Coronary Artery Calcium Screening: A Narrative Review and Guide to Preventive Strategies

Coronary Artery Calcium (CAC) scoring has become a central tool for detecting subclinical atherosclerosis and refining cardiovascular risk assessment, particularly in individuals with intermediate or atypical risk profiles. Traditional risk models such as the ASCVD Pooled Cohort Equations remain foundational but have important limitations, especially in younger adults and those with nontraditional risk patterns. CAC scoring provides direct visualization of atherosclerotic burden and can outperform serum biomarkers in predicting cardiovascular events. Recent cohort data suggest that CAC can be detected decades earlier than current guideline thresholds imply, and that early CAC presence and progression carry significant prognostic value, although evidence to support routine screening below current guideline-recommended age thresholds remains investigational rather than established practice. With advances in imaging technology and expanding population-based evidence, CAC scoring is evolving from a decision aid into an increasingly central tool in preventive cardiology, one whose benefits must be weighed against radiation exposure, incidental findings, overdiagnosis, and cost. This review summarizes current evidence on the biology of coronary calcification, available imaging techniques, CAC scoring systems, and the clinical application and limitations of CAC in primary prevention of cardiovascular diseases and situates guideline-endorsed uses of CAC alongside areas that remain hypothesis-generating.