Canadian Journal of Cardiology

Early Atherosclerosis Detection in Asymptomatic Patients: A Comparison of Carotid Ultrasound, Coronary Artery Calcium Score, and Coronary Computed Tomography Angiography

Published:October 28, 2013DOI:



      Detailed multimodality assessment of subclinical atherosclerosis in asymptomatic subjects referred for risk stratification has not been performed. We analyzed the detection of early atherosclerosis using 3 imaging modalities: coronary artery calcium (CAC) scoring, carotid ultrasound (US), and coronary computed tomography angiography (CCTA).


      Asymptomatic subjects free of known vascular disease scheduled to undergo a carotid US for risk stratification were invited to undergo CCTA/CAC. Subjects taking lipid-lowering medication were excluded. All images were assessed by experienced core laboratory personnel. Carotid intima media thickness ≥ 75th percentile for age and sex, CAC > 0, and detection of either carotid or coronary artery plaque were indicators of atherosclerosis.


      Fifty patients were included with a median age of 53 years. Atherosclerosis was observed in 28%, 78%, and 90% of subjects using CAC, CCTA, and carotid US, respectively. All subjects showed atherosclerosis on at least 1 modality. In 36 patients with a CAC score = 0, 69% and 86% had atherosclerosis on CCTA and carotid US, respectively.


      In this detailed analysis, all subjects identified to warrant further risk stratification had subclinical atherosclerosis on at least 1 imaging modality. Concordance between modalities was highly variable, dependent on the specific definition of atherosclerosis used. Carotid US and CCTA detection of plaque were significantly more sensitive than CAC > 0 in this middle-aged population. Considering the prevalence of subclinical disease on carotid US and CCTA, the threshold at which to treat warrants further research.



      L’évaluation détaillée de l’imagerie multimodale de l’athérosclérose subclinique chez les sujets asymptomatiques orientés pour la stratification du risque n’a pas été réalisée. Nous avons analysé la détection de l’athérosclérose précoce en utilisant 3 modalités d’imagerie : le score calcique des artères coronaires (CAC), l’échographie (EG) carotidienne et la coronarographie par tomodensitométrie (Coro-TDM).


      Les sujets asymptomatiques sans maladie vasculaire connue inscrits pour subir une EG carotidienne en vue de la stratification du risque ont été invités à subir la Coro-TDM/CAC. Les sujets prenant un hypolipidémiant ont été exclus. Toutes les images ont été évaluées par le personnel expérimenté du laboratoire central. L’épaisseur de l’intima-média de la carotide ≥ 75e percentile de l’âge et du sexe, le CAC > 0 et la détection de plaque carotidienne ou de plaque de l’artère coronaire ont été des indicateurs d’athérosclérose.


      Cinquante (50) patients dont l’âge moyen était de 53 ans ont été inclus. L’athérosclérose a été observée chez 28 %, 78 % et 90 % des sujets à l’aide de la CAC, la Coro-TDM et l’EG carotidienne, respectivement. Tous les sujets ont montré de l’athérosclérose dans au moins 1 modalité. Chez 36 patients ayant un score de CAC = 0,69 % et 86 % ont montré de l’athérosclérose à la Coro-TDM et l’EG carotidienne, respectivement.


      Dans cette analyse détaillée, tous les sujets identifiés pour justifier une stratification du risque plus poussée ont montré de l’athérosclérose subclinique dans au moins 1 modalité d’imagerie. La concordance entre les modalités a été très variable, dépendamment de la définition de l’athérosclérose utilisée. La détection de la plaque à l’EG carotidienne et à la Coro-TDM a été significativement plus sensible qu’à la CAC > 0 chez cette population d’âge moyen. Si l’on considère la prévalence de la maladie subclinique à l’EG carotidienne et à la Coro-TDM, le seuil auquel traiter justifie d’autres recherches.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Canadian Journal of Cardiology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Pitt B.
        • Rubenfire M.
        Risk stratification for the detection of preclinical coronary artery disease.
        Circulation. 1999; 99: 2610-2612
        • Grover S.A.
        • Coupal L.
        • Xiao-Ping H.
        Identifying adults at increased risk of coronary disease.
        JAMA. 1995; 274: 801-806
        • Sacks F.M.
        • Pfeffer M.A.
        • Moye L.A.
        • et al.
        The effect of pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels.
        N Engl J Med. 1996; 335: 1001-1009
        • Keenan N.L.
        • Shaw K.M.
        Centers for Disease Control and Prevention (CDC). Coronary heart disease and stroke deaths - United States, 2006.
        MMWR Surveill Summ. 2011; 60: 62-66
        • Anderson T.J.
        • Grégoire J.
        • Hegele R.A.
        • et al.
        2012 update of the Canadian Cardiovascular Society guidelines for the diagnosis and treatment of dyslipidemia for the prevention of cardiovascular disease in the adult.
        Can J Cardiol. 2013; 29: 151-167
        • D'Agostino Sr., R.B.
        • Vasan R.S.
        • Pencina M.J.
        • et al.
        General cardiovascular risk profile for use in primary care: the Framingham Heart Study.
        Circulation. 2008; 117: 743-753
        • National Cholesterol Education Program (NCEP) Expert Panel on Detection
        Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report.
        Circulation. 2002; 106: 3143-3421
        • Cleeman J.I.
        Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III).
        JAMA. 2001; 285: 2486-2497
        • Peters S.A.
        • den Ruijter H.M.
        • Bots M.L.
        • Moons K.G.
        Improvements in risk stratification for the occurrence of cardiovascular disease by imaging subclinical atherosclerosis: a systematic review.
        Heart. 2012; 98: 177-184
        • Greenland P.
        • Bonow R.O.
        • Brundage B.H.
        • et al.
        ACCF/AHA 2007 clinical expert consensus document on coronary artery calcium scoring by computed tomography in global cardiovascular risk assessment and in evaluation of patients with chest pain: a report of the American College of Cardiology Foundation clinical expert consensus task force (ACCF/AHA writing committee to update the 2000 expert consensus document on electron beam computed tomography) developed in collaboration with the Society of Atherosclerosis Imaging and Prevention and the Society of Cardiovascular Computed Tomography.
        J Am Coll Cardiol. 2007; 49: 378-402
      1. Anderson TJ, Grégoire J, Hegele RA, et al. Supplement to 2012 Update of the Canadian Cardiovascular Society Guidelines for the Diagnosis and Treatment of Dyslipidemia for the Prevention of Cardiovascular Disease in the Adult. Available at: Accessed October 23, 2013.

