Within the management of patients with known or suspected coronary artery disease (CAD), non-invasive coronary atherosclerosis imaging techniques are gradually gaining their position in addition to the more traditional functional imaging techniques. Coronary artery calcium scoring (CACS) in particular has been studied for almost two decades, initially by means of electron beam computed tomography (EBCT) while since more recently multi-detector row computed tomography (MDCT) is being used. Although CACS was heavily disputed at first, a wealth of data is currently available supporting its value as a non-invasive marker for atherosclerosis. Both prospective studies as well as retrospective systematic meta-analyses have demonstrated that the likelihood of cardiovascular events is strongly related to the extent of coronary calcium. Recent long-term observations from a large registry of 25,253 patients confirmed that 10-year survival (after adjustment for risk factors, including age) decreased from 99.4% in the absence of calcium to 87.8% for a CACS of exceeding 1,000 (p < 0.0001) . Moreover, it has been consistently shown that CACS provides incremental prognostic information over traditional risk stratification tools [2;3]. Accordingly, these observations have led to the notion that the patient with (extensive) calcium is a patient at risk requiring more intensive anti-atherosclerotic management with possible invasive evaluation and intervention. On the other hand, the low events rates observed in patients without evidence of calcium may suggest a relatively low risk of cardiovascular events and may obviate the need for aggressive therapeutic intervention. Indeed, in patients with no or limited calcium, risk factor modification may be sufficient and no further testing is required. Following these observations, CACS has been proposed to serve not only as a tool for risk stratification but also as a diagnostic tool. In patients presenting with suspected CAD, absence of calcium may exclude the presence of obstructive CAD and thus serve as a gatekeeper prior to further testing .
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