Evolving Role of Calcium Density in Coronary Artery Calcium Scoring and Atherosclerotic Cardiovascular Disease Risk

Alexander C. Razavi, Arthur S. Agatston, Leslee J. Shaw, Carlo N. De Cecco, Marly van Assen, Laurence S. Sperling, Marcio S. Bittencourt, Melissa A. Daubert, Khurram Nasir, Roger S. Blumenthal, Martin Bødtker Mortensen, Seamus P. Whelton, Michael J. Blaha, Omar Dzaye

Research output: Contribution to journalReview articlepeer-review

22 Scopus citations


Coronary artery calcium (CAC) is a specific marker of coronary atherosclerosis that can be used to measure calcified subclinical atherosclerotic burden. The Agatston method is the most widely used scoring algorithm for quantifying CAC and is expressed as the product of total calcium area and a quantized peak calcium density weighting factor defined by the calcification attenuation in HU on noncontrast computed tomography. Calcium density has emerged as an important area of inquiry because the Agatston score is upweighted based on the assumption that peak calcium density and atherosclerotic cardiovascular disease (ASCVD) risk are positively correlated. However, recent evidence demonstrates that calcium density is inversely associated with lesion vulnerability and ASCVD risk in population-based cohorts when accounting for age and plaque area. Here, we review calcium density by focusing on 3 main areas: 1) CAC scan acquisition parameters; 2) pathophysiology of calcified plaques; and 3) epidemiologic evidence relating calcium density to ASCVD outcomes. Through this process, we hope to provide further insight into the evolution of CAC scoring on noncontrast computed tomography.

Original languageEnglish (US)
Pages (from-to)1648-1662
Number of pages15
JournalJACC: Cardiovascular Imaging
Issue number9
StatePublished - Sep 2022


  • atherosclerosis
  • calcium density
  • coronary artery calcium
  • noncontrast computed tomography
  • Predictive Value of Tests
  • Calcium
  • Cardiovascular Diseases/complications
  • Risk Assessment
  • Vascular Calcification/complications
  • Humans
  • Risk Factors
  • Plaque, Atherosclerotic
  • Coronary Artery Disease/complications
  • Atherosclerosis
  • Coronary Vessels/diagnostic imaging

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Radiology Nuclear Medicine and imaging


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