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..................................... 4.2.1 Role of non-invasive cardiovascular imaging techniques in the assessment of total cardiovascular disease risk Non-invasive imaging techniques can detect the presence, estimate the extent, and evaluate the clinical consequences of atherosclerotic vascular damage. Detection of coronary artery calcification with noncontrast computed tomography (CT) gives a good estimate of the atherosclerotic burden and is strongly associated with CV events.18 A recent meta-analysis from the US Preventive Services Task Force summarized the available evidence on the value of non-traditional risk factors for risk prediction, and found that, although there are no randomized trials showing that the use of CAC reduces health outcomes, nevertheless it improves both discrimination and reclassification.19 Assessment of carotid or femoral plaque burden with ultrasound has also been demonstrated to be predictive of CV events, comparable to CAC,2023 while the measurement of the carotid intimamedia thickness is inferior to CAC score and carotid plaque detection.16,24,25 In asymptomatic patients at low or moderate risk who would be eligible for statin therapy (see Table 5), assessment of ASCVD with imaging may have an impact on medical treatment, both from the physician’s and the patient’s points of view. Data from the Multi- Ethnic Study of Atherosclerosis (MESA) showed that 4157% of individuals who would be eligible for statin therapy had a CAC score of zero and the rate of atherosclerotic CVD events in the 10 year ........................................................................................................................................................................ Table 5 Intervention strategies as a function of total cardiovascular risk and untreated low-density lipoprotein cholesterol levels Total CV risk (SCORE) % Untreated LDL-C levels <1.4 mmol/L (55 mg/dL) 1.4 to <1.8 mmol/L (55 to <70 mg/dL) 1.8 to <2.6 mmol/L (70 to <100 mg/dL) 2.6 to <3.0 mmol/L (100 to <116 mg/dL) 3.0 to <4.9 mmol/L (116 to <190 mg/dL) 4.9 mmol/L (190 mg/dL) Primary prevention <1, low-risk Lifestyle advice Lifestyle advice Lifestyle advice Lifestyle advice Lifestyle inter- vention, consider adding drug if uncontrolled Lifestyle inter- vention and concomitant drug intervention Classa/Levelb I/C I/C I/C I/C IIa/A IIa/A 1 to <5, or moderate risk (see Table 4) Lifestyle advice Lifestyle advice Lifestyle advice Lifestyle intervention, con- sider adding drug if uncontrolled Lifestyle intervention, con- sider adding drug if uncontrolled Lifestyle intervention and concomitant drug intervention Classa/Levelb I/C I/C IIa/A IIa/A IIa/A IIa/A 5 to <10, or high-risk (see Table 4) Lifestyle advice Lifestyle advice Lifestyle inter- vention, consider adding drug if uncontrolled Lifestyle inter- vention and concomitant drug intervention Lifestyle inter- vention and concomitant drug intervention Lifestyle inter- vention and concomitant drug intervention Classa/Levelb IIa/A IIa/A IIa/A I/A I/A I/A 10, or at very-high risk due to a risk condition (see Table 4) Lifestyle advice Lifestyle inter- vention, consider adding drug if uncontrolled Lifestyle inter- vention and concomitant drug intervention Lifestyle inter- vention and concomitant drug intervention Lifestyle inter- vention and concomitant drug intervention Lifestyle inter- vention and concomitant drug intervention Classa/Levelb IIa/B IIa/A I/A I/A I/A I/A Secondary prevention Very-high-risk Lifestyle inter- vention, consider adding drug if uncontrolled Lifestyle inter- vention and concomitant drug intervention Lifestyle inter- vention and concomitant drug intervention Lifestyle inter- vention and concomitant drug intervention Lifestyle inter- vention and concomitant drug intervention Lifestyle inter- vention and concomitant drug intervention Classa/Levelb IIa/A I/A I/A I/A I/A I/A CV = cardiovascular; LDL-C = low-density lipoprotein cholesterol; SCORE = Systematic Coronary Risk Estimation. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/41/1/111/5556353 by guest on 07 October 2026