CROSS REFERENCE TO RELATED APPLICATIONS

[0001] The present application claims the benefit of U.S. Provisional Patent

Application No. 63/131,580 filed December 29, 2020 and entitled “LOW DOSE CORONARY CALCIUM SCORING AT LOW TUBE POTENTIALS,” and U.S. Provisional Patent Application No. 63/019,541 filed May 4, 2020 and entitled “LOW DOES CORONARY CALCIUM SCORING AT LOW TUBE POTENTIALS,” each of which is hereby incorporated by reference in its entirety.

TECHNICAL FIELD

[0002] The present disclosure relates to medical imaging generally and more specifically to improvements in capturing and analyzing coronary calcification.

BACKGROUND

[0003] Heart disease remains a leading cause of death among many populations. For certain populations of individuals at intermediate or borderline risk of atherosclerotic cardiovascular disease (ASCVD), such as if risk-based decisions for preventive interventions (e.g., statin therapy) remain uncertain, it can be useful to measure a coronary artery calcium score to guide clinician-patient risk discussion and further monitoring and/or treatment.

[0004] Coronary calcium scoring (CCS) is a useful approach for cardiac risk prognostication. CCS involves using a computed tomography (CT) scan to detect plaque or calcium build-up in and/or around the heart, such as in coronary arteries. Since CCS relies on CT scans, each scan results in dosing the patient with ionizing radiation. While ionizing radiation can be used for important and beneficial reasons, exposure to this radiation can carry small, albeit nonzero, risks. Therefore, a desire exists to achieve successful CSS with a dose as low as reasonably achievable.

[0005] Current standard techniques for CCS perform CT scans at a peak kilovoltage

(kVp) of 120 kilovolts (kV) with a volume CT dose index (CTDIvoi) of approximately 3 milligray (mGy) and a dose-length product (DLP) of approximately 50 mGy*cm for patients of average size. The dose is higher for patients of large size. The resultant image can be analyzed to calculate a score based on the extent of coronary artery calcification. Standard techniques involve the calculation of an Agatston score, which is a weighted density score given to the highest attenuation value multiplied by the area of the calcification speck. More specifically, the measured calcium density in Hounsfield units (HU) of the highest density of calcification in a given coronary artery region is assigned a first score (e.g., a density factor) based on accepted thresholds. The accepted Hounsfield unit thresholds include densities of 0- 129 HU assigned a score of 0; densities of 130-199 HU assigned a score of 1; densities of 200- 299 HU assigned a score of 2; densities of 300-399 HU assigned a score of 3; and densities of 400 HU or more assigned a score of 4. This first score can be multiplied by the area of the coronary calcification (e.g., in square millimeters), which can then be added to the scores from other areas of the CT scan, including other slices, to obtain a total coronary artery calcium score (CAC score), which is the Agatston score. A CAC score of 0 can indicate no evidence of coronary artery disease (CAD), a CAC score of 1-10 can indicate minimal CAD, a CAC score of 11-100 can indicate mild CAD, a CAC score of 101-400 can indicate moderate CAD, and a CAC scores of greater than 400 can indicate severe CAD.

[0006] Since adjustments to the kVp result in radiographic contrast changes, standard techniques for reducing dose primarily rely on adjustment to the tube current and exposure time. Other approaches to performing CCS using lower kVp have been attempted, but have been unsuccessful, at least in part due to the lack of a consistent methodology to determine correct dosing for adequate calcium scoring, and because of degradation in the resultant image quality. For example, as kVp is lowered, the resultant image can show false calcifications due to the change in radiographic contrast. Overall, existing techniques to reduce dose have been unsuccessful, empirical, and inconsistent. Current techniques have simply been unable to reliably produce successful CCS at appropriate lower dose in general. Therefore, there is a need for improved CCS techniques to further lower dose while maintaining reliable and accurate coronary calcium scoring.

SUMMARY

[0007] The term embodiment and like terms are intended to refer broadly to all of the subject matter of this disclosure and the claims below. Statements containing these terms should be understood not to limit the subject matter described herein or to limit the meaning or scope of the claims below. Embodiments of the present disclosure covered herein are defined by the claims below, not this summary. This summary is a high-level overview of various aspects of the disclosure and introduces some of the concepts that are further described in the Detailed Description section below. This summary is not intended to identify key or essential features of the claimed subject matter, nor is it intended to be used in isolation to determine the scope of the claimed subject matter. The subject matter should be understood by reference to appropriate portions of the entire specification of this disclosure, any or all drawings and each claim.

[0008] Embodiments of the present disclosure relate to a method for measuring cardiac health, the method comprising: determining a target peak kilovoltage for driving a radiation source of a medical scanner, wherein the target peak kilovoltage is less than 120 kV; determining an appropriate dose based on the target peak kilovoltage, wherein the appropriate dose is determined to achieve a contrast-to-noise ratio equal to a contrast-to-noise ratio associated with a defined target peak kilovoltage of 120 kV; determining dose parameters based on the appropriate dose; and driving the medical scanner using the target peak kilovoltage and the dose parameters.

[0009] In some cases, the target peak kilovoltage is at or between 70 kV and 100 kV.

In some cases, the medical scanner is a computed tomography (CT) scanner. In some cases, determining the appropriate dose comprises applying a reducing factor to a reference dose, wherein the reference dose is associated with the defined target peak kilovoltage of 120 kV. In some cases, determining the appropriate dose comprises applying the formula where CTDIvoi is the appropriate dose in mGy, kVptarget is the target peak kilovoltage in kV, and CTDIvoi, ref is the reference dose in mGy at 120 kVp. In some cases, driving the medical scanner comprises generating radiation at the radiation source and directing the radiation through target tissue. In some cases, the target tissue comprises calcifications in a coronary artery.

[0010] In some cases, the method further comprises receiving scanner data associated with driving the medical scanner using the target peak kilovoltage and the dose parameters; and scaling the scanner data based on the target peak kilovoltage. In some cases, the method further comprises analyzing the scaled scanner data using standard Hounsfield unit thresholds to calculate an Agatston score associated with the scanner data. In some cases, the standard Hounsfield unit (HU) thresholds comprise a first threshold of 0-129 HU associated with a score of 0, a second threshold of 130-199 HU associated with a score of 1, a third threshold of 200- 299 HU associated with a score of 2, a third threshold of 300-399 HU associated with a score of 3, and a fourth threshold of 400 HU or greater associated with a score of 4. In some cases, scaling the scanner data comprises: determining a scaling factor using the target peak kilovoltage; and scaling each pixel of the scanner data by the scaling factor. In some cases, determining the scaling factor comprises applying the target peak kilovoltage to a lookup table. In some cases, the scaling factor is at or approximately 1.59 when the peak kilovoltage is 70 kV, the scaling factor is at or approximately 1.38 when the peak kilovoltage is 80 kV, the scaling factor is at or approximately 1.24 when the peak kilovoltage is 90 kV, and the scaling factor is at or approximately 1.14 when the scaling factor is 100 kV.

[0011] Embodiments of the present disclosure relate to a method for pre-processing data for coronary calcium scoring, the method comprising: receiving scanner data associated with driving a computed tomography (CT) scanner at a target peak kilovoltage below 120 kV; determining a scaling factor using the target peak kilovoltage; scaling each pixel of the scanner data by the scaling factor; and outputting the scaled scanner data, wherein the scaled scanner data is analyzable using standard Hounsfield unit thresholds to calculate an Agatston score associated with the scanner data.

[0012] In some cases, the standard Hounsfield unit (HU) thresholds comprise a first threshold of 0-129 HU associated with a score of 0, a second threshold of 130-199 HU associated with a score of 1, a third threshold of 200-299 HU associated with a score of 2, a third threshold of 300-399 HU associated with a score of 3, and a fourth threshold of 400 HU or greater associated with a score of 4. In some cases, the scaling factor is at or approximately 1.59 when the peak kilovoltage is 70 kV, the scaling factor is at or approximately 1.38 when the peak kilovoltage is 80 kV, the scaling factor is at or approximately 1.24 when the peak kilovoltage is 90 kV, and the scaling factor is at or approximately 1.14 when the scaling factor is 100 kV.

[0013] Embodiments of the present disclosure further relate to a system comprising: a control system including one or more processors; and a memory having stored thereon machine readable instructions; wherein the control system is coupled to the memory, and any one of the methods described above is implemented when the machine executable instructions in the memory are executed by at least one of the one or more processors of the control system. [0014] Embodiments of the present disclosure further relate to a system for assessing coronary artery calcification, the system including a control system configured to implement any one of the methods described above.

