CAVS begins with endothelial injury and lipid deposition (initiation phase), resembling atherosclerosis. This triggers an active, osteoblast-like biological process where valvular interstitial cells promote calcium deposition (propagation phase), eventually leading to left ventricular hypertrophy and heart failure.

Patients with BAV typically have larger valves and higher calcium scores than those with tricuspid valves. AVC density (AU/cm²) is often a superior metric in BAV to avoid misinterpretation of severity due to valve size.

Research is evolving toward automated AI-based quantification and radiation-free methods (e.g., Echo-CCS). 18F-NaF PET imaging may identify "microcalcification" activity before it becomes visible on CT, predicting future disease progression.

The scoring method was originally developed by Arthur Agatston in 1990 for coronary artery calcification. It was later adapted for the aortic valve, proving to be an accurate and software-independent indicator of stenosis severity.