Benjamin EJ, Muntner P, Alonso A, Bittencourt MS, Callaway CW, Carson AP, et al. Heart disease and stroke statistics—2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56–528.

Article  Google Scholar 

Lloyd-Jones DM, Braun LT, Ndumele CE, Smith SC Jr, Sperling LS, Virani SS, et al. Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology (vol 73, pg 3153, 2019). J Am Coll Cardiol. 2019;73(24):3234.

Article  Google Scholar 

Mortensen MB, Falk E. Limitations of the SCORE-guided European guidelines on cardiovascular disease prevention. Eur Heart J. 2017;38(29):2259–63.

PubMed  Google Scholar 

Mora S, Wenger NK, Cook NR, Liu J, Howard BV, Limacher MC, et al. Evaluation of the pooled cohort risk equations for cardiovascular risk prediction in a multiethnic cohort from the Women’s Health Initiative. JAMA Intern Med. 2018;178(9):1231–40.

Article  Google Scholar 

Erbel R, Budoff M. Improvement of cardiovascular risk prediction using coronary imaging: subclinical atherosclerosis: the memory of lifetime risk factor exposure. Eur Heart J. 2012;33(10):1201–13.

Article  Google Scholar 

Peters SA, den Ruijter HM, Bots ML, Moons KG. Improvements in risk stratification for the occurrence of cardiovascular disease by imaging subclinical atherosclerosis: a systematic review. Heart. 2012;98(3):177–84.

Article  Google Scholar 

Yeboah J, McClelland RL, Polonsky TS, Burke GL, Sibley CT, O’Leary D, et al. Comparison of novel risk markers for improvement in cardiovascular risk assessment in intermediate-risk individuals. JAMA. 2012;308(8):788–95.

CAS  Article  Google Scholar 

Yeboah J, Young R, McClelland RL, Delaney JC, Polonsky TS, Dawood FZ, et al. Utility of nontraditional risk markers in atherosclerotic cardiovascular disease risk assessment. J Am Coll Cardiol. 2016;67(2):139–47.

Article  Google Scholar 

Agatston AS, Janowitz WR, Hildner FJ, Zusmer NR, Viamonte M, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol. 1990;15(4):827–32.

CAS  Article  Google Scholar 

Orringer CE, Maki KC. HOPE for Rational Statin Allocation for Primary Prevention: A Coronary Artery Calcium Picture Is Worth 1000 Words. Mayo Clin Proc. 2020;95(8):1740–9. https://doi.org/10.1016/j.mayocp.2020.01.016.

CAS  Article  PubMed  Google Scholar 

Bild DE, Detrano R, Peterson D, Guerci A, Liu K, Shahar E, et al. Ethnic differences in coronary calcification: the Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2005;111(10):1313–20. https://doi.org/10.1161/01.CIR.0000157730.94423.4B.

Article  PubMed  Google Scholar 

Detrano R, Guerci AD, Carr JJ, Bild DE, Burke G, Folsom AR, et al. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med. 2008;358(13):1336–45. https://doi.org/10.1056/NEJMoa072100.

CAS  Article  PubMed  Google Scholar 

Paixao AR, Ayers CR, El Sabbagh A, Sanghavi M, Berry JD, Rohatgi A, et al. Coronary Artery Calcium Improves Risk Classification in Younger Populations. JACC Cardiovasc Imaging. 2015;8(11):1285–93. https://doi.org/10.1016/j.jcmg.2015.06.015.

Article  PubMed  Google Scholar 

Erbel R, Mohlenkamp S, Moebus S, Schmermund A, Lehmann N, Stang A, et al. Coronary risk stratification, discrimination, and reclassification improvement based on quantification of subclinical coronary atherosclerosis: the Heinz Nixdorf Recall study. J Am Coll Cardiol. 2010;56(17):1397–406. https://doi.org/10.1016/j.jacc.2010.06.030.

Article  PubMed  Google Scholar 

Vliegenthart R, Oudkerk M, Hofman A, Oei HH, van Dijck W, van Rooij FJ, et al. Coronary calcification improves cardiovascular risk prediction in the elderly. Circulation. 2005;112(4):572–7. https://doi.org/10.1161/CIRCULATIONAHA.104.488916.

Article  PubMed  Google Scholar 

Carr JJ, Jacobs DR Jr, Terry JG, Shay CM, Sidney S, Liu K, et al. Association of Coronary Artery Calcium in Adults Aged 32 to 46 Years With Incident Coronary Heart Disease and Death. JAMA Cardiol. 2017;2(4):391–9. https://doi.org/10.1001/jamacardio.2016.5493.

Article  PubMed  PubMed Central  Google Scholar 

Grundy SM, Stone NJ, Bailey AL, Beam C, Birtcher KK, Blumenthal RS, et al. 2018 AHA/ACC/AACVPR/AAPA/ABC/ACPM/ADA/AGS/APhA/ASPC/NLA/PCNA Guideline on the Management of Blood Cholesterol: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;139(25):e1082–143. https://doi.org/10.1161/CIR.0000000000000625.