[0015] Embodiments of the present disclosure further relate to a computer program product comprising instructions which, when executed by a computer, cause the computer to carry out any one of the methods described above. In some cases, the computer program product is a non-transitory computer readable medium. BRIEF DESCRIPTION OF THE DRAWINGS

[0016] The specification makes reference to the following appended figures, in which use of like reference numerals in different figures is intended to illustrate like or analogous components.

[0017] FIG. 1 is a schematic diagram of a system for assessing a coronary calcium score, according to certain aspects of the present disclosure.

[0018] FIG. 2 is a graph depicting contrast-to-noise ratio versus dose for an example

200 mg/cc sample at various kVps, according to certain aspects of the present disclosure. [0019] FIG. 3 is a graph depicting contrast-to-noise ratio versus dose for an example

800 mg/cc sample at various kVps, according to certain aspects of the present disclosure. [0020] FIG. 4 is a graph depicting the fitting of parameter “a” from the CNR-to-CTDIvoi equations of examples of FIGs 2-3, according to certain aspects of the present disclosure. [0021] FIG. 5 is a graph depicting the Agatston score for an example sample at various kVps and dose, according to certain aspects of the present disclosure.

[0022] FIG. 6A is a CT image of an example sample showing significant false calcifications, according to certain aspects of the present disclosure.

[0023] FIG. 6B is a simplified graphic representation of the CT image of FIG. 6A, according to certain aspects of the present disclosure.

[0024] FIG. 7A is a CT image of the example sample of FIG. 6A, showing minimized false calcifications, according to certain aspects of the present disclosure.

[0025] FIG. 7B is a simplified graphic representation of the CT image of FIG. 7A, according to certain aspects of the present disclosure.

[0026] FIG. 8 is a flowchart depicting a process for obtaining a coronary calcium score, according to certain aspects of the present disclosure.

[0027] FIG. 9 is a flowchart depicting a process for performing kVp-dependent scaling on a scanner image, according to certain aspects of the present disclosure.

[0028] FIG. 10 is a block diagram of an example system architecture for implementing features and processes according to certain aspects of the present disclosure.

[0029] FIG. 11 is a set of charts depicting calcium scores and CTDIvoi for scans at various kVp for a large-sized sample, broken out by density of calcification, according to certain aspects of the present disclosure. [0030] FIG. 12 is a set of charts depicting calcium scores and CTDIvoi for scans at various kVp for a medium-sized sample, broken out by density of calcification, according to certain aspects of the present disclosure.

[0031] FIG. 13 is a chart depicting measured blood pool noise versus CTDIvoi for two example samples, according to certain aspects of the present disclosure.

[0032] FIG. 14 is a chart comparing CTDIvoi for medium-to-large patient sizes between clinical data, a constant noise threshold approach, and an SCCT noise threshold approach, according to certain aspects of the present disclosure.

[0033] FIG. 15 is a chart comparing CTDIvoi for small-to-large patient sizes between clinical data, a constant noise threshold approach, and an SCCT noise threshold approach, according to certain aspects of the present disclosure.

[0034] FIG. 16 is a flowchart depicting a process for generating and using a CTDI _voi (L)

Model, according to certain aspects of the present disclosure.

DETAILED DESCRIPTION

[0035] Certain aspects and features of the present disclosure relate to determining dose for a coronary calcium scoring (CCS) computed tomography (CT) scan (e.g., a volume CT dose index (CTDIvoi)) at a lower tube voltages (e.g., a lower peak kilovoltage (kVp)) for a given reference tube voltage. A dose lookup table can be created and used to determine appropriate dosing for CCS while operating at lower kVp based on a reference kVp. This dose lookup table can be created specifically to achieve a consistent contrast-to-noise (CNR) ratio. Additionally, certain aspects and features of the present disclosure also relate to a kVp- dependent scaling method to process images so standard CCS software can be used with standard Houndsfield unit (HU) thresholds. Images captured at non-standard kVp can be processed according to the disclosed scaling method prior to being transferred to CCS software for scoring based on a presumed standard kVp.

[0036] In CT scanning, a peak kilovoltage (kVp), also known as a peak tube voltage or a tube voltage, is a measurement of the voltage applied across the x-ray tube to generate x-rays, and more specifically a measurement proportional to the maximum energy of the emitted x- rays. The peak kilovoltage used during a scan defines the amount of radiographic contrast of the resultant image (e.g., the ratio of transmitted radiation through regions of differing density or thickness). Depending on the tissue being imaged, different kVps are needed to provide appropriate contrast to the image. For CCS, a peak tube voltage of 120 kV is used in order to provide suitable contrast for scoring regions of calcification. [0037] In addition to tube voltage, tube current and exposure time can be adjusted, which can be measured in milliamperes (mA) and seconds (s), respectfully, or combined as mA*s. While tube voltage controls the energy of the x-rays that are produced (e.g., and thus their ability to penetrate different densities of tissue), tube current controls the number of x- rays produced for a unit time and exposure time controls the amount of time x-rays are produced to generate the image. Thus, for any given kVp, the overall dose can be adjusted by making changes in tube current and exposure time. However, such changes can affect the subsequent contrast and signal-to-noise ratio of the resultant image.

[0038] Existing CCS technologies and scoring methodologies rely on the assumption of a CT scan with a kVp of 120 kV. Other attempts to use lower kVp acquisitions for CCS have been attempted unsuccessfully, due at least in part to a lack of a systematic approach for prescribing the dose for any given kVp. In such attempts adjustment to the lowest CT number threshold was applied without changing the other thresholds, but was unsuccessful in obtaining suitable CCS. While it may be possible to adjust the various thresholds for the different Hounsfield unit ranges in order to make use of lower kVp acquisitions, doing so renders the images unable to be processed using existing and standard CCS software.

[0039] Using the current techniques, reducing dose by lowering kVp causes changes in the radiographic contrast of the resultant CT images, which can reduce the signal-to-noise ration and can result in false calcifications appearing in the acquired image. Additionally, changes to the kVp can affect the scores that are generated from standard HU thresholds, requiring ad-hoc adjustments to the HU thresholds to achieve the expected scores. Not only are such adjustments to thresholds for various Hounsfield unit ranges not available using standard CCS software, but such changes may be difficult to ascertain on the fly for each CT scan.

[0040] As disclosed herein, appropriate doses for lower kVp acquisitions can be obtained for a given benchmark kVp. Through non-trivial trial and experimentation, it has been determined that the contrast-to-noise ratio for a given sample of calcium exhibits a power relationship with the dose (CTDUoi) and with kVp. Leveraging this power relationship, an appropriate dose can be calculated for a desired kVp in which the calcium being imaged will exhibit the same contrast-to-noise ratio (CNR) as that of a reference kVp.

[0041] In some cases, this relationship between CNR and CTDUoi and kVp can be used to generate a dose lookup table for various kVp settings. To maintain the same CNR of calcium as a scan with a kVp of 120kV, the corresponding CTDUoi may need to be reduced by a certain factor, depending on the kVp used. For example, in order to maintain the same CNR of calcium as a scan with a kVp of 120 kV, the corresponding CTDIvoi may need to be reduced by a factor of 0.80 for a scan with a kVp of 100, a factor of 0.70 for a scan with a kVp of 90, a factor of 0.60 for a scan with a kVp of 80, and a factor of 0.51 for a scan with a kVp of 70. In an example case, for an individual with an average chest size, such as an anterior-posterior (AP) chest size of at or approximately 22 cm and a lateral (LAT) chest size of at or approximately 32 cm, the aforementioned factors were especially useful. In another example case, for an individual with a larger chest size, such as one with an AP chest size of at or approximately 33 cm and a LAT chest size of at or approximately 43 cm, the following factors can be especially useful: a factor of 0.80 for a scan with a kVp of 100, a factor of 0.70 for a scan with a kVp of 90, a factor of 0.61 for a scan with a kVp of 80, and a factor of 0.51 for a scan with a kVp of 70. In another example case, the following factors were found to be especially useful: a factor of 0.80 for a scan with a kVp of 100, a factor of 0.70 for a scan with a kVp of 90, a factor of 0.60 for a scan with a kVp of 80, and a factor of 0.51 for a scan with a kVp of 70.

[0042] When acquiring CT images using lower-than-standard kVps, the calcium HU scores will be intrinsically enhanced. While the dose can be adjusted, such as disclosed herein, to maintain a desired CNR, doing so may alter the HU thresholds necessary to achieve the appropriate CAC score (e.g., as determined form a standard dose, standard kVp scan). However, instead of adjusting the HU thresholds used to calculate the CAC score, the present disclosure provides a technique for pre-processing the CT images so that they can be scored using the standard HU thresholds, and thus can be scored using standard CCS software.

