madman
Super Moderator
Curated By Nelson Vergel | ExcelMale.com | Updated May 2026
If you're on testosterone replacement therapy (TRT), you're likely paying close attention to your labs - testosterone levels, estradiol, hematocrit, and lipids. But one critical cardiovascular test remains underutilized by most men on TRT and their physicians: the coronary artery calcium (CAC) score. This simple, inexpensive imaging test could tell you more about your real heart disease risk than any blood panel alone.
For men on TRT, cardiovascular risk is a topic that generates more confusion than clarity. A decade of conflicting studies left both patients and doctors unsure how to monitor heart health. The landmark TRAVERSE trial has since provided important reassurance - but also surfaced new questions about long-term monitoring. A baseline CAC score gives you a concrete, actionable picture of what is actually happening inside your arteries, regardless of what your cholesterol numbers show.
This article explains what the CAC score measures, how TRT relates to coronary plaque, and why every man on hormone therapy should consider getting a baseline scan.
| What You Will Learn in This Article |
| • What a CAC score is and how the Agatston scoring system works |
| • Whether TRT raises or lowers your coronary artery calcium score |
| • What score ranges mean and when to act |
| • Which men on TRT most urgently need this test |
| • Evidence-based strategies to slow or reverse plaque progression |
What Does a Coronary Artery Calcium (CAC) Score Actually Measure?
A coronary artery calcium score quantifies the amount of calcified plaque in the walls of your coronary arteries using a non-contrast CT scan. The result is expressed as an Agatston score - a number that reflects both the area and density of calcium deposits across all major coronary vessels.The CAC score does not measure cholesterol, blood pressure, or other conventional risk markers. Instead, it directly images what has already happened inside your arteries. As Dr. Matthew Budoff, a lead investigator on the MESA study, explains it: a zero score means no detectable calcified plaque; any score above zero confirms that atherosclerosis has begun.
Think of calcium as the tip of the iceberg. Wherever calcified plaque exists, soft non-calcified plaque is almost certainly present in greater volume beneath the surface. A CAC score therefore functions as a proxy for your overall plaque burden, not just the hardened, calcified fraction.
How Is the CAC Test Done and What Does It Cost?
The scan itself is fast and painless. You lie on a CT table, a few EKG leads are attached to track your heartbeat, and the scan takes roughly 30 seconds. There are no needles, no contrast dye, and no radiation exposure comparable to a full CT scan. The effective radiation dose is similar to a mammogram.Cost ranges from roughly $99 to $200 at most outpatient imaging centers. Some private insurers cover it for intermediate-risk patients; Medicare does not yet have a national coverage decision as of 2026, though this is actively under review. In many states, you can self-refer without a physician order, making it one of the most accessible preventive imaging tools available.
What Do the CAC Score Numbers Mean?
| CAC Score | Risk Category | Interpretation | Recommended Action |
| 0 | Very Low | No detectable calcified plaque | Lifestyle optimization; retest in 4-5 years |
| 1-99 | Mild | Mild subclinical atherosclerosis | Lifestyle changes; discuss statin with doctor |
| 100-299 | Moderate | Significant plaque burden; elevated 10-yr risk | Statin therapy; aggressive risk factor control |
| 300-399 | High | Extensive atherosclerosis | High-intensity statin; consider PCSK9 inhibitor |
| 400+ | Very High | Equivalent to known heart disease in many guidelines | Aggressive medical therapy; cardiology referral |
One important nuance: a score of zero does not mean zero risk, particularly in younger men or those with very high-risk genetics. It means no calcified plaque has formed yet. Soft, non-calcified plaque can be present and can rupture even when the CAC score is zero. For most men over 45 with a CAC of zero, however, the 5-year risk of a major cardiac event is very low.
Does Testosterone Replacement Therapy Affect Your CAC Score?
This is the question most men on TRT want answered. The honest answer: TRT does not appear to significantly raise your CAC score, but the relationship between testosterone, coronary plaque, and cardiovascular risk is more nuanced than a single number can capture.The TRAVERSE trial (2023), the largest randomized cardiovascular safety study of TRT ever conducted, enrolled 5,198 hypogonadal men with existing cardiovascular disease or elevated risk. The trial enrolled men with a CAC score above the 75th percentile for age and race as one criterion for elevated cardiovascular risk. After an average of 22 months, TRT was non-inferior to placebo for major adverse cardiac events including heart attack, stroke, and cardiovascular death. Notably, men who received TRT showed no significant difference in CAC score progression compared to the placebo group.
