How do you counsel patients with metabolic syndrome who decline statin therapy and have low coronary calcium scores regarding their long term CVD risk?  

This is a great question with many ramifications, and I can only give an incomplete answer that includes personal opinion. First, what is the risk? The MESA Risk Score Calculator (check it out) gives a CAC percentile score as well as a 10-year risk. The 10-year risk may be low, but a high percentile...

Metabolic syndrome is associated with increased CV risk. The discussion regarding statin therapy for an individual will depend upon their age, family history of ASCVD, esp premature, and other risk factors like HTN, prediabetes. If the CAC score is zero, and there is statin hesitancy, one can defer ...