Coronary Artery Calcium Scoring in 2019: Past, Present, and Future

  • Ramzi Dudum
  • Omar Dzaye
  • Steven J. Lahti
  • Sina Kianoush
  • Seamus P. Whelton
  • Michael J. BlahaEmail author
Cardiac Computed Tomography (B Chow and G Small, Section Editors)
Part of the following topical collections:
  1. Topical Collection on Cardiac Computed Tomography


Purpose of Review

In this review, we sought to present a clinically relevant history of coronary artery calcium (CAC) scoring from its initial introduction, to its more recent widespread adoption and guideline endorsement, to future directions of cutting-edge CAC research.

Recent Findings

Since prior exhaustive reviews on CAC scoring, the introduction of the Pooled Cohort Equations (PCEs) for the assessment of atherosclerotic cardiovascular disease (ASCVD) risk has been formative in reframing how clinicians discuss risk and prevention with their patients. However, given weaknesses in the performance of the PCEs, additional risk markers have been tested with none being equal to CAC scoring with its ability to reclassify risk. The use of CAC = 0 as a negative risk factor has proven reliable in diverse populations and has led to increased adoption of CAC scoring by clinical practice guidelines. Newer data explores how CAC scoring can be employed for the quantification of risk in different diseases including modeling the competing risks of ASCVD vs. cancer, how CAC can reclassify risk even on non-ECG gated chest computed tomography, and how the algorithm for scoring a CAC scan can be improved in the future.


CAC scoring is a powerful adjunct to the PCEs in further characterizing risk, particularly in borderline to intermediate-risk populations. Newer studies suggest that CAC scoring can be adapted to non-ECG gated chest CTs and that newer CAC scores, which take into consideration the number of vessels, the diffusivity of disease, and important gender-specific interactions, can improve on the traditional Agatston method. Future research will continue to explore these newer areas as well as provide models for forecasting the lifetime risks of ASCVD vs. cancer based on age and sex-specific CAC scores.