A meta-analysis published in European Urology in 2024 analyzed 30 randomized controlled trials involving 11,502 patients and reached the same conclusion: TRT did not increase the risk of any major cardiovascular event, cardiovascular mortality, or all-cause mortality in hypogonadal men.
The Androgen Society formally stated in 2024 that the question of whether TRT causes fatal cardiovascular events is now settled science - the answer is no, when therapy is properly managed within physiological ranges.
What Did the TTrials Find About TRT and Coronary Plaque?
Here is where the picture gets more complex. The cardiovascular arm of the TTrials - a separate NIH-funded study of older hypogonadal men - found that TRT was associated with a greater increase in non-calcified (soft) coronary plaque volume over 12 months compared to placebo, as measured by CT angiography. This was not reflected in the CAC score itself, since calcified and non-calcified plaque are measured differently.The clinical significance of this finding remains debated. At the end of the study, the total non-calcified plaque burden was still greater in the placebo group, because placebo patients had more at baseline. The TRAVERSE trial - larger, longer, and more statistically powered - found no difference in actual cardiovascular events. Most cardiologists and endocrinologists now interpret the TTrials plaque finding as a signal worth monitoring rather than evidence of harm.
The practical takeaway: a baseline CAC scan before starting TRT, or within the first year if you haven't had one, gives you a benchmark. If your score rises significantly (more than 20% per year) over serial measurements, that warrants investigation independent of whether you are on TRT.
Why Low Testosterone Itself May Be a Cardiovascular Warning Sign
An underappreciated finding in the cardiovascular literature is that untreated low testosterone is itself associated with elevated cardiovascular risk. Men with hypogonadism have higher rates of metabolic syndrome, insulin resistance, visceral adiposity, and coronary artery disease than age-matched men with normal testosterone levels.A study of 580 men undergoing coronary artery intervention found that those with low testosterone had more than twice the rate of major adverse cardiac events over 48 months compared to men with normal levels. This association held after adjusting for conventional risk factors.
In other words, the cardiovascular concern is not only about TRT; it is about the systemic metabolic burden that low testosterone creates. Treating hypogonadism appropriately may itself reduce cardiovascular risk in some men, particularly those whose low testosterone is driving insulin resistance, visceral fat accumulation, and inflammation.
Should Men on TRT Get a Baseline CAC Score - and When?
The 2018 ACC/AHA cholesterol guidelines formalized CAC scoring as a decision-support tool for intermediate-risk patients - men aged 40 to 75 where the decision to start a statin is uncertain. The TRAVERSE trial went further, explicitly using CAC score above the 75th percentile for age and race as a risk stratification criterion at enrollment.For men on TRT, the rationale for baseline CAC testing is straightforward:
• It provides direct evidence of subclinical atherosclerosis that cholesterol panels alone cannot detect
• It helps stratify your true cardiovascular risk so your TRT protocol can be properly contextualized
• It establishes a baseline for future comparison - so you and your physician can track whether plaque is stable, progressing, or responding to treatment
• It may influence decisions about statin therapy, blood pressure management, and lifestyle interventions independent of TRT
What Is the Right Age to Get Your First CAC Scan?
Most cardiovascular guidelines recommend CAC scoring between ages 40 and 75 for asymptomatic patients with intermediate risk. For younger men (under 40), the yield is low because soft, non-calcified plaque predominates and the CAC score may give false reassurance. For men over 40 on TRT with any of the following, a baseline CAC scan is reasonable to discuss with your doctor:• Family history of premature coronary artery disease (first-degree relative before age 55 for men)
• Hypertension, dyslipidemia, or diabetes
• Elevated Lp(a) levels (above 50 mg/dL or 125 nmol/L)
• High-sensitivity CRP above 2 mg/L
• Elevated ApoB or small dense LDL particles
• Metabolic syndrome or significant insulin resistance
• Prior long-term hypogonadism before TRT was initiated
What Should You Do If Your CAC Score Is High While on TRT?
