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For energy-integrating detector (EID)-CT, a new, multivendor validated protocol has been proposed. This study aimed to investigate the variability of photon-counting detector (PCD)-CT-based CAC scoring and propose a new protocol with decreased variability.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Materials and methods<\/jats:title>\n                    <jats:p>A chest phantom containing nine calcifications was scanned on a PCD-CT using various settings: tube voltages (90 kVp, 120 kVp), tube currents (100% to 25% dose), slice thickness (3\u2009mm, 1\u2009mm), quantum iterative reconstruction (IR, 1\u20134). To evaluate interscan variability, phantoms were scanned five times per protocol with slight translational (5\u2009mm) and rotational (2\u00b0) movements. The standard PCD-CT protocol used 120 kVp, 100% dose, 3\u2009mm slices. CAC scores, image noise, and calcification detectability were assessed. Results were compared to the standard PCD-CT, and standard and proposed EID-CT protocols.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Compared to the standard PCD-CT protocol, score variability decreased by 37% using a thin-sliced protocol at 120 kVp, 25% dose reduction and IR2. Compared to the proposed EID-CT protocol, variability was 66% lower. The optimized PCD-CT protocol met noise targets, eliminating the risk of false-positives. While 6.0\u2009\u00b1\u20090.0 and 7.0\u2009\u00b1\u20090.4 calcifications were detected using the PCD-CT standard and the proposed EID-CT protocol, respectively, 7.1\u2009\u00b1\u20090.7 calcifications were detected with the optimized PCD-CT protocol. Volume and mass scores were closer to physical reference.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>A thin-slice, 25%-dose-reduced PCD-CT protocol at 120 kVp improves CAC score reproducibility and outperforms the proposed EID-CT protocol, possibly offering more reproducible CAC quantification at lower radiation doses.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Key Points<\/jats:title>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Question<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Coronary artery calcium scoring is used for cardiovascular risk stratification. However, the current standard method lacks score reproducibility.<\/jats:italic>\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Findings<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>A thin-slice, 25%-dose-reduced photon-counting detector CT protocol at 120 kVp significantly reduces score variability compared to previous protocols, including the proposed energy-integrating detector CT protocol.<\/jats:italic>\n                    <\/jats:p>\n                    <jats:p>\n                      <jats:bold>\n                        <jats:italic>Clinical relevance<\/jats:italic>\n                      <\/jats:bold>\n                      <jats:italic>Improved reproducibility of coronary artery calcium scoring may enable more consistent cardiovascular risk prediction and provide a robust technical basis for further in vivo studies.<\/jats:italic>\n                    <\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s00330-026-12355-4","type":"journal-article","created":{"date-parts":[[2026,2,19]],"date-time":"2026-02-19T13:07:49Z","timestamp":1771506469000},"page":"5546-5556","update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Coronary artery calcium scoring: expanding the new standard by photon-counting detector CT\u2014Part I: Impact of tube voltage, tube current, slice thickness, and quantum iterative reconstructions"],"prefix":"10.1007","volume":"36","author":[{"given":"Nicola","family":"Fink","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lennart R.","family":"Koetzier","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Emese","family":"Zsarnoczay","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Milan","family":"Vecsey-Nagy","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dmitrij","family":"Kravchenko","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muhammad Taha","family":"Hagar","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jim","family":"O\u2019Doherty","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Moritz C.","family":"Halfmann","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pal","family":"Suranyi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Gijs D.","family":"van Praagh","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jens","family":"Ricke","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Pal","family":"Maurovich-Horvat","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tobias","family":"B\u00e4uerle","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Martin J.","family":"Willemink","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2781-7462","authenticated-orcid":false,"given":"Akos","family":"Varga-Szemes","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tilman","family":"Emrich","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,2,19]]},"reference":[{"key":"12355_CR1","doi-asserted-by":"publisher","first-page":"4459","DOI":"10.1007\/s00330-023-10439-z","volume":"34","author":"M Osborne-Grinter","year":"2024","unstructured":"Osborne-Grinter M, Ali A, Williams MC (2024) Prevalence and clinical implications of coronary artery calcium scoring on non-gated thoracic computed tomography: a systematic review and meta-analysis. 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Tilman Emrich received a speaker fee and travel support from Siemens Medical Solutions USA Inc., and institutional research support from Siemens Healthineers. Jim O\u2019Doherty is an employee of Siemens Medical Solutions USA Inc. Martin J. Willemink is a Junior Deputy Editor for\n                      European Radiology\n                      and, as such, did not participate in the selection or review processes for this article.","order":3,"name":"Ethics","group":{"name":"EthicsHeading","label":"Conflict of interest"}},{"value":"No complex statistical methods were necessary for this paper.","order":4,"name":"Ethics","group":{"name":"EthicsHeading","label":"Statistics and biometry"}},{"value":"This phantom study did not involve humans or animals. Therefore, Institutional Review Board approval and informed consent were not required.","order":5,"name":"Ethics","group":{"name":"EthicsHeading","label":"Informed consent"}},{"value":"Institutional Review Board approval was not required because this is a phantom study.","order":6,"name":"Ethics","group":{"name":"EthicsHeading","label":"Ethical approval"}},{"value":"The current study is based on a phantom experiment and does not involve human or animal subjects; therefore, IRB approval and informed consent were not required. There is no overlap with previously published work. However, we would like to note that this study is methodologically based on the phantom study published by van Praagh et al [\n                      \n                      ], which established a new protocol for CAC scoring on EID-CT systems. Our work adapts their validated approach exclusively to a PCD-CT system and directly compares CAC score reproducibility between the proposed PCD-CT protocol and previous protocols, including the proposed EID-CT protocol. We would like to confirm that this paper (both Part I and Part II) is original and is not under consideration elsewhere. It has not been published in any form previously.","order":7,"name":"Ethics","group":{"name":"EthicsHeading","label":"Study subjects or cohorts overlap"}},{"order":8,"name":"Ethics","group":{"name":"EthicsHeading","label":"Methodology"}}]}}