Key result
Early atherosclerosis imaging is linked to up to ~97% fewer ASCVD events than expected via improved treatment.
Why the study?
Traditional risk tools relying on clinical factors may fail to identify subclinical atherosclerosis, risking over- and undertreatment, whereas early imaging may improve risk stratification and guide personalized prevention.
Does early atherosclerosis imaging improve risk stratification and reduce ASCVD events in asymptomatic adults undergoing cardiovascular risk evaluation?
Does early atherosclerosis imaging improve risk stratification and reduce ASCVD events in asymptomatic adults undergoing cardiovascular risk evaluation?
Incorporating early atherosclerosis imaging into routine risk assessment for asymptomatic adults leads to significant treatment reclassification and is associated with substantially lower-than-expected ASCVD event rates.
May support imaging-guided reclassification in asymptomatic adults; supports consensus but leaves open need for RCTs to confirm benefit.
Background Traditional risk assessment tools primarily rely on clinical risk factors to estimate cardiovascular risk but may fail to accurately identify individuals with subclinical atherosclerosis. This limitation can lead to both over- and undertreatment, potentially affecting clinical outcomes. Early detection of atherosclerosis through imaging may improve risk stratification and guide more personalised prevention strategies. Purpose This study aims to assess the impact of early atherosclerosis imaging on risk stratification, treatment strategy modification, and clinical outcomes in a broad population of asymptomatic adults undergoing cardiovascular risk evaluation. Methods A total of 2,544 asymptomatic adults at the time of referral (mean age: 51.6, 47% women) were enrolled in a single-centre preventive cardiology programme. Patients underwent atherosclerosis imaging (coronary computed tomography angiography [CCTA], coronary artery calcium [CAC] scoring, or carotid ultrasound) based on clinical presentation and patient age. Treatment decisions were guided by imaging findings of atherosclerosis and traditional risk scores, with follow-up for a mean of 4.0 ± 1.7 years. The primary outcome was the observed-to-expected (O/E) ratio of atherosclerotic cardiovascular disease (ASCVD) events. Results Atherosclerosis was detected in 1,328 (52.2%) subjects, including 749 (41.7%) of those classified as low risk by traditional scoring. Imaging-based management resulted in net reclassification for lipid-lowering therapy in 931 (36.7%) of subjects. Observed ASCVD event rates were significantly lower than expected, as calculated from risk estimate models based on risk factors and CCTA and CAC score findings, with an O/E ratio ranging from 0.11 to 0.03. The number needed to treat (NNT) to prevent one myocardial infarction using an early atherosclerosis-based treatment strategy ranged from 14 to 65. Conclusion Incorporating atherosclerosis imaging into routine cardiovascular risk assessment enhances risk stratification, enables personalized treatment strategies, and is associated with a lower rate of cardiovascular events compared to traditional risk-based approaches.
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Nasibi et al. (2025) studied this question. Early atherosclerosis imaging improved risk stratification and treatment, yielding O/E ASCVD event ratios as low as 0.03 and NNT of 14-65 to prevent one MI.
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