A heart scan led to far fewer statin recommendations, and major cardiovascular event rates stayed at 2.7%

In a randomized trial of 5,772 adults, a coronary artery calcium scan steered doctors toward recommending statins less than a third as often as a standard risk calculator did, and major cardiovascular events occurred in 2.7% of patients in both groups. The CorCal Outcomes results were presented at a Hot Line session of ESC Congress 2026 in Munich, with follow-up averaging 4.2 years. The trial did not clear its own bar for showing the scan approach is as safe as the calculator, so the equal rates come with a caveat.

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Joseph B. Muhlestein of Intermountain Medical Center in Murray, Utah, the principal investigator, said lower-than-expected event rates reduced the study’s power to detect a difference. He has described the findings as hypothesis-generating. ScienceDaily posted the European Society of Cardiology’s account on Nov. 6, more than two months after the Munich session on Aug. 31.

Calcium scoring versus the pooled cohort equations

Per the European Society of Cardiology press release, patients from the Canyons and Desert regions of Intermountain Health Care were randomized 1:1. None had known atherosclerotic cardiovascular disease or diabetes, and none had taken a statin before. Mean age was 64, and 51% were women. One arm received statin guidance from the pooled cohort equations, a traditional risk-factor calculator. The other arm received guidance from a coronary artery calcium score, a number read from a CT scan of the heart. Patients and physicians both saw the protocol’s recommendation, but the final decision stayed with them.

The primary outcome was a composite of death from any cause, heart attack, stroke and arterial revascularization. ScienceDaily’s posting reports that the composite occurred in 2.7% of each group, with a hazard ratio of 0.99 and a 95% confidence interval of 0.71 to 1.38. Because the composite also counts deaths from any cause and procedures to reopen arteries, it is a broader measure than heart attack and stroke alone.

A 1:1 split of 5,772 people leaves roughly 2,900 in each arm, so by simple arithmetic a 2.7% event rate means on the order of 80 events per group over the 4.2-year average follow-up. That is a small number for a trial meant to prove equivalence. The participants were also a relatively low-risk population by design, with no known heart disease, no diabetes and no earlier statin use, which helps explain why events were scarcer than the investigators planned for.

Recommendation and adherence gaps between the two arms

The calculator arm was advised to start statins more than three times as often as the scan arm. Among patients who were advised to take one, adherence ran 62% in the scan group versus 23% in the calculator group, a split the American College of Cardiology’s conference summary also reports. ScienceDaily’s body text calls that about 2.7 times as likely while its summary says nearly three times; the percentages are the firmer numbers. A SciTechDaily account adds that Muhlestein called statins highly effective at preventing cardiovascular disease.

The investigators call both findings hypothesis-generating.

Put side by side, the numbers describe two different routes to the same destination. The calculator route recommended a statin to many more people, but fewer than a quarter of those who were advised to take one stayed on it, according to the 23% adherence figure. The scan route recommended far fewer prescriptions, and nearly two-thirds of the people who got one kept taking it. Which route covers more protection in practice depends on how many people take their pills, and this trial was not powered to settle that.

Why more scan-arm patients stuck with their prescriptions was not established. One proposed explanation is that seeing evidence of arterial disease on a scan motivates people to follow through, but the release labels that speculative. It is also unknown whether the adherence advantage would improve long-term outcomes, which matters because a recommendation that fewer patients receive but more patients follow can land at the same event rate as the opposite approach, as the equal 2.7% suggests.

Noninferiority, event rates and the next trial

The trial was built to test whether scan-guided care is noninferior to risk-calculator care, and it did not demonstrate that. The release lists a p value of 0.045 for noninferiority next to its statement that the predetermined requirement was not met, and it does not reconcile the two. The investigators emphasize the unmet criterion, and they attribute it mainly to fewer events than expected, which cut statistical power. Equal event rates in a trial with too few events cannot be read as proof that the two approaches are equivalent.

The guideline backdrop is moving toward the scan for some patients. The 2025 focused update of the ESC and EAS dyslipidaemia guidelines, published on Aug. 31, 2025, says imaging evidence of subclinical atherosclerosis or a raised calcium score, when measured, should be considered a risk modifier in people at moderate risk or near a treatment decision threshold. Muhlestein told the ACC that the data could be used to plan a larger, well-powered randomized trial comparing calcium scoring with risk-factor algorithms. The trial was funded through internal resources and the Dell Loy Hansen Foundation, and Muhlestein reported no related financial disclosures.

This article was produced with the assistance of AI and reviewed by Morning Overview editors prior to publication.

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