Incremental value of carotid intima-media thickness beyond SCORE2 in identifying subclinical atherosclerosis in psoriatic arthritis

Abstract Objectives Patients with psoriatic arthritis (PsA) are at increased risk of cardiovascular (CV) disease, which is not fully captured by traditional risk calculators. SCORE2 is widely recommended in Europe for CV risk stratification, but it may underestimate the burden of subclinical atherosclerosis in PsA. Carotid intima-media thickness (cIMT) is a validated surrogate marker of early atherosclerosis and may provide incremental value. We aimed to determine whether cIMT improves the performance of SCORE2 in detecting subclinical atherosclerosis in patients with PsA. Methods In this cross-sectional study of 146 PsA patients fulfilling CASPAR criteria, SCORE2 categories were determined. Bilateral cIMT was measured and averaged; an atherogenic threshold was defined as > 0.9 mm. Atherosclerotic plaques were assessed by ultrasound in carotid, femoral, and abdominal aortic territories. ROC analyses, DeLong’s test, and reclassification metrics (net reclassification index [NRI], integrated discrimination improvement [IDI]) were used to compare SCORE2 alone vs SCORE2+cIMT. Results SCORE2 correlated with mean cIMT (ρ = 0.54, p< 0.001). Optimal cIMT cut-offs were 0.79 mm for carotid and femoral plaques, and 0.90 mm for aortic plaques. SCORE2 alone showed an AUC of 0.81 for multisite plaque (≥2 sites). Adding cIMT increased the AUC to 0.85 (ΔAUC = 0.04, p< 0.05). Reclassification indices were modest (NRI ≈ 0.0, IDI = 0.0006). Exploratory analyses indicated that the 0.79 mm threshold provided a more favorable sensitivity–specificity balance for detecting multisite atherosclerosis. Conclusions cIMT improves SCORE2-based risk prediction in PsA, and exploratory analyses suggest that slightly lower thresholds (≈0.79 mm) may further enhance the detection of subclinical atherosclerosis.