Statins for a person with zero.plaque on a ct scan and one

For a person with zero coronary plaque on CT, the evidence for starting a statin is thin and rests on population risk, not on what their scan shows.

The retrieved studies do not directly test starting a statin in someone with a zero calcium score. What they do show is that a zero score is not a guarantee of safety. One study of 100 symptomatic patients found that 11 of 22 with significant stenosis had a calcium score of zero [5]. Another review notes that event rates for people with a CAC score above 300 match those of patients with established heart disease [4]. The PESA study found that almost 50% of middle-aged participants had subclinical atherosclerosis, and those with LDL below 60 mg/dL had none [1]. This suggests that very low LDL may prevent plaque from forming in the first place.

The evidence for statins in primary prevention is mostly about lowering LDL and slowing plaque progression, not about starting at zero plaque. A 2022 review reported a 26% relative risk reduction with rosuvastatin in asymptomatic adults over 70 [2], but that is a relative number. The absolute benefit depends on your baseline risk. For someone with zero plaque and no other major risk factors, the number needed to treat to prevent one event is very high. The same review puts the risk of new diabetes from statins at about 0.2% per year [2]. The PARADIGM trial showed that statins slow plaque volume growth but actually increase coronary calcium progression [3], which can make future scans harder to interpret.

My call: for a person with zero plaque on CT and no other major risk factors, the evidence does not support starting a statin. The absolute benefit is likely small, the harms are real, and the scan itself does not change the calculation. Confidence: moderate.