Heart health Insights: January 2026
Understanding Calcium Scoring: A Guide to Your Heart Health
Dr Primero Ng, Interventional Cardiologist
A coronary artery calcium (CAC) score is a simple and powerful test that helps assess your risk of heart disease. It measures the amount of calcium in the walls of the arteries that supply blood to your heart. Calcium in these arteries is a sign of atherosclerosis, a process where plaque gradually builds up over time and can increase the risk of heart attack or other cardiovascular problems.
Your CAC score is obtained using a specialised, non-invasive CT scan of the heart. The scan is quick, painless, and does not require needles or contrast dye. It uses a very low dose of radiation, similar to that of a routine mammogram. The result is reported as a single number, which helps your doctor better understand your heart risk and guide personalised prevention or treatment decisions.
Non-Invasive
No needles, dyes, or invasive procedures required
Low Radiation
Uses minimal radiation similar to a mammogram
Risk Assessment
Powerful tool for estimating future heart problems
Who Benefits from Calcium Scoring?
A CAC score is most helpful for adults aged 40 to 80 who do not have known heart disease, particularly when it is unclear whether preventive treatment is needed. It is especially useful if you have risk factors such as a family history of heart disease, high cholesterol, high blood pressure, diabetes, or if your overall risk feels uncertain.
This test provides a clearer picture of your future heart risk and helps guide personalised prevention decisions. Leading heart organisations, including the American College of Cardiology and the American Heart Association, recommend using the CAC score as part of a shared decision-making process between you and your healthcare team. This means your results are considered alongside your overall health, risk factors, and personal goals to develop a plan that is right for you.
Your calcium score can help determine whether you may benefit from:
- Cholesterol-lowering medications such as statins
- More focused blood pressure management
- Targeted lifestyle changes, including diet, exercise, and smoking cessation
- Further cardiac testing, when appropriate
By clarifying risk, calcium scoring helps avoid both under-treatment and unnecessary treatment, allowing care to be tailored with confidence.
Ideal Candidates
Adults aged 40 to 80 without known heart disease, particularly when it is unclear whether preventive medication is needed.
Understanding Your Score: What the Numbers Mean
Your CAC score falls into defined ranges, each offering important insight into your risk of heart disease and helping guide the next steps in your care. Interpreting your result involves more than just the number alone. Your age, overall cardiovascular risk factors, and whether you have symptoms such as chest pain all play a role in understanding what your score means for you and how it should inform your management plan.
01
CAC Score 0: Very Low Risk
No calcium detected - highly reassuring result
02
CAC Score 1–99: Modestly Increased Risk
Small amount of calcium indicating early atherosclerosis
03
CAC Score 100–399: High Risk
Moderate calcium burden requiring active intervention
04
CAC Score ≥400: Very High Risk
Substantial calcium requiring aggressive management
CAC Score 0: Very Low Risk
A coronary artery calcium score of zero means that no calcium was detected in the arteries supplying your heart. This is an excellent and very reassuring result. It indicates a very low risk of heart attack or other major cardiovascular events over the next 5 to 10 years, typically less than 2 percent in large long-term studies.
For adults aged 40 to 80 who do not have symptoms such as chest pain, a score of zero is the strongest marker we have for low short to medium term risk of atherosclerotic heart disease. In many cases, this result allows both patients and doctors to feel confident about focusing on lifestyle measures alone, without the immediate need for preventive medications, unless there are other important risk factors present.
It is important to remember that a CAC score of zero does not mean risk is zero forever. Ongoing attention to healthy habits, regular follow-up, and reassessment over time remain key parts of long-term heart health.
Medication Decisions
For many people, a CAC score of zero provides reassurance that preventive medication may not be immediately necessary. Major cardiology organisations, including the American College of Cardiology and the American Heart Association, advise that statin therapy can often be safely deferred when the calcium score is zero, provided no other high-risk features are present.
Exceptions may apply if you have one or more of the following:
- Diabetes
- Ongoing cigarette smoking
- A strong family history of premature heart disease
- Very high LDL cholesterol, typically ≥4.9 mmol/L
In these situations, medication may still be recommended despite a zero calcium score. Decisions are best made through an individualised discussion with your doctor, taking into account your overall risk profile, preferences, and long-term heart health goals.
