Plaque Echogenicity Research Articles

Identification of Vascularised Carotid Plaques Using a Standardised and Reproducible Technique to Measure Ultrasound Contrast Uptake

Contrast-enhanced ultrasonography (CEUS) has been used to assess the vascularisation of carotid plaques. Our aim was to develop and validate a standardised semi-automated method for CEUS examination of plaques, and test if the technique could be used to identify vulnerable plaques. Study participants were a mixed population of symptomatic and asymptomatic subjects, selected if they had a plaque with height >2.5 mm and <10% acoustic shadowing. Participants received a bolus of ultrasound contrast agent and a 90-s cine-loop was captured. A Contrast Quantification Program (CQP) was developed and trained to identify extent of contrast uptake after motion correction and application of a noise reduction algorithm. The technique was validated by comparing CQP values with visual assessment of contrast uptake. CQP values were also compared with plaque echogenicity and history of clinical events. CQP values correlated with a visual, 5-scale classification of contrast uptake by two blinded, experienced sonographers. Repeated contrast injections showed high reproducibility. Participants with a history of ipsilateral stroke/TIA had significantly higher CQP values than asymptomatic participants. We present a reproducible, semi-automatic method to identify vascularisation of carotid plaques, which could be used in prospective studies to determine the clinical value of plaque vascularisation.

An assessment of the vulnerability of carotid plaques: a comparative study between intraplaque neovascularization and plaque echogenicity

BackgroundCarotid plaque echolucency as detected by Color Doppler ultrasonography (CDUS) has been used as a potential marker of plaque vulnerability. However, contrast-enhanced ultrasound (CEUS) has recently been shown to be a valuable method to evaluate the vulnerability and neovascularization within carotid atherosclerotic plaques. The aim of this study was to compare CEUS and CDUS in the assessment of plaque vulnerability using transcranial color Doppler (TCD) monitoring of microembolic signals (MES) as a reference technique.MethodsA total of 46 subjects with arterial stenosis (≥ 50%) underwent a carotid duplex ultrasound, TCD monitoring of MES and CEUS (SonoVue doses of 2.0 mL) within a span of 3 days. The agreement between the CEUS, CDUS, and MES findings was assessed with a chi-square test. A p-value less than 0.05 was considered statistically significant.ResultsNeovascularization was observed in 30 lesions (44.4%). The vascular risk factors for stroke were similar and there were no age or gender differences between the 2 groups. Using CEUS, MES were identified in 2 patients (12.5%) within class 1 (non-neovascularization) as opposed to 15 patients (50.0%) within class 2 (neovascularization) (p = 0.023). CDUS revealed no significant differences in the appearance of the MES between the 2 groups (hyperechoic and hypoechoic) (p = 0.237).ConclusionThis study provides preliminary evidence to suggest that intraplaque neovascularization detected by CEUS is associated with the presence of MESs, where as plaque echogenicity on traditional CDUS does not. These findings argue that CEUS may better identify high-risk plaques.

Abstract WP163: 3D-versus 2D-Ultrasound for Plaque Analysis of Internal Carotid Arteries with Gray-Scale Median

Background: Gray-Scale Median (GSM) analysis of carotid artery stenosis allows quantification of plaque echogenicity, correlates with histology and showed an association with symptoms and cerebral embolic findings. The aim of the study is to demonstrate whether several systematically aquired sections of 3-dimensional Power-Doppler ultrasound (3D-PDUS) datasets comprising whole plaque stenoses provide different GSM than single sections acquired by 2D-PDUS as commonly used for this purpose. Methods: After informed consent, 27 patients were scanned with a 3D-ultrasound (US) probe at 10 Mhz. GSM-analysis was performed offline with a specially designed software (Matlab) in 2D longitudinal scans adjusted to the vessel center line, as well as 3 parasagital - longitudinal sections parallel to each other and 3 views rotated around the center of the plaque, that were aquired off-line from the 3D-datasets by multiplanar rendering. For comparison of the GSM, the median differences between 3D- and the 2D-images as well as standard deviations (SD) were calculated. Mixed model regression analysis was used for further descriptive statistics. Results: The GSM differences between the 3D-parallel and the central longitudinal 2D-reference section showed a markedly higher proportion of the variance due to image-to-image (63%) versus inherent technical-methodological scattering (37%), that was not found for rotated 3D sections (54 versus 46%). The GSM of the longitudinal 3D-sections correlates significantly with the GSM of the 2D-reference section (r = 0.60) as do the rotated 3D views (r = 0.52). Correlation coefficients of the central 3D- with the 2D-longitudinal section differed significantly, when rotation was performed (r = 0.63) instead of sagital rendering (r = 0.85, p &lt; 0.05). Significant over- versus underestimations were noted for high versus low GSM values in the 3D parasagital and rotated views compared to the 2D sections. Conlusions: Variations of the GSM values in between the 3D-sections were largely due to real differences of the echogenicity. The GSM of a single 2D-section may not be representative for the whole 3D plaque structure. Parasagital section rendering should be prefered to analyse whole plaque GSM over rotating sections.