Article  PubMed  Google Scholar 

Arnett DK, Blumenthal RS, Albert MA, Buroker AB, Goldberger ZD, Hahn EJ, et al. 2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2019;140(11):e596–646. https://doi.org/10.1161/CIR.0000000000000678.

Article  PubMed  PubMed Central  Google Scholar 

Hecht HS, Blaha MJ, Kazerooni EA, Cury RC, Budoff M, Leipsic J, et al. CAC-DRS: Coronary Artery Calcium Data and Reporting System. An expert consensus document of the Society of Cardiovascular Computed Tomography (SCCT). J Cardiovasc Comput Tomogr. 2018;12(3):185–91. https://doi.org/10.1016/j.jcct.2018.03.008.

Article  PubMed  Google Scholar 

Hecht H, Blaha MJ, Berman DS, Nasir K, Budoff M, Leipsic J, et al. Clinical indications for coronary artery calcium scoring in asymptomatic patients: Expert consensus statement from the Society of Cardiovascular Computed Tomography. J Cardiovasc Comput Tomogr. 2017;11(2):157–68. https://doi.org/10.1016/j.jcct.2017.02.010.

Article  PubMed  Google Scholar 

•• Orringer CE, Blaha MJ, Blankstein R, Budoff MJ, Goldberg RB, Gill EA, et al. The National Lipid Association scientific statement on coronary artery calcium scoring to guide preventive strategies for ASCVD risk reduction. J Clin Lipidol. 2021;15(1):33–60. https://doi.org/10.1016/j.jacl.2020.12.005. This NLA scientific statement provides expert recommendations for preventing ASCVD using CAC scoring. This document summarizes CAC scoring recommendations and provides approaches to CAC=0, incidental CAC, special populations, and the future of CAC scoring.

Mach F, Baigent C, Catapano AL, Koskinas KC, Casula M, Badimon L, et al. 2019 ESC/EAS Guidelines for the management of dyslipidaemias: lipid modification to reduce cardiovascular risk. Eur Heart J. 2020;41(1):111–88. https://doi.org/10.1093/eurheartj/ehz455.

Article  PubMed  Google Scholar 

Force USPST, Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, et al. Risk Assessment for Cardiovascular Disease With Nontraditional Risk Factors: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(3):272–80. https://doi.org/10.1001/jama.2018.8359.

Article  Google Scholar 

Schade DS, Obenshain SS, Eaton RP. Prevention of Statin Overtreatment and Increased Patient Compliance in High-Cardiovascular-Risk Individuals. Am J Med. 2019;132(10):1123–5. https://doi.org/10.1016/j.amjmed.2019.03.020.

Article  PubMed  Google Scholar 

Heller DJ, Coxson PG, Penko J, Pletcher MJ, Goldman L, Odden MC, et al. Evaluating the impact and cost-effectiveness of statin use guidelines for primary prevention of coronary heart disease and stroke. Circulation. 2017;136(12):1087–98.

Article  Google Scholar 

•• Abuzaid A, Saad M, Addoumieh A, Ha LD, Elbadawi A, Mahmoud AN, et al. Coronary artery calcium score and risk of cardiovascular events without established coronary artery disease: a systemic review and meta-analysis. Coronary Artery Dis. 2021;32(4):317–28. https://doi.org/10.1097/MCA.0000000000000974. This systematic review and meta-analyses of 45 studies compares the risk of ASCVD in patients with CAC=0 versus CAC >0, concluding absence of CAC is associated with low risk of future cardiovascular events.

Sarwar A, Shaw LJ, Shapiro MD, Blankstein R, Hoffmann U, Cury RC, et al. Diagnostic and prognostic value of absence of coronary artery calcification. JACC Cardiovasc Imaging. 2009;2(6):675–88. https://doi.org/10.1016/j.jcmg.2008.12.031.

Article  PubMed  Google Scholar 

Blaha M, Budoff MJ, Shaw LJ, Khosa F, Rumberger JA, Berman D, et al. Absence of coronary artery calcification and all-cause mortality. JACC Cardiovasc Imaging. 2009;2(6):692–700. https://doi.org/10.1016/j.jcmg.2009.03.009.

Article  PubMed  Google Scholar 

Valenti V, ó Hartaigh B, Heo R, Cho I, Schulman-Marcus J, Gransar H, et al. A 15-Year Warranty Period for Asymptomatic Individuals Without Coronary Artery Calcium: A Prospective Follow-Up of 9,715 Individuals. JACC Cardiovasc Imaging. 2015;8(8):900–9. https://doi.org/10.1016/j.jcmg.2015.01.025.

Article  PubMed  PubMed Central  Google Scholar 

Blaha MJ, Cainzos-Achirica M, Dardari Z, Blankstein R, Shaw LJ, Rozanski A, et al. All-cause and cause-specific mortality in individuals with zero and minimal coronary artery calcium: A long-term, competing risk analysis in the Coronary Artery Calcium Consortium. Atherosclerosis. 2020;294:72–9. https://doi.org/10.1016/j.atherosclerosis.2019.11.008.