Lifestyle Still Matters
Regardless of your calcium score, healthy lifestyle choices remain the foundation of lifelong heart health. These habits help protect your arteries, reduce future risk, and support overall wellbeing:
- A heart-healthy diet rich in vegetables, fruits, whole grains, and healthy fats
- Regular physical activity, aiming for at least 150 minutes of moderate exercise each week
- Maintaining a healthy weight
- Complete smoking cessation
Even when results are reassuring, continuing these habits helps preserve your low risk and supports long-term cardiovascular health.
Follow-Up Testing for Score of Zero
For people without symptoms, repeat calcium scoring is usually not needed for several years. In those at low overall risk, retesting is generally not considered for at least 5 to 7 years. If your risk is borderline or intermediate, repeat testing may be considered after 3 to 5 years. For individuals with diabetes or other higher-risk features, earlier reassessment around 3 years may be appropriate if the result would meaningfully influence treatment decisions.
The purpose of repeat testing is to identify whether calcium has developed over time. A change from a score of zero to detectable calcium can signal increasing risk and may prompt more intensive preventive strategies.
It is important to note that a calcium score of zero does not rule out all heart disease. If you have ongoing symptoms such as chest pain, shortness of breath, or reduced exercise tolerance, or if you have significant risk factors, further assessment may still be recommended. This can include additional imaging or stress testing to better understand your heart health.
Preventive medications should not be stopped solely because of a zero calcium score in people with symptoms or high-risk features. Ongoing risk factor management, including lifestyle measures and medical therapy when indicated, remains essential for long-term heart health.
Important Exception: Symptoms Matter
If you are experiencing symptoms such as chest pain, shortness of breath, or reduced exercise tolerance, a calcium score of zero is reassuring but not definitive. While it strongly suggests a low likelihood of significant artery blockages, it does not completely exclude early or non-calcified plaque.
In some people, particularly younger patients or those with multiple risk factors, plaque may be present without detectable calcium. Studies suggest that up to 1 in 10 symptomatic individuals with a calcium score of zero may still have non-calcified plaque.
For this reason, ongoing symptoms should always be evaluated further, regardless of calcium score, to ensure appropriate investigation and management.
CAC Score 1–99: Modestly Increased Risk
A calcium score between 1 and 99 means a small amount of calcium has been detected in the arteries supplying your heart. This reflects early or mild plaque build-up and indicates a slightly higher risk of heart attack or stroke compared with a score of zero.
The significance of this result depends strongly on age and overall risk profile. In older adults, low-level calcium can be a common finding and may represent early ageing of the arteries. In younger individuals, the same score can be more meaningful and may signal earlier development of heart disease. For this reason, results are always interpreted in the context of your age, symptoms, and other cardiovascular risk factors to guide the most appropriate next steps.
3.8%
Ages 45–54
10-year cardiovascular event rate
8.3%
Ages 65–74
10-year cardiovascular event rate
Treatment Recommendations
Asymptomatic Adults Over 55
For adults over 55 without symptoms, a calcium score between 1 and 99 suggests early coronary artery disease and a modest increase in future cardiovascular risk. In this setting, leading cardiology organisations, including the American College of Cardiology and the American Heart Association, recommend that cholesterol-lowering medication such as statins be actively considered, as the balance of benefit becomes more favourable.
Lifestyle measures remain the foundation of care and are essential at every stage. The decision to start medication should be made through a shared discussion with your healthcare team, taking into account your age, overall risk factors, test results, and personal preferences, to develop a prevention plan that feels appropriate and sustainable for you.
Younger Adults (40–55)
For adults aged 40 to 55, management decisions are best individualised. A calcium score in this range should be interpreted alongside your overall cardiovascular risk factors, family history, lifestyle, and personal preferences. Decisions about medication are ideally made through a thoughtful discussion with your healthcare team, focusing on what is most appropriate for you.
The National Lipid Association advises that repeat calcium scoring may be considered after 3 to 5 years if the result is likely to influence treatment decisions. This approach helps track changes over time and supports timely adjustment of preventive strategies when needed.
Symptomatic Individuals with CAC 1–99
If you have symptoms such as chest pain or shortness of breath, even a low calcium score between 1 and 99 becomes more significant. The presence of any coronary calcium increases the likelihood of underlying coronary artery disease, although the risk remains lower than with higher scores.
The American Heart Association advises that minimal calcium in symptomatic individuals should prompt consideration of further assessment, particularly if symptoms persist or additional risk factors are present. Depending on your situation, this may include stress testing or CT coronary angiography to better evaluate blood flow and identify any clinically important narrowing.
