{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"institution":[{"name":"medRxiv"}],"indexed":{"date-parts":[[2026,5,18]],"date-time":"2026-05-18T15:11:28Z","timestamp":1779117088329,"version":"3.51.4"},"posted":{"date-parts":[[2026,5,15]]},"group-title":"Cardiovascular Medicine","reference-count":25,"publisher":"openRxiv","license":[{"start":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T00:00:00Z","timestamp":1778803200000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by-nd\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"accepted":{"date-parts":[[2026,5,15]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                <jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Coronary artery calcium (CAC) scores inform subclinical atherosclerotic cardiovascular disease (ASCVD) burden, helping guide preventative treatments. However, prediction of cardiovascular (CV) events by CAC is largely limited to ASCVD outcomes. This study investigated whether a previously validated proteomic test for predicting a broad composite of four-year CV events could enhance the prognostic utility of CAC.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>We used a 27-protein CV risk score (Prot-CVR), derived from \u223c5,000 SomaScan\u2122 Assay plasma protein measurements, to predict four-year risk of a composite CV and mortality outcome (myocardial infarction, stroke\/TIA, heart failure hospitalization, death) in 2,122 participants with \u22651 CV risk factors from the Multi-Ethnic Study of Atherosclerosis (MESA) observational cohort at exam 5 and compared predictions to CAC Agatston scores. Discriminatory performance was assessed using C-Index and 4-year area under the curve (AUC). Cox Proportional Hazard (CoxPH) ratios were calculated for the composite outcome, ASCVD outcome (myocardial infarction, resuscitated cardiac arrest, stroke, coronary heart disease death), and individual events. Changes in Prot-CVR and CAC scores from baseline to MESA exam 5 (+10-years) in CV event versus event-free participants were assessed using 2-tailed paired t-tests. CoxPH regression models of CV event status distributed by Prot-CVR, CAC, and relevant co-variates were evaluated for performance relative to individual models.<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Individual Prot-CVR and CAC models predicting the composite outcome had comparable 4-year AUCs, but Prot-CVR had a higher C-index (0.68 (0.65-0.70) versus 0.63 (0.60-0.65), p=0.001) and greater hazard ratios for the composite outcome (p&lt;0.001), death (p&lt;0.001), and heart failure (p=0.015). A combined CoxPH model of Prot-CVR + CAC + Age had a higher 4-year AUC (0.72, p&lt;0.05) and C-Index (0.71, p&lt;0.05) than Prot-CVR or CAC alone. Both Prot-CVR and CAC scores detected an increase in risk prior to an approaching CV event in \u223c10-year sensitivity-to-change analysis. For 49.6% of MESA population with CAC=0 at baseline, Prot-CVR was greater in composite event versus event free participants at 4 years (0.23 versus 0.15, p=0.006) and full follow-up (0.18 versus 0.13, p&lt;0.001).<\/jats:p>\n                <\/jats:sec>\n                <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>Protein testing complements CAC for CV risk assessment although the improvement is modest. Prot-CVR may resolve which patients with CAC=0 are at heightened CV risk.<\/jats:p>\n                <\/jats:sec>","DOI":"10.64898\/2026.05.12.26353070","type":"posted-content","created":{"date-parts":[[2026,5,15]],"date-time":"2026-05-15T22:30:23Z","timestamp":1778884223000},"source":"Crossref","is-referenced-by-count":0,"title":["Plasma proteomics and coronary artery calcium score: synergistic, concordant and contrasting predictions of cardiovascular outcomes in The Multi-Ethnic Study of Atherosclerosis"],"prefix":"10.64898","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-2017-3094","authenticated-orcid":false,"given":"Jessica","family":"Chadwick","sequence":"first","affiliation":[{"name":"Illumina; 5200 Illumina Way, San Diego, CA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0009-0006-7244-2299","authenticated-orcid":false,"given":"Meredith","family":"Carpenter","sequence":"additional","affiliation":[{"name":"Illumina; 5200 Illumina Way, San Diego, CA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9616-1946","authenticated-orcid":false,"given":"Matthew","family":"Budoff","sequence":"additional","affiliation":[{"name":"The Institute for Translational Genomics and Population Sciences, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8250-2607","authenticated-orcid":false,"given":"Rajat","family":"Deo","sequence":"additional","affiliation":[{"name":"Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0498-1980","authenticated-orcid":false,"given":"Ruth F.","family":"Dubin","sequence":"additional","affiliation":[{"name":"Division of Nephrology, University of Texas Southwestern Medical Center, Dallas, TX"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6327-2439","authenticated-orcid":false,"given":"Philip","family":"Greenland","sequence":"additional","affiliation":[{"name":"Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0693-7075","authenticated-orcid":false,"given":"Michael A.","family":"Hinterberg","sequence":"additional","affiliation":[{"name":"SomaLogic, 2945 Wilderness Place, Boulder, CO"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0120-4630","authenticated-orcid":false,"given":"Rajeev","family":"Malhotra","sequence":"additional","affiliation":[{"name":"Heart & Vascular Institute, Mass General Brigham, Boston, MA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4276-3607","authenticated-orcid":false,"given":"Clint","family":"Miller","sequence":"additional","affiliation":[{"name":"Department of Genomic Sciences, Department of Biochemistry and Molecular Genetics, University of Virginia, Charlottesville, VA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7191-1723","authenticated-orcid":false,"given":"Jerome I.","family":"Rotter","sequence":"additional","affiliation":[{"name":"The Institute for Translational Genomics and Population Sciences, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2756-4370","authenticated-orcid":false,"given":"Kent D.","family":"Taylor","sequence":"additional","affiliation":[{"name":"The Institute for Translational Genomics and 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