Optimal risk assessment for primary prevention remains highly challenging. Recent registries have highlighted major discrepancies between guidelines and daily practice. Although guidelines have improved over time and provide updated risk scores, they still fail to identify a significant proportion of at-risk individuals, who then miss out on effective prevention measures until their initial ischemic events. Cardiovascular imaging is progressively assuming an increasingly pivotal role, playing a crucial part in enhancing the meticulous categorization of individuals according to their risk profiles, thus enabling the customization of precise therapeutic strategies for patients with increased cardiovascular risks. For the most part, the current approach to patients with atherosclerotic cardiovascular disease (ASCVD) is homogeneous. However, data from registries (e.g., REACH, CORONOR) and randomized clinical trials (e.g., COMPASS, FOURIER, and ODYSSEY outcomes) highlight heterogeneity in the risks of recurrent ischemic events, which are especially higher in patients with poly-vascular disease and/or multivessel coronary disease. This indicates the need for a more individualized strategy and further research to improve definitions of individual residual risk, with a view of intensifying treatments in the subgroups with very high residual risk. In this narrative review, we discuss advances in cardiovascular imaging, its current place in the guidelines, the gaps in evidence, and perspectives for primary and secondary prevention to improve risk assessment and therapeutic strategies using cardiovascular imaging.

Chronic coronary syndromes (CCS) comprehend a wide spectrum of conditions related to coronary artery disease (CAD). CCS definition includes either those patients who experienced an acute coronary syndrome such as myocardial infarction (MI) or unstable angina (UA), and the ones in which CAD has been detected through screening. This aspect creates a potential issue in differentiating medical treatments and modalities and timing for follow up. Another critical aspect is represented by the gap between American and European guidelines, which have been most recently updated respectively in 2023 and 2019. Furthermore, it is not clear what kind of patient must be screened for the detection for CAD and how to manage the eventual follow-up. Lastly, the latest guidelines are not clear for the choice of medical therapy and which are the patients who benefit the most from the eventual revascularization. The aim of this review is to analyze the issues related to the incongruities about CCS and propose potential options for adequate treatment and follow up.

The recently released 2025 ACC/AHA guidelines for the management of acute coronary syndromes (ACS) arise from the need to unify and update all contemporary evidence regarding the diagnosis, risk stratification, and treatment of ACS. The document addresses both out-of-hospital management and in-hospital care, providing dedicated flowcharts for patients with ST-segment elevation myocardial infarction (STEMI)-where the primary goal is immediate reperfusionand for those with non-ST-segment elevation ACS (NSTE-ACS), in whom therapeutic decisions depend on allocation into four distinct risk categories based on clinical presentation, hemodynamic status, and arrhythmic profile, supported by validated prognostic scores. The risk class determines the optimal timing of the invasive strategy. A central role is attributed to antithrombotic therapy, encompassing both antiplatelet and anticoagulant agents, with strong emphasis on an individualized, patient-tailored balance between ischemic and bleeding risks to guide drug selection and treatment duration. Guideline further addresses secondary prevention, highlighting lipid-lowering strategies and evidence-based use of cardioprotective drugs. Dedicated sections are devoted to the management of mechanical and electrical complications, cardiogenic shock, and advanced catheterization laboratory strategies, including complete revascularization in multivessel disease. In our editorial, we provide a comparative analysis with the 2023 ESC Guidelines on ACS, underscoring that while the core principles remain largely concordant, subtle differences in clinical approach persist between the American and European documents.

The 2026 ACC/AHA Multisociety Guideline marks a major shift in dyslipidemia management, extending the traditional LDL-C-centered approach to include non-HDL-C, ApoB, lipoprotein(a), triglyceride-rich lipoproteins, inherited lipid disorders, and severe hypertriglyceridemia. The introduction of PREVENT-ASCVD, the renewed use of explicit lipid targets, and the structured integration of risk enhancers and coronary artery calcium support a more individualized approach to cardiovascular prevention. This review critically examines the guideline’s main innovations, with particular attention to the distinction between recommendations supported by cardiovascular outcome evidence and those relying mainly on observational data, surrogate endpoints, or extrapolation. It also compares the US framework with the 2025 ESC/EAS Focused Update, highlighting growing agreement on LDL-C goals but persistent differences in risk estimation, imaging, biomarkers, and treatment pathways. Finally, we discuss unresolved issues involving implementation, adherence, access, cost, health equity, inclisiran outcomes, and emerging lipoprotein(a)-lowering therapies. The guideline’s impact will depend on translating greater precision into timely, feasible, and equitable care.

Conventional cardiovascular risk scores estimate the probability of future events; however, these risk scores do not directly quantify the presence or extent of subclinical atherosclerosis. This narrative review critically evaluates the current evidence on the carotid plaque score (CPS), a semiquantitative ultrasound-based measure of carotid atherosclerotic burden across predefined arterial segments. Population-based cohorts have consistently shown that carotid plaque presence and burden are independently associated with cardiovascular and cerebrovascular events. Studies specifically evaluating CPS have further suggested an incremental prognostic value beyond conventional risk models, particularly for ischemic stroke and major adverse cardiovascular event (MACE). However, CPS does not represent a single standardized metric. Therefore, proposed thresholds, including CPS ≥2 and CPS >3, were derived using different plaque definitions, arterial segments, scoring methods, and study populations and are not directly interchangeable. Meanwhile, CPS is more accessible, non-ionizing, and relatively inexpensive compared with coronary artery calcium (CAC), but it is less extensively validated and less standardized. Nonetheless, available comparative evidence indicates that CAC provides superior discrimination for coronary outcomes. In contrast, carotid plaque assessment may offer complementary information for cerebrovascular risk and in selected individuals with discordant estimated risk or no detectable coronary calcification. No randomized trial has demonstrated that treatment decisions guided by CPS improve clinical outcomes. Accordingly, current guidelines generally position carotid plaque imaging as a selective risk modifier rather than a routine screening or stand-alone treatment-allocation tool. Thus, broader clinical implementation will require standardized acquisition and reporting protocols, external validation across diverse populations, integration with established risk models, and prospective studies evaluating whether CPS-guided preventive strategies improve patient outcomes.