Can and should carotid ultrasound be used in cardiovascular risk assessment?: The internist's perspective

• Carotid atherosclerosis is associated with generalized atherosclerotic burden.
• Carotid atherosclerosis is independently associated with cardiovascular events.
• We recommend carotid ultrasound screening in patients at intermediate risk.
• We advise against periodic measurements to evaluate treatment response.

Cardiovascular risk management is a major and challenging task for internists. Risk scores using algorithms based on traditional risk factors are helpful in identifying patients in whom intensive prevention strategies are warranted. However there remains a need for more accurate screening tools to allow clinicians to individualize the primary prevention programs to their patients.Approximately 40–80% of apparently healthy, asymptomatic subjects exhibit increased thickness of the lamina intima-media of the carotid artery or have atherosclerotic carotid plaques. These abnormalities can be measured safely and at low cost by ultrasound. Subclinical carotid lesions are strongly associated with generalized atherosclerotic burden and the risk of future cardiovascular events. Although many cardiovascular risk management guidelines recommend the use of these parameters incorporation in clinical practice is still not commonplace.Based on the current literature it can be stated that in high risk patients there is no additional value of carotid ultrasound because even in the absence of carotid lesions these patients should receive an intensive risk reduction regime. In the large low-intermediate risk group however carotid ultrasound findings carry subtle but possibly clinically relevant information about cardiovascular risk profile. The effect of treatment decisions based on carotid ultrasound parameters has not been studied. Sequential measurements to monitor progression and evaluate treatment response on an individual basis are not sufficiently reproducible.We therefore recommend the use of carotid ultrasound in low to intermediate risk patients but emphasize the importance of interpreting the results in conjunction with all cardiovascular risk factors and avoid follow-up measurements.