Coronary artery calcification (CAC) is an established marker of subclinical atherosclerosis and an independent predictor of future coronary heart disease in the asymptomatic primary prevention population, particularly in the intermediate risk cohort. CAC also helps in reclassifying those patients and their risk of cardiovascular events into higher or lower risk categories. MESA (Multi-Ethnic Study of Atherosclerosis) is a National Heart, Lung, and Blood Institute—sponsored population-based medical research study involving 6,814 men and women from 6 U.S. communities without a medical history of clinical cardiovascular disease. The evidence from this population cohort revealed that CAC scoring was independently predictive and highly effective at risk stratification of major adverse cardiac events. This review provides available data based on MESA. We focus on the utility of CAC for cardiovascular disease risk stratification of individuals, and we describe its diagnostic value in identifying patients at risk.

Highlights

• This paper reviews the role of coronary artery calcification (CAC) in the assessment of coronary risk in the MESA (Multi-Ethnic Study of Atherosclerosis) study, which is a population-based, multicenter longitudinal study of 6,814 participants undergoing demographic, risk factor, and subclinical disease evaluations.
• The prevalence and progression of CAC is different among the subgroups defined by race, ethnicity, age, sex, smoking status, body mass index, lifestyle, a history of hypertension, dyslipidemia, diabetes, or a family history of premature coronary heart disease (CHD).
• The CAC score itself is a reliable independent predictor of CHD compared with other traditional risk factors and could improve the area under the operating curve for incident CHD after combination with traditional risk factors.
• A CAC score of 0 is a promising marker of very low risk for CHD. In contrast, a CAC score >0 equals increased risk of atherosclerosis. The most commonly used cutoff numbers of CAC for distinguishing the high-risk population of CHD are CAC score 1 to 100, 101 to 300, and >300.
• The CAC score is useful to reclassify low-to-intermediate risk groups and certain subgroups, especially women and young adults, most of whom may be classified as low risk by FRS (Framingham risk score) risk stratification. The clinical role of CAC score has been solidified as a part of our 2013 cholesterol guidelines, and now under discussion as a universally covered service by the U.S. Preventive Services Task Force. The CAC score will likely play an increasingly important role in health care management.