Highlights

• The evaluation of vessel wall thickness alone, without including plaque assessment, in a primary prevention cohort is like looking at an angiogram without coronary stenoses in an intervention cohort.
• Current ultrasound technology, with minimal user interface, automated measurements, high resolution, and the rapidly developing three-dimensional assessment, is ready for clinical use for risk stratification in patients in risk factor–based algorithms, particularly in medically underserved populations.
• ATP IV guidelines improve on ATP III for the appropriate identification of patients at risk, but may still lead to over- or undertreatment with statins in a significant number of subjects who do not or do have subclinical atherosclerosis, respectively.