Coronary artery calcium (CAC) scanning is being increasingly used for cardiac risk assessment in asymptomatic patients, particularly in those with a Framingham 10-year risk of 10% to 20%. Physician awareness of this technology and its appropriate uses and limitations is crucial to appropriate use.

With the goal of establishing clinical paradigms, this document integrates the results of key published articles, Framingham Risk Score, National Cholesterol Education Program Adult Treatment Plan III guidelines, American College of Cardiology/American Heart Association exercise testing and angiographic guidelines, and the authors' extensive clinical experience.

Coronary artery calcium scanning is best used in the asymptomatic population with a 10% to 20% risk of cardiac events over 10 years, with selected application in higher and lower risk categories. In the 10%-20% risk patient, coronary artery calcium scores >100 or >75th percentile for age and sex transform the moderately high-risk patient to higher risk status with the attendant recommendation for more aggressive therapy; scores from 11 to 100 and <75th percentile are consistent with the 10%-20% 10-year risk status and scores from 0 to 10 and <75th percentile convert the patient to lesser risk categories. If stress testing is planned in the asymptomatic patient, it should be preceded by coronary artery calcium scanning and performed only for scores >400; it should always precede coronary angiography in these patients.

Coronary artery calcium scanning is an important risk assessment tool with direct clinical applications; it is of particular utility in the Framingham 10%-20% 10-year risk population.