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Review article: Biomedical intelligence

Vol. 142 No. 4344 (2012)

Carotid intima-media thickness as a biomarker of subclinical atherosclerosis

  • Marcus Bauer
  • Seraina Caviezel
  • Alexandra Teynor
  • Raimund Erbel
  • Amir A Mahabadi
  • Arno Schmidt-Trucksäss
Cite this as:
Swiss Med Wkly. 2012;142:w13705


Intima-media thickness of the carotid artery (CIMT) and its increase is associated with several cardiovascular risk factors and manifest cardiovascular diseases. CIMT is suggested to be an important biomarker of subclinical atherosclerosis. CIMT is measured in B-mode ultrasound images of the carotid tree as a typical double line of the arterial wall. CIMT is best visible in the measurement segment of the distal common carotid artery with lowest measurement variability. The measurement is most reliable over a one centimeter-segment with automatic or semi-automatic reading methods, which minimises reading errors. Further structured training of sonographer and reader is important for valid and reproducible results.

CIMT is an accepted predictor for future cardiovascular events independent of age, gender and cardiovascular risk factors. Measurement seems to be best applicable in patients with intermediate risk in order to readjust cardiovascular risk. Plaques in the carotid tree and thickening of the CIMT are different atherosclerotic processes. From childhood to early adulthood CIMT is the only atherosclerotic marker of the carotid tree; plaques occur later in life. Both parameters contribute independently to risk assessment for future cardio-vascular events.

Aims of this review are to outline measurement procedures, reproducibility, prognostic value and ability to discriminate healthy subject and patients with manifest disease in a practical and scientifically contemporary manner.


