Impact of coronary artery calcification detection on cardiovascular care trajectories in patients undergoing lung cancer screening: a systematic review

Importance: Coronary artery calcification (CAC) is commonly identified on low-dose computed tomography (LDCT) performed for lung cancer screening (LCS) and is associated with increased cardiovascular (CV) risk. Although guidelines increasingly recommend reporting and incorporating CAC into CV risk stratification, whether its detection translates into downstream CV preventive care remains unclear. Objective: To systematically evaluate reporting practices and downstream clinical management following CAC detection during LDCT LCS. Evidence Review: We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science Core Collection from inception to September 23, 2026, and searched grey literature through September 20, 2026. We included original studies of adults undergoing LDCT within established or pilot LCS programs if they evaluated downstream management following CAC detection or reporting. Reviewers independently extracted data in duplicate on CAC assessment, reporting, communication, preventive pharmacotherapy, referrals, investigations, and clinical outcomes. We assessed study quality using the Newcastle-Ottawa Scale (NOS). Owing to clinical and methodological heterogeneity, we synthesized findings narratively. Findings: We included twelve studies published between 2020 and 2026 from the United States, Canada, United Kingdom, Australia, and France. Visual assessment was the predominant method for CAC identification, although reporting and communication practices varied substantially. Statin initiation (N=7) ranged from 3% to 38%, cardiology referral (N=3) from 6.9% to 44%, and cardiac stress testing (N=2) from 12.5% to 21.6%. Structured CV follow-up pathways were evaluated in five studies. Three studies found greater a CAC severity or a more explicit reporting was associated with increased statin initiation. Study quality was moderate overall, with NOS scores ranging from four to eight of nine; common limitations included absence of comparator groups and limited adjustment for confounding. Conclusions and Relevance: CAC detected during LCS was followed by variable downstream CV preventive care, and reporting alone does not consistently translate into clinical action. Greater CAC severity and more explicit reporting were associated with increased clinical action in some studies, but reporting alone did not consistently translate into preventive management. Comparative studies are needed to determine whether structured communication and follow-up pathways improve cardiovascular care and clinical outcomes.