Ongoing symptoms should always be discussed with your doctor, regardless of calcium score, to ensure appropriate investigation and management.
CAC Score 100–399: High Risk
A coronary artery calcium score between 100 and 399 indicates a moderate amount of calcium in the arteries supplying your heart. This reflects established coronary artery disease and is associated with a clearly increased risk of heart attack or stroke compared with lower scores.
Large population studies show that people with a calcium score above 100 have a higher likelihood of experiencing a major cardiovascular event over the next 10 years, with risk levels that exceed commonly used thresholds for preventive treatment. For this reason, this range strongly supports the use of cholesterol-lowering medication, alongside comprehensive risk factor management.
A score in this range also highlights the importance of optimising blood pressure control, addressing lifestyle factors, and closely monitoring symptoms. Your result should be interpreted in the context of your age, symptoms, and overall health, and used to guide a personalised prevention strategy aimed at reducing future cardiovascular risk.
7.5%
10-Year Event Risk
Hard cardiovascular events in this group
4×
Relative Risk
Compared to those with score of zero
Comprehensive Management Approach
Statin Therapy
Cholesterol-lowering medication is strongly recommended for this calcium score range. Major cardiology organisations advise statin treatment unless there is a clear reason not to use it, as it significantly reduces the risk of heart attack and stroke.
Blood Pressure Control
Keeping blood pressure within target range is essential. Medication may be recommended if levels are elevated, alongside healthy lifestyle changes.
Additional Therapies
In some higher-risk individuals, aspirin may be considered. This decision is individual and balances potential benefit against bleeding risk.
Lifestyle Modification
Healthy lifestyle choices remain critical. This includes a heart-healthy diet, regular exercise, weight management, and complete smoking cessation.
Repeat calcium scoring may be considered after around 3 years to assess whether calcium is progressing more rapidly than expected or has increased to a level where more intensive cholesterol-lowering treatment may be beneficial. This approach is most useful when the result is likely to change management decisions. For many people, repeat testing is not routinely required and should be individualised based on overall risk, symptoms, and treatment goals.
Symptomatic Patients with CAC 100–399
If you have symptoms such as chest pain or shortness of breath, a calcium score between 100 and 399 is a significant finding. It is associated with a substantially higher likelihood of important coronary artery narrowing and an increased risk of future cardiovascular events. Further diagnostic assessment is strongly recommended, particularly if symptoms persist, to evaluate blood flow and define the severity of disease. Management typically includes high-intensity cholesterol-lowering therapy, antiplatelet treatment when appropriate, and aggressive control of all cardiovascular risk factors, including blood pressure, cholesterol, lifestyle, and smoking cessation. Early, proactive management in this setting is essential to reduce heart attack risk and improve long-term outcomes.
CAC Score ≥400: Very High Risk
A coronary artery calcium score of 400 or higher indicates a heavy build-up of calcium in the arteries supplying your heart. This reflects a high burden of coronary artery disease and is associated with a very high risk of heart attack or other major cardiovascular events.
People with scores in this range have risks similar to, or higher than, those with known coronary artery disease. Large studies show that the chance of a major cardiovascular event over the next 10 years exceeds 13% and may be considerably higher in older adults. This result signals the need for intensive risk reduction and close medical follow-up.
13%
Minimum 10-Year Risk
Hard cardiovascular events
25%
Maximum 10-Year Risk
In older adults
50%
Stenosis Likelihood
≥50% coronary narrowing
Aggressive Management Strategy
For people with a calcium score of 400 or higher, intensive treatment is strongly recommended. Leading cardiology organisations, including the American College of Cardiology and the American Heart Association, advise high-intensity cholesterol-lowering therapy alongside comprehensive control of all cardiovascular risk factors. This approach is also strongly supported by the National Lipid Association and the Society of Cardiovascular Computed Tomography, reflecting the clear evidence that aggressive prevention is essential to reduce future heart attack and stroke risk.
Aspirin therapy may be considered for selected individuals with high cardiovascular risk and a low risk of bleeding, but this decision should always be individualised. Repeat calcium scoring is generally not recommended at this stage, as management should focus on intensive risk factor control and secondary prevention strategies aimed at reducing future cardiovascular events.
High-Intensity Statins
Strongly recommended unless there is a medical reason not to use them. If cholesterol targets are not achieved, additional lipid-lowering medications, such as ezetimibe or PCSK9 inhibitors, may be added to further reduce risk.
Optimal Blood Pressure
Strict blood pressure control is essential, with treatment aimed at achieving and maintaining recommended target levels to reduce cardiovascular risk.
