Coronary artery CT calcium score assessed by direct calcium quantification using atomic absorption spectroscopy and compared to macroscopic and histological assessments

  • Alexandra G. GheorgheEmail author
  • Christina Jacobsen
  • Ragnar Thomsen
  • Kristian Linnet
  • Niels Lynnerup
  • Claus B. Andersen
  • Andreas Fuchs
  • Klaus F. Kofoed
  • Jytte Banner
Original Article


The Agatston score (AS) is the gold standard CT calcium scoring method in clinical practice. However, the AS is an indirect method of determining calcium amount, whereas atomic absorption spectroscopy (AAS) can directly measure the calcium amount. Our primary aim was to investigate the association between the AS and the coronary calcium amount measured by AAS. Furthermore, we compared our outcome to the macroscopic and histological coronary calcification and stenosis assessment, thus allowing us to infer a clinical coronary artery status based on post-mortem findings. Deceased individuals were examined with a 64-slice multidetector CT scanner, and the AS was determined. At autopsy, the degree of CAC and stenosis was determined, and the coronary arteries were excised and weighed. The coronary arteries were decalcified in a solution that was examined using AAS to measure the calcium amount. The degree of CAC and stenosis was also assessed by a histological examination. One hundred thirty-two coronary arteries were examined, and AS was highly correlated to the coronary calcium amount, measured by AAS, (r2 = 0.72, Pearson 0.85, p < 0.0001). In cases with AS 0, AAS measurements showed zero or very low calcium amounts. AS was also correlated to macroscopic and histological calcification assessments (Spearman’s rho 0.68, p < 0.0001, Spearman’s rho 0.82, p < 0.0001). Furthermore, an underestimation of subclinical atherosclerosis was seen and AS 0 could not rule out stenosis.


Agatston score Atomic absorption spectroscopy Coronary artery calcification Coronary artery disease Calcium scoring Coronary calcium scoring method 



The authors would like to thank the physicians, morgue technicians, laboratory assistants, and medical students for their assistance in the SURVIVE project, as well as laboratory assistants at Vendsyssel sygehus; Region Nordjylland, for preparing, staining, and sending all the histological sections and statistician; and Kyle Raymond, PhD, for statistical guidance and help.


This project was sponsored by the Department of Forensic Medicine, University of Copenhagen (Unit number 361100).

Compliance with ethical standards

Conflict of interest

The authors declare that they have no competing interests.

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

The National Committee on Danish Health Research Ethics approved (01-20-2014) the research protocol (version 2.0 number 1377517).

Informed consent

Informed consent was obtained for all deceased individuals participants included in the study. The next of kin gave informed written or oral consents.

Supplementary material

414_2018_1998_MOESM1_ESM.docx (128 kb)
ESM 1 (DOCX 127 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Alexandra G. Gheorghe
    • 1
    Email author
  • Christina Jacobsen
    • 1
  • Ragnar Thomsen
    • 2
  • Kristian Linnet
    • 2
  • Niels Lynnerup
    • 1
  • Claus B. Andersen
    • 1
  • Andreas Fuchs
    • 3
  • Klaus F. Kofoed
    • 3
    • 4
  • Jytte Banner
    • 1
  1. 1.Section of Forensic Pathology, Department of Forensic MedicineUniversity of CopenhagenCopenhagenDenmark
  2. 2.Section of Forensic Chemistry, Department of Forensic MedicineUniversity of CopenhagenCopenhagenDenmark
  3. 3.Department of Cardiology, The Heart Centre, RigshospitaletUniversity of CopenhagenCopenhagenDenmark
  4. 4.Department of Radiology, Diagnostic Centre, RigshospitaletUniversity of CopenhagenCopenhagenDenmark

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