  1. Maier H. Präparierkurs Präparieranweisungen und Theorie. 2., erw. Aufl. Köln: Deutscher Ärzte-Verlag; 1987.
  2. Faxon DP, Creager MA, Smith SC Jr, Pasternak RC, Olin JW, Bettmann MA, et al. Atherosclerotic Vascular Disease Conference: executive summary: Atherosclerotic Vascular Disease Conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation. 2004;109(21):2595–604.
  3. Ross R, Faggiotto A, Bowen-Pope D, Raines E. The role of endothelial injury and platelet and macrophage interactions in atherosclerosis. Circulation. 1984;70(5 Pt 2):III77–82.
  4. Gossl M, Lerman LO, Lerman A. Frontiers in nephrology: early atherosclerosis – a view beyond the lumen. J Am Soc Nephrol. 2007;18(11):2836–242.
  5. Weber C, Noels H. Atherosclerosis: current pathogenesis and therapeutic options. Nat Med. 2011;17(11):1410–22.
  6. Hansson GK. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med. 2005;352(16):1685–95.
  7. Hegele RA. The pathogenesis of atherosclerosis. Clin Chim Acta. 1996;246(1–2):21–38.
  8. Johnsen SH, Mathiesen EB. Carotid plaque compared with intima-media thickness as a predictor of coronary and cerebrovascular disease. Curr Cardiol Rep. 2009;11(1):21–7.
  9. Pignoli P, Tremoli E, Poli A, Oreste P, Paoletti R. Intimal plus medial thickness of the arterial wall: a direct measurement with ultrasound imaging. Circulation. 1986;74(6):1399–406.
  10. Bauer M, Möhlenkamp S, Lehmann N, Schmermund A, Roggenbuck U, Moebus S, et al. The effect of age and risk factors on coronary and carotid artery atherosclerotic burden in males – results of the Heinz Nixdorf Recall Study. Atherosclerosis. 2009;205(2):595–602.
  11. Chambless LE, Heiss G, Folsom AR, Rosamond W, Szklo M, Sharrett AR, et al. Association of coronary heart disease incidence with carotid arterial wall thickness and major risk factors: the Atherosclerosis Risk in Communities (ARIC) Study, 1987–1993. Am J Epidemiol. 1997;146(6):483–94.
  12. O’Leary DH, Polak JF, Kronmal RA, Manolio TA, Burke GL, Wolfson SK. Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults. Cardiovascular Health Study Collaborative Research Group. N Engl J Med. 1999;340(1):14–22.
  13. Iglesias del Sol A, Bots ML, Grobbee DE, Hofman A, Witteman JCM. Carotid intima-media thickness at different sites: relation to incident myocardial infarction. The Rotterdam Study. Eur Heart J. 2002;23(12):934–40.
  14. Lorenz MW, von Kegler S, Steinmetz H, Markus HS, Sitzer M. Carotid intima-media thickening indicates a higher vascular risk across a wide age range: prospective data from the Carotid Atherosclerosis Progression Study (CAPS). Stroke. 2006;37(1):87–92.
  15. Nambi V, Chambless L, Folsom AR, He M, Hu Y, Mosley T, et al. Carotid intima-media thickness and presence or absence of plaque improves prediction of coronary heart disease risk: the ARIC (Atherosclerosis Risk In Communities) study. J Am Coll Cardiol. 2010;55(15):1600–7.
  16. Plichart M, Celermajer DS, Zureik M, Helmer C, Jouven X, Ritchie K, et al. Carotid intima-media thickness in plaque-free site, carotid plaques and coronary heart disease risk prediction in older adults. The Three-City Study. Atherosclerosis. 2011;219(2):917–24.
  17. Touboul P-J, Hennerici MG, Meairs S, Adams H, Amarenco P, Bornstein N, et al. Mannheim carotid intima-media thickness consensus (2004–2006). An update on behalf of the Advisory Board of the 3rd and 4th Watching the Risk Symposium, 13th and 15th European Stroke Conferences, Mannheim, Germany, 2004, and Brussels, Belgium, 2006. Cerebrovasc Dis. 2007;23(1):75–80.
  18. Dogan S, Kastelein JJP, Grobbee DE, Bots ML. Mean common or mean maximum carotid intima-media thickness as primary outcome in lipid-modifying intervention studies. J Atheroscler Thromb. 2011;18(11):946–57.
  19. Heinz Nixdorf Recall Studie [Internet]. [cited 2012 Jan 10].
  20. Oren A, Vos LE, Uiterwaal CSPM, Grobbee DE, Bots ML. Cardiovascular risk factors and increased carotid intima-media thickness in healthy young adults: the Atherosclerosis Risk in Young Adults (ARYA) Study. Arch Intern Med. 2003;163(15):1787–92.
