Multisite Atherosclerosis and SCORE2‐Based Risk Stratification in Psoriatic Arthritis: A Phenotype‐Dependent Role of Vascular Territories

Background: Cardiovascular (CV) risk is increased in psoriatic arthritis (PsA), yet vascular assessment has largely focused on carotid arteries, potentially underestimat-ing systemic atherosclerosis. Objective: To characterize the distribution and concord-ance of atherosclerotic plaques across carotid, femoral, and aortic territories in PsA and evaluate their incremental value over SCORE2. Methods: In this cross-sectional study, 250 unselected patients with PsA underwent carotid and femoral ultrasound and ab-dominal X-ray. Plaque prevalence and multiterritorial involvement (≥2 vascular beds) were assessed. Agreement between territories was evaluated using Cohen’s κ. In pa-tients aged 50–69 years, the incremental value of vascular territories over SCORE2 was evaluated using ROC curves, bootstrap-corrected decision curve analysis (DCA), and reclassification metrics (IDI and continuous NRI). Results: Plaques were detected in carotid (36.0%), femoral (62.8%), and aortic (31.6%) territories, with multiterritorial involvement in 43.2%. Agreement between vascular beds was moderate (κ ≈ 0.35). Notably, 48.1% of patients without carotid plaques had femoral involvement. SCORE2 categories showed a strong gradient with plaque prevalence (p < 0.0001). In patients aged 50–69 years, adding vascular imaging improved discrimination for multiterrito-rial disease (AUC 0.73 vs 0.86–0.90). Reclassification analyses showed greater im-provement for carotid and aortic plaque (IDI 0.28; NRI 1.24–1.33) than femoral plaque (IDI 0.21; NRI 1.11). Bootstrap-corrected DCA confirmed improved net benefit. Con-clusions: The incremental value of vascular imaging over SCORE2 is pheno-type-dependent, with femoral plaque enhancing detection of subclinical disease and carotid/aortic plaque better identifying multiterritorial burden. These findings support a tailored, multiterritorial approach to CV risk assessment in PsA.