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August 26, 2026JAMA
Predictive Utility of Coronary Artery Calcium Score Added to the PREVENT Atherosclerotic Cardiovascular Disease Equations
Key result
Adding CAC scores to PREVENT-ASCVD equations modestly improves 10-year ASCVD risk discrimination by 0.02.
- Change in Harrell C statistic 0.02
- 95% CI 0.01-0.03
- n=6,098
Why the study?
The utility of coronary artery calcium scoring alongside the newly recommended PREVENT equations for ASCVD risk estimation was not known.
Does the addition of coronary artery calcium (CAC) score to the PREVENT-ASCVD equations improve risk estimation for fatal and nonfatal ASCVD in adults without baseline ASCVD?
Key Points
- To determine the change in predictive performance when adding coronary artery calcium scores to the PREVENT atherosclerotic cardiovascular disease equations.
- Conducted a longitudinal observational cohort study using data from the Multi-Ethnic Study of Atherosclerosis across 6 US sites (N=6098; aged 45 to 79 years without baseline ASCVD).
- Evaluated fatal and nonfatal ASCVD risk over 10 years of follow-up across risk categories (<3%, 3% to <5%, 5% to <10%, and ≥10%) using Harrell C statistic, calibration, and net reclassification improvement.
- Over 10 years of follow-up, 366 participants (6%) experienced an ASCVD event; adding CAC scores to base PREVENT equations (C-statistic 0.73, 95% CI, 0.70-0.75) increased the C-statistic by 0.02 (95% CI, 0.01-0.03) with a categorical NRI of 0.095 (95% CI, 0.053-0.137).
- Model calibration slope was 1.09 (95% CI, 0.93-1.25) for base PREVENT equations and 0.92 (95% CI, 0.81-1.03) after adding CAC scores.
- Among individuals at borderline risk, incident 10-year ASCVD occurred in 1.9% of those with CAC score of 0, 3.9% with CAC 1 to 99, 7.4% with CAC 100 to 299, and 14.3% with CAC 300 or greater.
Study Design
Type
Cohort (n=6,098)
Multicenter
Yes
Structured PICO
Does the addition of coronary artery calcium (CAC) score to the PREVENT-ASCVD equations improve risk estimation for fatal and nonfatal ASCVD in adults without baseline ASCVD?
P
Population
6,098 US adults aged 45 to 79 years without ASCVD at baseline, followed for 10 years.
E
Exposure
Addition of coronary artery calcium (CAC) score to the PREVENT-ASCVD equations
C
Comparator
PREVENT-ASCVD base equations alone
O
Outcome
Performance metrics for estimation of risk of fatal and nonfatal ASCVD (assessed using the Harrell C statistic, calibration, and net reclassification improvement) over 10 years of follow-up
Main Result
Effect estimate: Change in Harrell C statistic 0.02 (95% CI 0.01-0.03)
Adding CAC scores to the PREVENT-ASCVD equations modestly improves risk discrimination and reclassification, supporting guideline recommendations for selective CAC use in borderline to intermediate risk patients.
Key expert perspectives
Captured external expert commentary on this paper, strongest first. Original sources are linked where available.
“For patients at borderline risk, knowing their calcium score can help determine whether their risk is actually lower or higher than initially estimated, which can help guide treatment decisions.”
“Our findings suggest that not everyone necessarily needs or would benefit from a coronary artery calcium scan for the purpose of predicting risk of heart attack and stroke. Routinely using a calcium scan in people who are at low risk may result in unnecessary radiation exposure, testing and costs with unclear clinical benefits.”
“The findings help us understand how best to use the available tools to estimate someone's risk of a heart attack or stroke. That provides more precise guidance for who is most likely to benefit from using a statin to help prevent heart disease.”
Implication
CAC modestly improves PREVENT-ASCVD discrimination overall, mainly in borderline-risk adults; supports selective guideline use but does not warrant routine addition.
Abstract
Importance The 2026 American College of Cardiology/American Heart Association/Multisociety Dyslipidemia Guideline newly recommends selective use of coronary artery calcium (CAC) scoring based on a 10-year risk of 3% to less than 10% estimated with the Predicting Risk of Cardiovascular Disease EVENTS (PREVENT) atherosclerotic cardiovascular disease (ASCVD) equations. However, the utility of CAC scoring alongside the PREVENT equations for ASCVD risk estimation is not known. Objective To determine the change in predictive utility when adding CAC scores to the PREVENT-ASCVD equations. Design, Setting, and Participants Longitudinal observational cohort study conducted at 6 sites in the United States and enrolling adult participants aged 45 to 79 years without ASCVD at baseline in the Multi-Ethnic Study of Atherosclerosis. Exposures Ten-year ASCVD risk with the PREVENT-ASCVD equations before and after adding CAC scores. Main Outcomes Performance metrics for estimation of risk of fatal and nonfatal ASCVD, assessed using the Harrell C statistic, calibration, and net reclassification improvement (NRI) for newly defined ASCVD risk categories: low (<3%); borderline (3% to <5%); intermediate (5% to <10%); and high (≥10%). Results A total of 6098 participants were included. At baseline, participant mean age was 61.4 (SD, 9.6) years, 52% were female, mean estimated 10-year ASCVD risk was 6.4% (SD, 4.8%) with the PREVENT-ASCVD base equations, and 49% had a CAC score greater than 0. During 10 years of follow-up, 366 (6%) experienced an ASCVD event. The Harrell C statistic for the PREVENT-ASCVD base equations was 0.73 (95% CI, 0.70-0.75). After adding CAC to the PREVENT-ASCVD base equations, the change in Harrell C statistic was 0.02 (95% CI, 0.01-0.03), and the categorical NRI was 0.095 (95% CI, 0.053-0.137). The calibration slope for the PREVENT-ASCVD base equations was 1.09 (95% CI, 0.93-1.25), and for the PREVENT-ASCVD base plus CAC equations was 0.92 (95% CI, 0.81-1.03). Among those at borderline risk, incident ASCVD occurred in 1.9% of those with CAC score of 0, 3.9% with CAC greater than 0 and less than 100, 7.4% with CAC 100 or greater and less than 300, and 14.3% with CAC 300 or greater. Conclusions and Relevance Among US adults aged 45 to 79 years, addition of CAC score to the PREVENT-ASCVD equations across all risk groups overall only modestly improved and, in some groups, did not change model discrimination and reclassification. Reclassification results support selective use of CAC in those with borderline to intermediate risk estimated by the PREVENT-ASCVD equations.
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Cite This Study
Huang et al. (2026) conducted a cohort in Atherosclerotic cardiovascular disease (ASCVD) risk (n=6,098). Addition of coronary artery calcium (CAC) score to the PREVENT-ASCVD equations vs. PREVENT-ASCVD base equations was evaluated on Estimation of risk of fatal and nonfatal ASCVD (Harrell C statistic) (Change in Harrell C statistic 0.02, 95% CI 0.01-0.03). Adding CAC scores to the PREVENT-ASCVD equations modestly improved model discrimination for 10-year ASCVD risk, with a change in Harrell C statistic of 0.02 (95% CI 0.01-0.03).