Point: Counterpoint
Ultrasound Protocols to Measure Carotid Intima-Media Thickness: One Size Does Not Fit All

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Observational Studies

It is generally recognized that far-wall CIMT most accurately reflects the true thickness of the carotid wall, whereas the near wall is only an approximation of the true thickness. To the best of our knowledge, there is no published evidence showing that combined near-wall and far-wall common CIMT is superior to far-wall common CIMT alone with respect to prevalent or incident disease. This is because it has not been studied or has not been reported, or the studies that have addressed the issue

Observational Studies

We agree with Polak that completeness rates for multiple angles of the common carotid artery across studies seem to depend on technical factors rather than on the use of multiple-angle protocols. As such, comparisons of completeness rates between studies are useless, because many factors in addition to the extensiveness of the ultrasound protocol alone may explain these rates. It is currently unknown whether CIMT measurements from multiple angles lead to differences in the magnitude of the

Observational Studies

There is no published evidence to show that CIMT measurements from the carotid bifurcation and internal carotid artery are superior to the common carotid artery when evaluating the relation between CIMT and incident cardiovascular disease. Several studies have shown an increased magnitude of the relation of a multiple-segment CIMT with future events compared with common CIMT alone, yet these studies were never powered to address this issue, and the differences were therefore never statistically

Limitations of Extensive Ultrasound Protocols

Although studies with extensive ultrasound protocols may be considered the most precise and most comprehensive, there are disadvantages in terms of cost and logistics. Extensive ultrasound protocols take more time for acquisition and quantification and are therefore more costly. Also, ultrasound protocols that include measurement from all carotid segments require more extensive training of sonographers than ultrasound protocols measuring the common carotid artery alone. Although the current

Future Directions

There is very limited evidence on the impact of methodologic differences of ultrasound protocols for single or repeat CIMT measurements. Hence, we strongly advocate further validation and improvements of ultrasound protocols. This could best be done by performing analysis of individual participant data from multiple studies in which the impact of differences in ultrasound protocols in terms of progression rates and relation to cardiovascular events systematically can be evaluated.

Carotid Intima-Media Thickness to Improve Cardiovascular Disease Risk Prediction

Next to the use of CIMT as a predictor of risk or as a primary outcome in trials, there is considerable interest in the use of CIMT as a means to improve the performance of risk scores for the prediction of cardiovascular events in asymptomatic populations. A number of recent studies have shown results on the added value of CIMT measurements in risk prediction for cardiovascular disease events in general. However, these results have been inconsistent. Therefore, the value of CIMT in improving

Conclusions

Extensive CIMT ultrasound protocols are the most comprehensive and increase the success rates of intervention studies. However, an ideal ultrasound protocol does not exist, and the choice of an ultrasound protocol should always be determined by the research question at hand and the population under study. Yet systematic evaluations of methodologic aspects of CIMT measurements will contribute importantly to the standardization of the measurement in different research settings.

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