Calcium score of Zero: Reassuring, butnot the whole story

Acoronary artery cakium (CAC) score of zero is reassuring, but it's not the full story. CAC=0 means no calcified plaque. It does NOT mean no plaque at all.

Early plaque can still be present in some people, and it matters.

The Key Insight

. CAC detects late stage (calcilied) plaque.

.

. About 6-16% of patients with symptoms of heart disease and -10% of those without

any symptoms may still have plaque buildup, despite CAC = 0.

Prevalence of Non-Calcified Plaques

The ocourrence of non calcihed plaques varies quite a bit among different groups of patientts:

. In people who don't have symptoms, a review of 37,808 individuals found that 10% had non-calcified plaques, with only 1.1% showing significant blockage of blood fkiw.

. For thase with symploms, the prevalence is higher, ranging from 6% to 16% depending on the specific group studed. For example, in a varied group from the Montefiore Healthcare System, 7% had plaque even though they had no calcium builup. In contrast, a rural group in Appalachia showed a much higher rate of 26%.

Other large studies provide additional insights:

. The Swedish SCAPIS study found that among asymptomatic adults aged 50-64 years with no calcium buildup, 5.5% had non-calcihed atherosderosis.

The Miami Heart Study reported that 16% of individuals without calcium buildup had identifiable non-calcified plaques.

Early plaque is non-calcified and invisible on these non-contrast enhanced CT scans done to detect calcium.

The Reassuring Part

CAC = 0 has a 98-99% negative predictive value, i.e.,

. Very low chance of blocked arteries.

. Very low short-term event risk.

Far mast people, this is excellent news.

When CAC = 0 Needs a Second Look

You may still be at risk if you have:

Chest symptoms (pain, tightness, shortness of breath).

Diabetes.

High blood pressure.

Smoking history.

High LDL cholesteral.

Male sex.

HIV.

Multiple risk factors.

Younger age (<45, where plaque is often non-calcified).

Why This Matters

Non-calcified plaque is active and poterially unstable.

Associated with ~2x higher risk of future cardiac events.

Seen in up to 23% of heart attack patients with CAC = 0.

Translation: "Zero cakcium" # zero bialogy.

When to Consider Different Testing

Acoronary CT angiogram (CCTA) may help if:

. You have symploms + risk factors.

You're younger with elevated LDL.

There's uncertainty about your risk.

It detects both cakified and non-calcified plaque, but:

Overall chance of finding dangerous blockage is still low (-1-2%).

Teeting should be selective, not routine, at least at thls time, till more data

emerges.

What You Should Do (Regardless of Score)

Get earlier soreering, even in your 20s or 30s.

Pay atteriion to lifestyle.

At Preventiononty, we don't walt for plaque to appear; we work to Identity riak before

the firet calclum deposit or even the earlleet non-calcifled plaque, using a

comprehenslve approach that combines llfestyle patter Identification from wearable

technology, famlly history, and advanced blomarkera.

Go Beyond a Single Number

With the PreventionPlus app, you can:

Track true cardiovascular risk markers.

. Monitor LDL, ApoB, metabolic health.

Get personalized prevention plans.

. Ideriify when advanced testing may help.

Because prevention is continuous, not a one-time test.

Key Evidence

. -10% of asymplomatic patienits have non-calcified plaque.

6-16% in symptomatic populations (up to 26% in high-risk groups).

. 2x increased risk with non-calcified plaque.

.

96-99% reassurance for mejor events with CAC = 0.

References

1. Non-Calcified Plaque in Asymptomatic Patients With Zero Coronary Artery Calcium Score: A Systematic Review and Meta-Analysis. Sama C, Abdelhaleem A, Velu D, et al. Journal of Cardiovascular Computed Tomography. 2024 Jan-Feb; 18(1):43-49. doi: 10.1016/j.joct.2023.10.002.

2. Interplay Between Zero CAC, Quantitative Plaque Analysis, and Adverse Events in a Diverse Patient Cohort. Fattouh M, Kuno T, Pina P, et al. Circulation. Cardiovascular Imaging. 2023;16(8):e015236. doi:10.1161/CIRCIMAGING.123.015238.

3. Prevalence of Noncalcified Plaques and Coronary Artery Stenosis in Patients With Coronary Calcium Scores of Zero. Al-Muhaidb SM, Aljebreen AMM, AlZamel ZA, Fathala A. Coronary Artery Disease. 2021;32(3):179-183. doi:10.1097/MCA.0000000000000937.

4. Predictors of Non-Calcified Plaque Presence and Future Adverse Cardiovascular Evenits in Symptomatic Rural Appelachian Patients With a Zero Coronary Artery Calcium Score. Miller T, Hana D, Patel B, et al. Joumal of Cardiovasoular Computed Tomography. 2023 Sep- Oct;17(5):302-309. doi:10.1016/j.joct.2023.07.003.

5. 2026 ACCIAHAIAACVPRIABCIACPMADAAGSIAPhAIASPC/NLA/PCNA Guideline on

the Management of Dyslipidemia: AReport of the American College of CardiologylAmerican Heart Association Joint Committee on Clinical Practice Guidelines. Blumerthal RS, Morris PB, Gaudino M, et al. Journal of the American Colege of Cardiology. 2026,:S0735- 1097(25)10254-4. doi:10.1016/j.jacc.2025.11.016.

6. Low-Density Lipoprotein Cholesterol and Cardiovascular Risk in the Absence af

Calcifications on Computed Tomography: The Western Denmark Hksart Registry. Andersen MH, Jensen JM, Kanstrup H, et al. Europesan Heart Journal. 2025;ehaf497.

doi: 10.1093/eurheartj/ehaf497.

7. Irfluence of Age on the Diagnostic Value of Coronary Artery Calcium Score for Ruling Out Obstructive Coronary Disease in Symptomatic Pafients. Albuquerque F, Lopes PM, Freitas P, et al. The American Joumnal af Cardialogy. 2023;205:35-39.

doi: 10.1016/j.amjcard.2023.07.115.

8. Coronary Calcium Score in the Initial Evaluation of Suspedted Coronary Artery Dissase. Pedersen ER, Hovland S, Karaji I, et al. Heart (British Cardiac Society). 2023;109(9):695- 701. doi:10.1136/heartjnl-2022-321682.

9. CTA-Derived Plaque Cheracteristios and Risk of Acute Coronary Syndrome in Patients With Coronary Artery Calcium Score of Zero: Insights From the ICONIC Trial. Jonas RA, Nurmohamed NS, Crabtree TR, et al. AIR. American Journal of Roentgendlogy. 2025 ;. doi: 10.2214/AJR.24.31476.