Distribution of CAC by Age-Sex-Race Among Patients Aged 30-45 Years

Quick Takes

  • Among the convincing support for CAC has been the utility of CAC = 0 and that CAC score provides better discrimination than age for incident ASCVD over long-term follow-up.
  • These findings are not applicable in young high-risk persons for whom age is not a good predictor of soft plaque for which treatment of lipids reduces progression and often regression.
  • An interactive webpage allows one to enter an age, sex, race, and CAC score to obtain the corresponding estimated percentile. I would be concerned that a CAC = 0 would suggest to the patient and provider that the risk factors do not need to be treated.

Study Questions:

Use of the coronary artery calcium score (CAC) to assist in risk stratification of asymptomatic men and women is effective but limited to ages 45-84 years. What is the probability of CAC >0, and what are the age-sex-race percentiles for US adults aged 30-45 years?


The authors harmonized three datasets—CARDIA (Coronary Artery Risk Development in Young Adults), the CAC Consortium (multicenter cohort physician referred for risk stratification), and the WRC (Walter Reed Cohort; armed forces)—to study CAC in 19,725 asymptomatic Black and White individuals aged 30-45 years without known atherosclerotic cardiovascular disease (ASCVD). After weighting each cohort equally, the probability of CAC >0 and age-sex-race percentiles of CAC distributions were estimated using nonparametric techniques.


Mean age was 41 (3.3) years, 27% were women, 17% were Black, and 45% were in the WRC. CV risk factors included hyperlipidemia in 41%, hypertension in 17%, smokers 10%, and diabetes 3%. The prevalence of CAC >0 was 26% among White males, 16% among Black males, 10% among White females, and 7% among Black females. CAC >0 automatically placed all females at the >90th percentile. In White males aged 36 years, 15% had a CAC >0. An observed CAC of 8 is at the 91st percentile for individuals of the same age, sex, and race who are free of clinical ASCVD.


In a large cohort of US adults aged 30-45 years without symptomatic ASCVD, the probability of CAC >0 varied by age, sex, and race. Estimated percentiles may help interpretation of CAC scores among young adults relative to their age-sex-race matched peers and can henceforth be included in CAC score reporting.


The CAC score has become an important tool for helping both the patient and physician decision regarding treatment and intensity. Among the convincing data has been the utility of CAC = 0 and that CAC score provides better discrimination than age for incident ASCVD over long-term follow-up. The three study cohorts were convenient but very much unrelated, and despite the ‘equal weighting to one third each’ may have introduced bias and thus not be readily generalizable; in particular, the 40% prevalence of hyperlipidemia, which is much higher than the US population of 30-45 years. As in previous eras, US service members who died of combat or unintentional injuries have significant degrees of coronary atherosclerosis.

Comparing coronary atherosclerosis prevalence among those with no CV risk factors (11%), there was a significantly greater prevalence of those with dyslipidemia (50%), hypertension (43.6%), obesity (22%), and smoking (14%). Of the risk factors, each was associated with a significant age-adjusted prevalence ratio, except for smoking (Webber BJ, et al., JAMA 2012;308:2577-83). A recent review concluded that identifying high-risk features that predict early-onset ASCVD among young adults (ages 20-39 years) can assist providers and their patients in modifying ASCVD risk factors earlier (Stone NJ, et al., J Am Coll Cardiol 2022;79:819-36).

Clinical Topics: Cardiovascular Care Team, Congenital Heart Disease and Pediatric Cardiology, Diabetes and Cardiometabolic Disease, Dyslipidemia, Noninvasive Imaging, Prevention, Atherosclerotic Disease (CAD/PAD), CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, CHD and Pediatrics and Prevention, CHD and Pediatrics and Quality Improvement, Computed Tomography, Nuclear Imaging, Hypertension

Keywords: Atherosclerosis, Coronary Artery Disease, Diabetes Mellitus, Dyslipidemias, Hyperlipidemias, Hypertension, Middle Aged, Obesity, Plaque, Atherosclerotic, Primary Prevention, Risk Assessment, Risk Factors, Smokers, Tomography, X-Ray Computed, Vascular Calcification, Young Adult

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