Coronary artery calcium in a 20-year-old South Asian patient - pushing the limits of detecting "early disease"

Coronary artery calcium (CAC) assessment has long been reserved for intermediate-risk individuals in mid- to older-adult populations. However, a growing body of evidence supports expanding CAC measurement to younger adults who exhibit multiple risk factors or other risk-enhancing features. We describe a case of a very young, 20-year-old, South Asian man with a CAC score of 15.7 Agatston Units. Despite his age and lack of overt symptoms, his CAC score placed him at the 99th percentile for his age and sex, underscoring the limitations of relying solely on traditional risk algorithms. Early CAC detection in such patients has potential for significant clinical impact, allowing timely implementation of intensive lifestyle modification and the most aggressive possible pharmacotherapy for cardiovascular risk reduction. Evidence indicates that even minimal CAC in very young individuals can progress exponentially, markedly increasing the risk of future atherosclerotic cardiovascular disease. Nonetheless, current guidelines do not recommend CAC testing in this population, creating a missed opportunity to detect and intervene in high-risk individuals during early adulthood. These observations underscore the need for more precise risk stratification strategies in select high-risk populations. Incorporating CAC measurements into care for young, high-risk individuals-alongside newer tools such as polygenic risk scores and low-radiation coronary CT angiography-could revolutionize preventive cardiology. Further research is needed to refine the cost-effectiveness and implementation strategies for early CAC measurement, develop more inclusive guidelines, and ensure a specialized workforce capable of delivering comprehensive preventive care.