A study comparing statin initiation based on coronary artery calcium (CAC) scores versus traditional risk factors found no difference in major cardiovascular events, according to results from the CorCal Outcomes trial presented at the 2026 ESC Congress.
The CorCal Outcomes trial, led by Dr. Joseph B Muhlestein of Intermountain Medical Center, evaluated whether using CAC scores to guide statin therapy for atherosclerotic cardiovascular disease (ASCVD) prevention was as effective as traditional risk factor-based approaches. The study followed 5,772 patients over 4.2 years, with no significant difference in major cardiovascular events (MACE) between those randomized to CAC-based or pooled cohort equation (PCE)-based statin initiation.
The trial compared two methods for selecting patients for statin therapy: CAC scoring via CT scans and PCE risk assessments. Participants were split evenly into groups, with physicians receiving protocol-directed recommendations on statin initiation. While patients randomized to the PCE group received a recommendation to initiate statins more than three times as frequently as those in the CAC group, the primary endpoint—MACE, including all-cause mortality, myocardial infarction, stroke, and arterial revascularisation—occurred in 2.7% of patients in both groups. The noninferiority criterion was not met (hazard ratio 0.99; 95% confidence interval 0.71 to 1.38; p=0.045 for noninferiority).
CAC-based statin initiation shows no difference in major cardiovascular
Patients without known ASCVD, diabetes, or prior statin therapy who were registered with the Canyons and Desert regions of Intermountain Health Care, USA, were invited to participate. Eligible patients were randomized (1:1) to receive guidance on statin initiation based on either their PCE risk score or their CAC score. The participants and their physicians received a protocol-directed recommendation on whether to initiate statin therapy based on the results and made the final treatment decisions. Dr. Muhlestein noted that the study’s power to detect a difference was reduced by the lower-than-expected event rates. The study did provide important hypothesis-generating insights into the efficiency of statin initiation and adherence when decisions are based on CAC scoring, he said. The findings suggest that while patients who were recommended a statin based on their CAC score were much more adherent with their medication than those in the PCE group (62% vs. 23%), the study did not demonstrate noninferiority between the groups.
CAC scoring has broader implications for cardiovascular risk assessment.
CAC testing is also gaining traction in cancer care. A pilot study on cardio-oncology intervention found that 40% of low-ASCVD-risk patients had detectable CAC, underscoring the need for comprehensive risk assessment. Baseline CAC on RT planning CT scans has been associated with increased risk of major cardiac events in patients with breast and lung cancer, the study reported. Approximately 50% of patients without known ASCVD had CAC > 0 in this cohort, consistent with data supporting shared risk factors and epidemiology for CVD and cancer.
Early cardio-oncology intervention in thoracic radiotherapy
Additional data from Source 2 includes prevalence statistics: in a study of U.S. adults aged 30–45 years, prevalence of CAC > 0 was 26% among White males, 16% among Black males, 10% among White females, and 7% among Black females. The 2018 American Heart Association (AHA) guidelines recommend CAC screening for individuals with certain risk-enhancing factors, and the Canadian Cardiovascular Society (CCS) reports that CAC screening can be considered for low-risk individuals >40 years of age with a family history of premature ASCVD and genetic risk-enhancing factors (i.e., familial hypercholesterolemia or elevated lipoprotein[a], as these patients may have more than a 40% rate of CAC > 0).
The CorCal Outcomes trial’s findings call for further research to refine CAC’s role in cardiovascular prevention. Our data could be used to plan an additional well-powered randomized trial comparing CAC with current risk factor-based algorithms, Muhlestein said. Meanwhile, the 2025 ESC/EAS Guidelines now recommend considering CAC scores as a risk modifier for moderate-risk individuals.
The study underscores the importance of ongoing research to determine optimal strategies for integrating CAC scoring into clinical practice.
