ArticleAmerican journal of preventive cardiology2026
Agatston-2.0: A next-generation AI-based coronary calcium quantification approach to improve risk stratification among individuals with zero Agatston scores - Part I: An AI-CVD Study within the Multi-Ethnic Study of Atherosclerosis and Framingham Heart Study.
Article in American journal of preventive cardiology, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
Background: A coronary artery calcium (CAC) score of zero using the conventional Agatston scoring method (Agatston-1.0) is associated with very low cardiovascular risk (the "Power of Zero"); however, a small proportion of individuals with CAC=0 still develop coronary heart disease (CHD). Agatston-1.0 relies on thick slices (2.5-3 mm) and a fixed attenuation threshold (≥130 HU), which may miss early, small, low-density, or partially calcified coronary plaques. Agatston-2.0 is an artificial intelligence (AI) framework for automated coronary segmentation and continuous voxel-wise calcium quantification without fixed thresholds, applicable to CT scans with slice thickness ≥0.2 mm and generating an AI-derived CAC score (AI-CAC). Objectives: To evaluate the prognostic value of Agatston-2.0 for risk stratification among individuals with a baseline CAC=0. Methods: We pooled 3,965 participants with CAC=0 from the Multi-Ethnic Study of Atherosclerosis (MESA, n=2,816) and the Framingham Heart Study (FHS, n=1,149). Associations with incident CHD were evaluated using Cox proportional hazards models with up to 20 years of follow-up. Results: An AI-CAC score>0 was detected in 862 participants (21.7%) in population with CAC=0. Participants with AI-CAC>0 had higher 20-year CHD incidence than those with AI-CAC=0 (7.7% vs. 3.8%, p<0.0001). After adjustment for traditional risk factors, AI-CAC>0 remained independently associated with incident CHD (HR 1.71, 95% CI 1.18-2.47). AI-CAC also predicted progression to positive CAC score (adjusted HR 1.95, 95% CI 1.70-2.24). Conclusions: The Agatston-2.0 framework identifies clinically meaningful coronary calcification in individuals classified as CAC=0. If validated in additional cohorts, Agatston-2.0 could become the new standard for coronary calcium scoring.
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