Why a zero calcium score may not mean you’re protected from a heart attack

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4 min readNew DelhiJun 4, 2026 09:28 AM IST

Heart health assessments often rely on tests that estimate a person’s future risk, and one tool increasingly discussed in preventive cardiology is the coronary artery calcium score. Recently, cardiologist Dr Dmitry Yaranov explained that while a calcium score can be useful, it does not tell the entire story about the health of the coronary arteries.

He noted that a calcium score measures calcified plaque and is primarily a risk-assessment tool rather than a complete evaluation of plaque. A calcium score of zero may indicate lower short-term risk of heart attack, a lower likelihood of significant calcified plaque, and a reassuring prognosis, particularly in low-risk individuals, but it does not necessarily mean there is no plaque at all.

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Dr Yaranov also highlighted that certain types of plaque — including soft plaque, inflamed plaque, non-calcified plaque, and unstable plaque — may not be detected by calcium scoring despite still carrying risks. He cautioned that “Some patients develop dangerous plaques before calcium develops.” According to him, higher-risk groups may include younger individuals, smokers, diabetics, people with a strong family history, those with inflammatory diseases, and patients experiencing symptoms. Discussing different imaging approaches, he added that “Calcium scoring is great for prevention and risk refinement,” while “CTA is better when symptoms, higher suspicion, or anatomy matter.”

What exactly does a calcium score tell us?

Dr CM Nagesh, Founder of Cardea Super Speciality Hospital, tells indianexpress.com, “A calcium score of zero is certainly reassuring, but it should not be interpreted as complete protection against a heart attack. The test only measures calcified plaque in the coronary arteries and does not capture every form of arterial disease. One of the biggest misconceptions is that a zero score means there is absolutely no plaque or cardiovascular risk, which is not always true. Younger individuals, smokers, diabetics, or those with a strong family history may still develop non-calcified plaque that remains undetected on calcium scoring. The result must always be interpreted alongside overall clinical risk factors and lifestyle patterns.

Soft or non-calcified plaque: Why these can still be concerning

Soft or non-calcified plaques are clinically significant because they are often more unstable and prone to rupture. When such plaques rupture, Dr Nagesh notes, they can trigger sudden clot formation and block blood flow to the heart, resulting in a heart attack.

Dr Nagesh adds, “Calcium scoring cannot visualise these early-stage plaques because they have not yet hardened or calcified. This is why some individuals with a calcium score of zero may still experience cardiac events, particularly if they have underlying inflammation, smoking history, diabetes, obesity, or uncontrolled cholesterol levels.”

How do doctors decide which assessment may be appropriate for a person?

According to Dr Nagesh, the choice of test depends on the patient’s overall risk profile and whether symptoms are present. Calcium scoring is generally used as a preventive risk assessment tool in asymptomatic individuals to estimate long-term coronary risk.

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“CT angiography, on the other hand, provides a more detailed view of both calcified and non-calcified plaque and is often preferred when patients report symptoms such as chest pain, breathlessness, or reduced exercise tolerance. Factors such as age, smoking status, diabetes, hypertension, family history, and cholesterol levels heavily influence decision-making. Cardiology today is moving toward personalised risk assessment rather than relying on a single test result in isolation,” concludes Dr Nagesh.