Coronary Calcification: A Nuanced View

Coronary artery calcification (CAC) is a marker of atherosclerosis. Various quantitative indicators, such as CAC score (CACS) and CAC volume, are associated with the risk of major adverse cardiovascular events (MACE), whereas CAC density has a protective effect. However, the interrelationships among these indicators and their respective risk factors remain to be fully elucidated. This narrative review explores the prognostic value and interrelationships of quantitative CAC indicators, as well as their associated risk factors. Traditional CACS, which integrates CAC volume and density, is generally positively correlated with MACE. Nevertheless, its prognostic significance is dual, particularly in the context of statin therapy, where an increase in density-driven scores often indicates plaque stability. High CAC density and its rapid progression serve as protective factors against MACE; however, this protective effect becomes insignificant when CAC volume exceeds 130 mm3. Male sex, smoking, and diabetes tend to promote the progression of CAC volume, whereas female sex, lipoprotein(a), physical activity, and body weight are associated with the progression of CAC density. Notably, CAC assessment has evolved from a single traditional CACS to a comprehensive, multi-parameter evaluation system incorporating such as CACS, CAC density, and volume. Effectively leveraging their interrelationships can help improve the predictive value of CAC.