Sex-informed interpretation of coronary artery calcium in primary prevention

Coronary artery calcium (CAC) scoring is selectively used to refine cardiovascular risk assessment in primary prevention, but interpretation still relies largely on absolute thresholds applied similarly to women and men. This approach may overlook relevant sex-related differences in coronary atherosclerosis. Women tend to develop detectable CAC later in life and have lower absolute CAC values for a given age, while sex-related differences in coronary plaque composition may not be fully captured by calcium scoring alone. Consequently, a low absolute CAC score may still represent a high age- and sex-specific percentile in women. Traditional risk algorithms and CAC-based strategies also do not systematically account for female-specific risk enhancers, including hypertensive disorders of pregnancy, gestational diabetes, premature menopause, and polycystic ovary syndrome. Relevant literature was identified through a PubMed search from database inception to September 2026. This Perspective examines sex-related differences in CAC distribution and prognosis and discusses how absolute CAC scores, demographic percentiles, and female-specific risk enhancers can inform preventive care. We propose integrating these measures while retaining established absolute CAC categories. The clinical value of distinct numerical treatment thresholds for women and men requires prospective evaluation.