A high CAC score is not a reason to stop TRT. It is a reason to take your cardiovascular risk seriously and apply evidence-based strategies to slow plaque progression. The goal is to stabilize existing plaque, reduce soft plaque volume, and prevent future events - all achievable with aggressive risk factor management.LDL cholesterol reduction is the most powerful tool available. Studies consistently show that driving LDL below 55 mg/dL - achievable with high-intensity statins or PCSK9 inhibitors such as evolocumab (Repatha) or alirocumab (Praluent) - produces measurable regression of soft non-calcified plaque. The calcified portion of plaque (what the CAC score measures) does not shrink with treatment, but its rate of growth can be slowed significantly.
The GLAGOV trial demonstrated that evolocumab achieved mean LDL levels of 36.6 mg/dL and induced plaque regression in 64% of treated patients, compared to 47% in the placebo group. PCSK9 inhibitors are particularly relevant for men on TRT who experience statin-related muscle side effects (elevated CPK), as PCSK9 inhibitors do not carry the myopathy risk associated with statins.
Additional evidence-based strategies include:
• Blood pressure control targeting below 130/80 mmHg
• Aerobic exercise: 150 minutes per week of moderate-intensity activity reduces plaque progression
• Mediterranean or low-inflammatory dietary pattern, with particular attention to limiting processed carbohydrates
• Hematocrit management on TRT - targeting below 50% reduces blood viscosity and thrombotic risk
• Sleep optimization: poor sleep drives inflammation and plaque progression independently of other risk factors
• Smoking cessation: the single highest-impact modifiable cardiovascular risk factor after LDL
| Key Takeaways |
| • The CAC score is a direct, inexpensive imaging test that reveals actual coronary plaque - not just estimated risk |
| • TRT does not appear to significantly increase CAC scores or major cardiovascular events at physiological doses |
| • Untreated low testosterone itself is associated with elevated cardiovascular risk |
| • Men on TRT aged 40 or older with any cardiovascular risk factors should discuss baseline CAC testing with their doctor |
| • A high CAC score is not a reason to stop TRT - it is a reason to aggressively manage LDL, blood pressure, and lifestyle |
| • Serial CAC measurements (every 2-5 years depending on baseline score) allow you to track whether risk is stable or progressing |
| • PCSK9 inhibitors offer meaningful plaque regression for men who cannot tolerate statins |
Frequently Asked Questions
Can a CAC score of zero happen even if I have been on TRT for years?
Yes. A CAC score of zero is common even in men who have been on TRT for many years, particularly those who maintain a healthy weight, exercise regularly, and have good lipid profiles. TRT at physiological doses does not appear to independently drive calcium deposition. If you are under 50 and score zero, that is a strong indicator of low near-term cardiovascular risk.Does TRT affect the accuracy of my CAC score?
No. The CAC scoring method measures calcified plaque using CT imaging - a physical finding that is not altered by testosterone itself. The concern raised in the TTrials was about non-calcified (soft) plaque, which requires CT angiography to detect. Your CAC score accurately reflects calcified plaque regardless of whether you are on TRT or not.If my CAC score is rising, should I reduce my TRT dose?
Not necessarily. CAC score progression at more than 20% per year indicates ongoing plaque activity that warrants evaluation, but the driver is more likely LDL, blood pressure, insulin resistance, or inflammation rather than TRT itself. Discuss with your cardiologist before making any changes to your hormone protocol. The TRAVERSE trial found no significant difference in CAC progression between the TRT and placebo groups, so TRT dose adjustment alone is unlikely to alter your trajectory. Focus on the metabolic drivers first.How often should men on TRT repeat a CAC scan?
Frequency depends on your baseline score. A score of zero warrants rescanning at 4 to 5 years. A score of 1 to 99 warrants rescanning at 2 to 3 years. A score of 100 or above warrants annual evaluation - often with CT angiography for more detail - especially if you are initiating or intensifying treatment. Your cardiologist will guide the monitoring interval based on your full risk profile.Does my TRT affect statin effectiveness or the ability to regress plaque?
