Ultrasonographic Measurements and ASCVD Events

Quick Takes

  • Incorporation of carotid intima-media thickness to traditional risk factors improved ASCVD risk prediction by 10.4%.
  • Measurements of carotid plaque area improved ASCVD risk prediction by 14.2% over traditional risk factors.
  • Plaque measurements from four key arterial bifurcation sites provided the greatest risk prediction improvement over traditional risk factors.

Study Questions:

How well do various arterial ultrasound measurements predict 10-year atherosclerotic cardiovascular disease (ASCVD) risk when added to conventional risk factors?


The authors studied 985 adults, mean age 58.1 years (standard deviation [SD], 10.2 years) who were free of ASCVD in the Cyprus Atherosclerosis Study. Conventional risk factors were recorded, and all patients underwent both carotid and common femoral bifurcation ultrasonography. The primary endpoint was a first-time fatal or nonfatal ASCVD event.


Over a mean follow-up of 13.2 years (SD, 3.7 years), ASCVD events occurred in 154 (15.6%) patients. The net reclassification index improved by 10.4% with the addition of maximal intima-media thickness, 9.5% with the addition of carotid plaque thickness, and 14.2% with the addition of carotid plaque area as compared to conventional risk factor assessment. The net reclassification improved by 16.1-16.4% when measurements from all four bifurcation locations were added (number of bifurcations with plaque, total plaque thickness, and total plaque area).


The authors concluded that various arterial ultrasound measurements of plaque from the carotid and common femoral arteries provided a better prediction of future ASCVD events than traditional measurements from any single site (e.g., single intima-medial thickness).


While use of traditional risk factors to identify patients at high, intermediate, and low risk for ASCVD events is helpful to guide primary prevention therapy, there has been longstanding interest in the addition of arterial imaging as a way to further improve risk prediction. While much of the prior work has focused on the use of carotid ultrasound imaging, especially the carotid intima-media thickness, other arterial bifurcation areas may offer insight into the atherosclerotic process. The authors report on the benefits of measuring plaque at four key arterial bifurcation areas (bilateral carotid and femoral bifurcations) over the use of any single sight to improve risk prediction beyond traditional risk factors. While noninvasive and not requiring any radiation, the routine use of imaging has long presented a challenge for broad implementation. If these findings are validated in datasets of diverse patient populations, then clinicians may need to consider the role of imaging when approaching risk stratification for ASCVD events. For now, more consistent use of traditional risk estimation and initiation of risk-modifying therapies (e.g., lipid lowering, tobacco cessation, blood pressure control) remain important targets.

Clinical Topics: Diabetes and Cardiometabolic Disease, Dyslipidemia, Noninvasive Imaging, Prevention, Vascular Medicine, Lipid Metabolism, Echocardiography/Ultrasound

Keywords: Atherosclerosis, Carotid Artery Diseases, Cardiometabolic Risk Factors, Carotid Intima-Media Thickness, Diagnostic Imaging, Diagnostic Techniques and Procedures, Dyslipidemias, Lipids, Plaque, Atherosclerotic, Primary Prevention, Risk Assessment, Risk Factors, Ultrasonography, Vascular Diseases

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