Research and evidence

 A study of portable ultrasound carried out in the USA, Canada and
Indiahas revealed the potential of this technology for detecting plaques in peripheral arteries that can lead to heart attacks and stroke before symptoms arise, in both developed and developing country settings, allowing preventive treatment in those affected. The study, published in Global Heart (the journal of the World Heart Federation), is by Dr Ram Bedi, Affiliate Assistant Professor, Department of Bioengineering, University of Washington, Seattle, WA, USA, and Professor Jagat Narula, Editor-in-Chief of Global Heart and Icahn School of Medicine at Mount Sinai, New York, USA, and colleagues.

Numerous research studies have shown that it is possible to assess subclinical atherosclerotic cardiovascular disease (ASCVD) using ultrasound imaging. Since more portable and lower cost ultrasound devices are now entering the market, along with increased automation and functionality, it may be possible in future to routinely examine people with ultrasound to establish any ASCVD present before symptoms emerge, so that future disease can be prevented, for example using medication. In this study, ASCVD was determined using ultrasound of both the carotid arteries (those in the neck) and
theileofemoral arteries (entering the top of the leg). The findings were conveniently summarised in an easy to understand index called the Fuster-Narula (FUN) Score.

Data were gathered from 4 cohorts, 2 Indian and 2 North American. In India, a medical
campsetting was used, and screening with automated ultrasound imaging was conducted over 8 days in 941 relatively young (mean age 44 years, 34% female) asymptomatic volunteers recruited from the semiurban town of Sirsa (Haryana) and urban city of Jaipur (Rajasthan) in northern India. The cohort from Sirsa was specifically recruited because all participants had already undergone aggressive lifestyle changes (smoking cessation, no alcohol, vegetarian diet, physically active lifestyles, daily meditation), Radiology resident doctors who had no prior training in vascular ultrasound were trained on the spot to perform the ultrasound examinations.

To compare the imaging findings with traditional risk factors, 2 cohorts (481 persons) were recruited from primary care clinics in North America (one in Richmond, Texas, USA, the other in Toronto, Canada). As well as the same
ultrasoundexaminations given in the Indian cohort, comprehensive ASCVD risk factor data was gathered from these participants, all of whom were self-referred asymptomatic individuals (mean age 60 years, 39% female). Data collected included cholesterol levels, blood pressure, glucose level, weight, height, smoking and family history. These people were attending clinics for routine health examinations in most cases. Effectiveness of established ASCVD prevention guidelines was then compared to results from direct imaging. Ultrasound was performed by trained experts at each centre.

In India, ultrasound revealed plaques in at least one artery in almost a quarter (24%) of those examined; 107 (11%) had plaques in only the carotids, 70 (7%) in both the carotids and iliofemoral arteries, and 47 (5%) had plaques in only the iliofemoral arteries. If just the carotids had been examined, 177 (19%) of the asymptomatic subjects would have been identified with plaques; by adding the iliofemoral examination, 47 additional individuals (5% of the total) were identified
withplaque. Older age and male sex were associated with the presence of plaque both in urban and semiurban populations (the much higher levels of smoking in men could account for their higher risk).

Data from the American and Canadian clinics showed that 203 subjects (42%) had carotid plaque; 166 of these (82% of those with plaque) would not have qualified for lipid-lowering therapy such as statins under the most widely used guidelines known as ATP III (Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults [Adult Treatment Panel]) guidelines. Using the recently published more stringent ATP IV guidelines, 67 people (
one third of those with plaque and 14% of the total US/Canadian cohort) individuals with carotid plaque would also have failed to qualify for treatment.

In addition, the study revealed 34 people in the USA/Canada setting who qualified for treatment under ATP III but did not have any plaques, and this number increased to 81 under ATP IV (if receiving treatment such as statins, these people could be said to be overtreated, since no plaques were evident).

The authors say: "Our study shows that automation in ultrasound imaging technology allows even non-expert users to rapidly evaluate the presence of subclinical atherosclerosis in a large population. Detection of subclinical atherosclerosis is further enhanced
byinclusion of the iliofemoral artery examination."

They add: "It seems that plaque information from ultrasound images may serve as a guide for initiating medical intervention regardless of the availability or knowledge of traditional risk factors. Our results further suggest that not only in low- and middle-income
countries, but even in the developed nations, ultrasound images may help refine strategies for medical intervention. It might however still be too contentious to suggest that risk factors-positive and imaging-negative asymptomatic subjects may be spared from medical intervention. Conversely, arguments against initiating medical intervention on risk factors-negative and imaging-positive asymptomatic subjects become harder to justify."

