Coronary artery calcium scoring in 2026: strengths, limitations, and optimized clinical use

Area of Science:

• Cardiovascular imaging and prevention
• Radiology and cardiac CT applications

Background:

• Coronary artery calcium (CAC) scoring is a validated method for assessing total coronary atherosclerotic burden.
• CAC provides prognostic information and improves risk reclassification beyond traditional clinical risk calculators.
• Emerging evidence highlights the significance of zero CAC scores and very high CAC levels (≥1,000).

Purpose of the Study:

• To review the updated strengths, limitations, and clinical guidance for CAC scoring.
• To synthesize recent evidence (2024-2026) on CAC's role in cardiovascular prevention.
• To present a clinical decision flowchart for the selective application of CAC in prevention pathways.

Main Methods:

• Review of recent scientific literature (2018-2026) focusing on CAC scoring.
• Synthesis of randomized evidence regarding CAC-guided treatment and plaque progression.
• Inclusion of advances in artificial intelligence (AI), spectral CT, and standardized reporting (SCCT/STR; CAC-DRS).

Main Results:

• The 'power of zero' CAC score is reinforced for near-term risk de-escalation.
• Very high CAC scores (≥1,000) identify a distinct, very-high-risk phenotype.
• Randomized trials demonstrate that CAC-guided treatment effectively reduces plaque progression.

Conclusions:

• CAC scoring remains a robust marker for coronary atherosclerosis and cardiovascular risk assessment.
• Advances in technology and reporting enhance automated and incidental CAC detection.
• CAC scoring plays a crucial role in guiding personalized preventive strategies for cardiovascular disease.