[0043] As disclosed herein, CT images acquired at kVps lower than a reference kVp and with reduced dose can be pre-processed to achieve a desired CNR, which can be analyzed using standard CCS software. The pre-processing can involve scaling each pixel in an acquired image. Specifically, each pixel can be scaled by the factor that enhanced the calcium due to the lower kVp, which is a kVp-dependent factor. For example, at a kVp of 70 kV, the factor is at or approximately 1.59; at a kVp of 80 kV, the factor is at or approximately 1.38; at a kVp of 90 kV, the factor is at or approximately 1.24; and at a kVp of 100 kV, the factor is at or approximately 1.14. After applying this preprocessing to the CT images, they can be analyzed using the standard CCS software using the standard HU thresholds.

[0044] In some cases, the CTDLoi at the reference kVp of 120 for a given subject can be calculated based on that subject’s size (e.g., chest size, such as chest diameter or effective chest diameter). Through non-trivial trial and experimentation, it has been determined that a suitable formula for calculating CTDLoi at a given subject’s size can be based on experimental data acquired from two known sample sizes (e.g., a sample subject greater than the given subject’s chest size and a sample subject smaller than the given subject’s size). In such cases, an appropriate CTDIvoi for a subject can be calculated even more precisely based on that subject’s specific anatomy (e.g., chest size).

[0045] Various aspects and features of the present disclosure can be implemented in various ways, including as a standalone system, a standalone module, a system combined with a CCS software system (e.g., a separate program running on the same computing device as the CCS software) , a system combined with a CT imager, a module of a CCS software system or CT imaging system (e.g., a plug-in), or the like.

[0046] These illustrative examples are given to introduce the reader to the general subject matter discussed here and are not intended to limit the scope of the disclosed concepts. The following sections describe various additional features and examples with reference to the drawings in which like numerals indicate like elements, and directional descriptions are used to describe the illustrative embodiments but, like the illustrative embodiments, should not be used to limit the present disclosure. The elements included in the illustrations herein may not be drawn to scale.

[0047] FIG. 1 is a schematic diagram of a system 100 for assessing a coronary calcium score, according to certain aspects of the present disclosure. The system 100 can include a scanner 102 (e.g., CT scanner) into which a patient 108 can be placed for image acquisition. The scanner 102 can include a radiation source 104 (e.g., an x-ray tube) and a detector 106 (e.g., a single detector or an array of detectors). The radiation source 104 can cause radiation 110 (e.g., x-rays) to be directed through the patient 108 towards the detector 106 to generate an image. While depicted as a torus-shaped CT scanner in FIG. 1, scanner 102 can be any suitable scanner or scanner configuration.

[0048] The scanner 102 can be communicatively coupled to a control and analysis system 120. In some cases, the control and analysis system 120 can be incorporated into a single housing or single computing device, although that need not always be the case. In some cases, various modules of the control and analysis system 120 can be incorporated into multiple computing devices, such as a first computing device for obtaining CT scans (e.g., a control system) and a second computing device for analyzing the CT scans (e.g., an analysis system). In such an example, the control system may include the imaging module 112, the dose calculation module 118, and the image scaling module 114, while the analysis system may include the coronary calcium scoring module 116. In some cases, other arrangements of modules may be used. [0049] The scanner 102 can be controlled by the imaging module 112 to obtain scanner data (e.g., images). The scanner data can include pixel-based and/or volumetric data associated with the type of scan being performed, and can be presented as a set of images and/or image slices. In a CT scanner, the scanner data can be one or more CT images, which can be stored as one or more CT scan files. The imaging module 112 can control various factors of the scanning process, such as the peak tube voltage (kVp), tube current (mA), and exposure time (s).

[0050] The imaging module 112 can be communicatively coupled to a dose calculation module 118, which can assist in calculating a needed dose for a given kVp. While standard CCS CT scans may operate at a kVp of 120 kV, system 100 can be used with kVps below 120 kV, such as at or approximately 100 kV, 90 kV, 80 kV, and/or 70 kV, although other kVps below 120 kV may be used. When a non-standard kVp (e.g., not 120 kV) is desired, such as to reduce the overall dose of radiation to the patient 108, the dose calculation module 118 can determine an appropriate dose, and thus appropriate tube current-time product (mA*s), at which the scanner 102 must be driven for the given target kVp to achieve accurate CCS results. [0051] In some cases, dose calculation module 118 can include memory containing a lookup table. In such cases, dose calculation module 118 can apply the target kVp to the lookup table to determine the appropriate dose. In some cases, dose calculation module 118 can include a memory containing a formula. In such cases, dose calculation module 118 can apply the target kVp to the formula to determine the appropriate dose.

[0052] The imaging module 112 can use the appropriate dose determined by the dose calculation module 118 to drive the scanner 102. At a given target kVp, the appropriate dose can be used to calculate the necessary tube current-time product (mA*s) for the scan. The imaging module 112 can then use the calculated parameters (e.g., mA and s) to drive the radiation source 104 of the scanner 102 at the desired target kVp for the appropriate amount of time and at the appropriate current based on the calculated parameters. As a result, the detector 106 will generate signal data in the form of scanner data (e.g., CT image(s)).

[0053] After obtaining the scanner data, the imaging scaling module 114 can perform pre-processing to the scanner data dependent upon the target kVp used. The imaging module 112 can send the scanner data and the target kVp used to the image scaling module 114, which can scale each pixel of the image (or voxel of the volumetric image) by a reduction factor. The reduction factor can be a kVp-dependent reduction factor.

[0054] In some cases, image scaling module 114 can include memory containing a lookup table. In such cases, image scaling module 114 can apply the target kVp to the lookup table to determine the appropriate reduction factor. In some cases, image scaling module 114 can include a memory containing a formula. In such cases, image scaling module 114 can apply the target kVp to the formula to determine the appropriate reduction factor.

[0055] After the scanner data has been scaled by the image scaling module 114, this pre-processed scanner data can be analyzed using the coronary calcium scoring module 116. The coronary calcium scoring module 116 can be standard CCS software used to analyze CT scan data to generate an Agatston score. The coronary calcium scoring module 116 can analyze the incoming data (e.g., the pre-processed scanner data) based on traditional Hounsfield unit thresholds to generate the Agatston score, such as using traditional techniques. The system can output the Agatston score, such as on a display. In some cases, the display can annotate or highlight regions of the scanned data (e.g., image) based on the Houndsfield unit scores. [0056] In some cases, all elements of the system 100 can be located in a single environment or facility, however that need not be the case. In some cases, some elements can be located in other locations and/or used non-sequentially. For example, in some cases, a radiologist or cardiologist may analyze the scanner data (e.g., analyze the post-processed scanner data or post-process and then analyze the scanner data) in a separate location from the scanner 102 and/or at a very different time than when the scan was completed (e.g., several days later).

[0057] In some cases, various functions of the various modules of the control and analysis system 120 can be automatic, without requiring additional user input. For example, after setting a target kVp, the dose calculation module 118 may automatically determine the appropriate dose and dose parameters (e.g., mA and s) and feed those to the imaging module 112. In another example, after performing the scan, the image scaling module 114 may automatically pre-process the scanner data, such as before or immediately after saving the scanner data to a storage medium.

[0058] FIGs. 2-3 are graphs 200, 300 depicting contrast-to-noise ratio versus dose for an example 200 mg/cc sample and an example 800 mg/cc sample, respectfully, at various kVps, according to certain aspects of the present disclosure. Any suitable system can be used to generate the results depicted in graphs 200, 300, such as system 100 of FIG. 1.

[0059] The contrast-to-noise ratio of a radiographic image (e.g., scanner data) is an important metric in differentiating tissues. Since the Agatston score is based on identifying regions of calcification in CT scans, it relies on contrast differences between the calcium in the coronary arteries and the surrounding tissue. As kVp decreases, the contrast-to-signal ratio will change. [0060] To generate the results of graph 200, CT scans were taken using an anthropomorphic heart phantom with inserts of hydroxyapatite (HA) having a density of 200 mg/cc. Soft tissue rods were used to fill the air cavity. The hydroxyapatite inserts accurately mimic calcification in the coronary arteries of the heart phantom. CT scans were taken using dual-source axial mode and manual techniques at various combinations of kVp and CTDIvoi. CT scans sets were taken at kVps of 120 kV, 100 kV, 90 kV, 80 kV, and 70 kV. For each scan set, scans were taken for various doses (CTDIvoi) from 0.5 to 15 mGy. Each scan was repeated three times and the images were reconstructed to a typical slice thickness (e.g., 3 mm) without iterative reconstruction. The CNR of the hydroxyapatite inserts was measured among all slices and the mean values were fitted to a function of CTDIvoi at each kVp. The results were further fitted to a function of kVp. A residual analysis was performed to demonstrate the fitting accuracy.

