CORONARY ATHEROSCLEROSIS AT 40: THE CONSEQUENCES MAY LAST A LIFETIME. And perhaps we are still detecting (I prefer the concept of individual patient's phenotyping) it too late. A new study published in JAMA Cardiology (2026) examined 12,847 adults aged 30–45 years, investigating the relationship between early coronary calcification and long-term mortality. The results are striking. Over a median follow-up of 22.6 years, individuals with coronary artery calcium (CAC) above the 90th percentile for age and sex had substantially higher mortality risks than those with CAC = 0. Estimated 30-year mortality: ➤ ALL-CAUSE MORTALITY: 12.9% vs 7.5% (adjusted HR 1.87). ➤ CARDIOVASCULAR MORTALITY: 4.5% vs 1.5% (adjusted HR 2.60). ➤ CORONARY MORTALITY: 3.0% vs 0.6% (adjusted HR 3.71). These are substantial differences for a disease already detectable around the age of 40. MY TAKE This study reinforces something we should never forget: ATHEROSCLEROSIS IS A CHRONIC, PROGRESSIVE DISEASE THAT BEGINS LONG BEFORE IT BECOMES SYMPTOMATIC. But there is another important consideration. CAC detects CALCIFIED atherosclerosis. It does not detect the entire atherosclerotic burden. Especially in younger individuals, coronary plaques may be predominantly NON-CALCIFIED. In other words: CAC = 0 DOES NOT NECESSARILY MEAN ABSENCE OF CORONARY ATHEROSCLEROSIS. And this raises an interesting question. IF CORONARY CALCIUM AT 40 PREDICTS MORTALITY 30 YEARS LATER, WHAT ARE WE MISSING BY WAITING FOR CALCIUM TO APPEAR? Coronary CTA already allows us to visualize non-calcified plaques and characterize coronary atherosclerosis beyond calcium scoring. Photon-Counting CT is further expanding our ability to investigate early and subtle coronary abnormalities. Of course, this study does not demonstrate that systematic CCTA screening of young adults improves outcomes, nor does it evaluate Photon-Counting CT. But it strengthens the rationale for investigating earlier, more personalized approaches to cardiovascular prevention. Because perhaps the most important question is no longer whether coronary atherosclerosis will eventually become obstructive. It is whether we can identify and address the disease decades before that happens. THE BEST TIME TO DETECT CORONARY ATHEROSCLEROSIS IS NOT WHEN IT BECOMES OBSTRUCTIVE. IT IS WHEN WE CAN STILL PREVENT ITS CONSEQUENCES. Reference: Choi S et al. Advanced Subclinical Atherosclerosis in Young Individuals and Risk of Mortality Over 30 Years. JAMA Cardiology, 2026. DOI: 10.1001/jamacardio.2026.4819. #CoronaryCTA #PhotonCountingCT #CardiovascularPrevention #Atherosclerosis #CardiacImaging #PreventiveCardiology #CAC #PrecisionMedicine