Cardiovascular (CV) risk scores are widely used to estimate future event risk and guide preventive strategies, including selection for coronary imaging. However, their relationship with coronary plaque burden and progression remains uncertain.

A multicenter prospective cohort study published in the American Journal of Preventive Cardiology enrolled asymptomatic, intermediate-risk individuals aged 40–70 years with a family history of coronary artery disease (CAD) who were not receiving statin therapy. Participants were recruited from seven hospitals across Australia.

Baseline CV risk scores were calculated, and coronary artery calcium scoring (CACS) was performed in all participants. Those with CACS between 1 and 400 underwent coronary angiography at baseline and repeat imaging after three years to assess plaque burden and progression.

Among 1,060 participants (mean age 56±7 years; 54% female), 499 (44%) had CACS >0. A subset of 365 individuals completed both baseline and follow-up coronary angiography. The PREDICT 5-year risk score demonstrated the strongest, though weak, correlation with baseline CACS (R²=0.273).

Correlations between baseline total plaque volume and CV risk scores were negligible (R²<0.2). In multivariable linear regression analysis, QRISK3 showed a statistically significant association with changes in plaque volume over time (β=0.193 [0.015]; p=0.004), after adjustment for age, sex, statin prescription, cholesterol levels, diabetes, and hypertension.

Conventional CV risk scores demonstrated limited association with coronary plaque burden and progression. These findings highlight limitations of current risk tools for identifying individuals who may benefit from early preventive strategies.