HoldsUp

Abuzaid · Coronary artery disease 2021 · systematic review and meta-analysis of cohort studies · n=45 studies (224,557 participants)

Coronary artery calcium score and risk of cardiovascular events without established coronary artery disease: a systemic review and meta-analysis.

Cited 37 times in the scientific literature.

Level 1 - systematic review of randomized trials

Systematic review and meta-analysis of cohort studies

PubMed 33417339 · doi:10.1097/MCA.0000000000000974 · record verified 2026-08-29

What was done

A systematic review and meta-analysis of electronic databases was conducted through January 2018 to evaluate cardiovascular outcomes in patients without established coronary artery disease. Cohort studies comparing individuals with coronary artery calcium (CAC) > 0 versus CAC = 0 across asymptomatic and symptomatic populations were included.

What was found

Forty-five studies were included with 192,080 asymptomatic and 32,477 symptomatic patients at a mean follow-up of 11 years. CAC > 0 compared with CAC = 0 was associated with an increased risk of major adverse cardiovascular and cerebrovascular events (MACE) in the asymptomatic arm (pooled RR 4.05, 95% CI 2.91-5.63, P < 0.00001, I2 = 80%) and in the symptomatic arm (pooled RR 6.06, 95% CI 4.23-8.68, P < 0.00001, I2 = 69%), with a gender subgroup analysis in asymptomatic patients showing higher MACE (RR 6.39, 95% CI 3.39-12.84, P < 0.00001). CAC > 0 was also associated with increased all-cause mortality in asymptomatic patients (pooled RR 3.23, 95% CI 2.12-4.93, P < 0.00001, I2 = 94%) and symptomatic patients (pooled RR 7.94, 95% CI 2.61-24.17, P < 0.00001, I2 = 85%). Revascularization was higher with CAC > 0 in asymptomatic patients (pooled RR 5.34, 95% CI 2.06-13.85, P = 0.0006, I2 = 93) and symptomatic patients (pooled RR 15, 95% CI 6.66-33.80, P < 0.00001, I2 = 72).

Why it matters

This review establishes that the absence of coronary artery calcium (CAC = 0) is consistently associated with low cardiovascular risk and mortality over long-term follow-up in individuals without known coronary disease.

Limits

All included evidence comes from observational cohort studies rather than randomized designs. Statistical heterogeneity was very high across all primary outcomes, with I2 values ranging from 69% to 94%. The binary comparison (CAC > 0 vs CAC = 0) does not distinguish between mild, moderate, and severe calcium score burdens. The database search concluded in January 2018.

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