Coronary Calcium Score

Who should get a coronary calcium CT test and how is it utilized to diagnose atherosclerosis and prevent heart attacks?

In November 2018 the ACC/AHA guidelines strongly embraced coronary calcium scanning for better assessing the risk of intermediate risk patients.

I discuss this welcome change here.

My most recent post discusses the importance of using coronary calcium scans in youngish patients.

In July 2019 I summarized coronary calcium scanning with the humbly named The Ultimate Guide To The Coronary Artery Calcium Scan (Score) Circa 2019

In earlier posts I referenced the ACC/AHA ASCVD risk estimator tool as the starting point but if I have information on my patient’s CACS I use a new and improved tool called the MESA risk score calculator.

It is available online and through an app for Apple and Android (search in the app store on “MESA Risk Score” for the (free) download.)

The MESA tool allows you to easily calculate how the CACS effects you or your patient’s 10 year risk of ASCVD.

To use the score you will need information on the following risk factors:

age, gender, race/ethnicity, diabetes (yes/no), current smoker (yes/no), total and HDL cholesterol, use of lipid lowering medication (yes/no), systolic blood pressure (mmHg), use of anti-hypertensive medication (yes/no), any family history of heart attack in first degree relative (parent/sibling/child) (yes/no), and a coronary artery calcium score (Agatston units).

In many cases the CACS dramatically lowers or increases the risk estimate.

In this example a 64 year old man with no discernible risk factors has a CACS of 175
The 10 year risk of a CHD event almost doubles from 4.7% to 7.6% when the CACS is added to the standard risk factors and moves into a range where we need much more aggressive risk factor modification.

On the other hand if we enter in zero for this same patient the risk drops to a very low 1.9%.

It’s also instructive to adjust different variables. For example, if we change the family history of heart attack (parents, siblings, or children) from no to yes, this same patient’s risk jumps to 7.2% (2.6% with zero calcium score and to 10.4% with CACS 175.)

It can also be used to help modify risk-enhancing behaviors. For example if you click smoker instead of non-smoker the risk goes from 4.7% to 7.5%. Thus, you can tell your smoking patient that his risk is halved if he stops.

Discussions on the value of tighter BP control can also be informed by the calculator. For example, if  our 64 year old’s systolic blood pressure was 160 his risk has increased to 6.8%.

How Does Your CACS Compare To Your Peers?

A separate calculator let’s you see exactly where your score stands in comparison individuals with your same age, gender, and ethnicity

The Coronary Artery Calcium (CAC) Score Reference Values web tool will provide the estimated probability of non-zero calcium, and the 25th, 50th, 75th, and 90th percentiles of the calcium score distribution for a particular age, gender and race. Additionally, if an observed calcium score is entered the program will provide the estimated percentile for this particular score. These reference values are based on participants in the MESA study who were free of clinical cardiovascular disease and treated diabetes at baseline. These participants were between 45-84 years of age, and identified themselves as White, African-American, Hispanic, or Chinese. The current tool is thus applicable only for these four race/ethnicity categories and within this age range.

The calculator tells us that 75% of 64 year old white males have a zero CACS and that the average CACS is 61.

Unlike SAT scores or Echo Board scores you don’t want your CACS percentile status to be high. Scores >75th percentile typically move you to a higher risk category, whereas scores <25th percentile move you to a lower risk category, often with significant therapeutic implications.

Scores between the 25th and 75th percentile typically don’t significantly change the risk calculation.

Exploring Gender Differences In CACS

If we change the gender from male to female on our 64 year old the risk drops considerably from 4.7% down to 3.3%. This graph demonstrates that over 20% of women between the ages of 75 and 84 years will have zero calcium scores.

The graph for men in that same range shows that only around 10% will have a zero CACS.

I’ve been asked what the upper limit is for CACS but I don’t think there is one. I’ve seen numerous patients with scores in the high two thousands and these graphs show individuals in the lowest age decile having scores over 2981.

If you want to be proactive about the cardiovascular health of yourself or a loved one, download the MESA app and evaluate your risk. Ask your doctor if a CACS will help refine that risk further.

Miscellaneous Posts On CAC

Is Coronary Calcium the mammography of the heart?

The coronary calcium score of Donald Trump versus that of Hilary Clinton.

Stents versus coronary calcium: The Widowmaker documentary

Heroes and Villains in cardiology:The Widowmaker documentary.

32 thoughts on “Coronary Calcium Score”

  1. It’s truly professional negligence that more at risk individuals are not being told to get a Cardiac Calcium Score. Blood tests are virtually worthless compared to this test in predictive value, yet middle aged individuals with clear risk factors go into physicals every year and are not told by their physicians to get this test. Are they waiting for their patients to keel over so that they can charge for quadruple bypasses and stents? Truly unconscionable.

  2. At what point do you recommend further testing? At what point does a high score indicate an invasive procedure to check for internal damage?

