HeartLung.AI Webcast
- Nov 17, 2025
- 2 min read
Hosted by Society of Cardiovascular Tomography (SCCT)
Agatston 2.0:
The next generation of calcium scoring in the era of AI-CAC and AI-CVD
Full Video
Webcast Summary
Thirty years ago, the Agatston Score pioneered CT-based coronary atherosclerosis imaging. Since then, extensive evidence has established CAC as the strongest predictor of CHD events. However, two limitations have constrained its clinical utility:
“Power of Zero” exceptions: Although a CAC score of zero is strongly protective, CHD events still occur in younger individuals (<55 years) with a score of zero. These cases are uncommon but clinically important.
Inability to monitor treatment: Because the Agatston Score increases in both treated and untreated patients, repeat CAC scans cannot reliably guide therapy and are therefore not recommended.
How Agatston 2.0 / AI-CAC Solves These Problems
By eliminating the fixed 130-HU threshold using a reference medium to correct for noise, and by removing the 3 mm slice thickness constraint, Agatston 2.0 detects small and semi-calcified (“soft”) plaques that traditional CAC scoring misses. This strengthens the “Power of Zero.”
In pooled analyses from MESA and the Framingham Heart Study, the 5-year CHD event rate in the AI-CAC zero population was below 0.05%. Considering that a portion of CHD events (5–10%, especially in women) arise from microvascular disease rather than epicardial plaque, the few remaining events in the AI-CAC-zero group may be unrelated to coronary atheroma. Thus, Agatston 2.0 brings us close to the maximal predictive potential of CT-based coronary anatomy.
In addition, by quantifying changes in plaque density versus area or volume, Agatston 2.0 enables monitoring of plaque progression and stabilization. Lower-density plaques confer higher risk, and increasing plaque density reflects stabilization.
AI-CVD: Beyond Coronary Arteries
AI-CVD incorporates AI-CAC and extends well beyond coronary disease. It provides automated quantitative measurements of:
Cardiac chamber volumes and left ventricular mass (for detecting LVH and predicting heart failure, atrial fibrillation, and stroke)
Aortic wall and valve calcification
Aortic and pulmonary artery dimensions
Pericardial fat
Thoracic muscle volume and myosteatosis
Hepatosteatosis
Osteopenia and osteoporosis
Emphysema and interstitial lung abnormalities
—all derived from the same CAC scan that today is used only to report the traditional Agatston Score.
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