Calcium Score (2025 Update): What You Need To Know and Why I No Longer Routinely Recommend
- Gregg M. Yamada, MD FACC
- Apr 30, 2023
- 5 min read
Updated: Oct 26
(Note: Understanding your heart condition is not difficult. Patients become frustrated and confused when doctors don’t explain things clearly. If you don’t understand what your doctor is talking about, then you won’t be able to ask meaningful questions. I hope that my posts provide you with a framework that you can build upon to become an active participant in your healthcare. )
New Interest in a (Very) Old Test
A calcium score or heart scan or CAC is not a new test. In fact, it’s a very old test that has been available since 1980.
In 2005 the calcium score was already outdated with the advances in cardiac CT angiography.
Around 30 years ago, when I started practicing in Hawaii, I recommended for asymptomatic patients or those who had a negative stress test but who had risk factors of HTN, hypercholesterolemia, diabetes, smoking, or family history of heart disease--to consider paying for a calcium score or heart scan--as a part of their preventive evaluation.
In those days, a calcium score (CAC) was considered a ‘rich and famous’ person’s test. For example, if you were the President of the US, had a private jet at the airport, the CEO of fortune 500 company, owned a bank or were a celebrity—you’d get a calcium score. Because the calcium score wasn’t covered by insurance, only the very wealthy would consider paying the ‘high’ $400 cost.
In the past decade and half, the somewhat antiquated calcium score fell out of the limelight and would cost around $50 dollars in most cities. In Hawaii, independent clinics and hospitals charge around $100-150 dollars.
Insurance carriers such as HMSA, locally, finally started paying for the calcium score a few years ago.
What is a Calcium Score?
I have previously discussed what a calcium score is and what role it plays in statin and aspirin use on other posts, so there’s no need to repeat that here. This is an excellent overview on the CAC from the Mayo Clinic.
There is also an excellent summary and video by a colleague of mine Dr. Matt Budoff (Chief of UCLA/Harbor) discussing the role of the calcium score and statin use/predicting future risk of cardiac events. (Click here). Dr. Budoff is the leading authority on calcium scoring and cardiac CT imaging.
Predicting Future Risk of a Heart Attack
The calcium score is only for patients without symptoms. The calcium score has no role if you have angina.
Be sure you understand the difference on how cardiologists evaluate symptomatic vs. asymptomatic patients.
Historically, in the asymptomatic patient, the CAC helps predicts future risk for a cardiac event (heart attack, stent, CABG, cardiac death). This is known as risk stratification.
I previously outlined the 6 tests that cardiologists use to evaluate for CAD in the symptomatic patient, so I won’t repeat that here. (Please refer to my post on ‘How Cardiologists Evaluate Chest Pain’). These same 6 tests are used in asymptomatic patients for stratification.
Calcium Score vs. Other Predictors of Cardiac Events: LDL Sub-fractionation or CIMT?
The calcium score is a most accurate method of determining if you have heart disease or not vs. CIMT or LDL subfractionation.
The calcium score is superior to blood tests such as LDL sub-fractionation and CIMT (carotid intimal medial thickness) studies.
Both LDL sub-fractionation (including CRP, lp(a), homocysteine and CIMT are routinely performed as a part of programs such as MDVIP, yet both are inferior to the calcium score and they often cost more.
For many, many decades doctors have been trying to find biological markers (biomarkers in the blood) that can predict which asymptomatic patient is going to have a heart attack.
In the future, tools such as genetic testing will be used for what is known as ‘personalized medicine’.
How the Calcium Score Integrates with Stress Testing
So let’s recap. For the asymptomatic patient with risk factors for CAD (HTN, hypercholesterolemia, smoking, family history, etc.); men over 45 and women over 50—the calcium score is used to further stratify risk for future cardiac events and determine appropriate physiologic (stress) testing including the necessity for statin/asa therapy.
If you have no CAD, calcium score is zero, then you don’t need statins, aspirin. If your stress test is negative you don’t even need a cardiologist.
If you have a small amount of CAD, a low CAC, statins and (possibly) aspirin are recommended, but there are options given your risk of cardiac complications are much lower. Annual follow ups and less frequent surveillance testing would be recommended.
If you have a high calcium score, then your treatments and evaluation are upscaled.
How Accurate (sensitive) is a Calcium Score and How Should It Be Utilized in 2025 and beyond?
My opinion*:
In my opinion, the calcium score is no longer an accurate test in detecting CAD in certain patients. Decades ago, the calcium score was highly sensitive. If a patient was in their mid 60s or greater and had a low calcium score, the likelihood of a future cardiac event was low.
In recent years, I have observed many patients who have low calcium scores, but still require stents or have high grade blockages (stenosis). Whether this is due to the testing protocol or the lowering of cholesterol levels with medications is uncertain. Regardless, a screening test which fails to detect the condition being screened, should not be relied upon in isolation.
For my patients, I will explain how I utilize calcium score results. Why I favor CCTA.
What are the Limitations of a Calcium Score?
In addition to my Winter 2025 update (above), here are general limitations for the calcium score.
A calcium score is only a screening tool. It should not be used for symptomatic patients. If you have symptoms you either need a stress test, CCTA or cardiac catheterization. There is no role for a CAC in the ER, for example.
If you are younger in age, you may not have developed calcified plaques. If so, even a calcium score of 0 may be misleading giving you a false sense of security. That is why I typically favor calcium scoring to be performed in ‘older’ individuals. See above
A CAC is not a stand-alone test for most people.
Stay Healthy!
Gregg M. Yamada MD FACC
Disclaimer: I hope you find my medical blogs to be educational, pertinent, interesting, and thought provoking. The information provided is educational and should not be taken as medical advice. I am a doctor, but I am not your doctor. Please schedule an appointment with your doctor to discuss these issues and to determine what is right for you.
© 2025. Gregg M. Yamada, MD FACC. All rights reserved
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