[0061] The results of graph 300 were generated using the same technique as those of graph 200, except with the use of hydroxyapatite inserts having a density of 800 mg/cc instead of 200 mg/cc.

[0062] As depicted in FIGs. 2-3, the relationship between CNR and CTDIvoi can be shown according to the following equation, in which a is a kVp-dependent parameter:

CNR = a * CTDI _vol ^0AS

[0063] The kVp-dependent parameter was fit as described with reference to FIG. 4.

[0064] FIG. 4 is a graph 400 depicting the fitting for parameter “a” of the CNR-to-

CTDIvoi equations from the examples of FIGs 2-3, according to certain aspects of the present disclosure. The fitting for parameter “a” is depicted for the two different hydroxyapatite densities (e.g., 200 mg/cc and 800 mg/cc) from the examples of FIGs. 2-3. Based on the fitting results shown in graph 400, the parameter a can be described by the following equation, where c is a proportionality constant dependent on the calcium physical density: a = ckVp ^~0 · ⁵⁴

[0065] It was determined that the CNR was fitted to a power relationship with CTDIvoi and kVp (r ² > 0.958). As further supported with reference to FIGs. 3-4, the power indices were found to be 0.43 and -0.54, respectively. The average residual was less than 3%. Based on the findings, in order to maintain the same CNR of calcium as at a kVp of 120 kV, the corresponding CTDIvoi for kVps of 100 kV, 90 kV, 80 kV, and 70 kV can be reduced by factors of 0.80, 0.70, 0.60, and 0.51, respectively. [0066] Thus, for the 200 and 800 mg/cc samples of hydroxyapatite, the equations relating the CNR to kVp and CTDIvoi are as follows:

[0067] To accommodate for different densities, the appropriate dose for a particular kVp can be based on the appropriate dose for a reference kVp, such as the standard kVp of 120 kV used for traditional CCS. Therefore, to achieve the same CNR as achieved with a reference kVp, an appropriate dose for a particular target kVp below a reference kVp can be obtained using the following equation, where CTDIvoi and CTDIvoi, ref are measured in mGy and kVp is measured in kV :

[0068] Applied to a reference kVp of 120 kV, the equation can be:

[0069] FIG. 5 is a graph 500 depicting the Agatston score for an example sample at various kVps and dose, according to certain aspects of the present disclosure. The data represented in graph 500 is for a sample that is a medium size phantom. Standard techniques CCS rely on acquisitions with a kVp of 120 kV, which limit dose reduction to mA adjustment. The utilization of lower kVp makes further dose reduction possible, but the intrinsic calcium enhancement at each kVp would normally require multiple HU threshold adjustments for scoring.

[0070] As depicted in FIG. 5, Agatston scores are calculated across different combinations of CTDIvoi and kVps, as labelled above or below each measurement on the graph 500. For illustrative purposes, the y-axis of graph 500 depicts the Agatston score and the x- axis depicts cases of various doses and kVps. The Agatston score taken at 3 mGy and 120 kV is used to define the horizontal reference line at an Agatston score of approximately 425. [0071] To obtain the results depicted in graph 500, Hydroxyapatite inserts of different densities (e.g., 50, 100, 250 and 400 mg/cc) and different sizes (e.g., 1.2 - 5mm) were placed inside a dynamic heart phantom within the coronary segments to simulate coronary calcium. The phantom was set in 3D motion with an ECG of 60 beats-per-minute and was scanned on a CT using a kVp of 120 kV and at various doses (e.g., CTDIvoi 0.76 - 3 mGy). Scans were taken at lower kVps (e.g., at 100, 90, 80 and 70), in which cases each scan dose was set to achieve a consistent contrast-to-noise ratio (CNR) as that of the clinical technique for the phantom size (e.g., 120 kVp and 1.56 mGy). Each scan was repeated six times and the images were reconstructed to 3 mm without iterative reconstruction.

[0072] The pixel values of the lower kVp images were scaled down by the previously found calcium CT number enhancement ratio relative to 120 kVp. This processing maintained the calcium CNR and the Agatston score thresholds (e.g., HU thresholds). Standard CCS software was used to obtain the coronary calcium scores for all image sets by six independent readers.

[0073] Line 502 represents the reference score, which is based on the reference images from the 120 kVp acquisition at the CTDIvoi of 3.0 mGy. As depicted in graph 500, after the aforementioned correction (e.g., pre-processing), the final Agatston scores of the acquisitions at various kVp below 120 kV are nevertheless accurate when compared to the reference score. [0074] It was determined that in order to maintain the same HU thresholds for calcium as at a kVp of 120 kV, the pixels of images acquisitions taken at kVps of 100 kV, 90 kV, 80 kV, and 70 kV can be scaled down by factors of 1.14, 1.24, 1.38, and 1.59, respectively. [0075] FIG. 6A is a CT image 600 of an example sample showing significant false calcifications, according to certain aspects of the present disclosure. Image 600 was acquired at a kVp of 120 kV and a CTDIvoi of 0.76 mGy. Image 600 shows significant false calcifications.

[0076] FIG. 6B is a simplified graphic representation 601 of the CT image 600 of FIG.

6 A, according to certain aspects of the present disclosure. For illustrative purposes, the simplified graphic representation 601 shows only the outline of the sample along with indications 602 of calcium deposits. Thus, the regions identified as calcium deposits from image 600, including all of the false calcifications (e.g., most of the small annotated speckles), are depicted as indications 602 in the simplified graphic representation 601.

[0077] FIG. 7A is a CT image 700 of the example sample showing minimized false calcifications, according to certain aspects of the present disclosure. The CT image 700 was acquired at a kVp of 70 kV and the same CTDIvoi of 0.76 mGv. As depicted in FIG. 7A, the image 700 shows minimized false calcifications when compared to image 600 of FIG. 6A. [0078] FIG. 7B is a simplified graphic representation 701 of the CT image 700 of FIG.

7 A, according to certain aspects of the present disclosure. For illustrative purposes, the simplified graphic representation 701 shows the outline of the sample along with indication 702 of calcium deposits. Thus, the regions identified as calcium deposits from image 700 are depicted as indication 702 in the simplified graphic representation 701. Areas 704 are regions of bone.

[0079] FIG. 8 is a flowchart depicting a process 800 for obtaining a coronary calcium score, according to certain aspects of the present disclosure. Process 800 can be performed by system 100 of FIG. 1, or any other suitable system.

[0080] At block 802, a target kVp can be set. The target kVp can be selected from a list of available kVp or can be otherwise selected. As used herein, determining a target kVp can include automatically determining a target kVp or manually determining a target kVp (e.g., based on user input or selection of a target kVp). At block 804, the target kVp can be used to determine an appropriate dose (e.g., CTDW). Determining the appropriate dose can make use of any of the equations as described above with reference to FIGs. 2-4. In some cases, determining the appropriate dose based on the target kVp applies the following equation:

[0081] In some cases, determining the appropriate dose can include accessing a lookup table and applying the target kVp to the lookup table to identify an appropriate dose.

[0082] In some cases, the reference dose (e.g., dose at the reference kVp, or CTDI _V oi,ref) can itself be determined or modified based on the size of the patient (e.g., the diameter of the patient’s chest), such as described with reference to FIGs. 13-14.

[0083] In some cases, instead of setting a target kVp at block 802 and then determining an appropriate dose at block 804, the process can be reversed and a target dose can be set first, from which an appropriate kVp can be determined. Other blocks of process 800 can be adjusted accordingly.

[0084] At block 806, dose parameters can be determined based on the appropriate dose determined at block 804. Determining dose parameters can include determining an appropriate tube current and exposure time for driving the scanner. Determining dose parameters can include using the target kVp and the CTDIvoi from blocks 802 and 804, respectively. In some cases, determining dose parameters can include determining a tube current-time product associated with the target kVp and CTDIvoi from blocks 802 and 804. Since the tube current time product is directly proportional to the CTDIvoi determined at block 804 (e.g., proportional based on kVp), appropriate dose parameters can be determined from the CTDIvoi using any suitable technique, such as calculating from a formula, measuring on a chart, or applying a lookup table. [0085] At block 808, the scanner can be driven at the target kVp using the dose parameters form block 806. Driving the scanner can include applying voltage through a radiation source, such as an x-ray tube, to achieve a kVp of the target kVp set at block 802 at a current and for an exposure time as dictated by the dose parameters determined at block 806. Applying the appropriate power to the radiation source can energize the radiation source to generate radiation that passes through a target area (e.g., a portion of a patient) towards a detector. Driving the scanner at block 808 can include receiving radiation at the detector and generating scanner data based on the detected radiation. The scanner data can be one or more x-ray images.

