Among asymptomatic middle-aged to older adults, one of the most sensitive, reliable, and reproducible ways of noninvasively identifying subclinical atherosclerosis is coronary artery calcium (CAC) testing. Numerous studies have demonstrated the robust association between presence and severity of CAC and future risk of cardiovascular disease (CVD).^1,2 Conversely, the absence of CAC has been associated with low rates of CVD.^3,4 Based on the available evidence of the role of CAC in improving the estimation of CVD risk, multisociety practice guidelines from the United States, Europe, and others endorse the selective use of CAC in adults aged 40 to 75 years with borderline or intermediate estimated 10-year atherosclerotic CVD risk to guide the intensification of preventive strategies (eg, lipid-lowering therapy).^5,6 When CAC is absent, current American Heart Association/American College of Cardiology guidelines recommend that clinicians consider providing no statin to some patients who are not at an elevated risk on the basis of smoking status, family history, and diabetes. Beyond this recommendation, however, some investigators have called for even more aggressive de-risking of patients with a CAC score of 0, suggesting that even those with familial hypercholesterolemia and a CAC score of 0 may not need statins.⁷ The article by Mortensen et al⁸ in this issue of JAMA Cardiology should give pause to efforts to broaden the use of a CAC score of 0 to de-escalate or defer statin therapy in all individuals.

在无症状的中老年人中，无创识别亚临床动脉粥样硬化最敏感、最可靠和可重复的方法之一是冠状动脉钙 (CAC) 检测。大量研究表明，CAC 的存在和严重程度与心血管疾病 (CVD) 的未来风险之间存在密切关联。^{1 ,2}相反，缺乏 CAC 与低 CVD 发生率相关。^{3 ,4}基于 CAC 在改进 CVD 风险估计中作用的现有证据，来自美国、欧洲和其他国家的多社会实践指南支持在 40 至 75 岁的边缘或中间估计 10-年动脉粥样硬化 CVD 风险，以指导强化预防策略（例如，降脂治疗）。^{5 ,6}当没有 CAC 时，当前的美国心脏协会/美国心脏病学会指南建议临床医生考虑不向某些基于吸烟状况、家族史和糖尿病风险不高的患者提供他汀类药物。然而，除了这一建议之外，一些研究人员呼吁对 CAC 评分为 0 的患者进行更积极的降低风险，这表明即使是患有家族性高胆固醇血症和 CAC 评分为 0 的患者也可能不需要他汀类药物。⁷ Mortensen 等人⁸在本期JAMA Cardiology上发表的文章应该暂停扩大使用 0 分的 CAC 评分来降低或推迟他汀类药物治疗的努力。