A calcium score of 400 or more means there is a large amount of calcified plaque in your heart arteries. In large studies, this is the range where the chance of a heart attack or stroke over the next decade is clearly high, in younger and older adults alike.
It is not, by itself, an emergency. If you feel well, nothing has to happen today. What should happen over the next few weeks is a proper review of your symptoms, your risk factors and your treatment with a clinician who takes the number seriously.
Key takeaways
- Scores from 400 up are commonly labeled severe or extensive and carry high ten-year risk.
- A high number built up over many years, so without symptoms it is a planning matter, not an urgent one.
- The scan counts calcium and cannot show whether blood flow is reduced.
- Clinicians usually respond with firmer treatment of risk factors and a careful check for symptoms.
- Any chest pain, pressure or new breathlessness changes the picture and needs prompt evaluation.
How much risk a score of 400 or more carries
Risk does not jump at exactly 400. The line is a convention that reports use to mark extensive plaque.
In MESA, a score above 400 carried about 20 times the risk of a coronary event of a score of zero over the first few years of follow-up.1 Absolute figures are more useful.
In a German study of more than 3,200 adults, those whose first scan showed 400 or more had a ten-year risk of about 12% for a heart attack or coronary death and about 31% for any cardiovascular event, a count that included procedures to open an artery.2 Put another way, most people with a high score did not have a heart attack in those ten years, but far more did than at lower scores.
One more finding shows how the balance shifts. In a registry of more than 66,000 people, cancer was the leading cause of death among those with a score of zero, and cardiovascular disease took over as the leading cause once the score passed 300.3
Does age soften a high score?
Not much. Calcium is common in older adults, and a score of 450 at 75 is less unusual than the same score at 50. But unusual and risky are different things.
A study of more than 44,000 people referred for a calcium scan found that scores above 400 predicted a higher death rate both in adults under 45 and in those 75 and older.4 An average percentile for your age means that many of your peers share the problem. It does not make the plaque harmless.
In a younger person, a score this high is rare and deserves a search for a cause such as inherited high cholesterol, a high Lp(a), diabetes or long-term smoking.
Why it is not an emergency without symptoms
Three facts keep a high score in proportion.
- It took years. Calcium collects slowly. The plaque on your scan was there last month and last year. The scan changed what you know, not what is in your arteries.
- Calcium is not the same as narrowing. The score is a total for all the calcified plaque in the coronary arteries. It can be spread along the artery walls without restricting flow anywhere.
- High scores and normal blood flow often go together. In a study of 1,195 patients without known coronary disease who had both tests, 31% of those whose stress imaging was normal had a calcium score of 400 or more.5
The same study found that reduced blood flow became steadily more likely as scores rose, and more likely still in people who had symptoms. So a high score does not prove a problem with flow, and it does make the question worth asking.
Symptoms are the dividing line. Chest pressure or pain, discomfort spreading to the arm, jaw or back, breathlessness that is new or comes with effort, or unexplained sweating or nausea need prompt medical attention. If they are severe or do not settle, call 911.
What clinicians usually consider
Our guide on what to do after a high calcium score walks through the general steps. At 400 and above, the discussion tends to be firmer on each point.
| Area | What is usually weighed |
|---|---|
| Symptoms | A careful history, including mild or vague symptoms you may have explained away |
| Cholesterol treatment | Whether to start a statin or step up current treatment, sometimes with a second class of medicine |
| Other drivers | Blood pressure, blood sugar, tobacco, weight, and inherited markers such as Lp(a) |
| Further testing | Whether a stress test or CT angiogram would add anything, mainly if symptoms or other concerns are present |
| Referral | Whether a cardiologist should be involved |
None of this is automatic. Further testing is a judgment call, and a stress test looks for something a calcium scan cannot see. Our comparison of a calcium score and a stress test explains the difference.
Medication decisions belong with your prescriber. Do not start, stop or change a medicine because of a number on a report.
What treatment can and cannot do
Treatment lowers the odds of a heart attack or stroke. It does not remove calcium, and the score is not expected to fall. No one can promise that an event will not happen.
The calcium is a record of past damage. The risk comes from plaque that is still active, and that is what treatment acts on.
If your score is in four figures, a few extra points apply. See our guide to a calcium score over 1,000.
How Cardio Res-Q fits with a high score
Cardio Res-Q is a prevention program. It is not emergency care and it does not replace a cardiologist. Where it helps is in working out what is driving the plaque. The Comprehensive Assessment ($775) includes Dr. Varano's clinical evaluation, advanced labs including ApoB, Lp(a), hs-CRP, homocysteine, insulin, glucose and A1c, and a personalized heart protection plan. The Enhanced Assessment ($999) adds a calcium score and CIMT ultrasound, which mainly suits people who have not yet been scanned.
You keep your own cardiologist and primary care doctor, and we share results with them. Read Cardio Res-Q vs. a cardiologist visit to see how the two fit together, or book from the Cardio Res-Q program page.
Are You a Candidate for Cardio Res-Q?
Three quick questions about the risk factors we screen for. Your answers stay between you and the clinic.
Frequently asked questions
Is a calcium score of 400 or 500 life-threatening?
It marks a high long-term risk, not an immediate threat. Most people with scores in this range do not have a heart attack in the following ten years, but many more do than at lower scores. That is why the result should lead to treatment and follow-up without delay.
Should I go to the emergency room with a score over 400?
Not for the score alone if you feel well. Go, or call 911, if you have chest pain or pressure, breathlessness, or other symptoms that could be a heart attack. Otherwise, arrange an appointment with your doctor within the next few weeks.
Will I need a stent or bypass?
Not because of the calcium score. Those procedures are for arteries that are significantly narrowed and causing symptoms or reduced blood flow, which the calcium scan does not measure. Many people with high scores are managed with medication and lifestyle change alone.
Related reading
This article is for general education and is not medical advice. Decisions about testing and medication should be made with your clinician. If you have chest pain or other symptoms of a heart attack, call 911.