[0086] At block 810, the scanner data can be scaled based on the target kVp. Scaling the scanner data at block 810 can occur within the scanner (e.g., scanner 102 of FIG. 1), within a control unit for the scanner, or within any other suitable computing device. For example, a scanner system (e.g., scanner and/or control unit for the scanner) can output an already pre- processed (e.g., scaled) image by scaling the scanner data prior to outputting it. Thus, the output from the scanner system can be directly analyzed by a CCS module (e.g., CCS analysis software). In another example, the scanner system can output the non-scaled scanner data, in which case a separate system (e.g., cloud-based computing device or a computing device for analyzing and generating a CAC score) can scale the scanner data prior to a CCS module analyzing the scaled scanned data.

[0087] Scaling the scanner data can include adjusting each pixel (or voxel) of an image based on a scaling factor. The scaling factor can be based on the target kVp. For example, at a kVp of 70 kV, the scaling factor is at or approximately 1.58; at a kVp of 80 kV, the scaling factor is at or approximately 1.38; at a kVp of 90 kV, the scaling factor is at or approximately 1.24; and at a kVp of 100 kV, the scaling factor is at or approximately 1.14. As used with reference to this scaling factor, the term “at or approximately” can include the number or within 10%, 9%, 8%, 7%, 6%, 5%, 4%, 3%, 2%, and/or 1% of the number. In an example case, for an individual with an average chest size, such as an anterior-posterior (AP) chest size of at or approximately 22 cm and a lateral (LAT) chest size of at or approximately 32 cm, the aforementioned scaling factors were especially useful. In another example case, for an individual with a larger chest size, such as one with an AP chest size of at or approximately 33 cm and a LAT chest size of at or approximately 43 cm, the following scaling factors can be especially useful: a scaling factor of at or approximately 1.61 when the peak kilovoltage is 70 kV, a scaling factor of at or approximately 1.38 when the peak kilovoltage is 80 kV, a scaling factor of at or approximately 1.24 when the peak kilovoltage is 90 kV, and a scaling factor of at or approximately 1.13 when the scaling factor is 100 kV. In another example case, the following scaling factors were found to be especially useful: a scaling factor of at or approximately 1.59 when the peak kilovoltage is 70 kV, a scaling factor of at or approximately 1.38 when the peak kilovoltage is 80 kV, a scaling factor of at or approximately 1.24 when the peak kilovoltage is 90 kV, and a scaling factor of at or approximately 1.14 when the scaling factor is 100 kV.

[0088] In an example, scaling can be performed by generating a new value for each pixel of an image using the current value of each pixel of the image scaled according to the following equation, where & is the scaling factor:

Image(i.j )

^New i _{mage(i,j )} = Nearest integer of ( - - - )

[0089] Scaling the scanner data at block 810 can include determining the scaling factor based on the kVp used to generate the scanner data (e.g., the target kVp from block 802). Determining the scaling factor can include using any suitable technique, such as calculating from a formula, measuring on a chart, or applying a lookup table.

[0090] At block 812, the scaled scanner data can be analyzed. The scaled scanner data can be analyzed to generate a CAC score, such as an Agatston score. The scaled scanner data can be analyzed using standard HU procedures (e.g., standard HU thresholds) to obtain the Agatston score. Thus, the scaled scanner data is usable in standard CCS software to generate an accurate Agatston score, despite the target kVp at block 902 being below the 120 kV standard kVp.

[0091] FIG. 9 is a flowchart depicting a process 900 for performing kVp-dependent scaling on a scanner image, according to certain aspects of the present disclosure. In some cases, process 900 can be performed as part of block 810 of process 800 of FIG. 8.

[0092] At block 902, scanner data is received. The scanner data can be associated with a target kVp. The target kVp can be other than a standard 120 kV, such as below 120 kV. In some cases, the scanner data includes the kVp, although that need not always be the case. In some cases, the target kVp can be received separately from the scanner data and separately associated with the scanner data.

[0093] At block 904, a scaling factor is determined based on the target kVp.

Determining the scaling factor can be performed as described with reference to block 810 of FIG. 8. In some cases, determining the scaling factor can include applying the target kVp to a formula, chart, or lookup table designed to produce suitable scaling factors for various target kVps. Such formula, chart, or lookup table can be generated as disclosed herein. [0094] At block 906, each pixel (or voxel) of the scanner data can be scaled according to the scaling factor determined at block 906. Scaling each pixel can include applying the equation described herein with reference to block 810 of FIG. 8.

[0095] At block 908, the scaled scanner data can be analyzed. The scaled scanner data can be analyzed to generate a CAC score, such as an Agatston score. The scaled scanner data can be analyzed using standard HU procedures (e.g., standard HU thresholds) to obtain the Agatston score. Thus, the scaled scanner data is usable in standard CCS software to generate an accurate Agatston score, despite the target kVp received at block 902 being below the 120 kV standard kVp.

[0096] FIG. 10 is a block diagram of an example system architecture for implementing features and processes of the present disclosure, such as those presented with reference to FIGs. 1-9. The architecture 1000 can be implemented on any electronic device that runs software applications derived from compiled instructions, including without limitation personal computers, servers, smart phones, electronic tablets, game consoles, email devices, and the like. In some implementations, the architecture 1000 can include one or more processors 1002, one or more input devices 1004, one or more display devices 1006, one or more network interfaces 1008, and one or more computer-readable mediums 1010. Each of these components can be coupled by bus 1012.

[0097] In some implementations, system architecture 1000 can correspond to a single server in a rack of servers. Various rack configurations can be implemented. For example, a rack can include multiple chassis and each chassis can contain multiple servers. Each server in the rack can be connected by various hardware components (e.g., backbone, middle plane, etc.). In some implementations, system architecture 1000 can correspond to a control console for a CT scanner and/or multiple devices coupled to a single control console for a CT scanner. [0098] Display device 1006 can be any known display technology, including but not limited to display devices using Liquid Crystal Display (LCD) or Light Emitting Diode (LED) technology. Processor(s) 1002 can use any known processor technology, including but not limited to graphics processors and multi-core processors. Input device 1004 can be any known input device technology, including but not limited to a keyboard (including a virtual keyboard), mouse, track ball, and touch-sensitive pad or display. Bus 1012 can be any known internal or external bus technology, including but not limited to ISA, EISA, PCI, PCI Express, NuBus, USB, Serial ATA or FireWire.

[0099] Computer-readable medium 1010 can be any medium that participates in providing instructions to processor(s) 1002 for execution, including without limitation, non- volatile storage media (e.g., optical disks, magnetic disks, flash drives, etc.) or volatile media (e.g., SDRAM, ROM, etc.). The computer-readable medium (e.g., storage devices, mediums, and memories) can include, for example, a cable or wireless signal containing a bit stream and the like. However, when mentioned, non-transitory computer-readable storage media expressly exclude media such as energy, carrier signals, electromagnetic waves, and signals per se. [0100] Computer-readable medium 1010 can include various instructions for implementing operating system 1014 and applications 1020 such as computer programs. The operating system can be multi-user, multiprocessing, multitasking, multithreading, real-time and the like. The operating system 1014 performs basic tasks, including but not limited to: recognizing input from input device 1004; sending output to display device 1006; keeping track of files and directories on computer-readable medium 1010; controlling peripheral devices (e.g., disk drives, printers, etc.) which can be controlled directly or through an I/O controller; and managing traffic on bus 1012. Computer-readable medium 1010 can include various instructions for implementing firmware processes, such as a BIOS. Computer-readable medium 1010 can include various instructions for implementing any of processes described herein, such as processes 800, 900, 1600 of FIGs. 8, 9, and 16, respectively.

[0101] Memory 1018 can include high-speed random access memory and/or non volatile memory, such as one or more magnetic disk storage devices, one or more optical storage devices, and/or flash memory (e.g., NAND, NOR). The memory 1018 (e.g., computer- readable storage devices, mediums, and memories) can include a cable or wireless signal containing a bit stream and the like. However, when mentioned, non-transitory computer- readable storage media expressly exclude media such as energy, carrier signals, electromagnetic waves, and signals per se. The memory 1018 can store an operating system, such as Darwin, RTXC, LINUX, UNIX, OS X, WINDOWS, or an embedded operating system such as VxWorks.