Coronary artery calcium Agatston method Atherosclerosis Negative risk factors 


Compliance with Ethical Standards

Conflict of Interest

All authors declare no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


  1. 1.
    Ardehali R, Nasir K, Kolandaivelu A, Budoff MJ, Blumenthal RS. Screening patients for subclinical atherosclerosis with non-contrast cardiac CT. Atherosclerosis. 2007;192:235–42.CrossRefGoogle Scholar
  2. 2.
    McClelland RL, Nasir K, Budoff M, Blumenthal RS, Kronmal RA. Arterial age as a function of coronary artery calcium (from the multi-ethnic study of atherosclerosis [MESA]). Am J Cardiol. 2009;103:59–63.CrossRefGoogle Scholar
  3. 3.
    Shaw LJ, Raggi P, Berman DS, Callister TQ. Coronary artery calcium as a measure of biologic age. Atherosclerosis. 2006;188:112–9.CrossRefGoogle Scholar
  4. 4.
    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;358:1336–45.CrossRefGoogle Scholar
  5. 5.
    Budoff MJ, McClelland RL, Nasir K, et al. Cardiovascular events with absent or minimal coronary calcification: the multi-ethnic study of atherosclerosis (MESA). Am Heart J. 2009;158:554–61.CrossRefGoogle Scholar
  6. 6.
    Blaha M, Budoff MJ, Shaw LJ, et al. Absence of coronary artery calcification and all-cause mortality. JACC Cardiovasc Imaging. 2009;2:692–700.CrossRefGoogle Scholar
  7. 7.
    Nasir K, Shaw LJ, Liu ST, Weinstein SR, Mosler TR, Flores PR, et al. Ethnic differences in the prognostic value of coronary artery calcification for all-cause mortality. J Am Coll Cardiol. 2007;50:953–60.CrossRefGoogle Scholar
  8. 8.
    Shaw LJ, Raggi P, Schisterman E, Berman DS, Callister TQ. Prognostic value of cardiac risk factors and coronary artery calcium screening for all-cause mortality. Radiology. 2003;228:826–33.CrossRefGoogle Scholar
  9. 9.
    Gibson AO, Blaha MJ, Arnan MK, Sacco RL, Szklo M, Herrington DM, et al. Coronary artery calcium and incident cerebrovascular events in an asymptomatic cohort. The MESA Study. JACC Cardiovasc Imaging. 2014;7:1108–15.CrossRefGoogle Scholar
  10. 10.
    Budoff MJ, Shavelle DM, Lamont DH, Kim HT, Akinwale P, Kennedy JM, et al. Usefulness of electron beam computed tomography scanning for distinguishing ischemic from nonischemic cardiomyopathy. J Am Coll Cardiol. 1998;32:1173–8.CrossRefGoogle Scholar
  11. 11.
    Handy CE, Desai CS, Dardari ZA, al-Mallah MH, Miedema MD, Ouyang P, et al. The Association of Coronary Artery Calcium with Noncardiovascular Disease: The Multi-Ethnic Study of Atherosclerosis. JACC Cardiovasc Imaging. 2016;9:568–76.CrossRefGoogle Scholar
  12. 12.
    Arthur S, Agatston WRJ, Hildner FJ, Zusmer NR, Viamonte M Jr, Detrano R. Quantification of coronary artery calcium using ultrafast computed tomography. J Am Coll Cardiol. 1990;15:827–32.CrossRefGoogle Scholar
  13. 13.
    Callister TQ, Cooil B, Raya SP, Lippolis NJ, Russo DJ, Raggi P. Coronary artery disease: improved reproducibility of calcium scoring with an electron-beam CT volumetric method. Radiology. 1998;208:807–14.CrossRefGoogle Scholar
  14. 14.
    Hong C, Bae KT, Pilgram TK. Coronary artery calcium: accuracy and reproducibility of measurements with multi-detector row CT--assessment of effects of different thresholds and quantification methods. Radiology. 2003;227:795–801.CrossRefGoogle Scholar
  15. 15.
    Alluri K, Joshi PH, Henry TS, Blumenthal RS, Nasir K, Blaha MJ. Scoring of coronary artery calcium scans: history, assumptions, current limitations, and future directions. Atherosclerosis. 2015;239:109–17.CrossRefGoogle Scholar
  16. 16.
    Detrano RC, Anderson M, Nelson J, Wong ND, Carr JJ, McNitt-Gray M, et al. Coronary calcium measurements: effect of CT scanner type and calcium measure on rescan reproducibility--MESA study. Radiology. 2005;236:477–84.CrossRefGoogle Scholar
