Abstract Body (Do not enter title and authors here): Background: Calcium score has been recommended to be utilized in addition to ACC/AHA risk score for optimizing risk category if needed particularly in the intermediate risk group.
Also, we have learned that excess epicardial fat volume (EFV) is a major cause of endothelial inflammation and endothelial dysfunction of the coronary arteries which might precede coronary calcification and plaque formation which might result in obstructive coronary artery disease (CAD).

Purpose: of this study to see whether subject with high coronary calcium score but normal EFV have significant structural and functional abnormalities including obstructive CAD as compared to subjects with high coronary calcium and excess EFV.

Methods: 55 asymptomatic subjects and on no medications were screened for cardiovascular risk assessment using the Early Cardiovascular Disease Risk Scoring System (ESCVDRS) known as Rasmussen Risk Score (RRS), previously published. The ESCVDRS includes 7 vascular and 3 cardiac tests. Among the additional test, including fasting blood sugar, lipid profile, CRP and waist circumference were also measured. Coronary artery calcium score (CACS) and epicardial fat volume was measured utilizing cardiac CT Siemens Somatom Definition Dual source CT scanner 64x2.The 55 subjects were divided in 2 groups: Group A (Elevated CACS and elevated EFV) and group B (ELEVATED CACS with normal EFV). All subjects in Group B underwent exercise stress test and/or cardiac catheterization.

Results:
1. All subjects in Group B had no significant obstructive CAD, as evidenced by cardiac cath, and/or maximum exercise nuclear stress test.
2. Subjects in group B and not obese have less structural and functional abnormalities including marker for oxidative stress such as CRP.
3. Excess EFV in group A is associated with significant structural and functional abnormalities, as seen in Table.

Conclusion:
1. High risk coronary calcium score without excess EFV might not be associated with significant obstructive CAD.
2. Excess EFV is associated with structural and functional abnormalities.
3. Cardio-adiposity is a major risk factor superseding and most likely preceding coronary calcium score formation.
Time to focus on epicardial fat volume as the major determinant and arbitrator for cardiovascular risk assessment which should be incorporated in the guidelines with and without coronary calcium score values. Time to include EFV in every CACS report. Early detect to protect!