Objectives <p>In this retrospective study, we aimed to assess the predictive value of the Carotid Plaque-RADS (Reporting and Data System) for coronary functional stenosis in candidates for carotid revascularization, using high-resolution magnetic resonance imaging (HR-MRI) coupled with computed tomography-derived fractional flow reserve (CT-FFR).</p> Materials and methods <p>A retrospective analysis was performed on data of 101 patients with carotid atherosclerosis who underwent HR-MRI for Carotid Plaque evaluation, and CT-FFR for coronary assessment was conducted. Patients were divided into two groups based on a CT-FFR threshold of ≤ 0.80. Logistic regression, correlation analyses, and receiver operating characteristic curve analyses were used to identify predictors of coronary functional stenosis.</p> Results <p>In the functional stenosis group (<i>n</i> = 76), both plaque volume and Carotid Plaque-RADS categories had higher values than those observed in the non-functional group (<i>n</i> = 25). Univariate analysis showed that Carotid Plaque-RADS, Carotid Plaque volume, and hypertension were associated with functional stenosis. After adjustment, Carotid Plaque-RADS remained an independent predictor (odds ratio: 2.35, <i>p</i> &lt; 0.01) and demonstrated the strongest correlation (<i>ρ</i> = 0.51, <i>p</i> &lt; 0.01). It also demonstrated good diagnostic performance (area under the curve [AUC]: 0.81; sensitivity: 85%; specificity: 68%) and favorable clinical utility on decision curve analysis. In an exploratory analysis, Carotid Plaque-RADS was also moderately correlated with CAD-RADS (<i>ρ</i> = 0.37, <i>p</i> &lt; 0.01) and predicted CAD-RADS ≥ 3 with good discrimination (AUC: 0.72).</p> Conclusion <p>Carotid Plaque-RADS is an independent, noninvasive predictor of coronary functional stenosis in candidates for carotid revascularization.</p> Critical relevance statement <p>Carotid Plaque-RADS provides a noninvasive imaging-based tool that independently predicts coronary functional stenosis, thereby enhancing preoperative coronary risk stratification and supporting integrated cardiovascular management in candidates for carotid revascularization.</p> Key Points <p><UnorderedList Mark="Bullet"> <ItemContent> <p>Carotid revascularization candidates face high coronary risk.</p> </ItemContent> <ItemContent> <p>Carotid Plaque-RADS independently predicts coronary functional stenosis.</p> </ItemContent> <ItemContent> <p>Carotid Plaque-RADS enhances preoperative coronary risk stratification.</p> </ItemContent> </UnorderedList></p> Graphical Abstract <p></p>