Coronary Artery Calcium Score as a Predictor of Cardiovascular Disease Events and Mortality Among Asymptomatic Working-Age Adults: A Systematic Review

The Coronary Artery Calcium (CAC) score is primarily used in asymptomatic individuals at intermediate risk for developing cardiovascular disease (CVD), particularly when there is uncertainty whether to initiate statins or intensify primary prevention measures. In this systematic review, we examined the value of the CAC score as a predictor of incident CVD events and mortality among asymptomatic working-age adults. We reviewed studies published from November 2009 to December 2022 examining asymptomatic adults 18-65 years of age. A total of 908 studies were identified. After the elimination of 578 and 326 studies based on abstract and full-text review, respectively, we examined four studies that met the inclusion criteria. Two of the studies showed that any CAC score above zero was associated with a four- to fivefold increased risk of incident cardiac events. In addition, we found that increasing CAC score was associated with a higher risk of incident cardiac events and/or all-cause mortality in a dose-response relationship documenting a strong criterion of causality. Furthermore, one of the studies elicited a higher discriminatory power of the CAC score compared to the Framingham and the Atherosclerotic Cardiovascular Disease (ASCVD) risk scores in distinguishing high-risk from intermediate-risk individuals for all-cause mortality. Our review showed that the CAC score is predictive of elevated risk for incident CVD events and mortality among asymptomatic working-age adults. However, prospective studies are warranted to perform cost-benefit analyses on the utility of CAC scoring as a screening tool in the general population.