Naples prognostic score shows potential complementary value to agatston scoring in patients with very high coronary calcium burden: A single-center hypothesis-generating study

Objective The Agatston score quantifies coronary artery calcium (CAC) but shows limited specificity for obstructive coronary artery disease (CAD) with extensive calcification. The Naples Prognostic Score (NPS) integrates inflammatory and nutritional parameters. This study evaluated NPS performance alongside Agatston scoring. Methods This is a retrospective, single-center study that analyzed 426 stable angina patients undergoing coronary CT angiography and invasive angiography at İzmir City Hospital in 2024. Agatston and NPS scores were calculated from routine parameters. Obstructive CAD was defined as significant lesions. Performance was assessed using ROC analysis and multivariate regression. Results Among 426 patients (age 61.7 ± 9.5 years, 63.4% male), 277 (65.0%) had obstructive disease. Obstructive CAD patients showed lower HDL ( P = .005), higher glucose ( P = .008), and elevated HbA1c ( P < .001). Agatston score showed moderate accuracy (area under the curve (AUC) 0.644), NPS limited performance (AUC 0.554). In Agatston ≥1000 subgroup ( n = 43), NPS achieved AUC 0.680, combined model AUC 0.725. NPS was an independent predictor (OR 1.22, P = .006). Correlation was negligible (ρ=0.048). Conclusions Metabolic markers (HDL, glucose, HbA1c) are more discriminative than inflammatory markers for obstructive CAD. NPS provides complementary value in extensive calcification (Agatston ≥1000), capturing distinct pathophysiologic domains.