Coronary Calcium Is Changing the Rules of Lipid Management: Treat the Plaque, Not Just the Risk Score! Article: Imaging Guided Treatment of Subclinical Atherosclerosis—We've Come a Long Way! Authors: Eugenia Gianos, MD, and Ron Blankstein, MD. Journal: Journal of Clinical Lipidology, 2026;20:11–14. 12 Clinically Important Pearls 1\. Risk scores alone are no longer the whole story. The 2026 ACC/AHA dyslipidemia guideline integrates PREVENT-ASCVD risk estimation, risk enhancers and selective coronary artery calcium (CAC) imaging to personalize lipid-lowering therapy. 2\. CAC scoring receives a Class I recommendation. In men aged ≥40 years and women aged ≥45 years with 10-year PREVENT-ASCVD risk of 3% to less than 10%, CAC scoring is recommended when the decision regarding lipid-lowering therapy remains uncertain. 3\. CAC = 0 does not mean zero risk. Statin deferral may be considered in selected individuals, but should not be automatic in patients with diabetes, familial hypercholesterolemia, active smoking or a strong family history of premature ASCVD. 4\. CAC 1–99: Consider moderate-intensity statin therapy, particularly when CAC is ≥75th percentile. The suggested LDL-C goal is below 100 mg/dL. 5\. CAC 100–299: Initiate LDL-C-lowering therapy, targeting LDL-C below 70 mg/dL. 6\. CAC 300–999: Target LDL-C below 70 mg/dL. A more intensive LDL-C goal below 55 mg/dL may be considered, particularly in selected high-risk patients. 7\. CAC ≥1000: Extensive coronary atherosclerosis warrants intensive lipid lowering, targeting LDL-C below 55 mg/dL, with an optional ApoB goal below 55 mg/dL. 8\. CAC may underestimate plaque burden. Patients with diabetes, HIV, inflammatory disorders or markedly elevated Lp(a) may have substantial noncalcified coronary plaque. Selective coronary CT angiography carries a Class IIb recommendation. 9\. Never ignore incidental CAC on chest CT. Coronary calcification detected during CT examinations for noncardiac indications provides valuable cardiovascular risk information. Moderate-to-severe incidental CAC supports considering moderate- to high-intensity statin therapy with an LDL-C goal below 70 mg/dL. 10\. The VESALIUS-CV trial strengthens primary prevention in selected high-risk patients. Evolocumab demonstrated cardiovascular benefit in patients with high-risk diabetes or atherosclerosis without previous myocardial infarction or stroke. 11\. Lower for longer is becoming increasingly important. Earlier and sustained reduction in LDL-C may reduce cumulative exposure to atherogenic lipoproteins and potentially prevent the development or progression of subclinical atherosclerosis. 12\. CAC is a decision-making tool, not a universal screening test. Patients who already have a clear indication for lipid-lowering treatment should not have therapy delayed merely to obtain a CAC score. CME INDIA – Take-Home Message The absence of cardiovascular symptoms does not imply the absence of coronary atherosclerosis. The emerging approach is to combine clinical risk estimation with selective plaque imaging, identify subclinical disease earlier and match LDL-C targets to atherosclerotic burden. Remember: CAC = 0 is not a lifetime guarantee of cardiovascular protection, while CAC ≥300 identifies substantial subclinical coronary disease that deserves serious consideration of intensive lipid lowering. doi.org/10.1016/j.jacl.2026.… CME INDIA – Learning Today, Improving Patient Care Tomorrow.