Filling the Evidence Gaps Toward a Coronary Artery Calcium-Guided Primary Prevention Strategy

Coronary artery calcium (CAC) testing is extremely appealing as a primary prevention strategy to personalize risk assessment and individualize the intensity of preventive therapy. This is because the test is widely available, fast, highly reproducible, low radiation, directly reflective of total coronary plaque burden, and highly predictive of future atherosclerotic cardiovascular disease (ASCVD) events. Guidelines around the world endorse CAC for advanced risk assessment (generally with a moderate IIA recommendation), and the recent 2022 American College of Cardiology Expert Consensus Decision Pathway on nonstatin use explicitly sets low-density lipoprotein cholesterol (LDL-C) goals based on CAC burden. However, detractors of a CAC-based primary prevention approach point to a relative lack of clinical trials directly supporting its use. Generally, those arguing against CAC fall into 1 of 2 camps: (1) advocates for a highly conservative treatment approach, with general skepticism of overmedicalization (ie, with statin therapy) in primary prevention or (2) advocates for a highly liberal treatment approach, with an openness to treating everyone with a statin (ie, “treat all”) without assessment of plaque burden.