Association of carotid plaque echogenicity with recurrence of ischemic stroke

Background:Atherosclerosis is related to various cardiovascular and cerebrovascular events like cerebral infarction. Recurrence of ischemic stroke is specifically related to atherosclerotic load as determined by the presence of carotid atheromatous plaques and its echogenicity.Aim:This study was to evaluate the association of recurrence of stroke with echogenic characteristics of carotid plaque in ischemic stroke patients.Materials and Methods:Carotid sonography using high-resolution 7.5 MHz along with gray-scale technique was done in each ischemic stroke patient to find the occurrence of plaque and its echogenicity according to Mannheim Carotid Intima-Media Thickness Consensus (2004-2006). Followup of patient done to know the recurrence of stroke during 6-month duration and its association with plaque echogenicity.Results:A significant association found between the presence of plaque and known cerebrovascular risk factors. Also significant association found between recurrence of stroke and echolucent character of carotid plaque in bivariate analysis (P = 0.0028).Conclusions:Recurrence of stroke is related to advanced stage of atherosclerosis that is specified by carotid plaque and its characteristics. It will help us to identify groups of patients at different risk for stroke and planning better strategies to prevent such events.

Early differential changes in coronary plaque composition according to plaque stability following statin initiation in acute coronary syndrome: classification and analysis by intravascular ultrasound-virtual histology.

PurposeThe aim of this study was to demonstrate the early effects of statin treatment on plaque composition according to plaque stability on Intravascular Ultrasound-Virtual Histology at 6 months after a coronary event. Previous trials have demonstrated that lipid lowering therapy with statins decreases plaque volume and increases plaque echogenicity in patients with coronary artery disease.Materials and MethodsFifty-four patients (54 lesions) with acute coronary syndrome were prospectively enrolled. We classified and analyzed the target plaques into two types according to plaque stability: thin-cap fibroatheroma (TCFA, n=14) and non-TCFA (n=40). The primary end point was change in percent necrotic core in the 10-mm subsegment with the most disease.ResultsAfter 6 months of statin therapy, no change was demonstrated in the mean percentage of necrotic core (18.7±8.5% to 20.0±11.0%, p=0.38). There was a significant reduction in necrotic core percentage in patients with TCFA (21.3±7.2% to 14.4±8.9%, p=0.017), but not in patients with non-TCFA. Moreover, change in percent necrotic core was significantly correlated with change in high-sensitivity C-reactive protein levels (r=0.4, p=0.003). Changes in low-density lipoprotein cholesterol levels and lipid core percentage demonstrated no significant associations.ConclusionA clear reduction of lipid core was observed only for the TCFA plaque type, suggesting that changes in plaque composition following statin therapy might occur earlier in vulnerable plaque than in stable plaque; the effect may be related to the anti-inflammatory effects of statins.

A young case of antiphospholipid antibody syndrome, with echogenic plaque observed by intravascular ultrasound in acute myocardial infarction

A young case of antiphospholipid antibody syndrome, with echogenic plaque observed by intravascular ultrasound in acute myocardial infarction

Alterations of baroreflex sensitivity after carotid endarterectomy according to the preoperative carotid plaque echogenicity

Baroreflex sensitivity is lower in patients with echogenic carotid plaques compared with patients with echolucent ones. The purpose of our study was to compare the baroreflex function after carotid endarterectomy (CEA) between patients with different plaque echogenicity. Spontaneous baroreflex sensitivity (sBRS), heart rate, and systolic and diastolic arterial pressure were calculated in 51 patients with a severe carotid stenosis (70%-99%) 24 hours before CEA, as well as 24 and 48 hours after CEA. Carotid plaque echogenicity was graded from 1 to 4 according to Gray-Weale classification, after duplex examination, and the patients were divided into two groups: the echolucent (grade 1 or 2) and the echogenic (grade 3 or 4). The postoperative mean systolic arterial pressure values in all 51 patients at 24 and 48 hours (143.2 and 135.5 mm Hg, respectively) were found to be significantly increased compared with the preoperative value (132.5 mm Hg; x2=32, P<.001). Mean sBRS value, in all patients, was significantly reduced postoperatively to 2.1 ms mm Hg(-1), from the mean preoperative value, 3.7 ms mm Hg(-1), independently of plaque echogenicity. Twenty patients (39%) were included in the echolucent group and 31 (61%) in the echogenic. The two groups had significant differences in two parameters: the rate of diabetes mellitus and the rate of symptomatic plaques. After adjusting the two groups for these differences, we found that the preoperative difference in sBRS between the two groups (F[1,51]=11, P<.003) was eliminated 24 and 48 hours after CEA (F[1,51]=.007, P<.9 and F[1,51]=.4, P<.5 for 24 and 48 hours, respectively). Before the removal of carotid atheroma, baroreflex sensitivity, which is a well established cardiovascular risk factor, seems to be affected by carotid plaque echogenicity. However, CEA has as a result a similar baroreflex response in all patients, regardless of plaque echogenicity, implying no association of plaque morphology and postoperative baroreflex sensitivity.

