To the Editor In the July issue of JAMA Cardiology, Yano et al1 reported that in older patients without known cardiovascular disease, the coronary artery calcium (CAC) score was superior to chronological age to discriminate risk for coronary heart disease. We agree and support the idea of including CAC score within cardiovascular risk evaluation scores in addition to age because of other comorbidities that cannot be ruled out with CAC score. However, we are concerned about the risk of readers misunderstanding the message and thinking a CAC score of 0 correlates with a cumulative probability of survival free of atherosclerotic cardiovascular events of greater than 90%. There is worldwide experience that finds low-risk and intermediate-risk patients aged 60 to 96 years (the same age range used by Yano et al1) with CAC scores of 0 who exhibit coronary artery disease with an incidence of 6.5% to 20%, and of those, significant stenoses were found in 0.9% to 7.2%. With CAC scores less than 100, noncalcified plaque is found in 23.4% to 65.2% of patients, and those having obstructive stenosis ranged from 2.8% to 17%; Schenker et al2 found that on positron emission tomography–computed tomography, 16% of patients with CAC scores of 0 had myocardial ischemia.