Highlight
– The 2026 AHA/ACC dyslipidemia guideline incorporates the PREVENT calculator for 10-year ASCVD risk evaluation, superseding the Pooled Cohort Equations.
– Coronary artery calcium (CAC) scoring effectively stratifies atherosclerotic cardiovascular disease (ASCVD) risk, especially in patients with borderline statin eligibility.
– Individuals with absent CAC still experience significant ASCVD event rates when statin therapy is guideline-recommended, suggesting CAC 0 should not replace guideline-based statin initiation.
– CAC scoring provides nuanced risk refinement near statin treatment thresholds, guiding prevention intensity and personalized therapy decisions.
Study Background
Atherosclerotic cardiovascular disease (ASCVD) remains a leading cause of morbidity and mortality globally, necessitating precise risk stratification to optimize preventive interventions such as statin therapy. Traditionally, the Pooled Cohort Equations (PCE) have guided statin eligibility by estimating 10-year ASCVD risk. In 2026, the American Heart Association (AHA) and American College of Cardiology (ACC) introduced the PREVENT ASCVD equations as the basis for updated dyslipidemia guidelines, aiming to improve risk prediction accuracy across diverse populations.
Coronary artery calcium (CAC) scoring, measured by noninvasive cardiac computed tomography, has served as a powerful risk modifier—particularly in instances where risk assessment is ambiguous. By quantifying calcified plaque burden within coronary arteries, CAC aids clinicians in discriminating between lower and higher risk patients beyond traditional risk factors.
The study explored the role of CAC in refining statin eligibility when using the PREVENT risk calculator, leveraging data from the Multi-Ethnic Study of Atherosclerosis (MESA), a large, diverse cohort with extensive cardiovascular phenotyping and adjudicated outcomes.
Study Design and Methods
This retrospective analysis included 5,698 MESA participants with comprehensive baseline data and subsequent cardiovascular event follow-up. The cohort’s mean age was 61.5 ± 10.3 years, and 52.8% were female.
Participants were stratified into three groups based on statin eligibility per current guidelines:
– Statin Not Recommended
– Statin Considered
– Statin Recommended
Additionally, participants without diabetes and with low-density lipoprotein cholesterol (LDL-C) between 70 and 189 mg/dL were further categorized by their 10-year PREVENT ASCVD risk: low (<3%), borderline (3% to <5%), intermediate (5% to <10%), and high (≥10%).
CAC scores were dichotomized as CAC=0 or CAC>0, and ASCVD event incidence rates per 1,000 person-years were compared across these strata within statin eligibility and PREVENT risk groups.
Key Findings
Statin eligibility distribution was as follows: 33.8% not recommended, 15.7% considered, and 50.5% recommended.
Among participants without CAC (CAC=0), event rates per 1,000 person-years were:
– Not recommended group: 1.2
– Considered group: 2.7
– Recommended group: 5.8
For participants with CAC>0, event rates markedly increased:
– Not recommended: 4.5
– Considered: 5.2
– Recommended: 16.6
Stratified by PREVENT risk categories (CAC=0 vs CAC>0), event rates were:
– Low risk (<3%): 1.1 vs 3.0
– Borderline risk (3% to <5%): 2.7 vs 5.2
– Intermediate risk (5% to <10%): 5.9 vs 11.3
– High risk (≥10%): 6.2 vs 20.9
These data indicate that CAC confers incremental prognostic information, particularly among those with borderline predicted risk and in the ‘considered’ statin group where treatment decisions often face uncertainty. However, in the recommended statin group, event rates remained significantly elevated despite CAC=0, highlighting that a zero CAC score does not equate to low risk sufficiently to withhold statin therapy in this population.
Expert Commentary
The findings elegantly reaffirm CAC’s long-recognized utility as a decision aid in risk stratification, adapting it to contemporary risk calculators like PREVENT. CAC scoring thus refines patient-level risk estimates, enabling more precise identification of individuals who may benefit from statin therapy and those who might safely defer treatment.
Importantly, the study corroborates guideline recommendations that caution against using CAC 0 alone to withhold statins where clinical indications exist, such as those with higher estimated risk or established thresholds for treatment. This reinforces the concept that while CAC is a valuable adjunct, it should be integrated with comprehensive clinical assessment rather than serving as a solitary arbiter. The persistence of elevated event rates despite CAC absence underlines potential pathophysiological processes not fully captured by calcium scoring, such as non-calcified plaques and other vascular risk contributors.
Limitations include the observational nature of MESA, potential residual confounding, and the applicability of findings to other populations or novel risk prediction tools beyond PREVENT.
Conclusion
This large multiethnic cohort confirms that coronary artery calcium scoring adds meaningful clinical value in the era of PREVENT-based risk assessment by refining statin eligibility decisions, especially among patients with borderline ASCVD risk. CAC measurement assists in contextualizing absolute risk and tailoring preventive strategies but should not overrule guideline-based recommendations, particularly in those meeting statin treatment criteria.
Overall, these insights advocate for a nuanced, individualized approach to cardiovascular prevention, where CAC informs but does not replace comprehensive clinical judgment. Future studies may further clarify CAC’s role alongside emerging biomarkers and imaging modalities in cardiovascular risk stratification and management.
Funding and Disclosures
The parent MESA study was funded by the National Heart, Lung, and Blood Institute (NHLBI). Specific funding sources and disclosures for this sub-analysis are detailed in the original publication.
References
1. Rikhi R, Chen H, Mirzai S, et al. The Role of Coronary Artery Calcium in Statin Eligibility Based on the American Heart Association’s PREVENT Calculator: Insights From MESA. J Am Coll Cardiol. 2026 Jul 7; PMID: 42455102.
2. Grundy SM, Stone NJ, Bailey AL, et al. 2026 AHA/ACC Guideline on the Management of Blood Cholesterol. J Am Coll Cardiol. 2026; DOI: 10.1016/j.jacc.2026.03.049.
3. Budoff MJ, Nasir K, McClelland RL, et al. Coronary calcium predicts events better with risk factor stratification: MESA study. Circulation. 2009;120(17): (no page numbers available here).
4. Goff DC Jr, Lloyd-Jones DM, Bennett G, et al. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. J Am Coll Cardiol. 2014;63(25 Pt B):2935-2959.