Since the introduction of TPA in 1992 by Dr David Spence and his sonographer Maria DiCocco, two large outcome studies have shown, that TPA has an acceptable power to predict future vascular death, vascular morbidity and mortality, and myocardial infarction. The published data are derived from two studies with >7000 subjects studies and a follow-up of 3 and 6 years, respectively. TPA is a simple and easily obtained measure of the atherosclerotic burden within both carotid arteries acquired by ultrasound technology. Furthermore, TPA may be used for follow-up examinations in the medical office, in order to guide the intensity of preventive therapies and may be used as a gate keeper for other atherosclerosis imaging techniques, such as coronary calcium imaging. Comparative data between coronary calcium and TPA have been generated in our laboratory since the year 2002 and allow to give estimates about the TPA diagnostic power to detect high coronary risk scores in the same subject, thereby avoiding risk from irradiation. Further, different risk prediction models will be discussed with special emphasis on posttest calculations from a real world experience. Finally, a short update on the Taskforce on Vascular Risk Prediction activities will conclude the presentation.