Association of Coronary Artery Calcification and Mortality in the National Lung Screening Trial: A Comparison of Three Scoring Methods

Radiology. 2015 Jul;276(1):82-90. doi: 10.1148/radiol.15142062. Epub 2015 Mar 9.


Purpose: To evaluate three coronary artery calcification (CAC) scoring methods to assess risk of coronary heart disease (CHD) death and all-cause mortality in National Lung Screening Trial (NLST) participants across levels of CAC scores.

Materials and methods: The NLST was approved by the institutional review board at each participating institution, and informed consent was obtained from all participants. Image review was HIPAA compliant. Five cardiothoracic radiologists evaluated 1575 low-dose computed tomographic (CT) scans from three groups: 210 CHD deaths, 315 deaths not from CHD, and 1050 participants who were alive at conclusion of the trial. Radiologists used three scoring methods: overall visual assessment, segmented vessel-specific scoring, and Agatston scoring. Weighted Cox proportional hazards models were fit to evaluate the association between scoring methods and outcomes.

Results: In multivariate analysis of time to CHD death, Agatston scores of 1-100, 101-1000, and greater than 1000 (reference category 0) were associated with hazard ratios of 1.27 (95% confidence interval: 0.69, 2.53), 3.57 (95% confidence interval: 2.14, 7.48), and 6.63 (95% confidence interval: 3.57, 14.97), respectively; hazard ratios for summed segmented vessel-specific scores of 1-5, 6-11, and 12-30 (reference category 0) were 1.72 (95% confidence interval: 1.05, 3.34), 5.11 (95% confidence interval: 2.92, 10.94), and 6.10 (95% confidence interval: 3.19, 14.05), respectively; and hazard ratios for overall visual assessment of mild, moderate, or heavy (reference category none) were 2.09 (95% confidence interval: 1.30, 4.16), 3.86 (95% confidence interval: 2.02, 8.20), and 6.95 (95% confidence interval: 3.73, 15.67), respectively.

Conclusion: By using low-dose CT performed for lung cancer screening in older, heavy smokers, a simple visual assessment of CAC can be generated for risk assessment of CHD death and all-cause mortality, which is comparable to Agatston scoring and strongly associated with outcome.

Publication types

  • Comparative Study
  • Randomized Controlled Trial

MeSH terms

  • Case-Control Studies
  • Coronary Artery Disease / complications
  • Coronary Artery Disease / diagnostic imaging*
  • Coronary Artery Disease / mortality*
  • Early Detection of Cancer
  • Female
  • Humans
  • Lung Neoplasms / complications
  • Lung Neoplasms / diagnostic imaging
  • Male
  • Middle Aged
  • Retrospective Studies
  • Risk Assessment
  • Tomography, X-Ray Computed*
  • Vascular Calcification / complications
  • Vascular Calcification / diagnostic imaging*
  • Vascular Calcification / mortality*