Why a “Zero Calcium Score” Doesn’t Mean Zero Heart Risk – Especially if Your LDL is High

For years, many people (and even some doctors) have looked at a coronary artery calcium score (CAC) of zero as a “free pass” against heart disease. After all, no calcifications mean no blocked arteries, right?

Not so fast.

A new study from the Western Denmark Heart Registry (published in European Heart Journal, Aug 2025) shows that LDL cholesterol—the “bad cholesterol”—still matters a lot, even when CAC = 0.

Here’s what they found after following 23,777 people with CAC = 0 for more than 7 years:

• 11% already had non-calcified plaque (the soft, early-stage buildup doctors worry about).
• For every 1 mmol/L increase in LDL, risk of non-calcified plaque went up by 21%.
• Younger people were hit hardest: at age ≤45, higher LDL was linked to a 39% higher risk of hidden plaque.
• Over time, 299 participants (1%) had a coronary heart disease event (like a heart attack). Again, higher LDL = higher risk across all ages, but especially in younger adults.

Key takeaway: A “zero calcium score” does not mean you’re in the clear—especially if your LDL cholesterol is high. Younger people with high LDL are particularly at risk because plaque often starts out soft (non-calcified) before it hardens and shows up on scans.

What this means for you

• Don’t ignore high LDL cholesterol just because your CAC score is zero.
• Lifestyle changes (diet, exercise, quitting smoking) and sometimes medication are still crucial for long-term heart health.
• The earlier you act, the better your odds of avoiding plaque buildup and heart disease later.

Bottom line: Think of a zero CAC score as a “clean snapshot” today—not a lifetime guarantee. Your LDL cholesterol tells the real story about future risk.

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Reference

Andersen MH, Jensen JM, Kanstrup H, Sand NPR, Busk M, Hansen MK, Thrane PG, Olesen KKW, Nordestgaard BG, Blaha MJ, Maeng M, Nørgaard BL, Mortensen MB. Low-density lipoprotein cholesterol and cardiovascular risk in the absence of calcifications on computed tomography: the Western Denmark Heart Registry. Eur Heart J. 2025 Aug 9:ehaf497. doi: 10.1093/eurheartj/ehaf497. Epub ahead of print. PMID: 40795407.