G.L.
        • et al.
        Coronary artery and thoracic calcium on noncontrast thoracic CT scans: comparison of ungated and gated examinations in patients from the COPD Gene cohort.
        J Cardiovasc Comput Tomogr. 2011; 5: 113-118
        • Arcadi T.
        Coronary artery calcium score on low-dose computed tomography for lung cancer screening.
        World J Radiol. 2014; 6: 381
        • Xie X.
        • Zhao Y.
        • de Bock G.H.
        • et al.
        Validation and prognosis of coronary artery calcium scoring in nontriggered thoracic computed tomography: systematic review and meta-analysis.
        Circ Cardiovasc Imag. 2013; 6: 514-521
        • Xia C.
        • Rook M.
        • Pelgrim G.J.
        • et al.
        Early imaging biomarkers of lung cancer, COPD and coronary artery disease in the general population: rationale and design of the ImaLife (Imaging in Lifelines) Study.
        Eur J Epidemiol. 2019; 35: 75-86
        • Scholtens S.
        • Smidt N.
        • Swertz M.A.
        • et al.
        Cohort Profile: LifeLines, a three-generation cohort study and biobank.
        Int J Epidemiol. 2015; 44: 1172-1180
        • McClelland R.L.
        • Chung H.
        • Detrano R.
        • Post W.
        • Kronmal R.A.
        Distribution of coronary artery calcium by race, gender, and age: results from the Multi-Ethnic Study of Atherosclerosis (MESA).
        Circulation. 2006; 113: 30-37
        • Agatston A.S.
        • Janowitz W.R.
        • Hildner F.J.
        • Zusmer N.R.
        • Viamonte M.
        • Detrano R.
        Quantification of coronary artery calcium using ultrafast computed tomography.
        J Am Coll Cardiol. 1990; 15: 827-832
        • Pletcher M.J.
        • Tice J.A.
        • Pignone M.
        • Browner W.S.
        Using the coronary artery calcium score to predict coronary heart disease events: a systematic review and meta-analysis.
        Arch Intern Med. 2004; 164: 1285-1292
        • Hutt A.
        • Duhamel A.
        • Deken V.
        • et al.
        Coronary calcium screening with dual-source CT: reliability of ungated, high-pitch chest CT in comparison with dedicated calcium-scoring CT.
        Eur Radiol. 2016; 26: 1521-1528
        • McHugh M.L.
        Interrater reliability: the kappa statistic.
        Biochem Med. 2012; : 276-282
        • Blaha M.J.
        • Cainzos-Achirica M.
        • Greenland P.
        • et al.
        Role of coronary artery calcium score of zero and other negative risk markers for cardiovascular disease: the multi-ethnic study of atherosclerosis (MESA).
        Circulation. 2016; 133: 849-858
        • Sarwar A.
        • Shaw L.J.
        • Shapiro M.D.
        • et al.
        Diagnostic and prognostic value of absence of coronary artery calcification.
        JACC Cardiovasc Imag. 2009; 2: 675-688
        • Chen Y.
        • Hu Z.
        • Li M.
        • et al.
        Comparison of nongated chest CT and dedicated calcium scoring CT for coronary calcium quantification using a 256-dector row CT scanner.
        Acad Radiol. 2019; 26: E267-E274
        • Sabour S.
        • Rutten A.
        • van der Schouw Y.T.
        • et al.
        Inter-scan reproducibility of coronary calcium measurement using Multi Detector-Row Computed Tomography (MDCT).
        Eur J Epidemiol. 2007; 22: 235-243
        • Detrano R.C.
        • Anderson M.
        • Nelson J.
        • et al.
        Coronary calcium measurements: effect of CT scanner type and calcium measure on rescan reproducibility--MESA study.
        Radiology. 2005; 236: 477-484
        • Budoff M.J.
        • McClelland R.L.
        • Chung H.
        • et al.
        Reproducibility of coronary artery calcified plaque with cardiac 64-MDCT: the Multi-Ethnic Study of Atherosclerosis.
        AJR Am J Roentgenol. 2009; 192: 613-617
        • Daniell A.L.
        • Wong N.D.
        • Friedman J.D.
