CORA: Generalizable coronary artery disease assessment and risk stratification from coronary CT angiography using pathology-centric representation learning
Authors: Jinkui Hao, Gorkem Durak, Halil Ertugrul Aktas, Ulas Bagci, Bradley D. Allen, Nilay S. Shah, Bo Zhou
Organizations: Department of Radiology, Northwestern University, Chicago, IL, USA · Department of Biomedical Engineering, Northwestern University, Evanston, IL, USA · Department of Cardiology, Northwestern University, Chicago, IL, USA · Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
Abstract
Coronary artery disease, a leading cause of cardiovascular mortality worldwide, can be assessed non-invasively by coronary computed tomography angiography (CCTA). Although deep learning has advanced automated CCTA analysis, clinical translation remains constrained by the scarcity of expert-annotated data and by the spatial sparsity of coronary pathology, which occupies only a small fraction of each scan. Widely used label-free pretraining strategies, such as masked image modeling and contrastive learning, optimize for global anatomical reconstruction and tend to under-represent these tiny localized pathological features. Here we present CORA, an annotation-efficient model for comprehensive coronary artery disease assessment. Rather than reconstructing background anatomy, CORA learns from volumetric CCTA through a synthesis-driven self-supervised strategy: an anatomy-guided engine inserts diverse synthetic calcified and non-calcified lesions into unlabeled scans, reframing pretraining as an abnormality-detection task that biases representation learning toward clinically relevant disease features. We pretrained CORA on 10,138 unlabeled CCTA volumes and evaluated it across datasets from nine independent hospitals. Across plaque characterization, stenosis detection, and coronary artery segmentation, CORA consistently outperformed strong self-supervised pretraining baselines, with the largest gains on external multi-center data, indicating robust generalization under distributional shift. Coupling the imaging encoder with structured clinical variables further enabled near-term major adverse cardiac event (MACE) risk stratification. Our results show that pathology-centric, synthesis-driven pretraining is an effective and scalable strategy for annotation-efficient coronary artery disease assessment from CCTA.
Accurate segmentation of the coronary vessel lumen is a prerequisite for quantitative assessment of atherosclerotic plaque and perivascular adipose tissue in coronary computed tomography angiography (CCTA). Cardiologists rely on semi-automated methods for this task because manual vessel tracing and segmentation are labour-intensive. Although many automated methods have been proposed, their validation remains limited by the lack of large, high-quality publicly available datasets. We provide a new dataset of voxel-wise annotations of the vessel lumen and coronary segments, alongside centerlines, and mesh surfaces for 800 scans from the publicly available ImageCAS dataset. Using this dataset, we benchmark established lumen segmentation methods against inter-observer variability, stratifying performance by disease, image quality, coronary dominance, coronary segment, vessel diameter, and lumen attenuation. These labels allow segmentation accuracy to be described in anatomical and clinical context rather than reported as a single aggregate score. The dataset supports the development and validation of methods for lumen segmentation, plaque and perivascular quantification, and haemodynamic modelling.
Kit M. Bransby, Esther Øksnebjerg, Kristoffer Kjær +7
Accurate pixel-level classification of coronary angiograms is critical for cardiovascular disease assessment, yet the field lacks standardized evaluation protocols. In this work we demonstrate a new benchmark for the assessment of deep learning models which densely classify pixels of coronary angiograms to one of SYNTAX classes (or background). The evaluation covers 24 distinct architectures starting with classic convnets to recent state-space-based vision algorithms. We release CARDIAG - a multi-center, multi-label dataset which we carefully split to reliably compute metrics, accounting for diameter error, overlap, centerline quality and calibration. The data contains SYNTAX labels, binary, uncertainty and segmentation masks as well as intermediate frames together with the selected non-sensitive DICOM metadata. From the multitude of algorithms, we nominate ConvNeXt V2 encoder with DeepLab V3 Plus decoder as the best performing, achieving macro F1=0.456, which we then ensemble with Mamba U-Net and Feature Pyramid Network, for an increased F1=0.479. We demonstrate all the architectures to be well calibrated and determine the generalization of the top 5 methods, together with the data efficiency of these architectures. We highlight the importance of both high-resolution and low-resolution features in encoding. We also demonstrate the model correctness in the context of patient demographic, vessel sides and projection angle configurations. Overall the released benchmark allows for future studies to robustly and rigorously assess the proposals, not only for SYNTAX segmentation, but lesion detection and many more.
Dominik Bernard Lau, Hubert Malinowski, Jerzy Szyjut +5
Accurate correspondence matching across multiple angiographic views is the prerequisite for 3D coronary reconstruction and interventional guidance. However, the development of robust deep learning models for this task has been stifled by a fundamental data bottleneck. Obtaining ground truth for matching tasks in angiography pairs is prohibitively expensive and hard to scale. To overcome this barrier, we introduce a physically-grounded data generation framework that synthesizes high-fidelity Digital Reconstructed Radiographs (DRRs) from 3D Coronary CT Angiography (CCTA) volumes. Our framework generates dense, highly accurate 3D-to-2D projection labels by simulating realistic C-arm acquisition geometry on patient anatomy at zero human cost. Leveraging this dense supervision, we propose a Geometry-Informed Matching Module (GIMM) that integrates global feature and anatomical structure into correspondence learning. Unlike real angiography where assessment relies on subjective human annotation, our dataset provides 2D correspondence labels with paired images, allowing human-free evaluation. We comprehensively evaluate our method on the proposed CT-derived DRR dataset and demonstrate improvements over other matching baseline models.