Coronary artery calcium scoring, what is answered and what questions remain

Coronary artery calcification (CAC) is a widely used imaging modality for cardiovascular risk assessment in moderate risk patients. It has been shown to have a superior role predicting future cardiac events and survival rates when combined with other traditional risk factor scoring systems as Framingham risk score (FRS). Furthermore, it significantly reclassifies moderate risk patients into lower or higher risk categories. Higher risk groups like patients with diabetes, a higher prevalence of CAC has been shown to impart a high short term risk of CV events, while those with zero calcium score had excellent event-free survival, similar to non-diabetic patients. Having a zero calcium score is currently used in United Kingdom practice guidelines (NICE) as a gatekeeper for any further investigations in patients presenting to the emergency department (ED) with chest pain. Unanswered questions include the concept of CAC progression that need to be standardized with respect to technique, interpretation and subsequent management strategies. Studies also demonstrated that risk assessment using CAC was motivational to patients leading to better adherence to their preventive practices as well as medications. However, statin did not consistently prove beneficial in slowing the CAC progression rate, but did reduce CV events significantly in patients with increased CAC. Accordingly, more studies need to be conducted to further help understand the ideal way to utilize this imaging tool and decreasing downstream utilization.