Prognostic value of coronary artery calcium score in symptomatic individuals: A meta-analysis of 34,000 subjects

Int J Cardiol. 2020 Jan 15;299:56-62. doi: 10.1016/j.ijcard.2019.06.003. Epub 2019 Jun 4.


Background: Coronary artery calcium (CAC) scanning has evolved into an important subclinical prediction method for cardiovascular diseases in asymptomatic subjects. However, the prognostic implication of CAC scanning in symptomatic individuals is less clear.

Objectives: To assess the prognostic utility of CAC in predicting risk of major adverse cardiac events (MACE) in stable patients with suspected CAD.

Methods: We did a systematic electronic literature search for studies presenting original data in CAC score, and reporting cardiovascular events in stable, symptomatic patients as primary outcome. Primary outcome of the meta-analysis was the occurrence of MACE, a composite of late coronary revascularization, hospitalization for unstable angina or heart failure, nonfatal myocardial infarction, and cardiac death or all-cause mortality. Using random effects models, we pooled relative risk ratios of CAC for MACE, and adjusted hazard ratios (HR) of the associations between different CAC strata (CAC 0-100,100-400, and ≥ 400, versus CAC = 0) and incident MACE.

Results: We included 19 observational studies (n = 34,041). In total, 1601 events were analyzed, of which 158 in patients with CAC = 0. The pooled relative risk ratio was 5.71 (95%-CI: 3.98;8.19) for subjects with CAC > 0. The pooled estimate of adjusted HRs demonstrated increasing, positive associations, with the strongest association for CAC > 400 (HR: 4.88; 95%-CI: 2.44;9.27).

Conclusions: This meta-analysis demonstrated that increased levels of CAC are strongly and independently associated with increased risk for MACE in stable, symptomatic patients with suspected CAD, showing increasing risk with greater CAC scores. Application of CAC scanning as a prediction method could be useful for a considerable number of such patients.

Keywords: Cardiovascular events; Computed tomography; Coronary artery calcium; Coronary artery disease; Prognosis.

Publication types

  • Meta-Analysis
  • Systematic Review

MeSH terms

  • Calcium / blood*
  • Coronary Angiography / methods
  • Coronary Vessels / diagnostic imaging*
  • Humans
  • Observational Studies as Topic / methods*
  • Prognosis
  • Tomography, X-Ray Computed / methods
  • Vascular Calcification / blood*
  • Vascular Calcification / diagnostic imaging*


  • Calcium