Testosterone at physiological levels does not appear to interfere with statin or PCSK9 inhibitor mechanisms. Some men on TRT see modest decreases in HDL cholesterol, which is one reason monitoring lipids at least annually is important. If your LDL rises on TRT, that is a signal to discuss lipid-lowering therapy with your physician - not to stop TRT.Related ExcelMale Forum Discussions
For deeper community discussion on these topics, explore these ExcelMale threads:Why You Need a Calcium Score to Know Your Real Heart Risk | Dr. Matthew Budoff
Dr. Budoff discusses the CAC scan as the most underutilized cardiovascular test and how imaging directly shifts the risk conversation from probability to presence of disease.
Repatha (Evolocumab) Effects on CAC Scoring and CCTA
Detailed review of PCSK9 inhibitor effects on coronary plaque, including the GLAGOV trial results and the calcium paradox. Includes Nelson Vergel's personal experience with Repatha.
TRT and Cardiovascular Risk: TRAVERSE with Caution
An in-depth analysis of the TRAVERSE trial findings, including the meta-analysis by Jaiswal et al. covering 30 RCTs and 11,502 patients showing no increased CVD risk with TRT.
Testosterone and Your Heart: What a Major New Study Really Found
Community discussion of the TRAVERSE trial conclusions and the Androgen Society's position that the cardiovascular safety of TRT is now settled science.
Is It the TRAVERSE Trial or a Travesty?
Critical community analysis of the TRAVERSE study design limitations, including early truncation and high dropout rates, and what those limitations mean for interpreting the results.
My CAC Calcium Score Is High - Should I Take Vitamin K?
Community discussion of what to do after receiving a high CAC score, including the evidence for vitamin K2, nattokinase, and conventional lipid-lowering therapy.
Fish Oil and Heart Health with a High CAC Score of 850
A member shares their CAC score of 850 and the community responds with practical guidance on managing high-risk plaque burden alongside TRT.
TRT and Long-Term Health Risks
Broad review of the literature on TRT and cardiovascular outcomes, including the cardioprotective effects of maintaining physiological testosterone levels.
Testosterone Replacement Therapy and Cardiovascular Risk
Discussion of the TTrials cardiovascular arm and what the increase in non-calcified plaque volume means in the context of overall risk management.
Key References
| # | Reference | Link |
| 1 | Budoff MJ et al. Assessment of coronary artery disease by cardiac computed tomography: a scientific statement. Circulation. 2006. | View |
| 2 | Gaine SP, Blumenthal RS, Sharma G. Coronary Artery Calcium Score as a Graded Decision Tool. JACC Advances. 2023. | View |
| 3 | Lincoff AM et al. Cardiovascular Safety of Testosterone-Replacement Therapy. N Engl J Med. 2023. | View |
| 4 | Jaiswal A et al. Testosterone therapy and cardiovascular risk in hypogonadal men: systematic review. Eur Urol. 2024. | View |
| 5 | Budoff MJ et al. Testosterone Treatment and Coronary Artery Plaque Volume in Older Men with Low Testosterone. JAMA. 2017. | View |
| 6 | Trumble BC et al. Testosterone is positively associated with coronary artery calcium in a low CVD-risk population. Evol Med Public Health. 2023. | View |
| 7 | Grundy SM et al. 2018 AHA/ACC Cholesterol Guidelines: executive summary. J Am Coll Cardiol. 2019. | View |
| 8 | Ballantyne CM et al. Evolocumab (Repatha): coronary plaque regression and stabilization (GLAGOV). JAMA. 2017. | View |
| 9 | Sniderman AD et al. Androgen Society Position Paper on Cardiovascular Risk With Testosterone Therapy. Mayo Clin Proc. 2024. | View |
| 10 | MESA Study Group. Coronary calcium as a predictor of coronary events in four racial or ethnic groups. N Engl J Med. 2008. | View |
Medical Disclaimer
This article is for educational purposes only and does not constitute medical advice. Always consult a qualified healthcare provider before starting or modifying any hormone therapy, medical treatment, or cardiovascular screening protocol.About ExcelMale
ExcelMale.com is a peer-to-peer men's health forum with more than 24,000 members and over 20 years of community discussion on testosterone replacement therapy, hormone optimization, peptides, sexual health, and preventive cardiology. The forum is founded and curated by Nelson Vergel, a chemical engineer, 34-year TRT patient, and author ofTestosterone: A Man's Guide and Beyond Testosterone. ExcelMale is home to one of the largest English-language archives of TRT-related clinical discussion and patient experience on the internet.
Last edited by a moderator:
