Preventive cardiovascular ultrasound imaging: a strategy for lifelong atherosclerosis control

INTRODUCTION: Atherosclerosis develops silently over decades before manifesting as myocardial infarction, stroke, or cardiovascular (CV) death. Carotid and femoral ultrasound can identify subclinical atherosclerosis SA), quantify plaque burden, and refine cardiovascular risk assessment beyond traditional risk factors. AREAS COVERED: This narrative review synthesizes evidence from population-based cohorts, longitudinal studies, clinical trials, and imaging investigations from 1987-2026 identified through PubMed, Scopus, and Google Scholar. Carotid and femoral plaque prevalence, associated risk factors, vulnerability, natural history, prediction of CV events across the lifespan, serial ultrasound assessment of plaque progression and regression, including responses to lifestyle modification and lipid-lowering therapy are discussed. Comparisons with other imaging modalities and the importance of primordial prevention to reduce cumulative exposure to CV risk factors are addressed. EXPERT OPINION: Carotid and femoral plaque ultrasound offers a practical, accessible, radiation-free approach to detecting subclinical atherosclerosis and supporting individualized prevention. Plaque assessment may inform risk discussions, reinforce lifestyle changes, and improve adherence to appropriate lipid-lowering therapy. Standardized acquisition, reproducible measurements, and validated thresholds are needed for broader implementation. Prospective trials should establish whether ultrasound-guided prevention improves clinical outcomes. Integrating plaque imaging with sustained risk factor control and primordial prevention may help reduce the lifetime burden of atherosclerotic CV disease.