Comparative systematic review of coronary artery calcium scoring guidelines: CSANZ versus ACC/AHA and ESC recommendations

Coronary artery calcium (CAC) scoring is increasingly recognised as a non-invasive tool to refine cardiovascular risk assessment, particularly in asymptomatic individuals at intermediate risk. However, its clinical use remains inconsistent, shaped by varying recommendations across international and local guidelines. This systematic review compares the major guideline documents from the Cardiac Society of Australia and New Zealand (CSANZ), the American College of Cardiology/American Heart Association (ACC/AHA) and the European Society of Cardiology (ESC), focusing on three core endpoints: eligibility criteria, therapeutic thresholds and recommendations for repeat testing. While broad agreement exists on the utility of CAC scoring in intermediate-risk populations, key differences were identified. These include divergent definitions of risk, the use of formal recommendation frameworks and inconsistencies in guidance for pharmacotherapy initiation, particularly regarding statins and aspirin. The review also highlights a lack of clarity in the role of repeat scanning and variable alignment with national risk calculators. These differences may contribute to clinical uncertainty and inconsistent implementation. In the context of rising interest in precision prevention, further research evaluating CAC-guided decision-making is needed to help eventually achieve guideline harmonisation. Clearer evidence-based guidance is needed to support equitable and effective integration into routine cardiovascular risk assessment.