Carotid Plaque Score: A Useful Tool or Futile Gadget for Risk Assessment? An Update

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.