We thank González-Clemente et al. (1) for their interest in our recent article published in Diabetes Care (2) and their commentary on it. We agree with the authors that the estimation of arterial stiffness has potential usefulness in our common purpose of individualizing cardiovascular risk. There is certainly a distinction between arteriosclerosis and atherosclerosis; however, they are probably different temporal stages of the same continuous process, and one may be a consequence of the other, as pointed out by González-Clemente et al. (1).
In this regard, we would like to point out some of the strengths of the carotid ultrasound, which is why we have opted for its use as a cardiovascular disease proxy in our research. First, it is a noninvasive, inexpensive, and reproducible technique that does not require any equipment other than an ultrasound scanner, which is widely available for various purposes in the health care setting. Second, and in light of the currently available evidence, the most recent European guidelines on cardiovascular disease prevention (3) consider carotid artery plaque assessment using ultrasonography as a risk modifier for selection of those individuals more suitable for cardioprotective treatment. Conversely, they argue against the widespread use of arterial stiffness for this purpose due to measurement difficulties and substantial publication bias. Third, the same procedure can be used to assess not only the presence/nonpresence of carotid plaque but also other measurements with potential predictive capacity, such as plaque number, location, size, plaque characterization (e.g., soft, calcified, fibrotic, or ulcerated), intima-media thickness, or, for example, the detection of nonfocal thickening in the common carotid artery, which could be a sign of undiagnosed hypertension. Fourth, even though another imaging technique, such as coronary artery calcium score, appears to have higher predictive performance for cardiovascular disease, it is expensive, emits radiation, and does not detect the presence of noncalcified plaques that ultrasound does. Fifth and last, we would like to emphasize that the detection of carotid plaque is a simple, understandable term for both the physician and the patient. Further, against a background where adherence to cardioprotective treatments is often lower than desirable, the mere visualization of the plaque and awareness of subclinical atherosclerosis could have an impact on adherence to heart-healthy lifestyle habits and pharmacological treatments, as we previously stated in our Mediterranean setting (4) and also in an open-label Scandinavian population trial (5).
Finally, we would like to highlight that the use of cardioprotective treatment is far from optimal at the population level, even for some individuals at high/very high risk of cardiovascular disease (i.e., subjects with type 1 diabetes). In this sense, any tool or marker that allows better identification of those at greatest risk and can help to overcome therapeutic inertia and allow for the early initiation and intensification of such treatments should be welcome.
See accompanying article, p. e85.
Article Information
Funding. A.J.A. received a research grant from the Associació Catalana de Diabetis, “Ajut per a la Recerca en Diabetis Modalitat Clínica 2018.”
Duality of Interest. No potential conflicts of interest relevant to this article were reported.
