Both carotid atherosclerosis or increased carotid intima-media thickness (IMT) are common manifestations of generalized atherosclerosis, closely associated with increased risk of stroke and myocardial infarction. Despite the predominant involvement of physical activity in cardiovascular prevention and rehabilitation strategies, its role in carotid atherosclerosis progression is less evaluated. The aim of our study was to review the literature for the contribution of increased physical activity or structured exercise to the prevention and treatment of carotid atherosclerosis.A systematic review was performed of all cross-sectional, interventional, prospective or retrospective, clinical studies. Using the following terms: carotid atherosclerosis, intima-media thickness, physical activity, exercise, life-style, stroke, cardiovascular risk factors, we searched MEDLINE and EMBASE databases from 1985 to 2007. Carotids ultrasonography and relevant quantitative indexes were prerequisites for our search.The majority of cross-sectional studies have demonstrated that physical inactivity is associated with increased carotid IMT, while structured lifestyle interventions have conferred inconsistent results on the progression of carotid thickening. The increment of cardiorespiratory fitness and the modification of numerous cardiovascular risk factors, such as hyperglycemia, insulin resistance, hyperlipidemia, hypertension and obesity provide plausible mechanisms by which exercise training may suppress the evolution of carotid atherosclerosis.It remains questionable whether long-term exercise can decelerate the development of carotid atherosclerosis. Perhaps increased physical activity suppresses the overall cardiovascular risk and hence curtails the progression of carotid atherosclerosis. If carotid artery disease is regarded as a coronary artery disease equivalent, it is reasonable to recommend similar patterns of physical activity in patients with subclinical or manifest carotid atherosclerosis as for those with coronary atherosclerosis.