Beyond Atherosclerosis: Coronary Calcium Scoring in Dyslipidemia, CKM Syndrome

Coronary calcium (CAC) scoring has experienced a resurgence after the official classification of cardio-kidney-metabolic (CKM) syndrome, with new guidelines supporting its use in dyslipidemia.¹

In a presentation at the American Society for Preventive Cardiology (ASPC) 2026 Virtual Imaging Symposium, Parag Joshi, MD, assistant professor of medicine at UT Southwestern Medical Center and adjunct assistant professor of medicine at Johns Hopkins School of Medicine, discusses the inherent value of CAC scoring in disease states beyond atherosclerotic cardiovascular disease (ASCVD).¹

“Plaque can form regardless of your cholesterol numbers for the most part; what is normal for a given individual may be very different than what is sort of low for a population,” Joshi told HCPLive in an exclusive interview. “What we think of as normal cholesterol may still be enough to develop significant amounts of plaque. While it’s more likely that people with higher cholesterol will develop plaque, and people with lower cholesterol will be somewhat protected from that, it’s not 100%.”

About CAC Scoring

CAC scoring is among the most thoroughly studied and widely available tests in cardiology. The process involves a computerized tomography (CT) scan of the heart, examining patients for calcium deposits in the arteries. Modern scans take roughly 10-15 minutes and roughly 1 mSy of radiation without the need for contrast agents.²

Current Guidelines for CAC

The 2026 Guideline on the Management of Dyslipidemia, released by the American College of Cardiology (ACC) and American Heart Association (AHA) Joint Committee on March 13, 2026, notes that CAC testing can potentially identify patients without CAC who are less likely to benefit from statin therapy for ASCVD, as well as identify those who are at risk without known ASCVD.³

The guideline also heavily emphasizes the value of CAC beyond solely atherosclerosis. The document recommends CAC scoring in men ≥40 years and women ≥45 years to provide guidance for LDL-C and non-HDL-C goals. Moreover, in patients resistant to implementing or reinitiating further lipid-lowering therapy or statins, CAC scoring is suggested as an option to support the need, or lack thereof, for further medication.³

Joshi also addresses the potential risks of CT scanning for CAC, particularly the need for radiation exposure. He posits that the impact of the radiation is not yet fully understood and that only time will tell if the value is worth the risk. Additionally, he mentions ongoing investigations into further advancements in CT scanning to optimize CAC while minimizing radiation exposure.

“Are the trade-offs worth it? What I mean is, is radiation exposure worth getting the more advanced test over just a simpler test like a calcium score?” Joshi said. “I think time will tell what the answer to that will be. There are companies that have platforms for AI evaluation of CT angiogram-based plaque, and some of those companies are doing trials to see how that will impact outcomes compared to usual care and repeating a CT angiogram to see how plaque progresses on a certain treatment regimen.”

Editors’ Note: Joshi reports disclosures with Novo Nordisk, Amgen, Kaneka, Novartis, and Eli Lilly.

References

1. Joshi P. CAC in Cardiometabolic Risk: Diabetes, CKD, Women, and “The Paradox of Normal LDL-C”. Presented at the American Society for Preventive Cardiology (ASPC) 2026 Virtual Imaging Symposium. April 25, 2026.

2. Greenland P, Blaha MJ, Budoff MJ, Erbel R, Watson KE. Coronary Calcium Score and Cardiovascular Risk. J Am Coll Cardiol. 2018;72(4):434-447. doi:10.1016/j.jacc.2018.05.027

3. Blumenthal RS, Morris PB, Gaudino M, et al. 2026 ACC/AHA/AACVPR/ABC/ACPM/ADA/AGS/APHA/ASPC/NLA/PCNA guideline on the management of dyslipidemia: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation. 2026;153(17). doi:10.1161/cir.0000000000001423