Further Testing
Additional non-invasive heart testing may be recommended to assess blood flow, particularly if symptoms develop or other high-risk features are present.
Lifestyle Changes
Ongoing lifestyle optimisation is essential, including a heart-healthy diet, regular physical activity, weight management, and complete smoking cessation.
Critical Note for Symptomatic Patients
If you have symptoms such as chest pain or breathlessness, a calcium score of 400 or higher is a serious finding. Around half of people in this range have significant artery narrowing. Prompt and thorough assessment is recommended to identify any flow-limiting disease, usually with coronary CT angiography or, in some cases, invasive coronary angiography.
Management should be as intensive as treatment for established heart disease. This typically includes high-intensity cholesterol-lowering therapy, antiplatelet treatment when appropriate, and consideration of additional lipid-lowering medications. If symptoms persist or testing shows reduced blood flow, procedures to restore blood supply may be considered following careful discussion with your healthcare team.
How Your Score Guides Personalised Heart Health Decisions
Your CAC score helps tailor a heart health plan that is specific to you. It guides decisions about whether to start or intensify medication, how closely to manage blood pressure and cholesterol, and whether further testing is needed. Leading organisations such as the American Heart Association and the American College of Cardiology emphasise that these choices are best made together with your healthcare team through shared decision-making, taking into account your results, overall risk, and personal preferences.
Your Values Matter
Decisions about your heart care should reflect your personal values, preferences, and overall health, not just a test result. Shared decision-making helps create a plan that feels right for you.
Flexible Options
If your CAC score is 0, you may choose to focus on lifestyle changes and defer medication, unless other high-risk features are present
Care Matched to Your Risk
As calcium scores increase, the benefits of medication become clearer. Treatment intensity and medication choice can still be tailored to your needs, goals, and preferences.
The Middle Ground: Scores 1–99
Calcium scores between 1 and 99 sit in a grey zone where shared decision-making is especially important. Whether to start medication depends on your age, overall risk factors, and personal health goals. There is no single right answer. Your results should be considered in the context of your individual circumstances, preferences, and long-term priorities to determine the most appropriate next steps.
Key Questions to Consider
Your calcium score is a starting point for meaningful discussion. It may help to reflect on questions such as:
- What are your main goals for your heart health now and in the future?
- Do you place greater value on minimising medication use, or on reducing cardiovascular risk as much as possible?
- Do you have concerns about side effects, costs, or the impact of treatment on your lifestyle?
- How do your personal health history and family history influence your preferences and priorities?
An Ongoing Process
Shared decision-making is not a one-time conversation. The American Heart Association emphasises that your care plan should evolve over time as your health, circumstances, and preferences change. Regular review ensures your heart health strategy remains appropriate, effective, and aligned with what matters most to you.
These conversations ensure your care is truly personalised and centred on what matters most to you. If you wish, family members or caregivers can be involved, and your cardiologist is always available to answer questions and support you through important decisions.
Common Questions and Misconceptions Explained
Your Next Steps: Moving Forward With Confidence
Your calcium score is an important insight, but it is only one part of your overall heart health picture. The greatest benefit comes from using this information in partnership with your healthcare team to build and maintain a plan that reflects your individual risks, priorities, and goals. Regardless of your score, healthy lifestyle choices remain the foundation of long-term heart health and support every other treatment decision you make.
1
Review Your Results
Take time to understand your calcium score and what it means for your heart health and future risk.
2
Schedule a Discussion
Book a dedicated appointment with your cardiologist to review your results in detail and discuss your options.
3
Ask Questions
Come prepared with questions about medications, lifestyle changes, further testing, or any concerns you may have.
4
Create Your Plan
Work together with your cardiologist to develop a personalised, realistic plan tailored to your goals and risk profile.
5
Implement Changes
Begin the agreed lifestyle changes and medications, focusing on sustainable steps that fit your daily life.
6
Follow Up
Attend scheduled follow-up appointments to track progress, reassess risk, and adjust your plan as needed over time.
"Your calcium score turns insight into action, helping you and your cardiologist understand risk and make personalised decisions to protect your heart."
© 2026 Dr Primero Ng. All rights reserved.
Consultant Interventional Cardiologist, Perth, Western Australia.
Information on this website is general in nature and does not replace individual medical advice.
Consultant Interventional Cardiologist, Perth, Western Australia.
Information on this website is general in nature and does not replace individual medical advice.