This case raises several interesting issues. Was the initial EBCT scan justified? Should the abnormal findings of the EBCT scan have dictated a course of treatment that proceeded directly to coronary angiography without the stress test? What treatment should be prescribed for his asymptomatic coronary disease? Occult coronary disease is a major public health concern in our country and is increasingly so in other regions. Coronary artery disease (CAD) remains the number one cause of death in the United States and by 2020 is projected to become a leading killer worldwide. Estimates indicate that at least 50% of the 1,000,000 myocardial infarctions (MIs) that occur annually are a first event for persons without known coronary disease. In many of these cases, death occurs early due to ventricular fibrillation even before the opportunity to benefit from current interventional or thrombolytic therapy. Identifying at-risk individuals is made difficult since 25 to 50% of persons experiencing MIs lack the conventional Framingham risk factors. Newer insights into the pathobiology of MI have indicated that two of three culprit plaques are < 50% stenotic. Inflammation has been suggested to weaken the protective fibrous cap and injure the overlying endothelium, predisposing the patient to plaque rupture or surface erosion with subsequent thrombosis. How do we detect persons at risk when we know that clinical risk factor analysis frequently is inadequate and that stress testing, either by echocardiography or a nuclear technique, will likely yield negative results if nonobstructive plaque is present? In fact, stress testing is not generally advocated to screen for asymptomatic occult CAD.1More recently, EBCT scanning has gained interest as a coronary screening modality since it can identify persons with both obstructive and nonobstructive plaque. An EBCT scan is able to quantify coronary calcium, which is typically found on pathologic analysis of atherosclerotic lesions. While only 20 to 25% of all plaque is calcified enough to be seen by EBCT scanning, it is unusual to have only “soft,” uncalcified, lipid-laden plaque in the absence of any calcified plaque that can be detected by EBCT scan. Moreover, the total CS correlates with the pathologic and angiographic quantity of atherosclerosis allowing EBCT to noninvasively estimate total plaque burden. Because the relationship between the severity of coronary stenosis and the CS is not a direct one, a high CS may occur in the absence of severe angiographic narrowing.2In addition to its capacity for the detection of occult CAD, the EBCT scan-derived CS is related to coronary prognosis. A 3.6-year study of 1,172 asymptomatic persons demonstrated an odds ratio for coronary events of 14.3 with a CS of > 80, and an odds ratio for coronary events of 19.7 with a CS of > 160. Importantly, EBCT scanning added independently to the prognostic information obtained from clinical risk factors.3The consideration of the age-related and sex-related percentiles might be a better way to categorize individuals in relation to coronary risk than the absolute CS. The risk to a 45-year-old woman with a score of 100 is greater than that for a 45-year-old man with a CS of 100, and both have a greater risk than a 65-year-old person with a similar CS. A recent study4 demonstrated that 96% of persons who experience a first MI have coronary calcium present. The risk of MI was related to the age and sex percentiles of the CS. About 90% of individuals who experienced an MI had a CS in > 50th percentile and 70% had a CS in > 75th percentile. Surprisingly, one third of those experiencing MIs had a relatively low CS of < 100.4 Very few such individuals would be expected to have severe stenosis, and they would almost certainly have escaped detection by conventional stress testing. Because inflammation may be a factor in plaque destabilization, it is possible that concomitant high-sensitivity C-reactive protein values would aid in risk stratifying subgroups with low-to-moderate levels of coronary calcium. However, a prospective study combining coronary CS and C-reactive protein values has yet to be reported.