[0102] System controller 1022 can be a service processor that operates independently of processor 1002. In some implementations, system controller 1022 can be a baseboard management controller (BMC). For example, a BMC is a specialized service processor that monitors the physical state of a computer, network server, or other hardware device using sensors and communicating with the system administrator through an independent connection. The BMC is configured on the motherboard or main circuit board of the device to be monitored. The sensors of a BMC can measure internal physical variables such as temperature, humidity, power-supply voltage, fan speeds, communications parameters and operating system (OS) functions. [0103] The described features can be implemented advantageously in one or more computer programs that are executable on a programmable system including at least one programmable processor coupled to receive data and instructions from, and to transmit data and instructions to, a data storage system, at least one input device, and at least one output device. A computer program is a set of instructions that can be used, directly or indirectly, in a computer to perform a certain activity or bring about a certain result. A computer program can be written in any form of programming language (e.g., Objective-C, Java), including compiled or interpreted languages, and it can be deployed in any form, including as a stand alone program or as a module, component, subroutine, or other unit suitable for use in a computing environment.

[0104] Suitable processors for the execution of a program of instructions include, by way of example, both general and special purpose microprocessors, and the sole processor or one of multiple processors or cores, of any kind of computer. Generally, a processor will receive instructions and data from a read-only memory or a random access memory or both. The essential elements of a computer are a processor for executing instructions and one or more memories for storing instructions and data. Generally, a computer will also include, or be operatively coupled to communicate with, one or more mass storage devices for storing data files; such devices include magnetic disks, such as internal hard disks and removable disks; magneto-optical disks; and optical disks. Storage devices suitable for tangibly embodying computer program instructions and data include all forms of non-volatile memory, including by way of example semiconductor memory devices, such as EPROM, EEPROM, and flash memory devices; magnetic disks such as internal hard disks and removable disks; magneto optical disks; and CD-ROM and DVD-ROM disks. The processor and the memory can be supplemented by, or incorporated in, ASICs (application-specific integrated circuits).

[0105] To provide for interaction with a user, the features can be implemented on a computer having a display device such as a CRT (cathode ray tube) or LCD (liquid crystal display) monitor for displaying information to the user and a keyboard and a pointing device such as a mouse or a trackball by which the user can provide input to the computer.

[0106] The features can be implemented in a computing system that includes a back end component, such as a data server, or that includes a middleware component, such as an application server or an Internet server, or that includes a front-end component, such as a client computer having a graphical user interface or an Internet browser, or any combination thereof. The components of the system can be connected by any form or medium of digital data communication such as a communication network. Examples of communication networks include, e.g., a LAN, a WAN, and the computers and networks forming the Internet.

[0107] The computing system can include clients and servers. A client and server are generally remote from each other and typically interact through a network. The relationship of client and server arises by virtue of computer programs running on the respective computers and having a client-server relationship to each other.

[0108] One or more features or steps of the disclosed embodiments can be implemented using an application programming interface (API). An API can define one or more parameters that are passed between a calling application and other software code (e.g., an operating system, library routine, function) that provides a service, that provides data, or that performs an operation or a computation.

[0109] The API can be implemented as one or more calls in program code that send or receive one or more parameters through a parameter list or other structure based on a call convention defined in an API specification document. A parameter can be a constant, a key, a data structure, an object, an object class, a variable, a data type, a pointer, an array, a list, or another call. API calls and parameters can be implemented in any programming language. The programming language can define the vocabulary and calling convention that a programmer will employ to access functions supporting the API.

[0110] In some implementations, an API call can report to an application the capabilities of a device running the application, such as input capability, output capability, processing capability, power capability, communications capability, and the like.

[0111] FIG. 11 is a set of charts 1100, 1101 depicting calcium scores and CTDIvoi for scans at various kVp for a large-sized sample, broken out by density of calcification, according to certain aspects of the present disclosure. The sample used for charts 1100, 1101 can be a large-sized phantom. Charts 1100, 1101 are examples from scanning an example sample equating to an individual having an AP chest size of 33 cm and a LAT chest size of 43 cm. [0112] Charts 1100, 1101 each depict several example scans performed at 120 kVp,

100 kVp, 90 kVp, 80 kVp, and 70 kVp. Chart 1101 depicts the regional calcium scores for calcification densities of 100 mg/cc and 250 mg/cc, whereas chart 1100 depicts the regional calcium score for a calcification density of 400 mg/cc and a total calcium score. For each density level, the dotted line represents the ground truth pinned to the 120 kVp scan at 6 mGy CTDIvoi.

[0113] As seen in charts 1100, 1101, many data points were taken for scans at kVp lower than 120 kVp, with dosages substantially lower than 6 mGy, while achieving the same or similar (e.g., within 10%) calcium scores as the ground truth. Further, the accuracy of the lower tube potential scans appear to even improve with higher-density calcifications.

[0114] FIG. 12 is a set of charts 1200, 1201 depicting calcium scores and CTDIvoi for scans at various kVp for a medium-sized sample, broken out by density of calcification, according to certain aspects of the present disclosure. The sample used for charts 1200, 1201 can be a medium-sized phantom. Charts 1200, 1201 are examples from scanning an example sample equating to an individual having an AP chest size of 22 cm and a LAT chest size of 32 cm.

[0115] Charts 1200, 1201 each depict several example scans performed at 120 kVp,

100 kVp, 90 kVp, 80 kVp, and 70 kVp. Chart 1201 depicts the regional calcium scores for calcification densities of 50 mg/cc, 100 mg/cc, and 250 mg/cc, whereas chart 1200 depicts the regional calcium score for a calcification density of 400 mg/cc and a total calcium score. For each density level, the dotted line represents the ground truth pinned to the 120 kVp scan at 3 mGy CTDIvoi.

[0116] As seen in charts 1200, 1201, many data points were taken for scans at kVp lower than 120 kVp, with dosages substantially lower than 3 mGy, while achieving the same or similar (e.g., within 10%) calcium scores as the ground truth. Further, the accuracy of the lower tube potential scans appear to even improve with higher-density calcifications.

[0117] FIG. 13 is a chart 1300 depicting measured blood pool noise versus CTDIvoi for two example samples, according to certain aspects of the present disclosure. Chart 1300 is used to depict the relationship between blood pool noise and CTDIvoi for both medium-sized and large-sized samples. For each sampled CTDIvoi, the measurement of the blood pool results in a certain level of noise that deceases as the CTDIvoi increases. For example, a CTDIvoi of approximately 0.75 mGy on a medium sample achieves a noise level of approximately 28.6 HU, and a CTDIvoi of approximately 2.6 mGy on a large sample achieves a noise level of approximately 29.3 HU.

[0118] The data from chart 1300 was collected using two thoracic phantoms (medium and large) with a moving heart module. Each phantom was scanned at 120 kVp (e.g., reference kVp) using a prospectively gated CACs with a CT imager at different CTDIvoi levels (0.76 - 6 mGy). The motion for each phantom was driven by an ECG of 60 beats-per-minute. Noise measurements were made in the heart blood pool. The medium phantom had an effective diameter of approximately 26.5 cm (Lo) and its noise values are depicted as circular data points in chart 1300. The large phantom had an effective diameter of approximately 37.7 cm (Lmax) and its noise values are depicted as square data points in chart 1300. [0119] Thus, for any given maximum threshold of noise, the suitable CTDIvoi values

(e.g., lowest CTDIvoi values that can be used and not exceed the maximum threshold of noise) can be determined for each phantom. Any suitable noise thresholds can be used, although two specific noise threshold approaches are described herein: a constant noise threshold approach and a Society of Cardiovascular CT (SCCT) recommended threshold approach. The constant noise threshold approach defined a maximum noise threshold of 20 HU for each phantom. The SCCT recommended threshold approach defined a maximum noise threshold of 20 HU for the size range in which the medium phantom falls and a maximum noise threshold of 23 HU for the size range in which the large phantom falls. The 20 HU threshold level is represented by line 1302 and the 23 HU threshold level is represented by line 1304.

[0120] A surrogate noise (SN) value was constructed as a function of the patient effective diameter and the CTDIvoi. SN was defined according to the following equation, in which L is the effective diameter and a is an experimentally derived constant:

[0121] CTDIvoi values were determined for each of the subject sizes (e.g., each of the medium and large phantoms or each of the selected small and large patients) using both the constant threshold approach and the SCCT recommended threshold approach. To derive the CTDIvoi, as a function of subject size within that range (e.g., the range between the two known sample sizes), it can be assumed that the threshold noise, and thus SN, varies linearly with the patient size.

