{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T15:33:52Z","timestamp":1787758432493,"version":"build-2784847793"},"reference-count":31,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T00:00:00Z","timestamp":1787702400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background: The absence of coronary artery calcium (CAC = 0) on computed tomography (CT) portends a low but not zero coronary risk. However, the frequency and prognostic significance of non-calcified plaques in CAC = 0 patients are incompletely defined, and non-coronary artery disease (CAD) causes of coronary risk have been proposed. We sought to define the ischemic burden, CAD status, and outcomes of CAC = 0 patients. Methods: The Intermountain electronic medical records were searched for CAC = 0 patients undergoing stress positron emission tomography (PET)\/CT between January 2016 and July 2022. We defined definite PET abnormality as ischemic burden (IB) \u2265 10%. Patients were followed for angiographic findings, interventions, and major adverse cardiovascular events (MACE) over 3.1 \u00b1 1.3 years. Results: Of 22,542 PET\/CT studies in primary prevention patients, 5054 (22.4%) had CAC = 0. Of these, 59 (1.2%) had IB \u2265 10% on PET. Selective coronary angiography was performed within 90 days in 25 (42%) of IB \u2265 10% patients. Severe CAD was present in 11, but findings were not explained by CAD in 14. Revascularization was indicated in 10 (16.9%) of 59 with IB \u2265 10% vs. 0.04% of IB = 0% (p &lt; 0.0001); 3-year outcomes also were lower with IB = 0%. Conclusions: In this large series of stress PET\/CT study data, IB \u2265 10% in patients with CAC = 0 was rare. Most positive PET tests were not explained by obstructive CAD. While CAC does not perfectly predict an absence of coronary ischemia or obstructive CAD, it is a strong marker of prognosis. Here, we show that IB by PET supplements CAC score to importantly refine risk assessment.<\/jats:p>","DOI":"10.3390\/jcm15176603","type":"journal-article","created":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T15:04:32Z","timestamp":1787756672000},"page":"6603","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Ischemic Risk in Patients with Zero Coronary Artery Calcium Undergoing Stress PET\/CT Testing"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-0825-8685","authenticated-orcid":false,"given":"Jeffrey L.","family":"Anderson","sequence":"first","affiliation":[{"name":"Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA"},{"name":"The University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Leslie K.","family":"Iverson","sequence":"additional","affiliation":[{"name":"Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7950-1267","authenticated-orcid":false,"given":"Daniel L.","family":"Bride","sequence":"additional","affiliation":[{"name":"Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Stacey","family":"Knight","sequence":"additional","affiliation":[{"name":"Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA"},{"name":"The University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Raymond O.","family":"McCubrey","sequence":"additional","affiliation":[{"name":"Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6659-5332","authenticated-orcid":false,"given":"Viet T.","family":"Le","sequence":"additional","affiliation":[{"name":"Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA"},{"name":"Rocky Mountain University of Health Professions, 1800 S Novell Pl, Provo, UT 84606, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2015-0631","authenticated-orcid":false,"given":"Mohanad","family":"Dakhakhni","sequence":"additional","affiliation":[{"name":"The University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Steve M.","family":"Mason","sequence":"additional","affiliation":[{"name":"Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3544-4130","authenticated-orcid":false,"given":"Kirk U.","family":"Knowlton","sequence":"additional","affiliation":[{"name":"Intermountain Medical Center Heart Institute, 5171 So. Cottonwood Street, Building 1, 5th Floor, Murray, UT 84107, USA"},{"name":"The University of Utah School of Medicine, 30 N 1900 E, Salt Lake City, UT 84132, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"1951","DOI":"10.1161\/01.CIR.93.11.1951","article-title":"Predictive value of electron beam computed tomography of the coronary arteries. 19-month follow-up of 1173 asymptomatic subjects","volume":"93","author":"Arad","year":"1996","journal-title":"Circulation"},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"e003144","DOI":"10.1161\/JAHA.115.003144","article-title":"Cardiovascular event prediction and risk reclassification by coronary, aortic, and valvular calcification in the Framingham Heart Study","volume":"5","author":"Hoffmann","year":"2016","journal-title":"J. Am. Heart Assoc."