        • European Association for Cardiovascular Prevention and Rehabilitation
        • Reiner Z.
        • Catapano A.L.
        • et al.
        ESC/EAS guidelines for the management of dyslipidaemias: the task force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS).
        Eur Heart J. 2011; 32: 1769-1818
        • Shah P.K.
        Screening asymptomatic subjects for sublinical atherosclerosis can we, does it matter, and should we?.
        J Am Coll Cardiol. 2010; 56: 98-105
        • Lloyd-Jones D.M.
        • Nam B.H.
        • D’Agostino R.B.
        • et al.
        Parental cardiovascular disease as a risk factor for cardiovascular disease in middle-aged adults – a prospective study of parents and offspring.
        JAMA. 2004; 291: 2204-2211
        • Raff G.L.
        • Abidov A.
        • Achenbach S.
        • et al.
        SCCT guidelines for the interpretation and reporting of coronary computed tomographic angiography.
        J Cardiovasc Comput Tomogr. 2009; 3: 122-136
        • Otton J.M.
        • Lønborg J.T.
        • Boshell D.
        • et al.
        A method for coronary artery calcium scoring using contrast-enhanced computed tomography.
        J Cardiovasc Comput Tomogr. 2012; 6: 37-44
        • Agatston A.S.
        • Janowitz W.R.
        • Hildner F.J.
        • Zusmer N.R.
        • Viamonte M.
        • Detrano R.
        Quantification of coronary artery calcium using ultrafast computed tomography.
        J Am Coll Cardiology. 1990; 15: 827-832
        • Touboul P.J.
        • Hennerici M.G.
        • Meairs S.
        • et al.
        Mannheim Carotid Intima-Media Thickness Consensus (2004-2006).
        Cerbrovasc Dis. 2007; 23: 75-80
        • Lester S.J.
        • Eleid M.F.
        • Khandheria B.K.
        • Hurst R.T.
        Carotid intima-media thickness and coronary artery calcium score as indicators of subclinical atherosclerosis.
        Mayo Clin Proc. 2009; 84: 229-233
        • Folsom A.R.
        • Kronmal R.A.
        • Detrano R.C.
        • et al.
        Coronary artery calcification compared with carotid intima-media thickness in prediction of cardiovascular disease incidence: the Multi-Ethnic Study of Atherosclerosis (MESA).
        Arch Intern Med. 2008; 168: 1333-1339
        • Brook R.D.
        • Bard R.L.
        • Patel S.
        • et al.
        A negative carotid plaque area test is superior to other non-invasive atherosclerosis studies for reducing the likelihood of having significant coronary artery disease.
        Arterioscler Thromb Vasc Biol. 2006; 26: 656-662
        • Sillesen H.
        • Muntendam P.
        • Adourian A.
        • et al.
        Carotid plaque burden as a measure of subclinical atherosclerosis: comparison with other tests for subclinical arterial disease in the High Risk Plaque BioImage study.
        JACC Cardiovasc Imaging. 2012; 5: 681-689
        • Bots M.L.
        • Baldassarre D.
        • Simon A.
        • et al.
        Carotid intima-media thickness and coronary atherosclerosis: weak or strong relations?.
        Eur Heart J. 2007; 28: 398-406
        • McGill H.
        • McMahan C.A.
        • Zieske A.W.
        • et al.
        Association of coronary heart disease risk factors with microscopic qualities of coronary atherosclerosis in youth.
        Circulation. 2000; 102: 374-379
        • Spence J.D.
        • Eliasziw M.
        • DiCicco M.
        • Hackam D.G.
        • Galil R.
        • Lohmann T.
        Carotid plaque area: a tool for targeting and evaluating vascular preventive therapy.
        Stroke. 2002; 33: 2916-2922
        • Johnsen S.H.
        • Mathiesen E.B.
        • Joakimsen O.
        • et al.
        Carotid atherosclerosis is a stronger predictor of myocardial infarction in women than in men: a 6-year follow-up study of 6226 persons: the Tromso Study.
        Stroke. 2007; 38: 2873-2880