PREVENT Meets the Power of Zero
From Calculated Risk to Coronary Reality
By Dr. Anup Taksande, Clinical Director - Cardiology & Interventional Cardiology
Does cardiovascular prevention need a new CPR? Calculate. Personalize. Reclassify.
For years, preventing a heart attack has meant looking at a familiar list of risk factors—cholesterol, blood pressure, diabetes, smoking, age, family history. We add these numbers up and arrive at a probability: what are the odds this person has a cardiovascular event in the next ten years?
It's a useful exercise. But it has an obvious blind spot.
Two people can walk into a clinic with nearly identical risk factors and yet have very different amounts of disease already sitting inside their coronary arteries. One calculator, two very different coronary realities.
The 2026 ACC/AHA Dyslipidemia Guideline gives us a more contemporary way to think through this—starting with the PREVENT risk calculator and, where it makes sense, sharpening that estimate with biomarkers and a CT Coronary Calcium (CAC) score.
PREVENT — A Better Starting Point
PREVENT stands for Predicting Risk of Cardiovascular Disease EVENTS. Unlike the older calculators, which leaned heavily on traditional risk factors alone, PREVENT casts a wider net—bringing cardiovascular, kidney, and metabolic health into the same picture.
For adults between 30 and 79 who don't already have established cardiovascular disease, we can use information we're already collecting in any OPD—age, sex, blood pressure, cholesterol, smoking status, diabetes, BMI, kidney function, and whether they're already on BP or lipid treatment—to generate a 10-year cardiovascular risk estimate. For younger adults, it's often worth looking further out, since longer-term risk tells a more complete story.
The categories themselves are simple enough to use at the bedside:
Less than 3%—Low risk
3 to under 5%—borderline risk
5 to under 10%—Intermediate risk
10% or more—High risk
But that number should really be where the conversation starts, not where it ends.
A New CPR for Prevention
I think of the 2026 approach with a familiar acronym—one that's easy to carry into a busy consult:
C — Calculate
Start by working out the patient's PREVENT risk.
P — Personalize
Then look past the calculator and at the person in front of you. Is there a strong family history of premature heart disease? South Asian ancestry? Elevated Lp(a) or ApoB? Chronic inflammation, kidney disease, or anything else suggesting their biological risk runs ahead of their calculated risk?
This step matters a great deal here in India, where coronary artery disease has a habit of showing up in people far younger than global data would predict.
R — Reclassify
And when there's still uncertainty after all that, we ask a different kind of question altogether:
Is atherosclerosis already present?
This is exactly where a simple CT Coronary Calcium score earns its place—it can tell us something the risk calculator simply cannot.
PREVENT Predicts. CAC Reveals.
A 2026 JACC analysis by Rikhi and colleagues, drawing on data from the MESA study, looked at CAC scores across the new PREVENT risk categories, and the findings are worth sitting with.
Even among people PREVENT classified as low risk (under 3%), roughly one in five already had detectable coronary calcium. At the other end of the spectrum, among people classified as high risk (10% or above), those who had CAC present had an observed event rate of 20.9 per 1,000 person-years—compared with just 6.2 per 1,000 person-years in those with a CAC of zero.
Same broad risk category on paper. A very different coronary reality underneath.
Which leaves us with a useful distinction to hold onto:
PREVENT tells us the probability of an event. CAC tells us whether calcified coronary atherosclerosis has already taken hold.
They're not competing against each other. They're simply answering two different questions.
When Zero Is Hero
A CAC score of zero means no calcified coronary plaque was found. For the right patient, that can be genuinely reassuring, and it can meaningfully change how we think about their near-term risk.
That's the power of zero—when zero is a hero.
But it comes with a caveat worth repeating to every patient: zero does not mean immunity. CAC won't pick up non-calcified plaque, especially in younger patients, and a zero score should never be a reason to wave away smoking, severe hypercholesterolemia, diabetes, a strong family history, or other major risk enhancers.
At the opposite end, a very high score—particularly a CAC of 300 or more—tells an entirely different story. This isn't someone with risk factors for atherosclerosis anymore. This is someone who already carries a substantial burden of it. That distinction changes how urgently we act.
What This Looks Like in Everyday Practice
Picture a 48-year-old executive who looks, by most measures, perfectly healthy. He exercises now, and then, his cholesterol and blood pressure are mildly elevated, he doesn't smoke, and he feels completely fine. His calculated 10-year risk probably won't raise many eyebrows.
But his father had a heart attack at 52. His Lp(a) turns out to be markedly elevated. And his CAC score comes back at 180.
The conversation changes instantly.
Now flip it: another patient has several conventional risk factors on paper, but his CAC comes back at zero. That, too, is useful—it can shape how aggressively we intervene, and it can also reassure a worried patient that his disease burden isn't where the numbers alone suggested it might be.
That's the real value of using these tools together. We move from asking, "What are your chances of developing heart disease?" to asking a sharper question: "What is your risk—and has the disease already begun?"
Why This Matters Even More in India
PREVENT was built and validated largely on contemporary US populations, so it's worth applying thoughtfully to Indian patients rather than assuming it captures everything relevant to us. South Asians have a well-documented tendency toward premature cardiovascular disease, and risk enhancers like Lp(a), ApoB, metabolic dysfunction, and family history often carry information a standard risk calculation simply can't express on its own.
That points to an approach that makes particular sense for Indian preventive cardiology:
PREVENT + risk enhancers + biomarkers + CAC
Not every healthy person needs a CT scan. Not every patient needs an ever-expanding biomarker panel. The goal was never more testing for its own sake—the goal is choosing the right test for the right patient, at the right time.
The Take-Home
Cardiovascular prevention may well need its own CPR:
Calculate—start with PREVENT.
Personalise—layer in family history, ethnicity, metabolic profile, and relevant biomarkers.
Reclassify—when uncertainty remains, let CAC show you whether coronary atherosclerosis has already declared itself.
Because in the end, PREVENT estimates the risk. Biomarkers reveal biological vulnerability. And CAC reveals disease that has already left its mark on the artery wall.
Sometimes, instead of calculating one more number, we simply need to look at the artery itself.
The power of zero. When zero is a hero.