EP 161: Calcium Score vs CCTA: Rethinking Primary Prevention Screening

About this episode

In this episode of Parallax, Dr Ankur Kalra is joined by Dr Matthew Budoff, Professor of Medicine at the David Geffen School of Medicine at UCLA and a leading authority on preventive cardiology and cardiac imaging. Together they examine the role of cardiac CT in detecting silent atherosclerosis, and ask whether imaging should displace traditional risk scores in routine practice. Dr Budoff makes the case for the coronary calcium score as the foundation of personalised cardiovascular care, arguing that population-based risk factors often fail at the individual level. He weighs the calcium score against CT angiography in primary prevention - covering cost, radiation, the uncertain significance of trivial plaque, and the risk of inappropriate stenting in asymptomatic patients - while noting that symptomatic patients warrant CCTA first-line. He also addresses elevated Lp(a) with a zero score and the case for CCTA in younger high-risk patients, before outlining his scalable, score-tiered approach to therapy, drawing on data from the VESALIUS trial. Is the calcium score ready to replace traditional risk scores? When should imaging guide therapy, and when should it be deferred? Question