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............................................................................................................................................................................. 3.3.3. Imaging 3.3.3.1 Coronary artery calcium Coronary artery calcium (CAC) scoring can reclassify CVD risk upwards and downwards in addition to conventional risk factors, and may thus be considered in men and women with calculated risks around decision thresholds.103,104 Availability and costeffectiveness of large-scale CAC scanning must, however, be considered in a locoregional context (see section 2.3 on costeffectiveness). If CAC is detected, its extent should be compared with what would be expected for a patient of the same sex and age. Higher-than-expected CAC increases the person’s calculated risk, whereas absent or lower-than-expected CAC is associated with lower than calculated risk. CAC scoring does not provide direct information on total plaque burden or stenosis severity, and can be low or even zero in middle-aged patients with soft non-calcified plaque. Clinicians are advised to consult existing protocols for details of how to assess and interpret CAC scores.

3.3.3.2 Contrast computed tomography coronary angiography Contrast computed tomography angiography (CCTA) allows identification of coronary stenoses and predicts cardiac events.119 In the SCOT-HEART (Scottish Computed Tomography of the Heart) study, 5-year rates of coronary death or myocardial infarction were reduced when CCTA was used in patients with stable chest pain.120 The relative reduction in myocardial infarction was similar in patients with non-cardiac chest pain. Whether CCTA improves risk classification or adds prognostic value over CAC scoring is unknown.

3.3.3.3 Carotid ultrasound Systematic use of intima-media thickness (IMT) to improve risk assessment is not recommended due to the lack of methodological standardization, and the absence of added value of IMT in predicting future CVD events, even in the intermediate-risk group.121 Plaque is defined as the presence of a focal wall thickening that is >_50% greater than the surrounding vessel wall, or as a focal region with an IMT measurement >_1.5 mm that protrudes into the lumen.122 Although the evidence is less extensive than it is for CAC, carotid artery plaque assessment using ultrasonography probably also reclassifies CVD risk,104,122 and may be considered as a risk modifier in patients at intermediate risk when a CAC score is not feasible.

3.3.3.4 Arterial stiffness Arterial stiffness is commonly measured using either aortic pulse wave velocity or arterial augmentation index. Studies suggest that arterial stiffness predicts future CVD risk and improves risk classification.123 However, measurement difficulties and substantial publication bias106 argue against widespread use.

3.3.3.5 Ankle brachial index Estimates are that 1227% of middle-aged individuals have an ankle brachial index (ABI) <0.9, around 5089% of whom do not have typical claudication.124 An individual patient data metaanalysis concluded that the reclassification potential of ABI was limited, perhaps with the exception of women at intermediate risk.125 3.3.3.6 Echocardiography In view of the lack of convincing evidence that it improves CVD risk reclassification, echocardiography is not recommended to improve CV risk prediction.

3.3.4.Frailty Frailty is a multidimensional state, independent of age and multimorbidity, that makes the individual more vulnerable to the effect of stressors. It constitutes a functional risk factor for unfavourable outcomes, including both high CV and non-CV morbidity and mortality.126,127 Frailty is not the same as ageing and the two should not be confused. The incidence of frailty increases with age, but people of the same chronological age can differ significantly in terms of health status and vitality. ‘Biological age’ is much more important in the context of clinical status (including frailty features) and hard clinical outcomes (including CVD events).126,127 Similarly, although the presence of comorbidities can exacerbate frailty within an individual, frailty is not the same as multimorbidity (see section 6.7). Frailty screening is indicated in every elderly patient, but should also be performed in every individual regardless of his/her age, when being at risk of accelerated ageing.126,127 Most of the tools relate to frail features, including slowness, weakness, low physical activity (PA), exhaustion, and shrinking (e.g. Fried scale, Short Physical Performance Battery, Rockwood Clinical Frailty Scale, handgrip strength, gait speed).126129 Frailty assessment is important at each stage of an ASCVD trajectory. During an acute CVD event, however, frailty assessment is more difficult, and either relies on history taking or should be postponed to when patients return to a stable condition. Frailty is a potential modifier of global CVD risk. The impact of frailty on CVD risk has been demonstrated across the spectrum of ASCVD, including people with ASCVD risk factors, patients with subclinical ASCVD, stable ASCVD, acute cerebral and coronary syndromes, and HF,126130 with frailty itself rather than classical CVD risk factors predicting both all-cause and CVD mortality in the very old.130,131 Importantly, the ability of frailty measures to improve CVD risk prediction has not been formally assessed. Hence, we do not recommend that frailty measures are integrated into formal CVD risk assessment. Importantly, frailty may influence treatment. Non-pharmacological interventions (e.g. balanced nutrition, micronutrient supplementation, exercise training, social activation) aiming to prevent, attenuate, or reverse frailty are of utmost importance.126,127,132 In terms of pharmacotherapy and device implantations, frailty assessment is not a method to determine the eligibility for any particular treatment, but rather serves to build an individualized care plan with predefined priorities. Frail individuals often have comorbidities, polypharmacy, and may be more susceptible to drug side-effects and serious complications during invasive and surgical procedures.126,127

3.3.5. Family history Family history of premature CVD is a simple indicator of CVD risk, reflecting the genetic and environment interplay.133 In the few studies that simultaneously assessed the effects of family history and genetics, family history remained significantly associated with CVD after adjusting for genetic scores.134,135 However, family history only marginally improves the prediction of CVD risk beyond conventional ASCVD risk factors.136141 Possible explanations are the varying definitions Downloaded from academic.oup.com/eurheartj/article/42/34/3227/6358713 by guest on 07 October 2026