1. Date of download: 6/1/2016 Copyright © The American College of Cardiology. All rights reserved. From: Carotid Intima-Media Thickness and Plaque in Cardiovascular Risk Assessment J Am Coll Cardiol Img. 2014;7(10):1025-1038. doi:10.1016/j.jcmg.2013.11.014 Plaque Phenotypes Images showing variation in plaque morphology. (A) Focal plaque at the far wall of the carotid bulb with calcification and acoustic shadowing. Note the entirely normal common carotid artery intima-media thickness (CCA-IMT). If only CCA-IMT is measured for risk stratification, this patient would be misclassified as having low cardiovascular risk. (B) This patient has a focal long homogeneous plaque at the region of the carotid bifurcation, but also thickening of the near and far wall carotid IMT. (C) Predominantly noncalcified multiple plaques in the carotid bulb. (D) A large calcified plaque layered along the vessel wall. Figure Legend:

2. Date of download: 6/1/2016 Copyright © The American College of Cardiology. All rights reserved. From: Carotid Intima-Media Thickness and Plaque in Cardiovascular Risk Assessment J Am Coll Cardiol Img. 2014;7(10):1025-1038. doi:10.1016/j.jcmg.2013.11.014 Where Should IMT Be Measured? The far wall of common carotid artery intima-media thickness (CCA-IMT) corresponds most closely to histological measures and is most reproducible. (A) Longitudinal ultrasound image of the CCA, carotid bulb, and internal carotid artery (ICA) is shown for a 50- year-old female patient with a Framingham Risk Score of 1% and normal CCA-IMT. (B) Bulb and ICA are shown in the same patient. There is a plaque in the near wall of the bulb and a diffuse increase in IMT at the far wall of the bulb and ICA. If far-wall CCA-IMT is measured and reported, the patient will be deemed low risk. If plaque is defined as focal protrusion with 1.5-mm thickness, the maximal near wall of the bulb IMT (1.2 mm) and maximal far wall of the ICA-IMT (1.15 mm) do not meet criteria. This patient will therefore be reported as low risk based on the American Society of Echocardiography consensus statement. Meta-analysis of studies that only measured CCA-IMT showed no incremental value over the FRS. This example suggests that assessment of IMT should be performed at the CCA, bulb, and ICA in select patients. Figure Legend:

3. Date of download: 6/1/2016 Copyright © The American College of Cardiology. All rights reserved. From: Carotid Intima-Media Thickness and Plaque in Cardiovascular Risk Assessment J Am Coll Cardiol Img. 2014;7(10):1025-1038. doi:10.1016/j.jcmg.2013.11.014 Measurement of CCA-IMT Longitudinal ultrasound images of the common carotid artery are shown for a 57-year-old Caucasian woman with a Framingham Risk Score (FRS) of 1% and with normal carotid intima-media thickness ( 75th percentile) as well as a plaque in the near wall of R bulb (not shown). Per ARIC study data, adding cardiac intima- media thickness adds to the area under the curve over and above the FRS and plaque presence in males. Hence, in this patient, both plaque and CIMT should be reported. Figure Legend:

4. Date of download: 6/1/2016 Copyright © The American College of Cardiology. All rights reserved. From: Carotid Intima-Media Thickness and Plaque in Cardiovascular Risk Assessment J Am Coll Cardiol Img. 2014;7(10):1025-1038. doi:10.1016/j.jcmg.2013.11.014 Carotid Plaque Burden Quantitation Three-dimensional plaque data acquired using a VL13-5 probe with a Philips iU22 ultrasound scanner (Philips Healthcare, Andover, Massachusetts). The VL13-5 is a high-resolution linear array with 192 elements that mechanically acquires a series of conventional images covering the whole carotid bifurcation with a sweep in ∼ 3 to 4 s. These images are automatically combined to create a 4 × 2.5 × 2.5-cm “block” of voxels. XRES is a post-processing technique that removes speckle from the image, yielding an image with better borders and less clutter (noise) in the image. A series of image slices in transverse section are shown by the thumbnails (middle). Each image slice is analyzed with semiautomated software to quantify plaque area, percentage of stenosis, and plaque volume. Plaque areas from all images in the entire image sequence are summed as “plaque burden.” An image of the common carotid artery in one of the slices is shown. The yellow border represents the lumen/intima border; the red border represents the media-adventitia border. The blue border represents the boundary of the plaque. The graph at the bottom of the image depicts the plaque (yellow line) area as a percentage of vessel area (percentage of stenosis), which is maximal in the image slice shown. Figure Legend: