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Updated: Feb 4, 2026
Signal Acquisition, Score Interpretation, and Economics of a Non-Invasive Point-of-Care Test for Coronary Artery Disease
Published on: August 9, 2024
Visual coronary calcium scoring to support opportunistic CAD screening: comparative evaluation of three established
Philipp Nicol1, Rafael Adolf2, Salvatore Cassese1
1Department of Cardiovascular Diseases, German Heart Center Munich, TUM University Hospital, Munich, Germany.
Insights
Visual scoring methods for coronary artery calcium (CAC) show high accuracy and reproducibility, correlating well with the Agatston score. A new Weston Extent Score (WES) offers a practical balance of CAC density and distribution.
Area of Science:
- Cardiology
- Radiology
- Medical Imaging
Background:
- Coronary artery calcium (CAC) scoring assesses atherosclerotic burden and cardiovascular risk.
- The Agatston score is the clinical standard, but visual scoring methods are gaining traction in opportunistic CT imaging.
- This study compares visual CAC scoring methods against the Agatston score for diagnostic performance and reliability.
Purpose of the Study:
- To compare the diagnostic performance of visual CAC scoring methods against the Agatston score.
- To evaluate the inter-observer reliability of different visual scoring techniques.
- To assess the correlation between visual scoring methods and the established Agatston score.
Main Methods:
- 299 ECG-gated CT scans were evaluated by two blinded observers using Visual Ordinal Score (VS), Weston Score (WS), and Vessel-specific extent-based score (VSES).
- A novel Weston Extent Score (WES) was derived by combining WS and VSES.
- Inter-observer agreement was assessed using Cohen's Kappa and ICC; classification performance was evaluated against Agatston categories.
Main Results:
- All visual scoring methods demonstrated high correlation with the Agatston score (Spearman ρ > 0.87).
- Visual scoring exhibited the highest inter-observer agreement (Kappa = 0.94, ICC = 0.97), followed by WS (Kappa = 0.90) and VSES (Kappa = 0.77).
- Visual scoring achieved the highest accuracy (90.0-91.3%); the WES score showed 80.9% accuracy with 93.8% specificity.
Conclusions:
- Visual CAC scoring methods offer excellent reproducibility and diagnostic accuracy for CAC classification, correlating strongly with the Agatston score.
- The novel WES score provides a practical balance of CAC density and anatomical distribution.
- Structured visual CAC scoring is supported for implementation in clinical and opportunistic CT settings.
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.
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