Serial Coronary Artery Calcium Progression and Risk of Major Adverse Cardiovascular Events in an Asian Cohort

Background: The prognostic value of serial coronary artery calcium (CAC) progression remains uncertain in Asian populations, particularly among patients receiving statin therapy. We evaluated whether CAC progression predicts major adverse cardiovascular events (MACE) in a Taiwanese cohort and whether this association differs by statin use. Methods: We retrospectively studied 1,942 individuals who underwent two cardiac computed tomography scans for CAC scoring at a tertiary medical center in Taiwan between 2006 and 2021. CAC progression was defined as an annualized Agatston score increase of ≥20 units/year. The primary outcome was MACE, defined as acute myocardial infarction, stroke, or cardiovascular death. Predictors of CAC progression were assessed using logistic regression. Associations between CAC progression and MACE were evaluated using Cox models with propensity score–based inverse probability weighting; 1,621 participants with complete covariate data were included in weighted analyses. Results: CAC progression occurred in 397 participants (20.4%). Independent predictors included male sex, hypertension, fasting glucose, lipid parameters, and baseline CAC score. CAC progression was associated with a higher risk of MACE, with increasing event rates across higher categories of annualized CAC change (p for trend < 0.0001). This association was consistent across clinical subgroups and was observed in both statin and non-statin users, without a significant CAC progression × statin interaction (p = 0.163). Conclusions: In this Asian serial CAC cohort, CAC progression was strongly associated with future MACE and may serve as a marker of residual cardiovascular risk, including among statin-treated patients. Serial CAC assessment may support dynamic risk stratification, but prospective studies are needed to determine whether progression-guided management improves outcomes.