Role of coronary artery calcium score in the preoperative evaluation of liver transplant candidates

Cardiovascular disease is a major contributor to morbidity and mortality among liver transplant candidates and recipients, reflecting the complex hemodynamic, inflammatory, metabolic, and renal disturbances associated with end-stage liver disease and the post-transplant period. Traditional cardiovascular risk assessment tools and stress tests screening modalities may perform suboptimally in this population, particularly because cirrhosis physiology and beta-blocker use may mask or alter ischemic responses. Coronary artery calcium score (CACS) has emerged as a noninvasive, reproducible, low-radiation method for assessing calcified coronary atherosclerotic burden and refining cardiovascular risk stratification. In the general population, CACS improves prediction of atherosclerotic cardiovascular disease beyond traditional risk factors and has strong negative predictive value for obstructive coronary artery disease. In liver transplant candidates, available studies suggest that absent or mild coronary calcification can help identify patients at low risk for obstructive coronary disease, whereas elevated CACS, particularly scores ≥400 Agatston units, has been associated with higher post-transplant cardiovascular event risk. However, CACS has limitations as it does not detect non-calcified plaque, define stenosis severity, assess lesion functionality, or provide procedural planning information. Coronary computed tomography angiography (CCTA) remains superior for anatomical characterization and plaque assessment. Overall, CACS is best considered a gatekeeper test within preoperative liver transplant evaluation, complementing rather than replacing CCTA or invasive coronary angiography. Further research is needed to standardize CACS thresholds and define its optimal integration into transplant-specific cardiovascular risk algorithms.