I saw a patient recently who came to see me for a preventive cardiovascular evaluation.
He was in his late 30s, had a stressful job, and little kids at home.
His father died young of heart disease young, but that history was muddled by smoking and poor health habits.
A few years back, the patient a coronary calcium scan. The score came back around 80.
His doctor at the time said that the score was low risk - and if you do your own research there, you’ll come to the same conclusion. After all, 80 isn’t a particularly high number for a calcium score.
This patient’s LDL cholesterol level was around 200mg/dL, but otherwise he was in good shape.
No smoking.
No diabetes.
No high blood pressure.
No Lp(a) elevation.
So what should we do with this information?
Does he need more testing? Should we recommend prescription medications?
And, perhaps more importantly, how urgent is any decision making?
Risk calculators miss patients like this
This case stood out to me because of the disconnect between how I assessed him—and how the standard risk calculators did.
By conventional risk scores, he comes out as low to intermediate risk.
PREVENT: 0.8% risk of a heart attack in the next 10 years, and a 6.4% risk over the next 30.
MESA: 6.6% risk over 10 years.1
Framingham: 1.6% risk of heart attack or death.
Most people would look at numbers like that and think - risk of anything bad happening over the next 10 years is so low, so we are totally fine.
These are the kinds of numbers that make most people feel reassured. But I have two major problems with that conclusion:
This is exactly the kind of patient risk calculators miss.
Even if the calculators were right, the risk is too high for someone this young.
Age driven algorithms can mislead
Risk calculators give a percentage with a decimal point, but that precision is often fictional.
These tools are “inspired by a true story” more than they are reliable predictors of any one individual’s future.
The biggest driver of calculated risk? Age. And that’s a problem.
Yes, older people are more likely to have heart attacks. But 1 in 5 heart attacks occur in patients under 40.
Youth is not immunity. It just makes events statistically less common—which is not the same as "unlikely for this person."
From an actuarial perspective, this patient looks okay. But from a clinical perspective, he's the opposite of okay.
This is a high-risk patient.
A Calcium Score of 80 in Your 30s Is Not “Mild”
It’s easy to dismiss a score of 80 or 90 as “a small amount of calcium.” But in a patient this young, any coronary calcification is a red flag.
Young people can have soft plaque—but it takes time for plaque to calcify. That process is more like scar formation than early inflammation. You simply don’t expect a CAC over 0 in people under 40.
So when a 35-year-old has a calcium score around 80, it’s not “a little calcification.” It’s an alarm bell.
Even if the risk calculator was right - which it isn’t! - this level of risk shouldn’t be acceptable in a young person
Most of these risk calculators spit out a risk of something bad happening over the next 10 years.
But a person in his 30s is not looking at a time horizon of just a decade.
That time horizon is unacceptable for a patient like this - we should be thinking of his cardiovascular health over many decades.
If I tell an 80-year-old that they’re unlikely to have a heart attack in 10 years, that’s good news.
But telling a 40-year-old patient that?
He doesn’t need to be ok for the next decade. Low risk on that timeline should not actually be news at all.
With someone like this - already significant cardiovascular disease present in the arteries at a really young age, with an alarming family history, and a very high LDL -not having a heart attack over the next 10 years does not even begin to define success.
And the path to catastrophe here isn’t complicated: early atherosclerosis, untreated, becomes progressive disease. That leads to stents. Or bypass surgery. Then, if we’re lucky, recovery. If we’re not? Heart failure.
That’s the optimistic path, assuming no sudden death from a major heart attack.
Not all risk is created equal
I have written before about the concept of asymmetric risk, when two risks may be numerically similar but qualitatively different.
Let’s say there’s a 5% risk of a medication side effect, and a 5% risk of a heart attack. Those aren’t the same.
Medication side effects are common—in my line of work, they’re almost always reversible. You stop the drug, the issue resolves. Side effects are rarely dangerous, and almost never permanent.
But if you avoid treatment because of side effect concerns and your patient has a preventable MI? That’s not just a number. That’s an outcome with permanent, potentially life-altering consequences.
That’s asymmetric risk: similar numbers, wildly different stakes.
This is a fascinating patient case - the patient feels fine, but the data says otherwise
What made this case so compelling is the disconnect between the patient’s subjective health—and the seriousness of their objective risk.
This is someone who appears well, has no symptoms, and whose formal risk assessment gives falsely reassuring numbers.
But this is also someone with:
Very high LDL
Alarming family history
Coronary artery calcification in his 30s
This is not a patient who needs reassurance. This is a patient who needs action.
The Bottom Line
Risk calculators are tools—not oracles. Used blindly, they can mislead. And when they do, patients like this—young, seemingly healthy, but biologically vulnerable—fall through the cracks.
I think this case is fascinating because there is a real discrepancy between how the patient feels - and how this patient would get informed about risk with a standard assessment - and my perception of how scary the situation actually is.
What keeps people alive isn’t the illusion of low risk. It’s recognizing early warning signs and acting on them.
When I reviewed the data here, I was incredibly alarmed - this is somebody who can very easily fall through the cracks and be undertreated, only to end up with catastrophic cardiac consequences down the road.
A cookie-cutter approach won’t do. Clinical judgment and individualized care matters.
To use the MESA calculator, the minimum age is 45, so I used that instead of his actual age. The MESA calculator is also the only one that uses the calcium score, so if you skip that data input you get a 10 year risk of 3.3% instead of 6.6%.