Subclinical Atherosclerosis Burden by 3D Ultrasound

Study Questions:

What is the association between three-dimensional vascular ultrasound (3DVUS)-based plaque burden and cardiovascular risk factors (CVRFs), and does 3DVUS add value over simple plaque detection in the carotid and femoral artery territories?


The study included 3,860 PESA (Progression of Early Subclinical Atherosclerosis) participants (ages 45.8 ± 4.3 years; 63% men). Bilateral carotid and femoral territories were explored by 3DVUS to determine the number of plaques and territories affected, and to quantify global plaque burden defined as the sum of all plaque volumes. Linear regression and proportional odds models were used to evaluate associations of plaque burden with individual CVRFs and estimated 10-year cardiovascular risk.


Overall, the PESA participants are a low-risk population (median atherosclerotic cardiovascular disease 10-year risk, 2.17%; interquartile range [IQR], 0.95-4.37%), with most (79.4%) in the low-risk category and 3.4% in men and 0.78% in women. Median global plaque burden was 50.8 mm3 (IQR, 18.7-121.5), being more pronounced in men than in women (63.4 mm3 vs. 25.7 mm3 (p < 0.001) and with increasing age (p < 0.001). Age, sex, smoking, and dyslipidemia were more strongly associated with femoral than with carotid disease burden, whereas hypertension and diabetes showed no territorial differences. Plaque burden was directly associated with estimated cardiovascular risk independently of the number of plaques or territories affected (p < 0.01).


3DVUS quantifies higher plaque burden in men, in the femoral territory, and with increasing age during midlife. Plaque burden correlates strongly with CVRFs, especially at the femoral level, and reflects estimated cardiovascular risk more closely than plaque detection alone.


There was a remarkable amount of plaque burden in this very low-risk cohort, including those with no CVRFs (45% of cohort). While hypothesis generating, as with the coronary calcium score, other tools to assess preclinical atherosclerotic vascular disease, and biomarkers, the value of 3DVUS measures of femoral and carotid plaque burden to identify risk for coronary events and strokes in individuals with excellent calibration and discrimination will require large longitudinal studies in various populations.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Noninvasive Imaging, Prevention, Echocardiography/Ultrasound, Hypertension, Smoking

Keywords: Atherosclerosis, Cardiovascular Diseases, Carotid Arteries, Cardiac Imaging Techniques, Diabetes Mellitus, Dyslipidemias, Femoral Artery, Hypertension, Plaque, Atherosclerotic, Primary Prevention, Risk Factors, Smoking, Ultrasonography

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