Special Review Coronary Artery Calcium Imaging in the ROBINSCA Trial: Rationale, Design, and Technical Background Marleen Vonder, MSc, Carlijn M. van der Aalst, MPH, PhD, Rozemarijn Vliegenthart, MD, PhD, EBCR, Peter M.A. van Ooijen, CPHIT, PhD, Dirkjan Kuijpers, MD, PhD, Jan Willem Gratama, MD, PhD, Harry J. de Koning, MD, PhD, Matthijs Oudkerk, MD, PhD Abbreviations CAC Coronary artery calcium CT Computed tomography CVD Cardiovascular disease DSCT Dual-source computed tomography EBCT Electron beam computed tomography ECG Electrocardiography eCRF Digital case report form FOV Field of view ROBINSCA Risk Or Benefit IN Screening for CArdiovascular Diseases Rationale and Objectives: To describe the rationale, design, and technical background of coronary artery calcium (CAC) imaging in the large-scale population-based cardiovascular disease screening trial (Risk Or Benefit IN Screening for CArdiovascular Diseases [ROBINSCA]). Materials and Methods: First, literature search was performed to review the logistics, setup, and set- tings of previously performed CAC imaging studies, and current clinical CAC imaging protocols of participating centers in the ROBINSCA trial were evaluated. A second literature search was per- formed to evaluate the impact of computed tomography parameter settings on CAC score. Results: Based on literature reviews and experts opinion an imaging protocol accompanied by data management protocol was created for ROBINSCA. The imaging protocol should consist of a fixed tube voltage, individually tailored tube current setting, mid-diastolic electrocardiography-triggering, fixed field-of-view, fixed reconstruction kernel, fixed slice thickness, overlapping reconstruction and without iterative reconstruction. The analysis of scans is performed with one type and version of CAC scoring software, by two dedicated and experienced researchers. The data management protocol describes the organization of data handling between the coordinating center, participating centers, and core anal- ysis center. Conclusion: In this paper we describe the rationale and technical considerations to be taken in de- veloping CAC imaging protocol, and we present a detailed protocol that can be implemented for CAC screening purposes. Key Words: Coronary artery calcification; outcomes; computed tomography; imaging; screening. © 2017 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. INTRODUCTION E arly detection of cardiovascular disease (CVD) fol- lowed by evidence-based treatment could potentially reduce CVD morbidity and mortality (1,2). Extent of coronary artery calcium (CAC) is a strong risk marker for coronary events, with evidence mainly derived from obser- vational studies and from prospective nonrandomized studies (3,4). So far, there is no evidence that CAC imaging fol- lowed by treatment leads to a decrease in CVD morbidity and mortality as prospective randomized studies on CVD risk stratification based on CAC imaging combined with treat- ment are lacking. Consequently, European and North- American guidelines on CVD prevention still classify the Acad Radiol 2017; ■:■■–■■ From the University of Groningen, University Medical Center Groningen, Center for Medical Imaging North-East Netherlands (CMI-NEN), Groningen (M.V., R.V., P.M.A.O., D.K., J.W.G., M.O.); Erasmus MC–University Medical Centre, Department of Public Health, Rotterdam (C.M.A., H.J.K.); University of Groningen, University Medical Center Groningen, Department of Radiology, Groningen, The Netherlands (P.M.A.O.); Department of Radiology, Haaglanden Medical Center Bronovo, The Hague (D.K.); Department of Radiology, Gelre Hospital, Apeldoorn (J.W.G.). Received June 1, 2017; revised July 18, 2017; accepted July 20, 2017. Funding: The ROBINSCA trial received an Ad- vanced Grant by the European Research (Funded under: FP7-IDEAS-ERC). Address correspondence to M.O. e-mail: m.oudkerk@umcg.nl © 2017 The Association of University Radiologists. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.acra.2017.07.010 1 ARTICLE IN PRESS