Coronary artery disease (CAD) remains a leading cause of disability and death worldwide. Noninvasive tests are crucial to ensure early diagnosis and risk stratification. The coronary artery calcium scoring (CACS), a non-invasive measure obtained using non-contrast computed tomography, reflects the calcific plaque burden, and may provide important diagnostic and prognostic information. This study aimed to systematically review and meta-analyze the recent literature to ascertain the diagnostic and prognostic usefulness of CACS in patients with suspected or established CAD. A literature search was conducted in PubMed, Scopus, and Web of Science for studies published between 2008 and 2024. The studies were included if they evaluated the prognostic and diagnostic value of CACS, either alone or with computed tomography angiography (CTA). Data extraction was performed for pooled sensitivities and specificities, hazard ratios (HRs), and event-free survival. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) criteria were used to assess methodological quality. Fourteen high-quality studies with a total of more than 80,000 patients were meta-analyzed. Subjects with CAC ≥ 100 were at a significantly increased risk of developing major adverse cardiac events (HR 2.7; 95% confidence interval: 2.1-3.6). CACS is highly beneficial in diagnostic discrimination (pooled sensitivity 88%, specificity 77%) in those presenting with chest pain but no prior history of CAD. It is essential to emphasize that CAC score of zero correlates with the best prognosis and very low rates of clinical events across various populations, including patients with diabetes and asymptomatic individuals. The CACS fills a special niche as a very strong predictor and non-invasive marker in the diagnosis and prognosis of CAD. Combining calcium scoring with CTA benefits clinical decision-making, particularly for patients categorized as low to intermediate risk.
Keywords: cardiovascular risk assessment; computed tomography angiography; coronary artery disease; coronary calcium scoring; meta-analysis.
© Pol J Radiol 2026.