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Visual Ordinal Coronary Calcium Scoring on Routine PET/CT for Predicting Perioperative Major Clinical Events After

Dongwoo Kim1, Hye Joo Son2, Min-Kyung Kang3,4

  • 1Department of Nuclear Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si, Gyeonggi, Republic of Korea.

AJR. American Journal of Roentgenology
|February 11, 2026
PubMed
Summary

A new visual scoring system for coronary artery calcification (CAC) on PET/CT scans can predict major clinical events after noncardiac surgery. This method offers a simple way to improve perioperative risk assessment.

Keywords:
CTPETcoronary artery diseaseperioperative medicinevascular calcification

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Area of Science:

  • Cardiology
  • Radiology
  • Oncology

Background:

  • Positron emission tomography/computed tomography (PET/CT) is frequently used in cancer staging.
  • Standard coronary artery calcification (CAC) scoring is not feasible with typical PET/CT protocols.
  • PET/CT offers a potential opportunity for opportunistic CAC assessment.

Purpose of the Study:

  • To evaluate the prognostic value of a visual ordinal CAC scoring system using PET/CT.
  • To assess its utility in stratifying perioperative risk for patients undergoing noncardiac surgery.

Main Methods:

  • Retrospective analysis of 972 patients undergoing PET/CT and noncardiac surgery.
  • Radiologists assigned visual ordinal CAC scores (0-3) to coronary arteries.
  • Multivariable logistic regression analyzed visual CAC grades for predicting 30-day major clinical events (MCEs), adjusting for RCRI.

Main Results:

  • High interobserver agreement (kappa=0.875) for visual CAC grading.
  • Moderate/severe CAC (16.0% of patients) independently predicted perioperative MCEs (adjusted OR=2.44).
  • Visual CAC grade showed a slightly higher AUC (0.652) than RCRI (0.608) for MCE prediction.

Conclusions:

  • Visual CAC scoring on routine PET/CT is a valuable tool for perioperative risk stratification.
  • This method is independent of the Revised Cardiac Risk Index (RCRI).
  • Standardized CAC reporting on preoperative PET/CT can enhance clinical decision-making for perioperative care.