Diagnostic Value of Fully Automated Artificial Intelligence Powered Coronary Artery Calcium Scoring from 18F-FDG PET/CT

Abstract Purpose: To assess the feasibility and accuracy of a fully automated artificial intelligence (AI) powered coronary artery calcium scoring (CACS) method on ungated CT in oncologic patients undergoing 18F-FDG PET/CT.Materials and Methods: A total of 100 oncologic patients examined between 2007 and 2015 were retrospectively included. All patients underwent 18F-FDG PET/CT and cardiac SPECT myocardial perfusion imaging (MPI) by 99mTc-tetrofosmin within 6 months. CACS was manually performed on non-contrast ECG-gated CT scans obtained from SPECT-MPI (i.e. reference standard). Additionally, CACS was performed fully automatically using a cloud-based, user-independent tool (AI-CACS) on non-contrast, free-breathing, ungated CT scans from 18F-FDG-PET/CT examinations. Agatston scores from the manual CACS and AI-CACS were compared. Results: On a per-patient basis, the AI-CACS tool achieved a sensitivity and specificity of 85% and 90% for the detection of coronary calcifications. Interscore agreement of CAC scores between manual CACS and AI-CACS was 0.88 (95% CI: 0.827, 0.918). Interclass agreement of risk categories was 0.8 in weighted Kappa analysis with a reclassification rate of 44% and an underestimation of one risk category by AI-CACS in 39% of cases. On a per-vessel basis, interscore agreement of CAC scores ranged from 0.716 (95%CI: 0.605, 0.799) for the circumflex artery to 0.863 (95%CI: 0.803, 0.906) for the left anterior descending artery. Conclusion: Fully automated AI-CACS as performed on non-contrast free-breathing, ungated CT scans from 18F-FDG-PET/CT examinations is feasible and provides a good estimation of CAC burden. CAC load on ungated CT is, however, generally underestimated by AI-CACS which should be taken into account when considering recommending further diagnostic workup for coronary heart disease.