  21. Kanters SD, Algra A, van Leeuwen MS, Banga JD. Reproducibility of in vivo carotid intima-media thickness measurements: a review. Stroke. 1997;28(3):665–71.
  22. Teynor A, Caviezel S, Dratva J, Künzli N, Schmidt-Trucksäss A. An automated, interactive analysis system for ultrasound sequences of the common carotid artery. Ultrasound Med. Biol. 2012;38(8):1440–50.
  23. Haller C, Schulz J, Schmidt-Trucksäss A, Burkardt H, Schmitz D, Dickhuth H-H, et al. Sequential based analysis of Intima-Media Thickness (IMT) in common carotid artery studies. Atherosclerosis. 2007;195(2):e203–e209.
  24. Cheng D, Schmidt-Trucksäss A, Cheng K, Burkhardt H. Using snakes to detect the intimal and adventitial layers of the common carotid artery wall in sonographic images. Comput Methods Programs Biomed. 2002;67(1):27–37.
  25. Jourdan C, Wühl E, Litwin M, Fahr K, Trelewicz J, Jobs K, et al. Normative values for intima-media thickness and distensibility of large arteries in healthy adolescents. J Hypertens. 2005;23(9):1707–15.
  26. Bots ML, Evans GW, Riley WA, Grobbee DE. Carotid intima-media thickness measurements in intervention studies: design options, progression rates, and sample size considerations: a point of view. Stroke. 2003;34(12):2985.
  27. O’Leary DH, Polak JF, Wolfson SK, Bond MG, Bommer W, Sheth S, et al. Use of sonography to evaluate carotid atherosclerosis in the elderly. The Cardiovascular Health Study. CHS Collaborative Research Group. Stroke. 1991;22(9):1155–63.
  28. Lorenz MW, Markus HS, Bots ML, Rosvall M, Sitzer M. Prediction of clinical cardiovascular events with carotid intima-media thickness. Circulation. 2007;115(4):459–67.
  29. Stensland-Bugge E, Bønaa KH, Joakimsen O. Reproducibility of ultrasonographically determined intima-media thickness is dependent on arterial wall thickness. The Tromsø Study. Stroke. 1997;28(10):1972–80.
  30. Montauban van Swijndregt AD, De Lange EE, De Groot E, Ackerstaff RG. An in vivo evaluation of the reproducibility of intima-media thickness measurements of the carotid artery segments using B-mode ultrasound. Ultrasound in Medicine & Biology. 1999;25(3):323–30.
  31. Espeland MA, Craven TE, Riley WA, Corson J, Romont A, Furberg CD. Reliability of longitudinal ultrasonographic measurements of carotid intimal-medial thicknesses. Stroke. 1996;27(3):480–5.
  32. Bots ML, Hoes AW, Koudstaal PJ, Hofman A, Grobbee DE. Common carotid intima-media thickness and risk of stroke and myocardial infarction: The Rotterdam Study. Circulation. 1997;96(5):1432–7.
  33. Salonen J, Salonen R. Ultrasonographically assessed carotid morphology and the risk of coronary heart disease. Arterioscler Thromb Vasc Biol. 1991;11(5):1245–9.
  34. Chambless LE, Folsom AR, Clegg LX, Sharrett AR, Shahar E, Nieto FJ, et al. Carotid wall thickness is predictive of incident clinical stroke: The Atherosclerosis Risk in Communities (ARIC) Study. Am J Epidemiol. 2000;151(5):478–87.
  35. Naghavi M, Falk E, Hecht HS, Jamieson MJ, Kaul S, Berman D, et al. From vulnerable plaque to vulnerable patient—part III: Executive Summary of the Screening for Heart Attack Prevention and Education (SHAPE) Task Force Report. Am J Cardiol. 2006;98(2, Supplement 1):2–15.
  36. Stein JH, Korcarz CE, Hurst RT, Lonn E, Kendall CB, Mohler ER, et al. Use of carotid ultrasound to identify subclinical vascular disease and evaluate cardiovascular disease risk: a consensus statement from the American Society of Echocardiography Carotid Intima-Media Thickness Task Force endorsed by the Society for Vascular Medicine. J Am Soc Echocardiogr. 2008;21(2):93–111.
  37. Jäger KA, Staub D. Did you measure the intima-media thickness? Ultraschall Med. 2009;30(5):434–7.
  38. Crouse JR 3rd, Raichlen JS, Riley WA, Evans GW, Palmer MK, O’Leary DH, et al. Effect of rosuvastatin on progression of carotid intima-media thickness in low-risk individuals with subclinical atherosclerosis: the METEOR Trial. JAMA. 2007;297(12):1344–53.
  39. Lorenz MW, Polak JF, Kavousi M, Mathiesen EB, Völzke H, Tuomainen T-P, et al. Carotid intima-media thickness progression to predict cardiovascular events in the general population (the PROG-IMT collaborative project): a meta-analysis of individual participant data. Lancet. 2012;379(9831):2053–62.
