Intended for healthcare professionals

Clinical Review State of the Art Review

Role of coronary artery calcium score in the primary prevention of cardiovascular disease

BMJ 2021; 373 doi: (Published 04 May 2021) Cite this as: BMJ 2021;373:n776
  1. Khurram Nasir, chief1 2,
  2. Miguel Cainzos-Achirica, associate director of research1 2
  1. 1Division of Cardiovascular Prevention and Wellness, Department of Cardiology, Houston Methodist DeBakey Heart & Vascular Center, Houston, TX, USA
  2. 2Center for Outcomes Research, Houston Methodist, Houston, TX, USA
  1. Correspondence to K Nasir knasir{at}


First developed in 1990, the Agatston coronary artery calcium (CAC) score is an international guideline-endorsed decision aid for further risk assessment and personalized management in the primary prevention of atherosclerotic cardiovascular disease. This review discusses key international studies that have informed this 30 year journey, from an initial coronary plaque screening paradigm to its current role informing personalized shared decision making. Special attention is paid to the prognostic value of a CAC score of zero (the so called “power of zero”), which, in a context of low estimated risk thresholds for the consideration of preventive therapy with statins in current guidelines, may be used to de-risk individuals and thereby inform the safe delay or avoidance of certain preventive therapies. We also evaluate current recommendations for CAC scoring in clinical practice guidelines around the world, and past and prevailing barriers for its use in routine patient care. Finally, we discuss emerging approaches in this field, with a focus on the potential role of CAC informing not only the personalized allocation of statins and aspirin in the general population, but also of other risk-reduction therapies in special populations, such as individuals with diabetes and people with severe hypercholesterolemia.


  • Series explanation: State of the Art Reviews are commissioned on the basis of their relevance to academics and specialists in the US and internationally. For this reason they are written predominantly by US authors

  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: Khurram Nasir is on the advisory board of Amgen, Novartis, Medicine Company, and his research is partly supported by the Jerold B. Katz Academy of Translational Research. Miguel Cainzos-Achirica is fully supported by the Jerold B Katz Academy of Translational Research and has no other disclosures to report.

  • Contributorship statement and guarantors: KN and MC-A contributed to the planning, drafting, and critical review of the manuscript. Both are responsible for the overall content as guarantors.

  • No patients were asked for input in the creation of this article.

  • Provenance and peer review: commissioned; externally peer reviewed.

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