Same Risk Factors, Different Arteries: Selective Carotid Screening in Asymptomatic Patients

Consider two asymptomatic patients of the same age, with the same blood pressure, the same cholesterol profile and the same smoking history. On paper they are identical. Yet when you place the probe on the neck, one has a clean carotid bifurcation and the other has a substantial plaque. Same inputs, different arteries.

That everyday observation is the reason risk-factor counting alone cannot tell the whole story. It also explains why current guidance, including ESVS 2023, treats carotid imaging in asymptomatic patients as a selective tool rather than a universal one: the aim is to identify the patients whose findings will actually change prevention, and to leave the rest alone.

Key takeaways

• Patients with identical risk factors can have very different carotid findings, because risk factors predict probability, not where or how much disease develops.

• ESVS 2023 supports selective screening in patients with multiple vascular risk factors, with the goal of optimising prevention and medical therapy.

• Selective screening means choosing patients in whom the result will change management – not scanning everyone.

• Imaging findings should feed into cardiovascular prevention, not into reflex intervention.

• Structured, reproducible ultrasound assessment and reporting are what make the information usable.

Two patients, one risk profile

Picture a 62-year-old man with treated hypertension, a modest elevation in LDL cholesterol and a history of smoking that stopped five years ago. His calculated risk sits in an intermediate band. He feels well and has no neurological symptoms.

The first patient in our pair has a normal carotid examination. His scan supports continuing his current regimen, with a focus on lifestyle and adherence.

The second patient, with the same profile, has a focal plaque at the carotid bulb. Nothing about his symptoms distinguishes him from the first patient. The difference lies entirely in the wall of the artery.

This is not an unusual scenario. It is the norm. Risk factors describe the conditions under which atherosclerosis develops; they do not describe how much disease a given individual has accumulated.

Why the same risk factors produce different arteries

Several mechanisms explain why identical risk profiles diverge when the artery is examined.

Exposure differs by duration and intensity. Two people who both smoke may have very different cumulative exposure, and the arterial response reflects the total burden over time.

Genetic susceptibility varies. Inherited factors influence lipid handling, inflammation and the structure of the arterial wall, shifting how a given risk profile translates into plaque.

Arterial beds differ in vulnerability. Some territories develop disease earlier and more aggressively, so a systemic process can look very different from one artery to the next.

Plaque phenotype varies. Even when plaque is present, its composition and stability differ between individuals, which matters for how the finding is interpreted.

The practical consequence is straightforward: a risk score is a probabilistic input, while the artery is the outcome. The two will not always agree.

What the evidence shows about discordance

Discordance between risk scores and imaging findings is well recognised in clinical practice. Some patients with modest calculated risk carry substantial plaque; some with higher scores have comparatively little.

This is precisely why several guideline frameworks allow imaging to act as a risk modifier. When the image and the score tell a consistent story, the picture is clear. When they diverge, the divergence itself is informative, and it can justify revisiting the intensity of prevention.

What ESVS 2023 says about selective screening

The ESVS 2023 clinical practice guidelines on atherosclerotic carotid and vertebral artery disease do not endorse systematic screening of the general population for asymptomatic carotid disease. Screening everyone would generate many normal results, expose patients to unnecessary investigation, and rarely change management.

Instead, the guidance supports selective consideration in patients with multiple vascular risk factors. In that group, identifying subclinical atherosclerosis can inform the optimisation of prevention and medical therapy. The emphasis is on targeted assessment, where the result is likely to alter the plan.

The distinction matters. Selective screening is a clinical decision, tailored to the individual and grounded in their risk profile. Indiscriminate screening is a population intervention applied without discrimination. The guidelines point clearly toward the former.

Who may be considered for selective assessment

In practice, the patients most often considered are those whose risk profile raises pre-test suspicion and whose management is not yet settled. Typical features include:

• Multiple vascular risk factors acting together, such as hypertension, dyslipidaemia, diabetes and smoking.

• A family history of premature cardiovascular disease.

• Evidence of atherosclerosis in another vascular bed, which suggests systemic disease.

• A calculated risk estimate that is borderline, or discordant with the clinical picture.

None of these features individually guarantees that imaging will be useful. Together they identify patients in whom the scan is more likely to contribute to a decision.

What selective screening is not

It is worth stating plainly what this approach does not mean.

It is not universal screening. Applying carotid ultrasound to whole populations is not supported and would be difficult to justify clinically or economically.

It is not a substitute for risk-factor management. Imaging complements prevention; it does not replace attention to blood pressure, lipids, glucose and lifestyle.

It is not a trigger for reflex intervention. Finding plaque does not automatically mean surgery, stenting or a specific drug. Those decisions depend on the full clinical picture, and in asymptomatic carotid disease the thresholds for procedural intervention are narrow and carefully defined.

Turning findings into better prevention

The value of selective imaging lies in what it does to prevention. A finding of subclinical atherosclerosis can support a more assertive approach to risk-factor control – intensifying lipid-lowering, tightening blood pressure management, reinforcing lifestyle change – in a patient whose need was previously uncertain.

The ESC 2024 and ESC/EAS 2025 frameworks guide the intensity of preventive therapy, and imaging information can help position a patient within those frameworks. The scan does not prescribe; it informs the conversation about how aggressively to treat.

In this way, selective screening connects a single ultrasound finding to the broader goal stated in the guidelines: optimising prevention and medical therapy in the patients most likely to benefit.

Scanning and reporting considerations

For the finding to be useful, the assessment must be reliable. A reproducible acquisition protocol, consistent terminology and clear documentation of plaque presence, location and acoustic characteristics make the report actionable for the treating clinician.

Equally important is restraint in interpretation. The sonographer’s role is to describe accurately, not to determine therapy. A precise, well-structured report supports good decisions without overreaching.

The bottom line

Identical risk factors do not produce identical arteries. That reality is why selective carotid assessment, framed by ESVS 2023 and integrated with ESC 2024 and ESC/EAS 2025 prevention guidance, has a legitimate place in the care of asymptomatic patients with multiple vascular risk factors.

The goal is not to scan more people. It is to scan the right people, at the right time, so that the findings can improve prevention and medical therapy for those who stand to gain.

Learn more at abcvascular.com.

References

• European Society for Vascular Surgery (ESVS). 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. European Journal of Vascular and Endovascular Surgery.

• European Society of Cardiology (ESC). 2024 ESC Clinical Practice Guidelines. European Heart Journal.

• European Society of Cardiology / European Atherosclerosis Society (ESC/EAS). 2025 Guidelines for the management of dyslipidaemias. European Heart Journal.