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1452","DOI":"10.1161\/CIRCULATIONAHA.119.044720","article-title":"Low-attenuation noncalcified plaque on coronary computed tomography angiography predicts myocardial infarction: Results from the Multicenter SCOT-HEART Trial (Scottish Computed Tomography of the HEART)","volume":"141","author":"Williams","year":"2020","journal-title":"Circulation"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1643","DOI":"10.1016\/j.jacc.2015.08.035","article-title":"10-year coronary heart disease risk prediction using coronary artery calcium and traditional risk factors: Derivation in the MESA (Multi-Ethnic Study of Atherosclerosis) with validation in the HNR (Heinz Nixdorf Recall) Study and the DHS (Dallas Heart Study)","volume":"66","author":"McClelland","year":"2015","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2232","DOI":"10.1093\/eurheartj\/eht508","article-title":"Impact of coronary artery calcium on coronary heart disease events in individuals at the extremes of traditional risk factor burden: The Multi-Ethnic Study of Atherosclerosis","volume":"35","author":"Silverman","year":"2014","journal-title":"Eur. Heart J."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"579","DOI":"10.1016\/j.jcmg.2015.02.006","article-title":"Coronary artery calcium scanning: Past, present, and future","volume":"8","author":"Hecht","year":"2015","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"849","DOI":"10.1161\/CIRCULATIONAHA.115.018524","article-title":"Role of coronary artery calcium score of zero and other negative risk markers for cardiovascular disease: The Multi-Ethnic Study of Atherosclerosis (MESA)","volume":"133","author":"Blaha","year":"2016","journal-title":"Circulation"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"e000945","DOI":"10.1136\/openhrt-2018-000945","article-title":"A zero coronary artery calcium score in patients with stable chest pain is associated with a good prognosis, despite risk of non-calcified plaques","volume":"6","author":"Wang","year":"2019","journal-title":"Open Heart"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"961","DOI":"10.1016\/j.jacc.2020.05.084","article-title":"Spontaneous coronary artery dissection: JACC State-of the Art Review","volume":"76","author":"Hayes","year":"2020","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"A299","DOI":"10.1016\/S0735-1097(15)61244-X","article-title":"Impact of Transitioning from SPECT to PET on Myocardial Ischemia Detection: Experience from a High Volume \u201cReal World\u201d Practice (Abstract)","volume":"65","author":"Meredith","year":"2015","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e120949","DOI":"10.1172\/jci.insight.120949","article-title":"Implementation of a cardiac PET stress program: Comparison of outcomes to the preceding SPECT era","volume":"3","author":"Knight","year":"2018","journal-title":"JCI Insight"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"507","DOI":"10.2967\/jnumed.119.229799","article-title":"Quantitative clinical nuclear cardiology, Part 1: Established applications","volume":"60","author":"Garcia","year":"2019","journal-title":"J. Nucl. Med."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"783","DOI":"10.2967\/jnumed.106.032789","article-title":"Clinical myocardial perfusion PET\/CT","volume":"48","author":"Dabala","year":"2007","journal-title":"J. Nucl. Med."},{"key":"ref_14","first-page":"185","article-title":"Clinical Value of Positron Emission Tomography Myocardial Perfusion Imaging and Blood Flow Quantification","volume":"41","author":"DiCarli","year":"2023","journal-title":"Cardiol. Clin."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"827","DOI":"10.1016\/0735-1097(90)90282-T","article-title":"Quantification of coronary artery calcium using ultrafast computed tomography","volume":"15","author":"Agatston","year":"1990","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"580","DOI":"10.1016\/j.jcmg.2015.11.023","article-title":"CACS and the Frequency of Stress-Induced Myocardial Ischemia During MPI. A Meta-Analysis","volume":"9","author":"Bavishi","year":"2016","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"1693","DOI":"10.1161\/CIRCULATIONAHA.107.717512","article-title":"Interrelation of Coronary Calcification, Myocardial Ischemia, and Outcomes in Patients With Intermediate Likelihood of Coronary Artery Disease","volume":"117","author":"Schenker","year":"2008","journal-title":"Circulation"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1016\/j.ijcard.2009.09.550","article-title":"Absent coronary artery calcium excludes inducible myocardial ischemia on computed tomography\/positron emission tomography","volume":"147","author":"Esteves","year":"2011","journal-title":"Int. J. Cardiol."