Health AI Central
Peer-Reviewed Publication
Am J Prev Cardiol2026;30101698.December 1, 2026Journal Article

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.

Morteza Naghavi1, Amir Azimi1, Kyle Atlas1, Anthony P Reeves2, Chenyu Zhang1, Seyed Reza Mirjalili1, Mohammadhossein Mozafarybazargany1, Amir Ghaffari Jolfayi1, Ali Hashemi1, Thomas Atlas3, Jakob Wasserthal4, Rozemarijn Vliegenthart5, Claudia I Henschke6, David F Yankelevitz6, Andrea D Branch7, Sion K Roy8, Jamal S Rana9, Zahi A Fayad10, Oren Mechanic11, Koen Nieman12, Jagat Narula13, Roxana Mehran7, Prediman K Shah14, John A Rumberger15, Kim A Williams Sr16, Paolo Raggi17, David J Maron18, Michael V McConnell18, Robert A Kloner19,20, Matthew J Budoff14, Nathan D Wong21, Arthur S Agatston11
1HeartLung.AI, Houston, TX 77021, USA.
2Department of Electrical and Computer Engineering, Cornell University, Ithaca, NY 14853, USA.
3Tustin Teleradiology, Tustin, CA 92780, USA.
4Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.
5Department of Radiology, University Medical Center Groningen, Groningen, the Netherlands.
6Department of Diagnostic, Molecular, and Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
7Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
8The Lundquist Institute, Torrance, CA 90502, USA.
9Division of Cardiology, Kaiser Permanente Oakland Medical Center, Oakland, CA, USA.
10BioMedical Engineering and Imaging Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.
11The Agatston Center, Miami Beach, FL, USA.
12Departments of Medicine and Radiology, Stanford University, Stanford, CA, USA.
13University of Houston, Houston, TX 77030, USA.
14Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
15Department of Cardiac Imaging, Princeton Longevity Center, Princeton, NJ, USA.
16University of Louisville, Louisville, KY 40202, USA.
17Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
18Stanford Prevention Research Center, Stanford University School of Medicine, Stanford, CA 94305, USA.
19Huntington Medical Research Institutes, Pasadena, CA 91105, USA.
20Keck School of Medicine of the University of Southern California, Los Angeles, CA 90033, USA.
21Heart Disease Prevention Program, Mary and Steve Wen Cardiovascular Division, University of California Irvine, Irvine, CA 92697, USA.
PubMed PMC DOI PDF

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 earl…

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