Background: The 2018 American College of Cardiology/American Heart Association (ACC/AHA) and 2021 European Society of Cardiology/European Atherosclerosis Society (ESC/EAS) guidelines recommend coronary artery calcium (CAC) score for risk refinement in primary prevention of atherosclerotic cardiovascular disease (ASCVD).

Objectives: To compare CAC utility as a risk-refining tool following the ACC/AHA using Pooled Cohort equations (PCE) or Predicting Risk of cardiovascular disease EVENTs equations (PREVENT) and ESC/EAS guidelines using Systematic COronary Risk Evaluation 2 (SCORE2).

Methods: A total of 1903 statin-naive participants aged 55-75 years, free of ASCVD and diabetes, with LDL cholesterol <190 mg/dL from the prospective population-based Rotterdam Study were included. Per guideline, we determined proportions of CAC scan eligible and reclassified men and women, ASCVD incidence rates, and numbers needed to treat for 10-years (NNT10y).

Results: By ACC/AHA (PCE), 18.3% of men and 11.9% of women and by ACC/AHA (PREVENT), 13.4% of men and 3.4% of women were eligible for a CAC scan. By ESC/EAS, 46.6% of men and 44.9% of women were CAC eligible. Proportions of uprisked and derisked individuals varied per guideline. Among ACC/AHA and ESC/EAS CAC eligible individuals, incidence rates ranged from 9.3 to 23.8 per 1000 person-years, and estimated NNT10y to prevent one ASCVD event, based on high-intensity statin use, varied from 11 to 26.

Conclusions: ACC/AHA and ESC/EAS guidelines differ in the selection and application of CAC score for primary prevention of ASCVD. Guideline-directed application of CAC score in a middle-aged apparently healthy population improved risk stratification at acceptable NNT10y for both guidelines.

Editors
Editor-in-Chief
Y.S. Chandrashekhar, MD, DM, FACC

CME Editor
Kenneth A. Ellenbogen, MD

Author
Talal Alnabelsi, MD, FACC

Important Dates
Date of Release: April 7, 2025
Term of Approval/Date of CME/MOC Expiration: April 6, 2026