Role of Coronary Artery Calcium Scoring in Asymptomatic Diabetes: A Step Towards Primary Prevention

Background: Asymptomatic individuals with type 2 diabetes mellitus (T2DM) face a significantly elevated risk of atherosclerotic cardiovascular disease (ASCVD), often underestimated by traditional risk calculators. Coronary artery calcium scoring (CACS) is a noninvasive imaging method for quantifying subclinical atherosclerosis and enhancing cardiovascular risk stratification. Objective: To evaluate the utility of CACS in asymptomatic T2DM patients in Pakistan and review recent literature on its prognostic role in this population. Methods: This multicenter study is designed with a mixed-method approach , combining cross-sectional data collection at baseline and prospective follow-up over a 24-month period,600 asymptomatic T2DM patients aged 40–75 were enrolled from two tertiary hospitals in Lahore and Karachi. Participants underwent coronary computed tomography for CACS calculation using the Agatston method. Patients were stratified into four categories: 0, 1–100, 101–400, and >400. Clinical and biochemical data were collected, and multivariable logistic regression was used to identify predictors of high CACS (≥100). Major adverse cardiovascular events (MACE)—including myocardial infarction, revascularization, and death—were tracked over 24 months. Results: The mean age was 57.0 ± 5.5 years; 58% were male. Prevalence of hypertension, dyslipidemia, and smoking was 62%, 55%, and 24%, respectively. CACS was 0 in 40%, 1–100 in 35%, 101–400 in 15%, and >400 in 10% of patients. Higher CACS was associated with older age, higher BMI, elevated LDL cholesterol, and longer diabetes duration. No MACE occurred in the CACS 0 group, while 20 events occurred in higher strata. Age, systolic blood pressure, LDL cholesterol, and diabetes duration independently predicted high CACS and MACE. Conclusions: CACS effectively identified subclinical atherosclerosis and predicted future cardiovascular events in asymptomatic T2DM patients. Incorporating CACS into routine assessment could guide preventive therapy in high-risk diabetic populations.