Coronary Artery Calcium in ACC/AHA Prevention Guidelines

Coronary artery calcium (CAC) scoring is an established marker of subclinical atherosclerosis that improves cardiovascular risk stratification beyond traditional risk factors. Since the 2007 ACCF (American College of Cardiology Foundation)/AHA (American Heart Association) Clinical Expert Consensus Statement, the role of CAC in prevention guidelines has progressively evolved. The strength of CAC recommendations has increased from a Class IIb recommendation for selected intermediate-risk adults in 2007 to a Class IIa recommendation for risk refinement in the 2018 ACC/AHA cholesterol guideline and to Class I recommendations for selected CAC-defined populations in the 2026 ACC (American College of Cardiology)/AHA multisociety dyslipidemia guideline. The 2018 guideline incorporated CAC primarily to guide statin allocation when treatment decisions were uncertain. The 2026 guideline further expands CAC-based recommendations by incorporating age- and sex-adjusted percentiles, CAC-guided treatment intensity, and low-density lipoprotein-cholesterol goals, including management of very high CAC phenotypes. In this brief report, the authors review the evolution of CAC across the 2007, 2018, and 2026 ACC/AHA guideline documents and discuss the expanding role of CAC in personalized cardiovascular prevention.