The evolving role of coronary artery calcium in preventive cardiology 30 years after the Agatston score

PURPOSE OF REVIEW: On the brink of the 30th anniversary of the Agatston score we summarize the epidemiological data that shaped the recommendations relevant to coronary artery calcium (CAC) included in the 2018/2019 US and European guidelines for the primary prevention of atherosclerotic cardiovascular disease (ASCVD). We also discuss the implications of novel CAC research conducted in asymptomatic populations within the past 2 years. RECENT FINDINGS: Based on a wealth of observational evidence, CAC has emerged as a mainstay in personalized risk assessment and is now endorsed as a class IIa tool in both US and European guidelines. In the past 2 years, data supporting the prognostic power of CAC has kept mounting, with longer term follow-up data now available. CAC has been evaluated in a variety of patient populations including individuals with severe hypercholesterolemia, diabetes mellitus and younger adults with family history of ASCVD, in all of whom it may be able to inform a more personalized management. Novel CAC scoring approaches are also discussed. SUMMARY: Despite a strong endorsement in recent guidelines, active research in the last 2 years has provided further insights on the potential utility of CAC in informing a more individualized preventive management in broader populations.