Standard Visual and Ordinal Coronary Calcium Scoring on PET/CT: Agreement with Agatston Scoring and Prognostic Implications

Pak, Sehyun; Son, Hye Joo; Kim, Dongwoo; Moon, Jung Won; Kim, Yoo Na; Woo, Ji Young; Kang, Min-Kyung; Won, Dong-Ok; Lee, Suk Hyun

doi:10.3390/diagnostics15232969

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Standard Visual and Ordinal Coronary Calcium Scoring on PET/CT: Agreement with Agatston Scoring and Prognostic Implications

by

Sehyun Pak

^1,†

,

Hye Joo Son

^2,†,

Dongwoo Kim

³,

Jung Won Moon

⁴,

Yoo Na Kim

⁴,

Ji Young Woo

⁴

,

Min-Kyung Kang

⁵,

Dong-Ok Won

^1,6,7

and

Suk Hyun Lee

^4,*

¹

Department of Medicine, Hallym University College of Medicine, Chuncheon 24252, Gangwon, Republic of Korea

²

Department of Nuclear Medicine, Dankook University Medical Center, Cheonan 31116, Chungnam, Republic of Korea

³

Department of Nuclear Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang-si 14068, Gyeonggi, Republic of Korea

⁴

Department of Radiology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea

⁵

Department of Cardiology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea

⁶

Department of Artificial Intelligence Convergence, Hallym University, Chuncheon 24252, Gangwon, Republic of Korea

⁷

Department of Population and Quantitative Health Sciences, University of Massachusetts Chan Medical School, Worcester, MA 01655, USA

^*

Author to whom correspondence should be addressed.

^†

These authors contributed equally to this work as first authors.

Diagnostics 2025, 15(23), 2969; https://doi.org/10.3390/diagnostics15232969 (registering DOI)

Submission received: 23 October 2025 / Revised: 16 November 2025 / Accepted: 21 November 2025 / Published: 22 November 2025

(This article belongs to the Special Issue Applications of PET/CT in Clinical Diagnostics)

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Abstract

Background: Visual assessment of coronary artery calcium (CAC) on ungated chest CT has been described previously. However, its reliability and clinical utility remain uncertain, particularly in PET/CT studies that use low-dose, low-slice CT and are susceptible to respiratory artifacts. Methods: We retrospectively analyzed 106 patients (median age, 66 years [interquartile range, 60–75 years]; 67 men [63.2%]) who underwent PET/CT and electrocardiogram (ECG)-gated chest CT within a 90-day interval. Six readers (three radiologists and three nuclear medicine physicians) independently assessed CAC on PET/CT using a standard four-point visual scale and a 0–12 ordinal scale based solely on written instructions. Agatston scoring was also performed. Interobserver agreement and concordance with ECG-gated chest CT Agatston score categories were calculated. Major adverse cardiovascular events (MACE) were recorded over a median follow-up of 3.5 years. Results: Interobserver agreement was good for both the standard visual (κ = 0.761) and ordinal (κ = 0.779) scales. Concordance with ECG-gated CT Agatston categories was higher for standard visual (κ = 0.849) and ordinal (κ = 0.750) scoring than for PET/CT Agatston categories (κ = 0.464). Both qualitative scales tended to underestimate CAC categories compared with ECG-gated CT; however, severe CAC on PET/CT predicted MACE (hazard ratios: 4.41 standard visual; 6.59 ordinal), and the ordinal scale significantly stratified MACE-free survival (p = 0.047). Conclusions: Standard visual and ordinal CAC scoring on the ungated CT portion of PET/CT is quick, reproducible, closely mirrors ECG-gated-CT Agatston grading, and offers prognostic value for future MACE in cancer patients.

Keywords: vascular calcification; coronary artery disease; neoplasms; positron emission tomography; computed tomography

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MDPI and ACS Style

Pak, S.; Son, H.J.; Kim, D.; Moon, J.W.; Kim, Y.N.; Woo, J.Y.; Kang, M.-K.; Won, D.-O.; Lee, S.H. Standard Visual and Ordinal Coronary Calcium Scoring on PET/CT: Agreement with Agatston Scoring and Prognostic Implications. Diagnostics 2025, 15, 2969. https://doi.org/10.3390/diagnostics15232969

AMA Style

Pak S, Son HJ, Kim D, Moon JW, Kim YN, Woo JY, Kang M-K, Won D-O, Lee SH. Standard Visual and Ordinal Coronary Calcium Scoring on PET/CT: Agreement with Agatston Scoring and Prognostic Implications. Diagnostics. 2025; 15(23):2969. https://doi.org/10.3390/diagnostics15232969

Chicago/Turabian Style

Pak, Sehyun, Hye Joo Son, Dongwoo Kim, Jung Won Moon, Yoo Na Kim, Ji Young Woo, Min-Kyung Kang, Dong-Ok Won, and Suk Hyun Lee. 2025. "Standard Visual and Ordinal Coronary Calcium Scoring on PET/CT: Agreement with Agatston Scoring and Prognostic Implications" Diagnostics 15, no. 23: 2969. https://doi.org/10.3390/diagnostics15232969

APA Style

Pak, S., Son, H. J., Kim, D., Moon, J. W., Kim, Y. N., Woo, J. Y., Kang, M.-K., Won, D.-O., & Lee, S. H. (2025). Standard Visual and Ordinal Coronary Calcium Scoring on PET/CT: Agreement with Agatston Scoring and Prognostic Implications. Diagnostics, 15(23), 2969. https://doi.org/10.3390/diagnostics15232969

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Standard Visual and Ordinal Coronary Calcium Scoring on PET/CT: Agreement with Agatston Scoring and Prognostic Implications

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