Blaha MJ, Bodtker Mortensen M, Kianoush S, Tota-Maharaj R, Cainzos-Achirica M. Coronary artery calcium scoring: is it time for a change in methodology? JACC Cardiovasc Imaging. 2017 Aug;10(8):923-37.

Quantification of coronary artery calcium (CAC) has been shown to be reliable, reproducible, and predictive of cardiovascular risk.  Formal CAC scoring was introduced in 1990, with early scoring algorithms notable for their simplicity and elegance.  Yet with little evidence available on how to best build a score, or a conceptual model guiding score development, these scores were to large degree arbitrary.  In this review, we describe the traditional approaches for clinical CAC scoring, noting their strengths, weaknesses, and limitations.  We then discuss a conceptual model for developing an improved CAC score, reviewing the evidence supporting approaches most likely to lead to meaningful score improvement (for example, accounting for CAC density and regional distribution).  After discussing the potential implementation of an improved score in clinical practice, we follow with a discussion of the future of CAC scoring, asking the central question – do we really need a new CAC score?

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