Perspective:

While use of traditional risk factors to identify patients at high, intermediate, and low risk for ASCVD events is helpful to guide primary prevention therapy, there has been longstanding interest in the addition of arterial imaging as a way to further improve risk prediction. While much of the prior work has focused on the use of carotid ultrasound imaging, especially the carotid intima-media thickness, other arterial bifurcation areas may offer insight into the atherosclerotic process. The authors report on the benefits of measuring plaque at four key arterial bifurcation areas (bilateral carotid and femoral bifurcations) over the use of any single sight to improve risk prediction beyond traditional risk factors. While noninvasive and not requiring any radiation, the routine use of imaging has long presented a challenge for broad implementation. If these findings are validated in datasets of diverse patient populations, then clinicians may need to consider the role of imaging when approaching risk stratification for ASCVD events. For now, more consistent use of traditional risk estimation and initiation of risk-modifying therapies (e.g., lipid lowering, tobacco cessation, blood pressure control) remain important targets.