  40. Salonen R, Nyyssönen K, Porkkala E, Rummukainen J, Belder R, Park JS, et al. Kuopio Atherosclerosis Prevention Study (KAPS). A population-based primary preventive trial of the effect of LDL lowering on atherosclerotic progression in carotid and femoral arteries. Circulation. 1995;92(7):1758–64.
  41. Hodis HN, Mack WJ, LaBree L, Selzer RH, Liu C, Liu C, et al. Reduction in carotid arterial wall thickness using lovastatin and dietary therapy: a randomized controlled clinical trial. Ann Intern Med. 1996;124(6):548–56.
  42. de Groot E, Jukema JW, van Boven AJ, Reiber JH, Zwinderman AH, Lie KI, et al. Effect of pravastatin on progression and regression of coronary atherosclerosis and vessel wall changes in carotid and femoral arteries: a report from the Regression Growth Evaluation Statin Study. Am J Cardiol. 1995;76(9):40C–46C.
  43. Taylor AJ, Kent SM, Flaherty PJ, Coyle LC, Markwood TT, Vernalis MN. ARBITER: Arterial Biology for the Investigation of the Treatment Effects of Reducing Cholesterol: a randomized trial comparing the effects of atorvastatin and pravastatin on carotid intima medial thickness. Circulation. 2002;106(16):2055–60.
  44. Smilde TJ, van Wissen S, Wollersheim H, Trip MD, Kastelein JJ, Stalenhoef AF. Effect of aggressive versus conventional lipid lowering on atherosclerosis progression in familial hypercholesterolaemia (ASAP): a prospective, randomised, double-blind trial. Lancet. 2001;357(9256):577–81.
  45. Kastelein JJP, Akdim F, Stroes ESG, Zwinderman AH, Bots ML, Stalenhoef AFH, et al. Simvastatin with or without ezetimibe in familial hypercholesterolemia. N Engl J Med. 2008;358(14):1431–43.
  46. Brown BG, Taylor AJ. Does ENHANCE diminish confidence in lowering LDL or in ezetimibe? N Engl J Med. 2008;358(14):1504–7.
  47. Hense H-W, Schulte H, Löwel H, Assmann G, Keil U. Framingham risk function overestimates risk of coronary heart disease in men and women from Germany – results from the MONICA Augsburg and the PROCAM cohorts. Eur Heart J. 2003;24(10):937–45.
  48. Mozaffarian D, Wilson PWF, Kannel WB. Beyond established and novel risk factors lifestyle risk factors for cardiovascular disease. Circulation. 2008;117(23):3031–8.
  49. Lorenz MW, Schaefer C, Steinmetz H, Sitzer M. Is carotid intima media thickness useful for individual prediction of cardiovascular risk? Ten-year results from the Carotid Atherosclerosis Progression Study (CAPS). Eur Heart J. 2010;31(16):2041–8.
  50. Greenland P, Lauer MS, Beller GA, Benjamin EJ, Budoff MJ, Fayad ZA, et al. 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic Adults. Circulation. 2010;122(25):e584–e636.
  51. Spence J. The importance of distinguishing between diffuse carotid intima-media thickening and focal plaque. Can J Cardiol. 2008;24:61C–64C.
  52. Inaba Y, Chen JA, Bergmann SR. Carotid plaque, compared with carotid intima-media thickness, more accurately predicts coronary artery disease events: A meta-analysis. Atherosclerosis. 2012;220(1):128–33.
  53. Spence JD, Hegele RA. Non-invasive assessment of atherosclerosis risk. Curr Drug Targets Cardiovasc Haematol Disord. 2004;4(2):125–8.
  54. Landry A, Spence JD, Fenster A. Quantification of carotid plaque volume measurements using 3D ultrasound imaging. Ultrasound Med Biol. 2005;31(6):751–62.
  55. Staub D, Partovi S, Schinkel AFL, Coll B, Uthoff H, Aschwanden M, et al. Correlation of carotid artery atherosclerotic lesion echogenicity and severity at standard US with intraplaque neovascularization detected at contrast-enhanced US. Radiology. 2011;258(2):618–26.
  56. Staub D, Patel MB, Tibrewala A, Ludden D, Johnson M, Espinosa P, et al. Vasa vasorum and plaque neovascularization on contrast-enhanced carotid ultrasound imaging correlates with cardiovascular disease and past cardiovascular events. Stroke. 2010;41(1):41–7.
  57. Joakimsen O, Bonaa KH, Stensland-Bugge E, Jacobsen BK. Age and sex differences in the distribution and ultrasound morphology of carotid atherosclerosis: the Tromsø Study. Arterioscler Thromb Vasc Biol. 1999;19(12):3007–13.

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