A chest X-ray is one of the most familiar examinations in medical imaging. But could it reveal clinically important information beyond the reason it was originally ordered?
Recent research has investigated the use of single exposure dual-energy spectral chest X-ray for visualizing coronary artery calcification (CAC) — a marker associated with coronary artery disease. The work raises an intriguing possibility: identifying previously unsuspected coronary calcium during chest X-rays performed for unrelated, non-cardiac indications.
KA Imaging’s Reveal™ 35C detector, powered by SpectralDR® technology and used in the research, captures spectral information from a single standard X-ray exposure. It generates conventional, bone-selective and soft-tissue images without requiring changes to existing X-ray workflows.
We spoke with Michael H. Lev, MD, co-author in two related studies1-2 presented at RSNA in 2025, about what prompted the research, what surprised him in the results, and where he believes the work should go next.
What initially made you think coronary calcium might be something worth investigating with spectral chest X-ray?
Michael H. Lev: I can tell you exactly when I started thinking about this. It was when I read a few papers written by my radiology clinical and research colleagues, discussing the potential role of chest X-ray in the cardiac area.
In these papers3-5, a very simple AI model — for predicting mortality from nothing but a standard CXR — had surprising predictive power, especially given that it’s based on a single portable CXR, and was written before the era of scary super powerful generative LLM’s! Imagine what we can do by adding KA spectral imaging and current generation LLM’s to this AI model!
Was there anything you saw in the images or data that surprised you?
Michael H. Lev: The detection of coronary artery calcification was surprisingly accurate, approaching that of the reference standard CT scan.
When you look at the results across the studies, what do you think is the most important finding, and why?
Michael H. Lev: The most important consideration here is the question of “how is this information being used clinically” and, specifically, “does detecting these calcifications potentially impact either individual patient treatment or, more broadly, public health”?
The fact that KA CXR helps me detect coronary calcifications almost as accurately as chest CT is critically important for opportunistic screening.
What do we mean by opportunistic screening? It basically means detecting something important – that can be used to change a patient’s medical management — that is unrelated to the reason the study was originally ordered.
Specifically, for the detection of coronary artery disease, there is much literature showing that the presence of any coronary calcification means that clinically relevant coronary artery disease (CAD) is likely, some of which may warrant statins or other treatments for primary prevention. For most older patients, CAD has already been diagnosed and/or is symptomatic by the time a CXR is obtained in an ED or urgent care setting, so opportunistic detection of calcifications doesn’t add much to patient management.
For younger people, however, without known CAD, who are getting their urgent care CXR for non-cardiac symptoms such as “rule out pneumonia”, the opportunistic detection of unsuspected coronary calcifications can make the difference between them being diagnosed and treated for CAD or not, potentially avoiding MACE (Major Adverse Cardiovascular Events). Thus, there is substantial potential public health value, especially for individuals with intermediate risk for a cardiac event, for whom the presence or absence of coronary calcifications can help select those most likely to benefit from statin treatment.
What did you learn about spectral chest X-ray for visualizing coronary calcium?
Michael H. Lev: It’s important to look at both the AP and lateral images, since they can help with both anatomic localization and level of confidence regarding the findings.
What do you think radiologists should understand about these findings?
Michael H. Lev: The findings should be reviewed in addition to, rather than instead of, the standard CXR findings, not only to clarify/confirm the findings on conventional non-spectral imaging, but also to further characterize findings — like coronary calcification — that are not accurately evaluated by standard imaging.
What questions did this research raise that you couldn’t answer with the current studies?
Michael H. Lev: This study was performed using a fixed detector. We’ll need to replicate these results with the portable units. We’ll also need to train an AI to analyze these exams.
It would be great to also look at rib fractures and aortic/mitral valve calcification. Our current study has some preliminary data suggesting that there is substantial added value in using KA over standard CXR for detection of these pathologies, but there were insufficient cases with reference standard proof of diagnosis to reach statistical significance.
The views expressed in this interview are those of Dr. Michael Lev and reflect his interpretation of the research and perspectives on future investigation. They should not be interpreted as performance, clinical, regulatory, or intended-use claims by KA Imaging.
- Utarat Kaewumporn, MD, DMRD, Joel K.R. Samuel, MD,MBBS, Brian B. Ghoshhajra, MD, MBA, Nathaniel D. Mercaldo, Rajiv Gupta, PhD, MD, Michael H. Lev, MD, Michael Hood, MD. Accuracy of dual-energy compared to standard chest X-ray for detection of coronary artery calcifications as an opportunistic screening tool. Radiological Society of North America-RSNA 2025,2025.
- Utarat Kaewumporn, MD, DMRD, Joel K.R. Samuel, MD,MBBS, Nathaniel D. Mercaldo, Rajiv Gupta, PhD, MD, Brian B. Ghoshhajra, MD, MBA, Michael H. Lev, MD, Michael Hood, MD. Performance of Dual-energy chest X-ray, compared to standard CXR and CT, for diagnosis of clinically confirmed coronary artery disease. Radiological Society of North America-RSNA 2025,2025.
- Radiological Society of North America. (2022, November 29). AI predicts heart disease risk using single X-ray. RSNA 2022 Daily Bulletin. https://dailybulletin.rsna.org/db22/index.cfm?pg=22tue17
- Lu, M. T., Ivanov, A., Mayrhofer, T., Hosny, A., Aerts, H. J. W. L., & Hoffmann, U. (2019). Deep learning to assess long-term mortality from chest radiographs. JAMA Network Open, 2(7), e197416. https://doi.org/10.1001/jamanetworkopen.2019.7416
- Nerlekar N, Vasanthakumar SA, Whitmore K, et al. Effects of combining coronary calcium score with treatment on plaque progression in familial coronary artery disease. JAMA 2025; 333:1403–1412.