What is a reasonable approach to coronary calcification that is incidentally found on CT in a patient who does not have symptoms suggestive of angina?

This patient needs aggressive medical therapy and risk factor modifications. Statins will be the primary lipid-lowering agent but other agents as needed to get an LDL under 70. Hypertension needs to be identified and controlled. Aspirin is also a consideration depending on the extent of coronary calcification. Dietary and exercise counseling should also be done.

I look at the patient's age and other risk factors. For instance, if it is a 75-year-old female non-smoker with scattered Ca++, then there probably is no data for primary prevention with statins or ASA - but it might depend on the LDL.

I am willing to use qualification as opposed to "quantification" for this free data.

On the other hand, with a younger patient <60, I would go all in with treatment. MESA data suggest only 0 is truly safe, although CT is not that accurate at very low levels.

I agree with the rest of the comments. This has become the most common cause of referrals in my office. Unfortunately, the primary physicians order this test on many patients and every calcification (most of the patients) will generate a cardiology referral. As a cardiology community, we have a long way to go to educate primary physicians about the indication of the test and how to interpret the result instead of referring to cardiology. We already have a shortage of cardiologists nationwide and flooding their offices with these referrals will only lead to further delay in accommodating other patients.