The Role of Coronary Artery Calcium in Statin Eligibility Based on the American Heart Association’s PREVENT Calculator

BACKGROUND The 2026 American College of Cardiology/American Heart Association/multisociety dyslipidemia guideline incorporates the PREVENT atherosclerotic cardiovascular disease (ASCVD) equations for estimation of 10-year ASCVD risk, replacing the Pooled Cohort Equations used in previous prevention guidelines. Coronary artery calcium (CAC) has historically been used to refine risk assessment when treatment decisions are uncertain. OBJECTIVES In this study, the authors sought to evaluate cardiovascular event rates across CAC strata within statin eligibility groups and 10-year PREVENT risk categories. METHODS Individuals from the MESA (Multi-Ethnic Study of Atherosclerosis) were included. Three groups were created based on statin eligibility: statin recommended, considered, and not recommended. In addition, participants with a low-density lipoprotein cholesterol 70 to 189 mg/dL without diabetes were grouped by 10-year PREVENT-ASCVD risk categories: 0, the event rates were 4.5, 5.2, and 16.6, respectively. The event rates per 1,000 person-years in participants with CAC 0 vs CAC >0 were, respectively, 1.1 and 3.0 for 10-year PREVENT-ASCVD risk <3%, 2.7 and 5.2 for 10-year PREVENT-ASCVD risk 3% to <5%, 5.9 and 11.3 for 10-year PREVENT-ASCVD risk 5% to <10%, and 6.2 and 20.9 for 10-year PREVENT-ASCVD risk ≥10%. CONCLUSIONS In this large multiethnic cohort, CAC provided its greatest clinical value when statin treatment decisions were uncertain, particularly among individuals with borderline predicted risk. Among participants who already met guideline-based treatment thresholds, observed ASCVD event rates remained elevated even when CAC was absent, suggesting that CAC 0 should not generally be used to withhold statin therapy in these individuals. These findings support a guideline-centered role for CAC in the PREVENT era: refining risk near treatment thresholds, contextualizing absolute risk, and informing the intensity of preventive efforts.