    1. Mike,
      These are good questions.
      1. At what calcium score should you get further testing? Some guidelines have suggested stress testing at a score of >400. I can’t make this a blanket recommendation for several reasons. One, stress nuclear tests have such a high rate of false positives in some testing centers that if the patient is asymptomatic, a positive test is much more likely to be a false positive than to actually indicate a problem. Second, a score of 400 in older white males can be normal, thus the recommendation would trigger doing stress testing on all men over a certain age. I’ll ponder this a little further and see if I can develop or find a better approach.
      2. I would not recommend an invasive procedure for any level of score. I have lots of patients who have scores well over a thousand and are free of symptoms with normal stress tests. We manage them with statins and aspirin and they do well. A cath or invasive procedure should only be done for significant exertional symptoms or significant ischemia on stress testing.

  3. Hello, calcium scores cannot give an accurate picture of heart health. When I was 73 I entered a research program that involved a calcium coronary scan. My score was 1003. No symptoms. Understand, I had been diabetic for 20 yrs and on low carb, high fat diet, basically in ketosis for all that time to solve the problem. I have averaged HbA1c of 5 or lower all these years. I also had been running for nearly 40 years. It was recommend I undergo angiogram to find out the true picture. Result was absolutely no blockage anywhere, no narrowing, in fact the cardiologist remarked the wide open arteries. He was impressed. Four years have passed and I still run (about 2 miles a day), So what is going on here?

    1. Randy,
      Good question. I’m actually in the process of preparing a post that discusses the limitations of the “angiogram” (also known as cardiac cath) that you had. You can have lots of plaque in the lining of the coronary arteries both calcified and non-calcified but have no clearly visible impingement on the lumen of the artery. Angiograms are only looking at the lumen:imagine a cast of inside of the artery. I have numerous examples of angiograms that were called normal but if you look at the film before die is injected you can see lots of calcium lining the walls of the arteries.
      As long as the plaque doesn’t impinge on the inside of the artery and limit blood flow (termed a blockage or narrowing) there are no symptoms even though what we term the “atherosclerotic plaque burden” is high.
      Despite this, population studies clearly put a score >1000 in a high risk category for risk of stroke and heart attack.
      Plaques too small to detect on the angiogram can rupture and cause heart attack.
      Your excellent lifestyle may have prevented the plaque from progressing to cause blockage or heart attack and the high calcium score represents “healing” of pre-existing diffuse soft plaque.

      1. Thanks, Dr AnthonyP for your reply. You pointed out a likely ‘healing” process which is exactly the way my cardiologist described it. He even used the expression, like a “tuck and point” a mason might employ to repair concrete between bricks.

        I don’t know if you or your readers would enjoy hearing about my adventure with the cardiologists who fretted over my high score and lamented my LDL of 160 but seemingly ignoring my HDL of 100 and nearly 0 Trigs. In fact I had to fire two of the statinators associated with the cardiologists who did the angiogram. They insisted I take statins. But the specialist who did the angiogram agreed with me as he saw the proof that something seemed right about what I was doing.

        I noticed your post on coconut oil. Yes, you could say I drink the stuff. Many eggs. And when I say I’m in ketosis I mean deep ketosis. It gives me extraordinary energy and mental clarity.

        One other secret and possibly the most important clue to warding off heart disease. At least I have followed this. And that is an abundance of omega 3s. I eat a massive amount of fish, fatty ones including sardines. The omega 6 ratio to omega 3 is 1 to 1 and has been since 2000 when I was diagnosed with diabetes. (This, some of my docs think, was precisely what promoted the “healing” you mentioned, along with the low carb) My GP finds all this very interesting and tracks such things with blood tests. He also is a rare doc who thinks low carb and high fat solves problems.

        Sorry for the extended remarks, perhaps someone can try the same if they have the problem I had with the diabetes years ago.

        Glad I found your site, Doc, keep up the good work and skepticism. Though I fear the pressure may mount on you to get in line with standard nonsense the AHA, ADA, AMA teaches.

        1. Randy,
          Interesting. I enjoyed hearing of your adventures with cardiologists and your years of deep ketosis. You may have read elsewhere on this site of my “adventures in ketoland”. I definitely have more clarity and energy when i consume lowish carb but it’s interesting how many comments I get from Esselstyn/Vegan readers who feel fantastic on diets that have ultra low fat. Perhaps each individual has to find by trial and error what particular diet works best for their particular condition.
          I have many readers who are advocates of high omega-3 to omega-6 and personally I minimize omega-6 sources and maximize omega-3 sources. I keep trying to put together a post on this but have failed thus far to come up with any recommendations I feel confident about.
          Fortunately, thus far I have felt no pressure from organized medicine to tow the party line.

    2. you are on the right track. Your insulin sparing diet most likely has turned of the atherogenic process. Incidentally there is a big difference when you have corrected your IR and although a potential diabetic for 20 yrs it is now in remission.