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"24","DOI":"10.1016\/j.pcad.2023.10.005","article-title":"Comparison of coronary artery calcium scores among patients referred for cardiac imaging tests","volume":"81","author":"Rozanski","year":"2023","journal-title":"Prog. Cardiovasc. Dis."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1514","DOI":"10.1007\/s12350-022-03174-3","article-title":"The power of zero calcium in 82-Rubidium PET irrespective of sex and age","volume":"30","author":"Frey","year":"2023","journal-title":"J. Nucl. Cardiol."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"e-12599","DOI":"10.1161\/CIRCIMAGING.121.012599","article-title":"Prognostic Relationship Between Coronary Artery Calcium Score, Perfusion Defects, and Myocardial Blood Flow Reserve in Patients With Suspected Coronary Artery Disease","volume":"15","author":"Patel","year":"2022","journal-title":"Circ. Cardiovasc. Imaging"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1056\/NEJMoa1803538","article-title":"Five-year outcomes with PCI guided by fractional flow reserve","volume":"379","author":"Xaplanteris","year":"2018","journal-title":"N. Engl. J. Med."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2533","DOI":"10.1016\/j.jacc.2011.10.851","article-title":"Prevalence and Severity of Coronary Artery Disease and Adverse Events Among Symptomatic Patients With Coronary Artery Calcification Scores of Zero Undergoing Coronary Computed Tomography Angiography","volume":"58","author":"Villines","year":"2011","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"922","DOI":"10.1093\/ehjci\/jex037","article-title":"Prevalence of obstructive coronary artery disease and prognosis in patients with stable symptoms and a zero-coronary calcium score","volume":"18","author":"Mittal","year":"2017","journal-title":"Eur. Heart J. Cardiovasc. Imaging"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1745","DOI":"10.1016\/j.jcmg.2022.03.031","article-title":"The prognostic value of CAC zero among individuals presenting with chest pain: A meta-analysis","volume":"15","author":"Agha","year":"2022","journal-title":"JACC Cardiovasc. Imaging"},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"333","DOI":"10.1038\/s41440-021-00798-9","article-title":"Coronary calcium as a predictor of outomes in the hypertensive COVID-19 population: Results from the Italian (S) Core-Covid-19 Registry","volume":"45","author":"Cereda","year":"2022","journal-title":"Hypertens. Res."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1245","DOI":"10.1016\/j.jacc.2023.06.043","article-title":"Comprehensive management of ANOCA, Part 1-definition, patient population, and diagnosis: JACC State-of-the-Art Review","volume":"82","author":"Samuels","year":"2023","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"1264","DOI":"10.1016\/j.jacc.2023.06.044","article-title":"Comprehensive management of ANOCA, Part 2\u2014Program development, treatment, and research initiatives: JACC State-of-the-Art Review","volume":"82","author":"Smilowitz","year":"2023","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"1034","DOI":"10.1007\/s12350-020-02385-w","article-title":"Spectrum of radionuclide perfusion study abnormalities in Takotsubo cardiomyopathy","volume":"29","author":"Anderson","year":"2022","journal-title":"J. Nucl. Cardiol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1007\/s10554-026-03623-x","article-title":"Coronary atherosclerosis on AI-based plaque analysis in patients with chest pain and calcium score zero","volume":"42","author":"Molnar","year":"2026","journal-title":"Int. J. Cardiovasc. Imaging"},{"key":"ref_31","first-page":"100707","article-title":"Coronary artery calcium sore of zero does not rule out obstructive CAD in young adults","volume":"62","author":"Smettei","year":"2025","journal-title":"Am. Heart J. Plus"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/17\/6603\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T15:13:20Z","timestamp":1787757200000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/17\/6603"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,26]]},"references-count":31,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["jcm15176603"],"URL":"https:\/\/doi.org\/10.3390\/jcm15176603","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,26]]}}}