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Coronary calcium scoring (CCS) is a simple, robust and powerful weapon for optimizing patient management that is still underused and poorly understood. Evidence shows that rather than identifying coronary stenosis and areas of ischemia, we should instead identify the patient at risk, using appropriate stratifying tools and treating high-risk patients accordingly while avoiding unnecessary medication in low-risk patients. But, somehow, the appeal of identifying the responsible plaque and the exact area of myocardial ischemia involved in symptoms seems to outweigh any evidence that science can produce. As cardiologists, we like to know the mechanisms involved and try to act on them. Despite evidence that it is not really necessary to know exactly where the stenosis is and that stenoses do not need to be treated in stable coronary patients, years of common practice and cardiology teaching make us keep trying to find an obstructed vessel and areas of ischemia to act on. We are, once more, forgetting that rather than treating the stenosis and myocardial ischemia, we should be treating the patient. And patients with no obstructive disease are sometimes at higher risk of a coronary event than others with identified obstructive coronary artery disease (CAD). This is why fundamental information concerning overall coronary atherosclerotic burden and CV risk is frequently overlooked by physicians in general and cardiologists in particular.

Prime time for coronary calcium scoring: It should come, but will it?