Calcium-free hearts can still be at risk: LDL history matters
A zero coronary calcium score often signals low short-term risk, but in a CARDIA analysis of young-to-middle-aged adults, higher cumulative LDL-C exposure over the prior 25 years predicted more cardiovascular events even when CAC was zero. At age ~50, those in the highest LDL-C exposure quartile had about a 3.36-fold higher adjusted risk than the lowest, though absolute event rates remained modest (roughly 3.9% vs 1.3% over about a decade). This means zero CAC is reassuring but must be interpreted in the context of age, sex, family history, and lifelong LDL exposure.
