Coronary calcium scoring on virtual non-contrast and virtual non-iodine reconstructions compared to true non-contrast images using photon-counting computed tomography

Objectives To compare coronary artery calcification (CAC) scores measured on virtual non-contrast (VNC) and virtual non-iodine (VNI) reconstructions computed from coronary computed tomography angiography (CCTA) using photon-counting computed tomography (PCCT) to true non-contrast (TNC) images.Methods We included 88 patients (mean age = 59 years +/- 13.5, 69% male) who underwent a TNC coronary calcium scan followed by CCTA on PCCT. VNC images were reconstructed in 87 patients and VNI in 88 patients by virtually removing iodine from the CCTA images. For all reconstructions, CAC scores were determined, and patients were classified into risk categories. The overall agreement of the reconstructions was analyzed by Bland-Altman plots and the level of matching classifications.Results The median CAC score on TNC was 27.8 [0-360.4] compared to 8.5 [0.2-101.6] (p < 0.001) on VNC and 72.2 [1.3-398.8] (p < 0.001) on VNI. Bland-Altman plots depicted a bias of 148.8 (ICC = 0.82, p < 0.001) and - 57.7 (ICC = 0.95, p < 0.001) for VNC and VNI, respectively. Of all patients with CAC(TNC) = 0, VNC reconstructions scored 63% of the patients correctly, while VNI scored 54% correctly. Of the patients with CAC(TNC) > 0, VNC and VNI reconstructions detected the presence of coronary calcium in 90% and 92% of the patients. CAC(VNC) tended to underestimate CAC score, whereas CAC(VNI) overestimated, especially in the lower risk categories. According to the risk categories, VNC misclassified 55% of the patients, while VNI misclassified only 32%.Conclusion Compared to TNC images, VNC underestimated and VNI overestimated the actual CAC scores. VNI reconstructions quantify and classify coronary calcification scores more accurately than VNC reconstructions.Clinical relevance statement Photon-counting CT enables spectral imaging, which might obviate the need for non-contrast enhanced coronary calcium scoring, but optimization is necessary for the clinical implementation of the algorithms.