In a linked comment published with this paper, Dr Tasneem Z Naqvi, Professor of Medicine at the Mayo College of Medicine and Division of Cardiology, Scottsdale, Arizona, USA, adds: "This study shows that the assessment of subclinical atherosclerosis by a portable, user-friendly bedside tool is feasible in large populations and the technique of carotid ultrasound imaging and IMT assessment could be adopted by novices after an 8-hour crash course."

She concludes: "The study by Bedi et al puts into perspective the weakness of risk factor-based approach to identify individuals with subclinical atherosclerosis who are more likely to develop future cardiovascular events. The study shows that the vascular ultrasound imaging technology is ripe and that the previously existing barriers such as poor resolution, cumbersome protocols, need for off line processing and need for expert performer no longer exist. The question that this study does not address?and perhaps no study in future might?is whether this imaging based approach would save more lives than the risk-based approach. We need to ponder if treating nearly 50% of the adults with statins with a risk scoring algorithm (as happens in the USA) is more appropriate versus treating only those who
havesubclinical atherosclerosis based on comprehensive and readily available, cheap and simple screening method. This study makes a compelling argument in favour of imaging for screening."

In an additional comment, Professor Paul Leeson, a member of the Imaging Enhancement Expert Working Group for UK Biobank (with specific responsibility for the vascular imaging component), Professor of Cardiovascular Medicine at the University of Oxford and Clinical Director of the Oxford Cardiovascular Clinical Research Facility, UK, and not connected to the study or the journal, says: "Ultrasound seems to be firmly establishing itself as the advanced imaging technology of choice for global health care issues. Current ultrasound scanners generate accurate cardiovascular measures safely, rapidly and relatively inexpensively. This paper nicely demonstrates how people with little imaging experience can undergo a short
trainingprogramme and then use portable ultrasound systems in a wide variety of global health care settings. The fact this imaging technology can be applied to large populations has also made it an attractive option for many of the major biobank research projects, such as UK Biobank. These projects are planned to generate vascular images for hundreds of thousands of individuals in different countries that, over the next few years, can be used to determine the true value of vascular imaging for disease prediction."

World Heart Federation. "Can ultrasound detect potential
heartattacks,stroke before symptoms arise." ScienceDaily. ScienceDaily, 12 January 2015. <>.  


Research Presented at International Conference Supports Use of Community-Based Screening to Detect Early Signs of Atherosclerosis and other Vascular Disease

— Findings reveal that identifying and targeting asymptomatic individuals can reduce rate of disability and death from heart attack and stroke by 50% —

— World opinion leaders present findings at the International Union of Angiology conference in Sydney, Australia —

— Additional study reveals 9 out of 10 U.S. practicing cardiovascular physicians support preventive screening for cardiovascular disease for patients with two or more key risk factors —

August13,2014“Atherosclerotic arterial disease which is responsible for heart attacks and strokes develops slowly and silently for many years before it manifests as disease. Its detection and silent progression can be recorded accurately with ultrasound scans,” said Professor Andrew Nicolaides, MS, FRCS,

“These findings show that the presence of such silent deposits places an individual at high risk and in need of prevention – which with modern medical therapy can reduce the risk of heart attacks and strokes by 50%.”

INDEPENDENCE, Ohio--(BUSINESS WIRE)--Research presented today at the International Union of Angiology (IUA) conference in Sydney, Australia, strongly supported the value of preventive screenings for atherosclerosis—deposits of cholesterol that harden the arteries— and other vascular diseases. These findings illustrate the importance of identifying asymptomatic individuals at risk early and targeting them for aggressive risk factor modification, which can significantly improve health outcomes for patients. 

09:03 AM Eastern Daylight TimeFRCSE,

PhDFor chronic kidney disease (CKD), patients
Identifying asymptomatic individuals at risk early and targeting them for aggressive risk factor modification can reduce disability and death from myocardial infarction (MI) (heart attack) and stroke by 50%.

Highlights from the research presented include:

Early signs of vascular disease such as atherosclerotic plaques and narrowing of the arteries are indicators of risk and can be easily detected through ultrasound screenings. This means that by screening a patient with appropriate risk factors (e.g. age, smoking, high blood pressure or cholesterol, family history of heart disease, etc.), the patient’s physician can identify asymptomatic individuals at risk as early as possible, and target them for aggressive risk factor modification – refining the traditionally accepted Framingham Risk Factor approach, and dramatically reducing morbidity and mortality from heart attack and stroke in the process.

