Carotid Plaque Score: A Useful Tool or Futile Gadget for Risk Assessment? An Update
13 affiliations
- 1ACTION Study Group, Inserm UMRS1166, Heart Institute, Pitié-Salpêtrière Hospital, Sorbonne University, 75013 Paris, France
- 2Department of Physiology and Aging, College of Medicine, University of Florida, Gainesville, FL 32611, USA
- 3UOC UTIC Emodinamica e Cardiologia, Santa Maria Goretti Hospital, 04100 Latina, Italy
- 4Department of Medical-Surgical Sciences and Biotechnologies, Sapienza University of Rome, 04100 Latina, Italy
- 5National Institute of Cardiology, Cardiovascular Surgery and Interventional Cardiology (INCCI), 1210 Luxembourg City, Luxembourg
- 6Cardiac Rehabilitation Unit, Rehabilitation Clinic ‘Villa delle Magnolie’, 81020 Castel Morrone, Caserta, Italy
- 7IRCCS Humanitas Research Hospital, 20089 Rozzano, Milan, Italy
- 8Department of Biomedical Sciences, Humanitas University, 20072 Milan, Italy
- 9Faculty of Medicine, Alexandria University, 5372066 Alexandria, Egypt
- 10Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, 81100 Caserta, Italy
- 11Department of Clinical and Experimental Medicine, University of Messina and Azienda Ospedaliera Papardo, 98124 Messina, Italy
- 12Center for Prevention of Cardiovascular Disease, Department of Cardiovascular Medicine, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
- 13Jesselson Integrated Heart Center, Shaare Zedek Medical Center, Eisenberg R&D authority and Faculty of Medicine, Hebrew University of Jerusalem, 9103102 Jerusalem, Israel
Abstract
Conventional cardiovascular risk scores estimate the probability of future events; however, these risk scores do not directly quantify the presence or extent of subclinical atherosclerosis. This narrative review critically evaluates the current evidence on the carotid plaque score (CPS), a semiquantitative ultrasound-based measure of carotid atherosclerotic burden across predefined arterial segments. Population-based cohorts have consistently shown that carotid plaque presence and burden are independently associated with cardiovascular and cerebrovascular events. Studies specifically evaluating CPS have further suggested an incremental prognostic value beyond conventional risk models, particularly for ischemic stroke and major adverse cardiovascular event (MACE). However, CPS does not represent a single standardized metric. Therefore, proposed thresholds, including CPS ≥2 and CPS >3, were derived using different plaque definitions, arterial segments, scoring methods, and study populations and are not directly interchangeable. Meanwhile, CPS is more accessible, non-ionizing, and relatively inexpensive compared with coronary artery calcium (CAC), but it is less extensively validated and less standardized. Nonetheless, available comparative evidence indicates that CAC provides superior discrimination for coronary outcomes. In contrast, carotid plaque assessment may offer complementary information for cerebrovascular risk and in selected individuals with discordant estimated risk or no detectable coronary calcification. No randomized trial has demonstrated that treatment decisions guided by CPS improve clinical outcomes. Accordingly, current guidelines generally position carotid plaque imaging as a selective risk modifier rather than a routine screening or stand-alone treatment-allocation tool. Thus, broader clinical implementation will require standardized acquisition and reporting protocols, external validation across diverse populations, integration with established risk models, and prospective studies evaluating whether CPS-guided preventive strategies improve patient outcomes.
Related
- Territory-based ultrasound assessment for extracranial and vertebrobasilar arterial stenosis and carotid plaque vulnerability: a multicentre comparison with digital subtraction angiography and histopathology
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- Carotid atherosclerotic plaque characterization using dual-energy computed tomography angiography and its correlation with cerebral ischemic stroke
- Quantitative CTA-Based Carotid Plaque Composition Across Stroke Etiologies and Residual Vascular Risk
- Transient perivascular inflammation of the carotid artery superimposed on carotid atherosclerotic plaque, recurring at the mid-common carotid artery: a case report
BibTeX
@article{sulman2026carotid,
title = {{Carotid Plaque Score: A Useful Tool or Futile Gadget for Risk Assessment? An Update}},
author = {David Sulman and Stefano Cacciatore and Marco Bernardi and Luigi Spadafora and Atul Pathak and Francesco Perone and Stefano Figliozzi and Ali Abdelaziz and Felice Gragnano and Paolo Calabro and Dario Mafrica and Giuseppe Andò and Michael D. Shapiro and Elad Asher and Pierre Sabouret},
journal = {Reviews in Cardiovascular Medicine},
year = {2026},
month = oct,
doi = {10.31083/rcm50123},
url = {https://doi.org/10.31083/rcm50123},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Carotid Plaque Score: A Useful Tool or Futile Gadget for Risk Assessment? An Update
AU - David Sulman
AU - Stefano Cacciatore
AU - Marco Bernardi
AU - Luigi Spadafora
AU - Atul Pathak
AU - Francesco Perone
AU - Stefano Figliozzi
AU - Ali Abdelaziz
AU - Felice Gragnano
AU - Paolo Calabro
AU - Dario Mafrica
AU - Giuseppe Andò
AU - Michael D. Shapiro
AU - Elad Asher
AU - Pierre Sabouret
PY - 2026
DA - 2026/10/23
JO - Reviews in Cardiovascular Medicine
DO - 10.31083/rcm50123
UR - https://doi.org/10.31083/rcm50123
AB - Conventional cardiovascular risk scores estimate the probability of future events; however, these risk scores do not directly quantify the presence or extent of subclinical atherosclerosis. This narrative review critically evaluates the current evidence on the carotid plaque score (CPS), a semiquantitative ultrasound-based measure of carotid atherosclerotic burden across predefined arterial segments. Population-based cohorts have consistently shown that carotid plaque presence and burden are independently associated with cardiovascular and cerebrovascular events. Studies specifically evaluating CPS have further suggested an incremental prognostic value beyond conventional risk models, particularly for ischemic stroke and major adverse cardiovascular event (MACE). However, CPS does not represent a single standardized metric. Therefore, proposed thresholds, including CPS ≥2 and CPS >3, were derived using different plaque definitions, arterial segments, scoring methods, and study populations and are not directly interchangeable. Meanwhile, CPS is more accessible, non-ionizing, and relatively inexpensive compared with coronary artery calcium (CAC), but it is less extensively validated and less standardized. Nonetheless, available comparative evidence indicates that CAC provides superior discrimination for coronary outcomes. In contrast, carotid plaque assessment may offer complementary information for cerebrovascular risk and in selected individuals with discordant estimated risk or no detectable coronary calcification. No randomized trial has demonstrated that treatment decisions guided by CPS improve clinical outcomes. Accordingly, current guidelines generally position carotid plaque imaging as a selective risk modifier rather than a routine screening or stand-alone treatment-allocation tool. Thus, broader clinical implementation will require standardized acquisition and reporting protocols, external validation across diverse populations, integration with established risk models, and prospective studies evaluating whether CPS-guided preventive strategies improve patient outcomes.
SN - 1530-6550
SN - 2153-8174
ER -