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• W3136701414 abstract "HomeCirculationVol. 143, No. 12Letter by Saleh Regarding Article, “Carotid Atherosclerosis Evolution When Targeting a Low-Density Lipoprotein Cholesterol Concentration <70 mg/dL After an Ischemic Stroke of Atherosclerotic Origin” Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBLetter by Saleh Regarding Article, “Carotid Atherosclerosis Evolution When Targeting a Low-Density Lipoprotein Cholesterol Concentration <70 mg/dL After an Ischemic Stroke of Atherosclerotic Origin” Christian Saleh, MD Christian SalehChristian Saleh https://orcid.org/0000-0002-5225-5414 REHAB Basel, Clinic for Neurorehabilitation and Paraplegiology, Basel, Switzerland. Search for more papers by this author Originally published22 Mar 2021https://doi.org/10.1161/CIRCULATIONAHA.120.050617Circulation. 2021;143:e790–e791To the Editor:I read the article authored by Amarenco et al1 with interest.In the TST-Plus study (Treat Stroke to Target-Plaque Ultrasound Study), the authors used carotid intima media thickness (cIMT) measurement using the semiautomated software M’Ath to evaluate carotid artery atherosclerosis evolution.1For a more exhaustive evaluation of the TST-Plus study, some points need mentioning.In the medical and scientific community, there is no consensus about cIMT as surrogate marker of atherosclerosis.2 cIMT is a combined ultrasound measure, encompassing the intimal and medial layers of the arterial wall, whereas atherosclerosis affects solely the intima. Increased cIMT can also be seen in conditions that are nonatherosclerotic affecting the intima or media.cIMT can be measured in different sections of the carotid artery tree. Measuring cIMT at only 1 predefined section, eg, the distal common carotid artery (CCA) wall,1,3 is technically favorable. However, it can coincide with a normal cIMT while missing altered cIMT sections, consequently misclassifying patients as normal; atherosclerosis is a systemic but asymmetrical disease. Composite measurements will therefore provide a more precise estimate of the actual cIMT. A critical aspect to be considered is that cIMT varies during the cardiac cycle, with cIMT reduction occurring during systole, given systolic lumen vessel expansion.4 The TST-Plus study did not specify whether cIMT measurement was synchronized with a specific cardiac phase.1The authors write, “We used carotid artery ultrasound examination and IMT software…allowing a semiautomated measure of IMT measure of IMT and plaque thickness.”1 With the M’Ath software, plaque/stenoses are “measured on horizontal cross-sections based on residual lumen relative to the external diameter of the artery.”5 However, the article did not detail further plaque measurement and how artefacts affecting stenosis measurement were dealt with, because the M’Ath software cannot differentiate between plaque/stenoses and artefacts.The consensus cIMT Mannheim article that the TST-Plus article cited,3 which is not universally accepted, has Touboul as its first author. Touboul is the senior author of the TST-Plus trial article1 and a stockholder in Intelligence in Medical Technology, which produces the M’Ath software.1The article concludes, “…carotid atherosclerosis disease as measured by CCA-IMT was reduced by lipid-lowering drugs…given the positive effect in CCA-IMT reduction, CCA-IMT proved to be a very sensitive end point to detect a difference with a relatively small sample size.”However, because apparently the study did not pay attention to the cardiac cycle, one cannot compare the baseline with the follow-up cIMT measurements, and one wonders whether the reduced cIMT seen in the follow-up was secondary to more frequent (albeit accidental) measurements made during systole respect baseline examinations, rather than to reduced low-density lipoprotein cholesterol concentrations.For scientific rigor, the pros and cons of the applied biomarker (cIMT) as well as of the applied method (M’Ath) needed mentioning.The use of proxy measures is an important area of research; however, in the current state of research, the use of cIMT as surrogate marker should be considered with caution.Disclosures None.Footnoteshttps://www.ahajournals.org/journal/circReferences1. Amarenco P, Hobeanu C, Labreuche J, Charles H, Giroud M, Meseguer E, Lavallée PC, Steg PG, Vicaut É, Bruckert E, et al.. Carotid atherosclerosis evolution when targeting a low-density lipoprotein cholesterol concentration <70 mg/dL after an ischemic stroke of atherosclerotic origin.Circulation. 2020; 142:748–757. doi: 10.1161/CIRCULATIONAHA.120.046774LinkGoogle Scholar2. Sharma K, Blaha MJ, Blumenthal RS, Musunuru K. Clinical and research applications of carotid intima-media thickness.Am J Cardiol. 2009; 103:1316–1320. doi: 10.1016/j.amjcard.2009.01.020CrossrefMedlineGoogle Scholar3. Touboul PJ, Hennerici MG, Meairs S, Adams H, Amarenco P, Bornstein N, Csiba L, Desvarieux M, Ebrahim S, Hernandez Hernandez R, et al.. Mannheim carotid intima-media thickness and plaque consensus (2004-2006-2011). An update on behalf of the advisory board of the 3rd, 4th and 5th watching the risk symposia, at the 13th, 15th and 20th European Stroke Conferences, Mannheim, Germany, 2004, Brussels, Belgium, 2006, and Hamburg, Germany, 2011.Cerebrovasc Dis. 2012; 34:290–296. doi: 10.1159/000343145CrossrefMedlineGoogle Scholar4. Polak JF, Johnson C, Harrington A, Wong Q, O’Leary DH, Burke G, Yanez ND. Changes in carotid intima-media thickness during the cardiac cycle: the multi-ethnic study of atherosclerosis.J Am Heart Assoc. 2012; 1:e001420. doi: 10.1161/JAHA.112.001420LinkGoogle Scholar5. Amarenco P, Lavallée PC, Labreuche J, Ducrocq G, Juliard JM, Feldman L, Cabrejo L, Meseguer E, Guidoux C, Adraï V, et al.. Prevalence of coronary atherosclerosis in patients with cerebral infarction.Stroke. 2011; 42:22–29. doi: 10.1161/STROKEAHA.110.584086LinkGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetails March 23, 2021Vol 143, Issue 12 Advertisement Article InformationMetrics © 2021 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.120.050617PMID: 33750204 Originally publishedMarch 22, 2021 PDF download Advertisement SubjectsAtherosclerosisStenosisVascular Disease" @default.
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