Iterative Image Reconstruction Techniques for CT Coronary Artery Calcium Quantification: Comparison with Traditional Filtered Back Projection in Vitro and in Vivo

PURPOSE: To investigate in vitro and in vivo the use of image-based and raw data-based iterative reconstruction algorithms for quantification of coronary artery calcium by using the Agatston score and subsequent cardiac risk stratification. MATERIALS AND METHODS: In vitro data were obtained by using a moving anthropomorphic cardiac phantom containing calcium inserts of different concentrations and sizes. With institutional review board approval and HIPAA compliance, coronary calcium imaging data of 110 consecutive patients (mean age ± standard deviation, 58.2 years ± 9.8; 48 men) were reconstructed with filtered back projection (FBP), iterative reconstruction in image space (IRIS), and sinogram-affirmed iterative reconstruction (SAFIRE). Image noise was measured and the Agatston score was obtained for all reconstructions. Assignment to Agatston scores and percentile-based cardiac risk categories was compared. Statistical analysis included the Cohen κ coefficient and Friedman and Wilcoxon testing. RESULTS: In vitro, mean Agatston scores ± standard deviation for FBP (638.9 ± 9.6), IRIS (622.7 ± 15.2), and SAFIRE (631.4 ± 17.6) were comparable (P = .30). The smallest phantom calcifications were more frequently detected when iterative reconstruction techniques were used. The Agatston scores in the patient cohort were not significantly different among FBP, IRIS, and SAFIRE in paired comparisons (median Agatston score [25th and 75th percentiles]: 76.0 [20.6, 243.9], 76.4 [22, 249.3], and 75.7 [21.5, 49.1], respectively; P = .20 each). Comparison of categorization based on Agatston score percentiles showed excellent agreement for both IRIS and SAFIRE with FBP (κ = 0.975 [0.942-1.00] and κ = 0.963 [0.922-1.00], respectively). The mean effective dose was 1.02 mSv ± 0.51. Mean image noise was significantly (P < .001) higher with FBP than that with iterative reconstructions. CONCLUSION: In comparison with FBP, iterative reconstruction techniques do not have a profound effect on the reproducible quantification of coronary calcium according to Agatston score and subsequent cardiac risk classification, although risk reclassification may occur in a small subset of subjects.