Reproduced with permission from Grundy et al.S2.2-4 Copyright 2018, American Heart Association, Inc., and American College of Cardiology Foundation. CLINICAL STATEMENTS AND GUIDELINES been shown to be associated with the likelihood of benefit from statin therapy for ASCVD risk Coronary artery calcium scoring has superior discrimination and risk reclassification as compared with other subclinical imaging mark- ers or biomarkers.S2.2-22,S2.2-27 In the MESA (Multi- Ethnic Study of Atherosclerosis) trial, the coronary artery calcium score was strongly associated with 10-year ASCVD risk in a graded manner across age, sex, and racial/ethnic groups, independent of traditional risk factors.S2.2-17 Coronary artery cal- cium may even refine ASCVD risk estimates among younger adults (<45 years of age),S2.2-20 and older adults ( 75 years of age),S2.2-26 but more data are needed to support its use in these subgroups. A coronary artery calcium score of zero identifies indi- viduals at lower risk of ASCVD events and death who appear to derive little or no benefit from statins for ASCVD Thus, the absence of coronary artery calcium could reclassify a patient downward into a lower risk group in which preventive interven- tions (eg, statins) could be postponed.S2.2-22 Note that the absence of coronary artery calcium does not rule out noncalcified plaque, and clinical judg- ment about risk should prevail. Coronary artery cal- cium might also be considered in refining risk for selected low-risk adults (<5% 10-year risk), such as those with a strong family history of premature coronary heart disease (CHD).S2.2-23 and Astro-CHARM (Astronaut Cardiovascular Health and Risk Modification)S2.2-29 are risk estimation tools that incorporate both risk factors and coronary artery calcium for estimating 10-year CHD and ASCVD risk, respectively. 