  17. 17.
    Sabour S, Rutten A, van der Schouw YT, Atsma F, Grobbee DE, Mali WP, et al. Inter-scan reproducibility of coronary calcium measurement using multi detector-row computed tomography (MDCT). Eur J Epidemiol. 2007;22:235–43.CrossRefGoogle Scholar
  18. 18.
    Rumberger JA, Schwartz RS, Simons DB, Sheedy PF 3rd, Edwards WD, Fitzpatrick LA. Relation of coronary calcium determined by electron beam computed tomography and lumen narrowing determined by autopsy. Am J Cardiol. 1994;73:1169–73.CrossRefGoogle Scholar
  19. 19.
    Greenland P, LaBree L, Azen SP, Doherty TM, Detrano RC. Coronary artery calcium score combined with Framingham score for risk prediction in asymptomatic individuals. JAMA. 2004;291:210–5.CrossRefGoogle Scholar
  20. 20.
    Polonsky TS, McClelland RL, Jorgensen NW, et al. Coronary artery calcium score and risk classification for coronary heart disease prediction. JAMA. 2010;303:1610–6.CrossRefGoogle Scholar
  21. 21.
    Yeboah J, McClelland RL, Polonsky TS, et al. Comparison of novel risk markers for improvement in cardiovascular risk assessment in intermediate-risk individuals. JAMA. 2012;308:788–95.CrossRefGoogle Scholar
  22. 22.
    Nasir K, Rubin J, Blaha MJ, Shaw LJ, Blankstein R, Rivera JJ, et al. Interplay of coronary artery calcification and traditional risk factors for the prediction of all-cause mortality in asymptomatic individuals. Circ Cardiovasc Imaging. 2012;5:467–73.CrossRefGoogle Scholar
  23. 23.
    Stone NJ, Robinson JG, Lichtenstein AH, Bairey Merz CN, Blum CB, Eckel RH, et al. 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association task Force on practice guidelines. Circulation. 2014;129:S1–45.CrossRefGoogle Scholar
  24. 24.
    Colantonio LD, Richman JS, Carson AP, et al. Performance of the atherosclerotic cardiovascular disease pooled cohort risk equations by social deprivation status. J Am Heart Assoc. 2017;6(3).Google Scholar
  25. 25.
    DeFilippis AP, Young R, Carrubba CJ, et al. An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort. Ann Intern Med. 2015;162:266–75.CrossRefGoogle Scholar
  26. 26.
    DeFilippis AP, Young R, McEvoy JW, et al. Risk score overestimation: the impact of individual cardiovascular risk factors and preventive therapies on the performance of the American Heart Association-American College of Cardiology-Atherosclerotic Cardiovascular Disease risk score in a modern multi-ethnic cohort. Eur Heart J. 2017;38:598–608.PubMedPubMedCentralGoogle Scholar
  27. 27.
    Rana JS, Tabada GH, Solomon MD, Lo JC, Jaffe MG, Sung SH, et al. Accuracy of the atherosclerotic cardiovascular risk equation in a large contemporary, multiethnic population. J Am Coll Cardiol. 2016;67:2118–30.CrossRefGoogle Scholar
  28. 28.
    Yeboah J, Polonsky TS, Young R, McClelland RL, Delaney JC, Dawood F, et al. Utility of nontraditional risk markers in individuals ineligible for statin therapy according to the 2013 American College of Cardiology/American Heart Association cholesterol guidelines. Circulation. 2015;132:916–22.CrossRefGoogle Scholar
  29. 29.
    Dudum R, Dzaye O, Mirbolouk M, et al. Coronary artery calcium scoring in low risk patients with family history of coronary heart disease: validation of the SCCT guideline approach in the coronary artery calcium consortium. J Cardiovasc Comput Tomogr. (in press).Google Scholar
  30. 30.
    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;66:1657–68.CrossRefGoogle Scholar
  31. 31.
    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;133:849–58.CrossRefGoogle Scholar
  32. 32.
