Low risk does not mean absence of disease: from the cardiovascular score to atherosclerosis demonstrated by imaging

Abstract

Cardiovascular risk scores are central tools for primary prevention, but they should not be interpreted as diagnostic proof of the absence of atherosclerosis. In young or middle-aged adults, chronological age and the 10-year time horizon may yield low-risk estimates despite significant arterial disease. This discordance becomes clinically relevant when vascular ultrasound, coronary artery calcium scoring, or coronary computed tomography angiography identify an atherosclerotic burden not anticipated by the probabilistic model. We propose integrating estimated risk, clinical-biological modifiers, and targeted vascular imaging to reclassify discordant patients and adjust preventive intensity according to actually demonstrated disease.