Primary prevention: risk factors assessment, coronary calcium score or arterial imaging?

During the past decades many efforts have been done to improve our capacities to identify patients at high risk of vascular disease who may benefit by preventive strategies based on vascular risk factors (VRFs) control. Emerging evidences, however, have shown that approximately one-third of vascular events are not attributable to conventional VRFs and that a number of cardiac events occur in individuals free of VRFs. This has induced the scientific community in looking for refining strategies for a better stratification of patient’s risk. Recent developments in imaging techniques have allowed the assessment of innovative markers of atherosclerosis which may be used to accomplish with this task. Among imaging techniques, the assessment of subclinical atherosclerosis in carotid arteries by ultrasonic techniques and in particular of carotid intima media thickness (CIMT), as well as the assessment of coronary calcium score (CCS) by computed tomography or electron bean tomography have been advocated as useful tools to be used in the clinical practice to improve the cardiovascular risk stratification. Clinical and experimental studies have shown that both CIMT and CCS are able to characterize the arterial disease and to better stratify the patient’s cardiovascular risk. In view of its completely non-invasive nature, CIMT can be repeatedly determined in all kind of subjects (even in children), in an office-based outpatient care environment (even with portable devices). In addition, as we have recently shown, even when measured in routine clinical practice, the additional information provided by CIMT evaluation, combined with the easily calculated Framingham Risk Score (FRS), has the potential to substantially improve the physician’s ability to identify at an early stage the asymptomatic patient at high risk of cardiovascular events. On these basis, the evaluation of CIMT has been proposed in the primary step of vascular disease screening and for the implementation of primary-prevention strategies and its use to clarify patient’s cardiovascular risk is supported by several international societies.