Is there a role for routine stress testing in intermediate-high risk CAD patients with a significantly elevated coronary calcium score who are otherwise asymptomatic?

Current data does not support stress testing in asymptomatic intermediate risk individuals in general and those with incidental CAC also do not have an indication for the test. ASCVD risk factor modification suffices.

I focus on aggressive risk factor modification.

A common scenario, and I agree with aggressive risk factor modification with a low threshold overall for any symptoms that may be attributable to coronary artery disease (CAD). This would include significant ectopy/arrhythmia, etc.

Stress test for silent ischemia. Prefer nuclear dual isotope protocol.

"Significant" means what in reference to Agatston scoring?

Does it matter in terms of where the calcification is located? If the LMCA is involved - by what score in that location would exclusion of ischemia be reasonable?

Lots more questions than answers.