    McClelland RL, Jorgensen NW, Budoff M, Blaha MJ, Post WS, Kronmal RA, et al. 10-year coronary heart disease risk prediction using coronary artery calcium and traditional risk factors: derivation in the MESA (multi-ethnic study of atherosclerosis) with validation in the HNR (Heinz Nixdorf recall) study and the DHS (Dallas heart study). J Am Coll Cardiol. 2015;66:1643–53.CrossRefGoogle Scholar
  33. 33.
    Catapano AL, Graham I, De Backer G, et al. 2016 ESC/EAS guidelines for the Management of Dyslipidaemias. Eur Heart J. 2016;37:2999–3058.CrossRefGoogle Scholar
  34. 34.
    Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice: The Sixth Joint Task Force of the European Society of Cardiology and Other Societies on Cardiovascular Disease Prevention in Clinical Practice (constituted by representatives of 10 societies and by invited experts)Developed with the special contribution of the European Association for Cardiovascular Prevention & Rehabilitation (EACPR). Eur Heart J. 2016;37:2315–81.CrossRefGoogle Scholar
  35. 35.
    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;11:157–68.CrossRefGoogle Scholar
  36. 36.
    McClelland RL, Chung H, Detrano R, Post W, Kronmal RA. Distribution of coronary artery calcium by race, gender, and age: results from the multi-ethnic study of atherosclerosis (MESA). Circulation. 2006;113:30–7.CrossRefGoogle Scholar
  37. 37.
    Grundy SM, Stone NJ, Bailey AL, et al. 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 Foundation/American Heart Association Task Force on Clinical Practice Guidelines. J Am Coll Cardiol. 2019;73:e285–350.Google Scholar
  38. 38.
    Khera A. The New 2018 Cholesterol Guidelines: Filling Gaps and Expanding Opportunities. Circulation. 2019;139:2805–8.CrossRefGoogle Scholar
  39. 39.
    Pallazola V, Cardoso R, Blumenthal RS, Martin SS. Was the juice worth the squeeze? Understanding the new 2018 AHA/ACC cholesterol guideline. Accessed 19 April 2019.
  40. 40.
    Hecht HS. A zero coronary artery calcium score: priceless. J Am Coll Cardiol. 2010;55:1118–20.CrossRefGoogle Scholar
  41. 41.
    Blaha MJ, Mortensen MB, Kianoush S, Tota-Maharaj R, Cainzos-Achirica M. Coronary artery calcium scoring: Is It Time for a Change in Methodology? JACC Cardiovasc Imaging. 2017;10:923–37.CrossRefGoogle Scholar
  42. 42.
    Fayad ZA, Fuster V. Clinical imaging of the high-risk or vulnerable atherosclerotic plaque. Circ Res. 2001;89:305–16.CrossRefGoogle Scholar
  43. 43.
    Williams M, Shaw LJ, Raggi P, Morris D, Vaccarino V, Liu ST, et al. Prognostic value of number and site of calcified coronary lesions compared with the total score. JACC Cardiovasc Imaging. 2008;1:61–9.CrossRefGoogle Scholar
  44. 44.
    Bairey Merz CN, Shaw LJ, Reis SE, et al. Insights from the NHLBI-sponsored Women's ischemia syndrome evaluation (WISE) study: part II: gender differences in presentation, diagnosis, and outcome with regard to gender-based pathophysiology of atherosclerosis and macrovascular and microvascular coronary disease. J Am Coll Cardiol. 2006;47:S21–9.CrossRefGoogle Scholar
  45. 45.
    Raggi P, Shaw LJ, Berman DS, Callister TQ. Gender-based differences in the prognostic value of coronary calcification. J Women's Health (Larchmt). 2004;13:273–83.CrossRefGoogle Scholar
  46. 46.
    Criqui MH, Denenberg JO, Ix JH, McClelland RL, Wassel CL, Rifkin DE, et al. Calcium density of coronary artery plaque and risk of incident cardiovascular EventsCoronary artery plaque and cardiovascular EventsCoronary artery plaque and cardiovascular events. JAMA. 2014;311:271–8.CrossRefGoogle Scholar
  47. 47.
    Blaha MJ, Budoff MJ, Tota-Maharaj R, et al. Improving the CAC score by addition of regional measures of calcium distribution: Multi-Ethnic Study of Atherosclerosis. JACC Cardiovasc Imaging. 2016;9:1407–16.CrossRefGoogle Scholar
  48. 48.