        • et al.
        Concordance of coronary artery calcium estimates between MDCT and electron beam tomography.
        AJR Am J Roentgenol. 2005; 185: 1542-1545
        • Horiguchi J.
        • Matsuura N.
        • Yamamoto H.
        • et al.
        Coronary artery calcium scoring on low-dose prospective electrocardiographically-triggered 64-slice CT.
        Acad Radiol. 2009; 16: 187-193
        • Horiguchi J.
        • Matsuura N.
        • Yamamoto H.
        • et al.
        Variability of repeated coronary artery calcium measurements by 1.25-mm- and 2.5-mm-thickness images on prospective electrocardiograph-triggered 64-slice CT.
        Eur Radiol. 2008; 18: 209-216
        • Ghadri J.R.
        • Goetti R.
        • Fiechter M.
        • et al.
        Inter-scan variability of coronary artery calcium scoring assessed on 64-multidetector computed tomography vs. dual-source computed tomography: a head-to-head comparison.
        Eur Heart J. 2011; 32: 1865-1874
        • Willemink M.J.
        • Vliegenthart R.
        • Takx R.A.
        • et al.
        Coronary artery calcification scoring with state-of-the-art CT scanners from different vendors has substantial effect on risk classification.
        Radiology. 2014; 273: 695-702
        • Hecht H.
        • Blaha M.J.
        • Berman D.S.
        • et al.
        Clinical indications for coronary artery calcium scoring in asymptomatic patients: expert consensus statement from the Society of Cardiovascular Computed Tomography.
        J Cardiovasc Comput Tomogr. 2017; 11: 157-168
        • Van Der Aalst C.
        • Vonderb M.
        • Gratamad J.
        • Adriaansend H.
        • Kuijpers D.J.J.C.T.
        Risk or benefit in screening for cardiovascular disease (ROBINSCA): the rationale and study design of a population-based randomized-controlled screening trial for cardiovascular disease.
        . 2019; 9 (2167-0870.1000361)
        • Rutten A.
        • Isgum I.
        • Prokop M.
        Coronary calcification: effect of small variation of scan starting position on Agatston, volume, and mass scores.
        Radiology. 2008; 246: 90-98
        • Vonder M.
        • Vliegenthart R.
        • Kaatee M.A.
        • et al.
        High-pitch versus sequential mode for coronary calcium in individuals with a high heart rate: potential for dose reduction.
        J Cardiovasc Comput Tomogr. 2018; 12: 298-304
        • Willemink M.J.
        • Abramiuc B.
        • den Harder A.M.
        • et al.
        Coronary calcium scores are systematically underestimated at a large chest size: a multivendor phantom study.
        J Cardiovasc Comput Tomogr. 2015; 9: 415-421
        • Vonder M.
        • van der Werf N.R.
        • Leiner T.
        • et al.
        The impact of dose reduction on the quantification of coronary artery calcifications and risk categorization: a systematic review.
        J Cardiovasc Comput Tomogr. 2018; 12: 352-363
        • Vonder M.
        • Pelgrim G.J.
        • Huijsse S.E.M.
        • et al.
        Coronary artery calcium quantification on first, second and third generation dual source CT: a comparison study.
        J Cardiovasc Comput Tomogr. 2017; 11: 444-448
        • Apfaltrer G.
        • Albrecht M.H.
        • Schoepf U.J.
        • et al.
        High-pitch low-voltage CT coronary artery calcium scoring with tin filtration: accuracy and radiation dose reduction.
        Eur Radiol. 2018; 28: 3097-3104
        • Marwan M.
        • Mettin C.
        • Pflederer T.
        • et al.
        Very low-dose coronary artery calcium scanning with high-pitch spiral acquisition mode: comparison between 120-kV and 100-kV tube voltage protocols.
        J Cardiovasc Comput Tomogr. 2013; 7: 32-38
        • McQuiston A.D.
        • Muscogiuri G.
        • Schoepf U.J.
        • et al.
        Approaches to ultra-low radiation dose coronary artery calcium scoring based on 3rd generation dual-source CT: a phantom study.
        Eur J Radiol. 2016; 85: 39-47