[0122] Based on the results of the data, the derived formula for calculating CTDIvoi can be expressed according to the following equation, referred to herein as the CTDIvoi, ref(L) Model: where L is the effective diameter of the subject sample, Lmax is the effective diameter of the larger known sample size (e.g., large phantom or large clinical patient), Lo is the effective diameter of the smaller known sample size (e.g., medium phantom or small clinical patient), Tmax is the threshold noise for the larger known sample size (e.g., large phantom or large clinical patient), To is the threshold noise for the smaller known sample size (e.g., medium phantom or small clinical patient), and a is the experimentally derived constant from the previous equation. CTDIvoi(Lo) is the CTDIvoi value identified in chart 1300 at the To threshold noise level. [0123] This CTDIvoi _, ref(L) Model, which is based on a reference kVp of 120 kVp, can be used to establish a new reference dose (e.g., CTDI _V oi,ref) that is patient-size-dependent. [0124] Under the constant threshold approach, To = Tmax = 20 HU. However, under the SCCT recommended threshold approach, To = 20 HU and Tmax = 23 HU. As seen in chart 1300, under the constant thresholds, the CTDUoi for the medium and large phantoms are approximately 1.5 mGy and 6 mGy, respectively. Under the SCCT recommended thresholds, the CTDUoi for the medium and large phantoms are approximately 1.5 mGy and 4.5 mGy, respectively.

[0125] FIG. 14 is a chart 1400 comparing CTDUoi, ref for medium-to-large patient sizes between clinical data, a constant noise threshold approach, and an SCCT noise threshold approach, using the two phantoms as the known sample sizes, according to certain aspects of the present disclosure. The data from chart 1400 is based on the experimental data and CTDUoi, ref(L) Model referenced with respect to chart 1300 of FIG. 13.

[0126] In chart 1400, the square data points represent the CTDUoi, ref values plotted according to patient sizes for a set of 33 clinical cases using dose modulation with a reference effective mAs of 80. The round data points represent the CTDUoi, ref values per patient size as calculated from the CTDUoi, ref(U) Model using the constant noise threshold approach (e.g., To = Tmax = 20 HU). The triangular data points represent the CTDUoi, ref values per patient size as calculated from the CTDUoi, ref(U) Model using the SCCT recommended noise threshold approach (e.g., To = 20 HU and Tmax = 23 HU).

[0127] As depicted in chart 1400 and according to the CTDUoi _, ref(U) Model, the doses to achieve the constant noise threshold (20 HU) were found more consistent with the observed patient doses, but switching to the SCCT variable thresholds resulted in a dose reduction of up to 25%. Thus, the CTDUoi, ref(U) Model can be used to quantitatively model a prescribed patient-size-dependent optimal dose at standard 120 kVp for CACs. Further, this model can also serve as an optimal baseline for further dose reduction at lower kVp values.

[0128] Thus, by using the CTDUoi, ref(U) Model, an appropriate dose at the reference

120 kVp for an individual can be calculated based on the individual’s own anatomy (e.g., the diameter of the individual’s chest).

[0129] FIG. 15 is a chart 1500 comparing CTDUoi, ref for small-to-large patient sizes between clinical data, a constant noise threshold approach, and an SCCT noise threshold approach, using actual clinical patient data as the known sample sizes, according to certain aspects of the present disclosure. The data from chart 1500 is based on the CTDUoi, ref(U) Model referenced with respect to chart 1300 of FIG. 13 as applied to small patients (24.8 cm effective diameter) through large patients (40 cm effective diameter). The model used for chart 1500 was derived from a CTDI(Lo) of 1.46 mGy (for an Lo of 24.8 cm with a To = 20 HU) and a CTDI(Lmax) of 5.23 mGy (for an Lmax of 40.0 cm with a Tmax = 23 HU) based on the low dose clinical data.

[0130] In chart 1500, the hexagonal data points represent the CTDIvoi, ref values plotted according to patient sizes for a set of 119 clinical cases using dose modulation with a reference effective mAs of 80. Of those 119 clinical cases, a subset of 48 cases of low dose usage, identified with inverted triangles within the hexagonal data point, lined up with the CTDIvoi, ref(L) Model within 10%. The square data points represent the CTDIvoi, ref values per patient size as calculated from the CTDIvoi, ref(L) Model using the constant noise threshold approach (e.g., To = Tmax = 20 HU). The triangular data points represent the CTDIvoi, ref values per patient size as calculated from the CTDIvoi, ref(L) Model using the SCCT recommended noise threshold approach (e.g., To = 20 HU and Tmax = 23 HU) (“Optimal with Adjustable Noise”).

[0131] The data from chart 1500 show a room of dose reduction of 20% on average, with greater dose reduction available for larger patients.

[0132] As depicted in chart 1500 and according to the CTDIvoi, ref(L) Model, the doses to achieve the constant noise threshold (20 HU) were found more consistent with the observed patient doses, but switching to the SCCT variable thresholds resulted in a dose reduction of up to 25%. Thus, the CTDIvoi, ref(L) Model can be used to quantitatively model a prescribed patient-size-dependent optimal dose at standard 120 kVp for CACs. Further, this model can also serve as an optimal baseline for further dose reduction at lower kVp values.

[0133] Thus, by using the CTDIvoi, ref(L) Model, an appropriate dose at the reference

120 kVp for an individual can be calculated based on the individual’s own anatomy (e.g., the diameter of the individual’s chest).

[0134] FIG. 16 is a flowchart depicting a process 1600 for generating and using a

CTDIvoi, ref(L) Model, according to certain aspects of the present disclosure. Process 1600 can be performed by system 100 of FIG. 1, or any other suitable system.

[0135] At block 1602, one or more acceptable noise thresholds can be determined for use in CACs, according to certain aspects of the present disclosure. The one or more acceptable noise thresholds can be based on constant noise thresholds (e.g., a single noise threshold irrespective of diameter of the subject) or variable noise thresholds (e.g., different noise thresholds based on diameter of the subject). In some cases, the acceptable noise thresholds can be SCCT recommended noise thresholds. [0136] At block 1604, the desired CTDIvoi value can be determined for at least one of a smaller subject and a larger subject. The smaller subject is smaller in diameter than the larger subject. For example, the smaller subject and larger subject can be the medium-sized and large sized phantoms described with reference to FIGs. 13-14. The desired CTDIvoi for a given subject can be based on the acceptable noise threshold for that subject as determined at block 1602. In some cases, the desired CTDIvoi is the lowest possible CTDIvoi that will not cause the acceptable noise threshold to be exceeded. In some cases, the desired CTDIvoi is offset from such a lowest possible CTDIvoi, such as being offset by a given value of mGy, being offset by a given percentage, or being the nearest CTDIvoi of a set of available CTDIvoi that will achieve sub-threshold noise levels. The CTDIvoi levels for a subject can be determined using any suitable technique, such as comparison to experimental data acquired for the subject at various CTDIvoi levels.

[0137] At block 1606, a CTDIvoi, ref(L) Model is generated using the determined CTDIvoi level(s) from block 1604 and the determined acceptable noise thresholds from block 1602. The CTDIvoi _{, ref} (L) Model can take the form of the following equation 'max io)] ² where L is a dependent variable and the effective diameter of a given subject to be evaluated, Lmax is the effective diameter of the larger subject, Lo is the effective diameter of the smaller subject, Tmax is the threshold noise for the larger subject, To is the threshold noise for the smaller subject, and a is an experimentally derived constant. CTDIvoi(Lo) is the CTDIvoi value for the smaller subject as determined at block 1604.

[0138] In some cases, process 1600 can end at block 1606, resulting in the creation of a model suitable for determining CTDIvoi, ref based on a given effective diameter of a subject. In some cases, however, process 1600 can proceed at block 1608. Block 1608 can follow block 1606 by any suitable length of time, such as minutes, days, months, years, or the like. In some cases, process 1600 can start at block 1608 and not include blocks 1602, 1604, 1606, in which case the CTDIvoi, ref(L) Model that is used can be accessed from a preprogrammed memory. [0139] At block 1608, patient size is determined, such as via measurement or accessing electronic medical records. The patient size can be a chest size, such as an effective diameter of the chest of the patient.

[0140] At block 1610, the patient size is applied to a CTDIvoi _{, ref} (L) Model to determine the optimized CTDIvoi, ref to use for that patient. The optimized CTDIvoi, ref can be the most optimum CTDI _V oi,ref or a near-optimum CTDI _V oi,ref. The optimized CTDI _V oi,ref can be lower than a standard CTDI _V oi,ref under traditional CACs. The CTDI _V oi,ref(L) Model can be the CTDIvoi,ref(L) Model from block 1606.

[0141] At block 1612, CACs CT can be performed using the optimized CTDIvoi, ref from block 1610. Performing the CACs CT can occur similarly as described with reference to process 800 of FIG. 8, but using the optimized CTDIvoi, ref as the reference dose from which an appropriate dose is based.

[0142] The foregoing description of the embodiments, including illustrated embodiments, has been presented only for the purpose of illustration and description and is not intended to be exhaustive or limiting to the precise forms disclosed. Numerous modifications, adaptations, and uses thereof will be apparent to those skilled in the art.

[0143] Although the invention has been illustrated and described with respect to one or more implementations, equivalent alterations and modifications will occur or be known to others skilled in the art upon the reading and understanding of this specification and the annexed drawings. In addition, while a particular feature of the invention may have been disclosed with respect to only one of several implementations, such feature may be combined with one or more other features of the other implementations as may be desired and advantageous for any given or particular application.

[0144] While various embodiments of the present invention have been described above, it should be understood that they have been presented by way of example only, and not limitation. Numerous changes to the disclosed embodiments can be made in accordance with the disclosure herein, without departing from the spirit or scope of the invention. Thus, the breadth and scope of the present invention should not be limited by any of the above described embodiments.

[0145] The terminology used herein is for the purpose of describing particular embodiments only, and is not intended to be limiting of the invention. As used herein, the singular forms “a,” “an,” and “the” are intended to include the plural forms as well, unless the context clearly indicates otherwise. Furthermore, to the extent that the terms “including,” “includes,” “having,” “has,” “with,” or variants thereof, are used in either the detailed description and/or the claims, such terms are intended to be inclusive in a manner similar to the term “comprising.”

[0146] Unless otherwise defined, all terms (including technical and scientific terms) used herein have the same meaning as commonly understood by one of ordinary skill in the art. Furthermore, terms, such as those defined in commonly used dictionaries, should be interpreted as having a meaning that is consistent with their meaning in the context of the relevant art, and will not be interpreted in an idealized or overly formal sense unless expressly so defined herein.

[0147] As used below, any reference to a series of examples is to be understood as a reference to each of those examples disjunctively (e.g., "Examples 1-4" is to be understood as "Examples 1, 2, 3, or 4").

[0148] Example 1 is a method for measuring cardiac health, the method comprising: determining a target peak kilovoltage for driving a radiation source of a medical scanner, wherein the target peak kilovoltage is less than 120 kV; determining an appropriate dose based on the target peak kilovoltage, wherein the appropriate dose is determined to achieve a contrast- to-noise ratio equal to a contrast-to-noise ratio associated with a defined target peak kilovoltage of 120 kV; determining dose parameters based on the appropriate dose; and driving the medical scanner using the target peak kilovoltage and the dose parameters.

[0149] Example 2 is the method of example(s) 1, wherein the target peak kilovoltage is at or between 70 kV and 100 kV.

[0150] Example 3 is the method of example(s) 1 or 2, wherein the medical scanner is a computed tomography (CT) scanner.

[0151] Example 4 is the method of example(s) 1-3, wherein determining the appropriate dose comprises applying a reducing factor to a reference dose, wherein the reference dose is associated with the defined target peak kilovoltage of 120 kV.

[0152] Example 5 is the method of example(s) 4, wherein determining the appropriate dose comprises applying the formula where CTDIvol is the appropriate dose in mGy, kVptarget is the target peak kilovoltage in kV, and CTDIvol, ref is the reference dose in mGy.

[0153] Example 6 is the method of example(s) 4-5, wherein determining the appropriate dose includes determining the reference dose, and wherein determining the reference dose includes: determining a chest size of a subject; and calculating the reference dose using the chest size.

[0154] Example 7 is the method of example(s) 6, wherein calculating the reference dose using the chest size includes applying the chest size to a reference dose model, and wherein the reference dose model is based on experimental data from a smaller subject and a larger subject, wherein the smaller subject is smaller than the chest size and the larger subject is larger than the chest size.

[0155] Example 8 is the method of example(s) 7, wherein calculating the reference dose further comprises determining a first noise threshold for the smaller subject and a second noise threshold for the larger subject, and wherein applying the chest size to the reference dose model further includes applying the first noise threshold and the second noise threshold. [0156] Example 9 is the method of example(s) 8, wherein determining the reference dose includes applying the formula where L is the chest size, Lmax is a size of the larger subject, Lo is a size of the smaller subject, Tmax is the second noise threshold, To is the first noise threshold, and a is a constant.

[0157] Example 10 is the method of example(s) 1-9, wherein driving the medical scanner comprises generating radiation at the radiation source and directing the radiation through target tissue.

[0158] Example 11 is the method of example(s) 10, wherein the target tissue comprises calcifications in a coronary artery.

[0159] Example 12 is the method of example(s) 1-11, further comprising: receiving scanner data associated with driving the medical scanner using the target peak kilovoltage and the dose parameters; and scaling the scanner data based on the target peak kilovoltage.

[0160] Example 13 is the method of example(s) 12, further comprising analyzing the scaled scanner data using standard Hounsfield unit thresholds to calculate an Agatston score associated with the scanner data.

[0161] Example 14 is the method of example(s) 13, wherein the standard Hounsfield unit (HU) thresholds comprise a first threshold of 0-129 HU associated with a score of 0, a second threshold of 130-199 HU associated with a score of 1, a third threshold of 200-299 HU associated with a score of 2, a third threshold of 300-399 HU associated with a score of 3, and a fourth threshold of 400 HU or greater associated with a score of 4.

[0162] Example 15 is the method of example(s) 12-14, wherein scaling the scanner data comprises: determining a scaling factor using the target peak kilovoltage; and scaling each pixel of the scanner data by the scaling factor.

[0163] Example 16 is the method of example(s) 15, wherein determining the scaling factor comprises applying the target peak kilovoltage to a lookup table. [0164] Example 17 is the method of example(s) 15 or 16, wherein the scaling factor is at or approximately 1.59 when the peak kilovoltage is 70 kV, wherein the scaling factor is at or approximately 1.38 when the peak kilovoltage is 80 kV, wherein the scaling factor is at or approximately 1.24 when the peak kilovoltage is 90 kV, and wherein the scaling factor is at or approximately 1.14 when the scaling factor is 100 kV.

[0165] Example 18 is a method for pre-processing data for coronary calcium scoring, the method comprising: receiving scanner data associated with driving a computed tomography (CT) scanner at a target peak kilovoltage below 120 kV; determining a scaling factor using the target peak kilovoltage; scaling each pixel of the scanner data by the scaling factor; and outputting the scaled scanner data, wherein the scaled scanner data is analyzable using standard Hounsfield unit thresholds to calculate an Agatston score associated with the scanner data. [0166] Example 19 is the method of example(s) 18, wherein the standard Hounsfield unit (HU) thresholds comprise a first threshold of 0-129 HU associated with a score of 0, a second threshold of 130-199 HU associated with a score of 1, a third threshold of 200-299 HU associated with a score of 2, a third threshold of 300-399 HU associated with a score of 3, and a fourth threshold of 400 HU or greater associated with a score of 4.

[0167] Example 20 is the method of example(s) 18 or 19, wherein the scaling factor is at or approximately 1.59 when the peak kilovoltage is 70 kV, wherein the scaling factor is at or approximately 1.38 when the peak kilovoltage is 80 kV, wherein the scaling factor is at or approximately 1.24 when the peak kilovoltage is 90 kV, and wherein the scaling factor is at or approximately 1.14 when the scaling factor is 100 kV.

[0168] Example 21 is a system comprising: a control system including one or more processors; and a memory having stored thereon machine readable instructions; wherein the control system is coupled to the memory, and the method of any one of example(s)s 1 to 20 is implemented when the machine executable instructions in the memory are executed by at least one of the one or more processors of the control system.

[0169] Example 22 is a system for assessing coronary artery calcification, the system including a control system configured to implement the method of any one of example(s)s 1 to 20

[0170] Example 23 is a computer program product comprising instructions which, when executed by a computer, cause the computer to carry out the method of any one of example(s)s 1 to 20.

[0171] Example 24 is the computer program product of example(s) 23, wherein the computer program product is a non-transitory computer readable medium.