CAS  Article  PubMed  Google Scholar 

•• Patel J, Pallazola VA, Dudum R, Greenland P, McEvoy JW, Blumenthal RS, et al. Assessment of Coronary Artery Calcium Scoring to Guide Statin Therapy Allocation According to Risk-Enhancing Factors: The Multi-Ethnic Study of Atherosclerosis. JAMA Cardiol. 2021;6(10):1161–70. https://doi.org/10.1001/jamacardio.2021.2321. According to this analysis of MESA, most risk-enhancing factors resulted in ASCVD event rates lower than the recommended threshold for initiating statin therapy when CAC=0. The addition of CAC significantly improved risk reclassification and discrimination of ASCVD events, suggesting that a CAC-based approach to statin allocation may be an effective tool.

Blaha MJ, Cainzos-Achirica M, Greenland P, McEvoy JW, Blankstein R, Budoff MJ, et al. Role of Coronary Artery Calcium Score of Zero and Other Negative Risk Markers for Cardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis (MESA). Circulation. 2016;133(9):849–58. https://doi.org/10.1161/CIRCULATIONAHA.115.018524.

CAS  Article  PubMed  PubMed Central  Google Scholar 

Nasir K, Bittencourt MS, Blaha MJ, Blankstein R, Agatson AS, Rivera JJ, et al. Implications of Coronary Artery Calcium Testing Among Statin Candidates According to American College of Cardiology/American Heart Association Cholesterol Management Guidelines: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol. 2015;66(15):1657–68. https://doi.org/10.1016/j.jacc.2015.07.066.

CAS  Article  PubMed  Google Scholar 

Blaha MJ, Budoff MJ, DeFilippis AP, Blankstein R, Rivera JJ, Agatston A, et al. Associations between C-reactive protein, coronary artery calcium, and cardiovascular events: implications for the JUPITER population from MESA, a population-based cohort study. Lancet. 2011;378(9792):684–92. https://doi.org/10.1016/s0140-6736(11)60784-8.

CAS  Article  PubMed  PubMed Central  Google Scholar 

Mortensen MB, Fuster V, Muntendam P, Mehran R, Baber U, Sartori S, et al. A Simple Disease-Guided Approach to Personalize ACC/AHA-Recommended Statin Allocation in Elderly People: The BioImage Study. J Am Coll Cardiol. 2016;68(9):881–91. https://doi.org/10.1016/j.jacc.2016.05.084.

Article  PubMed  Google Scholar 

• Lloyd-Jones DM, Braun LT, Ndumele CE, Smith SC Jr, Sperling LS, Virani SS, et al. Use of Risk Assessment Tools to Guide Decision-Making in the Primary Prevention of Atherosclerotic Cardiovascular Disease: A Special Report From the American Heart Association and American College of Cardiology. Circulation. 2019;139(25):e1162-e77. https://doi.org/10.1161/CIR.0000000000000638. This report from the AHA/ACC provides a clinical approach to CAC as a primary prevention tool for patients at borderline to intermediate ASCVD risk. It is recommended that CAC be used when uncertainty exists regarding statin benefit: CAC=0 is below the threshold for benefit, and ≥100 or 75th percentile is above the threshold for benefit.

Nasir K, Cainzos-Achirica M, Valero-Elizondo J, Ali SS, Havistin R, Lakshman S, et al. Coronary Atherosclerosis in an Asymptomatic U.S. Population. JACC Cardiovasc Imaging. 2022. https://doi.org/10.1016/j.jcmg.2022.03.010.

Article  PubMed  Google Scholar 

Bergstrom G, Persson M, Adiels M, Bjornson E, Bonander C, Ahlstrom H, et al. Prevalence of Subclinical Coronary Artery Atherosclerosis in the General Population. Circulation. 2021;144(12):916–29. https://doi.org/10.1161/CIRCULATIONAHA.121.055340.

CAS  Article  PubMed  PubMed Central  Google Scholar 

Dzaye O, Dardari ZA, Cainzos-Achirica M, Blankstein R, Szklo M, Budoff MJ, et al. Incidence of New Coronary Calcification: Time to Conversion From CAC = 0. J Am Coll Cardiol. 2020;75(13):1610–3. https://doi.org/10.1016/j.jacc.2020.01.047.

Article  PubMed  Google Scholar 

•• Dzaye O, Dardari ZA, Cainzos-Achirica M, Blankstein R, Agatston AS, Duebgen M, et al. Warranty Period of a Calcium Score of Zero: Comprehensive Analysis From the Multiethnic Study of Atherosclerosis. JACC Cardiovasc Imaging. 2020. https://doi.org/10.1016/j.jcmg.2020.06.048. According to this recent analysis of MESA, individuals with CAC=0 have a "warranty" of 3 to 7 years before re-scanning is recommended, depending on individual demographics and risk profile.