How do you counsel patients with metabolic syndrome who decline statin therapy and have low coronary calcium scores regarding their long term CVD risk?  

This is a great question with many ramifications, and I can only give an incomplete answer that includes personal opinion. First, what is the risk? The MESA Risk Score Calculator (check it out) gives a CAC percentile score as well as a 10-year risk. The 10-year risk may be low, but a high percentile...