Coronary Angiographic Scoring Systems

An Evaluation of Their Equivalence and Validity

Ian J. Neeland, MD; Riyaz S. Patel, MD; Parham Eshtehardi, MD; Saurabh Dhawan, MD; Michael C. McDaniel, MD; S. Tanveer Rab, MD; Viola Vaccarino, MD, PhD; A. Maziar Zafari, MD, PhD; Habib Samady, MD; Arshed A. Quyyumi, MD


Am Heart J. 2012;164(4):547-552.e1. 

In This Article

Abstract and Introduction


Background Multiple scoring systems have been devised to quantify angiographic coronary artery disease (CAD) burden, but it is unclear how these scores relate to each other and which scores are most accurate. The aim of this study was to compare coronary angiographic scoring systems (1) with each other and (2) with intravascular ultrasound (IVUS)–derived plaque burden in a population undergoing angiographic evaluation for CAD.
Methods Coronary angiographic data from 3600 patients were scored using 10 commonly used angiographic scoring systems and interscore correlations were calculated. In a subset of 50 patients, plaque burden and plaque area in the left anterior descending coronary artery were quantified using IVUS and correlated with angiographic scores.
Results All angiographic scores correlated with each other (range for Spearman coefficient [ρ] 0.79–0.98, P b .0001); the 2 most widely used scores, Gensini and CASS-70, had a ρ = 0.90 (P b .0001). All scores correlated significantly with average plaque burden and plaque area by IVUS (range ρ 0.56–0.78, P b .0001 and 0.43–0.62, P b .01, respectively). The CASS-50 score had the strongest correlation (ρ 0.78 and 0.62, P b .0001) and the Duke Jeopardy score the weakest correlation (ρ 0.56 and 0.43, P b .01) with plaque burden and area, respectively.
Conclusions Angiographic scoring systems are strongly correlated with each other and with atherosclerotic plaque burden. Scoring systems therefore appear to be a valid estimate of CAD plaque burden.


Coronary angiography is an important tool for the quantification of coronary artery disease (CAD) burden in both clinical practice and scientific investigation.[1] Researchers have attempted to define angiographic CAD burden using quantitative scoring systems. Historically, this was performed by designation of a single-, double-, triple-vessel, and left main disease classification, with luminal stenosis of either ≥50% or ≥70% used to define significance.[2] However, this simple scoring system was limited in its ability to stratify patients with different levels of disease risk[3] and led to the development of more comprehensive scoring systems for defining atherosclerotic burden and prognosis.[3,4]

Current scoring systems are heterogeneous, lack standardization, and have not been directly compared with each other. Some scoring systems are easily reproducible, have been validated in multiple settings, and provide prognostic value, whereas others require sophisticated computer software and are not widely applicable.[5,6] In addition, use of angiography to estimate CAD burden is challenged by under- or overestimation of atherosclerotic narrowing and diffuseness, limitations in technique and resolution, and disparities between lesion severity determined by angiography and true atherosclerosis burden.[7–9]

Intravascular ultrasound (IVUS) is a powerful tool for the evaluation of atherosclerosis and is more accurate and reproducible than coronary angiography for the assessment of atherosclerotic burden, because unlike angiography it measures wall atheroma and not just luminal encroachment.[10–14] Because widespread use of IVUS is limited by cost and availability and because the vast majority of CAD registries continue to use angiography to measure atherosclerosis severity, it is important to determine the relationship between IVUS and angiographic assessment of CAD burden. Therefore, using a comprehensive coronary angiographic database, we sought to (1) compare different angiographic CAD burden scores with each other and (2) determine which scoring systems most accurately estimate IVUS-derived plaque burden and area.