Establishing the warranty of a coronary artery calcium score of zero

The inherent limitations of traditional risk factor-based cardiovascular disease (CVD) risk assessment [1] have triggered the development and implementation of imaging tests aimed at directly measuring the presence and burden of subclinical atherosclerosis in diverse vascular beds within individual patients. Such individualized disease assessment clearly trumps risk factors as the strongest predictor of incident CVD events and death [2]. The promising results of incorporating such imaging-based risk information into clinical decision-making has led experts to advance a CVD risk assessment paradigm shift from a risk-factor based model (prediction) to an atherosclerosis imaging-based approach (disease detection).