OBJECTIVES: To investigate the impacts of a deep learning-based iterative reconstruction algorithm on image quality and measuring accuracy of bone mineral density (BMD) in low-dose chest CT. METHODS: Phantom and patient studies were separately conducted in this study. The same low-dose protocol was used for phantoms and patients. All images were reconstructed with filtered back projection, hybrid iterative reconstruction (HIR) (KARL®, level of 3,5,7), and deep learning-based iterative reconstruction (artificial intelligence iterative reconstruction [AIIR], low, medium, and high strength). The noise power spectrum (NPS) and the task-based transfer function (TTF) were evaluated using phantom. The accuracy and the relative error (RE) of BMD were evaluated using a European spine phantom. The subjective evaluation was performed by 2 experienced radiologists. BMD was measured using quantitative CT (QCT). Image noise, signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR), BMD values, and subjective scores were compared with Wilcoxon signed-rank test. The Cohen's kappa test was used to evaluate the inter-reader and inter-group agreement. RESULTS: AIIR reduced noise and improved resolution on phantom images significantly. There were no significant differences among BMD values in all groups of images (all P >
0.05). RE of BMD measured using AIIR images was smaller. In objective evaluation, all strengths of AIIR achieved less image noise and higher SNR and CNR (all P <
0.05). AIIR-H showed the lowest noise and highest SNR and CNR (P <
0.05). The increase in AIIR algorithm strengths did not affect BMD values significantly (all P >
0.05). CONCLUSION: The deep learning-based iterative reconstruction did not affect the accuracy of BMD measurement in low-dose chest CT while reducing image noise and improving spatial resolution. ADVANCES IN KNOWLEDGE: The BMD values could be measured accurately in low-dose chest CT with deep learning-based iterative reconstruction while reducing image noise and improving spatial resolution.