A Modified Length-Based Grading Method for Assessing Coronary Artery Calcium Severity on Non-Electrocardiogram-Gated Chest Computed Tomography: A Multiple-Observer Study

Objective: To validate a simplified ordinal scoring method, referred to as modified length-based grading, for assessing coronary artery calcium (CAC) severity on non-electrocardiogram (ECG)-gated chest computed tomography (CT).Materials and Methods: This retrospective study enrolled 120 patients (mean age ± standard deviation [SD], 63.1 ± 14.5 years; male, 64) who underwent both non-ECG-gated chest CT and ECG-gated cardiac CT between January 2011 and December 2021.Six radiologists independently assessed CAC severity on chest CT using two scoring methods (visual assessment and modified length-based grading) and categorized the results as none, mild, moderate, or severe.The CAC category on cardiac CT assessed using the Agatston score was used as the reference standard.Agreement among the six observers for CAC category classification was assessed using Fleiss kappa statistics.Agreement between CAC categories on chest CT obtained using either method and the Agatston score categories on cardiac CT was assessed using Cohen's kappa.The time taken to evaluate CAC grading was compared between the observers and two grading methods.Results: For differentiation of the four CAC categories, interobserver agreement was moderate for visual assessment (Fleiss kappa, 0.553 [95% confidence interval {CI}: 0.496-0.610])and good for modified length-based grading (Fleiss kappa, 0.695 [95% CI: 0.636-0.754]).The modified length-based grading demonstrated better agreement with the reference standard categorization with cardiac CT than visual assessment (Cohen's kappa, 0.565 [95% CI: 0.511-0.619for visual assessment vs. 0.695 [95% CI: 0.638-0.752]for modified length-based grading).The overall time for evaluating CAC grading was slightly shorter in visual assessment (mean ± SD, 41.8 ± 38.9 s) than in modified length-based grading (43.5 ± 33.2 s) (P < 0.001). Conclusion:The modified length-based grading worked well for evaluating CAC on non-ECG-gated chest CT with better interobserver agreement and agreement with cardiac CT than visual assessment.