(Hon), Emeritus Professor of Vascular Surgery, Imperial College. “These findings show that the presence of such silent deposits places an individual at high risk and in need of prevention – which with modern medical therapy can reduce the risk of heart attacks and strokes

asymptomatic“Ultrasound screening showing a patient a real-time image of atherosclerotic deposits in their arteries is a powerful motivational tool to prompt lifestyle modification and ensure compliance to treatment,” says Dr. Andrew Manganaro,

High blood pressure, carotid artery disease, peripheral artery disease, and history of stroke or heart disease double the risk of developing CKD.
carotid artery
diseasehave a 200% greater risk of developing CKD.FACC,


, Chief Medical Officer of Life Line Screening. “There is a growing body of research that points to vascular screening as a model that can detect subclinical disease at a time when preventive approaches can have the best outcome. Unfortunately, we cannot depend on conventional risk factor documentation alone – particularly when you consider that 80% of strokes occur in people who otherwise show no symptoms or warnings until it is too late.”

Each year, 20 million people in middle and old age die due to vascular disease. Atherosclerosis screening allows risk factors that have gone unnoticed for years to be identified, allowing doctors to have the right risk stratification for the patient and consider the best treatment option accordingly. 80% of strokes occur without warning in asymptomatic patients, so they can only be significantly reduced by finding and treating the disease before it happens.

U.S. Study Findings

A recent study found that:

Nine out of 10 U.S. cardiovascular physicians see preventive screening for cardiovascular disease, particularly with patients that have two or more key risk factors (age 55+, tobacco use, high blood pressure, obesity, etc.) as a valuable health tool.
Nearly seven out of 10 (68%) of respondents don’t believe enough is being done to raise awareness of atherosclerosis as an underlying cause of stroke, heart

disease and other cardiovascular problems.

“These findings support our long-held position that practicing cardiovascular physicians, the specialists who see patients every day, recognize the importance of screening appropriate patients to educate them and their physicians about their cardiovascular health before symptoms occur,” said Dr. Manganaro.


of Oxford.University Richard Bulbulia, Consultant Vascular Surgeon at Mr Mohsen Chabok, Medical Research Physician, Life Line Screening UK.
“Bigger is Better - Large scale observational studies can provide uniquely reliable results”
Dr Mohsen Chabok, Medical Research Physician, Life Line Screening UK.
“Association of vascular diseases with Chronic Kidney Disease in asymptomatic population” -Dr population-based cohort study Neurology 73 (1074-76) (2009).

Key papers FROM the IUA session supported by Life Line Screening:

“The value of different screening methods” - Prof Andrew Nicolaides, Imperial College London.
"Community-based private vascular screening in Australia" - Professor Scott Kitchener, Medical Director Screen for Life Australia.
“The prevalence of abdominal aortic aneurysm, carotid stenosis, peripheral arterial disease and atrial fibrillation among 295 000 screened British and Irish
adults”-warning:A3. Hackam D. et al Most stroke patients do not get

2. Assmann G1, Schulte H. The Prospective Cardiovascular Münster (PROCAM) study: prevalence of hyperlipidemia in persons with hypertension and/or diabetes mellitus and the relationship to coronary heart disease. Am Heart J. (1988)

Nicolaides, A. Screening for cardiovascular risk. Br J Cardiol. (2010)a    











[The Wall Street Journal]


 Research Report

Tests on Leg Arteries May Tell More Than Neck Studies
Signs of cardiovascular disease could be detected much earlier

[Doctors may find it more effective to test the health of arteries to the legs, not the neck as pictured above, especially for younger patients. The woman is getting an ultrasound scan.]

By: Ann Lukits

July 18, 2016 9:15 a.m. ET

Doctors may be able to detect early signs of cardiovascular disease in patients at a much younger age by taking ultrasound scans of the femoral arteries that supply blood to the legs instead of the more common scans of the carotid, or neck, arteries, says a study published online in the journal AngiologThe study found

y.significantly more femoral plaquethancarotid plaque in people without symptoms of cardiovascular disease who underwent ultrasound scans on both arteries. Younger participants, age 40 and below, showed the greatest differences in plaque deposits between the different arteries. Blood-vessel narrowing was also more prevalent in the femoral arteries, especially in men 40 and younger.

A combined ultrasound examination of both arterial sites could lead to an earlier start on preventive treatments, such as cholesterol-lowering statins, in high-risk patients, the researchers suggest.

Carotid ultrasound scans are routinely conducted on patients at high risk of stroke. In 2014, the U.S. Preventive Services Task Force recommended against carotid screening in the general population.

From March to December 2014, researchers at the University of Rome recruited 322 subjects, age 52 years old on average. On average, 30.4% of the subjects had carotid plaque and 40.7% had femoral plaque. The prevalence of both typesofplaque was higher in men than women, but increased in both sexes with age.

Of those age 40 and younger, 10.5% had femoral plaque and 2.3% had carotid plaque. From age 41 to 55, femoral- and carotid-plaque deposits were present in 31% and 18% of subjects, respectively. After age55,femoral plaque was detected in 66.9% and carotid plaque in 57.4%.