  4. Hi dr I am a 51 year old man a little over a year ago I had a calcium score of 240 I never smoked and have been over weight most of my life drink occasionally but always ate poorly but have a very active career as a contractor since my test I also had echocardiogram that was normal ekg that was normal and stress test that was normal as well my insurance denied nuclear testing as they said my calcium score was moderate since then I eat a very healthy whole food diet exercise regularly have lost about 70 lbs my blood work six months in showed ldl of 68 hdl of 42 triglycerides I think we’re 120 the dr was pleased with the results but is mainly focused on the ldl my total cholesterol I don’t remember but was very good but I still fear every day of having a heart attack due to my score what is your take on this everyone tells me I’m worrying to much but I feel like I am a ticking time bomb thank you in advance for any feedback

  5. Oh and I have also been taking 81 mg aspirin and 10 mg Lipitor daily and vitamin d omega 3 fish oil and multi vitamin

  6. I have a friend who has a cardiac calcium score of >600. However, he was in top 1% on his stress test and has no abnormal lab values. He is 51, great shape & never smoked. His BP is mildly high, but controlled with a low dose BP med. He had some “fainting” episodes after exercising recently. He also had an episode where appeared to be having a seizure or TIA. Should he be worried?

    1. Your friend should be concerned for three reasons
      1. The very high calcium score for age indicating advanced plaque in his coronaries.
      2. The symptoms of “faining” on exertion.
      3. The possible seizure or TIA.
      These may or may not be related but definite warrant further evaluation.
      He should check with his PCP or cardiologist ASAP.

  7. My coronary calcium score was 1,327. I just got the results of my nuclear stress test and it was normal. How can this be? I do have an appointment with my cardiologist in 3 weeks.

  8. Hello. 57 year old female. I have just had a calcium score done.Results 434. Report said I am in top 99% for my age. Scared to death! I have been an avid exerciser for over 35 years. I am not overweight, but have fought high triglycerides for years – put on fish oil, crestor, fenfibrate. My cardiologist told me just to keep exercising and up my crestor to 10 mg per day. I am getting a second opinion and I asked for a stress test. He ordered an exercise stress test, non nuculeur. The LAD and the RCA were the arteries with high score, the other two were zero and three.
    I feel pretty good, but maybe a little tired. Today I walked for two hours, on most days I exercise for an hour. Do you have any thoughts or suggestions?

    1. I think I covered your situation in a recent post I may not have added to this page.
      Its on whether you should get an exercise test if you have no symptoms and have a high calcium score.
      The most important thing long term for asymptomatic patients with high calcium scores is aggressive treatment of dyslipidemia and lifestyle modification.You might also want to check out my most recent post on Vascepa.

  9. So I went and got a Cardiac Calcium Score on my own since my cardiologist wouldn’t order one because he says they are basically voodoo.. Family History is awful for me.. I got my score of 320 and I’m 48 years old.. Doc looked at it and basically did the oh well.. so I switched docs and the other doc basically did the same thing.. I try so very hard to live a good lifestyle..I just don’t understand why docs wait so long to actually take a look at your heart.. I would have thought a score of 320 would have brought on more testing.. It did not..

    1. If your cardiologist tells you coronary calcium scores are voodoo I would strongly consider changing cardiologists.
      A score of 320 at age 48 puts you in a very high risk category for stroke and heart attack over the next 10 years.
      You need to find a physician who understands how to incorporate coronary calcium into his practice and will help you with lifestyle changes and medications to reduce that risk.

    2. Both parents have atherosclerosis and bypasses at a young age. I am 53 and my score was 1207 (even though I have never smoked and am not diabetic). My cardiologist basically said the same thing . . . voodoo. He is an Advanced Heart Failure Cardiologist too. I cannot find anything on the internet that says this is voodoo medicine.

  10. I am 68 years old, T2. CAC score 843. Been on various Statins for 20 years. Now on 20 mg Crestor. Statins May be saving my life ( can only imagine what score might be without them). But, why is generic Crestor labeled “ calcium tablets”?? Is it adding calcium to my arteries? Doing Keto (1.5 years)- improves A1C from high of 8.8 down to low of 6.2. Lost 20 pounds (9%of body weight). Doing K2, magnesium, vita D, etc in hopes of stopping or slowing down CAC progression. Any advice ( besides keep my life insurance paid up?).

  11. I was wondering if advanced lipid and inflammation tests ie; cardio CRP, fibrinogen, LP-PLA2, Apo B, OX LDL, MPO, provide info as valuable as a CAC score?..

    Also, can a carotid ultrasound have a small amt of plaque and yet all the measurements be within normal ranges without any obstructive disease?…

  12. I’m onto my third cardiologist in recent months. My problem is that I have adverse reactions to a wide variety of anti-hypertensives and the one’s that don’t bother me in other ways send my pulse rate into the lower 40s. In the past few years my resting pulse rate has dropped to about 55. The most recent cardiologist says he doesn’t think the cause is “pathological.”

    But I’m mystified by their reactions to calcium scoring. They all claim to believe in it, but none of them think I am a candidate for it. I bought the test myself about 15 years ago and had a higher than normal calcium score. I’m 64 and have had hypertension for about 15 years. Why would they not think calcium scoring is apt for me?

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