Darío Gómez-Díaz, Pablo Díez‐Villanueva, Beatriz López‐Melgar, Luis Egido Flores, Gianluca de Toffol, Agustín Ramos, Álvaro Montes, Alberto Cecconi, Luis Jesús Jiménez‐Borreguero, Fernándo Alfonso
BACKGROUND: The evaluation of coronary artery disease has undergone significant transformation in recent years, with increasing emphasis on the detection and characterization of subclinical atherosclerotic plaques in order to improve cardiovascular prevention. In this context, coronary computed tomography (CT) has emerged as a promising tool. Coronary artery calcium scoring (CACS) is a powerful predictor of cardiovascular events. METHODS: A narrative review on the role of CACS in risk stratification of asymptomatic adults is conducted through a structured search in PubMed (2010-2025), including guidelines, consensus documents, observational studies, and clinical trials published in English. RESULTS: CACS reliably identifies subclinical atherosclerosis and stratifies cardiovascular risk in asymptomatic individuals. Large studies, including the Multi-Ethnic Study of Atherosclerosis (MESA), demonstrate that CACS predicts 10-year cardiovascular events, improves risk reclassification beyond traditional scores, and identifies very low-risk individuals (those with a CAC of 0). Moreover, CACS retains prognostic value across age, sex, and ethnic subgroups; supports decision-making for lipid-lowering therapy and aspirin use; and correlates with non-gated CT assessments. Progression of CAC further informs risk, although its interpretation is influenced by preventive therapies and is complemented by more comprehensive plaque imaging. CONCLUSIONS: CACS is a validated tool for detecting subclinical atherosclerosis and refining cardiovascular risk in asymptomatic individuals. CACS thus complements traditional risk scores and represents a key component of contemporary and future cardiovascular prevention in clinical practice.