A silent threat: Asymptomatic extensive coronary artery disease identified by coronary artery calcium

A BSTRACT Coronary artery calcium (CAC) scoring is an established tool for cardiovascular risk stratification and is primarily recommended when preventive treatment decisions remain uncertain. Current guidelines do not routinely support CAC screening in asymptomatic individuals already receiving guideline-directed medical therapy. We present a case in which a significant vascular calcification was incidentally identified on a knee X-ray, leading to CAC scoring that identified severe multivessel coronary artery disease (CAD) in an asymptomatic patient with controlled cardiovascular risk factors. Clinical history, diagnostic imaging, operative management, and follow-up data were reviewed for an asymptomatic 77-year-old man who underwent CAC scoring after incidental vascular calcification was identified on knee radiography. A physically active 77-year-old man with multiple cardiovascular risk factors was referred for CAC scoring after popliteal artery atherosclerosis was incidentally noted on knee radiography. He denied chest pain, dyspnea, and claudication. Despite well-controlled medically managed comorbidities, CAC scoring demonstrated an Agatston score of 4011. Subsequent stress myocardial perfusion imaging revealed a large partially reversible perfusion defect in the right coronary artery (RCA) territory. Coronary angiography demonstrated chronic total occlusion of the RCA and approximately 80% stenoses of the left anterior descending and left circumflex arteries. The patient subsequently underwent successful quadruple coronary artery bypass grafting with good postoperative recovery. This case highlights the potential diagnostic and prognostic value of CAC scoring in selected asymptomatic patients. Significant obstructive CAD may remain clinically silent despite good functional status and optimized medical therapy. In carefully selected contexts, CAC scoring may facilitate earlier identification of advanced coronary disease that might otherwise remain undetected.