Calcified coronary artery disease: Mechanisms, risk factors and clinical consequences

Coronary artery calcification is a common manifestation of advanced atherosclerosis and an important determinant of cardiovascular risk and procedural complexity during percutaneous coronary intervention (PCI). Calcification evolves from microcalcifications within the intima to larger fragmented, sheet-like or nodular deposits. Although extensive calcification often reflects stable plaque, specific patterns such as spotty calcification and eruptive calcified nodules are associated with plaque vulnerability and thrombotic events. In calcified lesions, PCI is technically challenging because calcium impairs balloon expansion, stent delivery and optimal stent deployment, increasing the risk of under-expansion and adverse outcomes. Intracoronary imaging with intravascular ultrasound and optical coherence tomography enables detailed calcium characterization and guides lesion preparation. This review summarizes the mechanisms, prevalence, risk factors, clinical consequences and contemporary management of calcified coronary artery disease.