    Lahti SJ, Feldman DI, Dardari Z, Mirbolouk M, Orimoloye OA, Osei AD, et al. The association between left main coronary artery calcium and cardiovascular-specific and total mortality: the coronary artery calcium consortium. Atherosclerosis. 2019;286:172–8.CrossRefGoogle Scholar
  49. 49.
    Shaw LJ, Min JK, Nasir K, Xie JX, Berman DS, Miedema MD, et al. Sex differences in calcified plaque and long-term cardiovascular mortality: observations from the CAC consortium. Eur Heart J. 2018;39:3727–35.CrossRefGoogle Scholar
  50. 50.
    Whelton SP, Al Rifai M, Dardari Z, et al. Coronary artery calcium and the competing long-term risk of cardiovascular vs. cancer mortality: the CAC consortium. Eur Heart J Cardiovasc Imaging. 2019;20:389–95. CrossRefGoogle Scholar
  51. 51.
    Lung cancer: screening. U.S. preventive services task force. 2015. Accessed 21 April 2019.
  52. 52.
    Budoff MJ, Nasir K, Kinney GL, Hokanson JE, Barr RG, Steiner R, et al. Coronary artery and thoracic calcium on noncontrast thoracic CT scans: comparison of ungated and gated examinations in patients from the COPD gene cohort. J Cardiovasc Comput Tomogr. 2011;5:113–8.CrossRefGoogle Scholar
  53. 53.
    Hughes-Austin JM, Dominguez A 3rd, Allison MA, et al. Relationship of coronary calcium on standard chest CT scans with mortality. JACC Cardiovasc Imaging. 2016;9:152–9.CrossRefGoogle Scholar
  54. 54.
    Jacobs PC, Isgum I, Gondrie MJ, et al. Coronary artery calcification scoring in low-dose ungated CT screening for lung cancer: interscan agreement. AJR Am J Roentgenol. 2010;194:1244–9.CrossRefGoogle Scholar
  55. 55.
    Jacobs PC, Prokop M, van der Graaf Y, Gondrie MJ, Janssen KJ, de Koning HJ, et al. Comparing coronary artery calcium and thoracic aorta calcium for prediction of all-cause mortality and cardiovascular events on low-dose non-gated computed tomography in a high-risk population of heavy smokers. Atherosclerosis. 2010;209:455–62.CrossRefGoogle Scholar
  56. 56.
    Hecht HS, Cronin P, Blaha MJ, Budoff MJ, Kazerooni EA, Narula J, et al. 2016 SCCT/STR guidelines for coronary artery calcium scoring of noncontrast noncardiac chest CT scans: a report of the Society of Cardiovascular Computed Tomography and Society of thoracic radiology. J Thorac Imaging. 2017;32:W54–66.CrossRefGoogle Scholar
  57. 57.
    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;12:185–91.CrossRefGoogle Scholar
  58. 58.
    Dzaye O, Dudum R, Mirbolouk M, Orimoloye OA, Osei AD, Dardari ZA, et al. Validation of the coronary artery calcium data and reporting system (CAC-DRS): dual importance of CAC score and CAC distribution from the coronary artery calcium (CAC) consortium. J Cardiovasc Comput Tomogr. (in press).Google Scholar
  59. 59.
    Matthew C. Hooks, Prabhjot Nijjar, Ko-Hsuan Chen et al. Abstract 1331–416: Rates of clinical reporting and actions taken based on coronary calcium on cancer computed tomography scans in patients at risk for cardiovascular disease after potentially cardiotoxic cancer treatment.: American College of Cardiology Scientific Session; March 16–18, 2019; New Orleans, 2019.Google Scholar
  60. 60.
    Williams KA Sr, Kim JT, Holohan KM. Frequency of unrecognized, unreported, or underreported coronary artery and cardiovascular calcification on noncardiac chest CT. J Cardiovasc Comput Tomogr. 2013;7:167–72.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Ramzi Dudum
    • 1
    • 2
  • Omar Dzaye
    • 1
    • 2
  • Steven J. Lahti
    • 1
    • 2
  • Sina Kianoush
    • 1
    • 2
  • Seamus P. Whelton
    • 1
    • 2
  • Michael J. Blaha
    • 1
    • 2
    Email author
  1. 1.Johns Hopkins Ciccarone Center for the Prevention of Heart DiseaseBaltimoreUSA
  2. 2.Departments of Medicine and CardiologyThe Johns Hopkins HospitalBaltimoreUSA

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