In vivo measurement of plaque neovascularisation and thermal heterogeneity in intermediate lesions of human carotid arteries

ObjectivesBoth neoangiogenesis and inflammation contribute in atherosclerosis progression. Contrast-enhanced ultrasound (CEUS) provides visualisation of plaque neovascularisation. Microwave radiometry (MR) allows in vivo non-invasive measurement of temperature of tissues, reflecting inflammatory...

3D- versus 2D-Power-Doppler Ultrasound for Evaluation of Internal Carotid Arteries: Implications for Whole Plaque Analysis with Gray-Scale Median

Whole plaque analysis of carotid artery stenosis with Gray-Scale Median (GSM) allows quantification of plaque echogenicity, correlates with histology and was shown to be associated with symptoms and embolic cerebral findings. The aim of the study is to find out whether 3-dimensional Power-Doppler ultrasound (3D-PDUS) datasets comprising whole plaque stenoses provide different GSM than single sections acquired by 2D-PDUS as commonly used for this purpose.

Sonographic assessment of acute changes in plaque size and echogenicity and in intima‐media thickness of carotid arteries after neck radiation therapy

Ultrasonic assessment of acute changes in carotid artery walls before and after neck radiation therapy (RT). Fifty cancer patients scheduled for curative neck irradiation were included and underwent sonographic examination of carotid arteries, with assessment of intima-media thickness (IMT) and plaque size and echogenicity before and immediately after completion of RT. IMT was linearly correlated with age and before RT (r = 0.267, p = 0.007) and increased after RT (0.68 ± 0.11 versus 0.87 ± 0.16, p < 0.001), without correlation with total RT dose and protocol. New plaques (six hypoechoic, one hyperechoic, and one calcified) were found in eight patients after RT, while 17 of the 44 plaques that were present before RT increased in size, and 8 soft and 1 dense plaques in nine patients became calcified. Radiation in the acute phase not only increases the IMT but also causes new plaque formation and changes in plaque size and echogenicity.

Echolucency of carotid plaques and cerebrovascular events

To assess the relationship between carotid plaque echogenicity and degree of stenosis with acute and chronic stroke. A retrospective study of cerebral MRI and carotid B-mode and Doppler ultrasonography in 60 patients with stroke. Plaque echogenicity was graded as echolucent (1), predominantly echolucent (2), predominantly echogenic (3), or echogenic (4). Sonographic findings were compared between patients with acute (group 1) and chronic (group 2) stroke. In group 1 (n = 39 patients), the carotid plaques were grade 1 in 21, grade 2 in 22, grade 3 in 9, and grade 4 in 4 carotid arteries. In group 2 (n = 21), the carotid plaques were grade 1 in 2, grade 2 in 8, grade 3 in 4, and grade 4 in 11 carotid arteries. Plaque echogenicity was lower in group 1 than in group 2 (p < 0.05). Plaque echolucency was associated independently with acute stroke from the degree of stenosis. Patients with acute infarcts have predominantly echolucent plaques, regardless of the degree of stenosis.

Association between Plaque Echogenicity and Embolic Material Captured in Filter during Protected Carotid Angioplasty and Stenting

Objectives/design: The aim of the study was to investigate debris captured in filter embolic protection devices (EPDs) during carotid artery stenting (CAS) and its possible correlation with plaque echogenicity and other risk factors. Materials/methods: Between June 2010 and March 2011, 51 consecutive CAS patients (11 females, mean age 71.2 ± 7, 10 symptomatic) who underwent 53 procedures were included in this prospective study. Ultrasonographic Gray-Weale plaque type (I–V, echolucent to echogenic) characterisation was obtained in all cases. The same type of stent and filter EPD was used. Filters were collected and, after macroscopic evaluation, they were examined using the Thin-Prep® liquid-based cytology (LBC) technique. Results: Technical success was 100%. Thirty-day stroke and death rates were 1.8% (1/53) and 0%, respectively. Visible debris was detected in eight (15%) filters, whereas LBC revealed the presence of embolic material particles in 30 filters (56.6%). The presence of embolic material into the filter EPD was 2.38-fold increased for every category change from type IV to type I carotid plaques (OR = 2.38, 95% CI = 1.15-4.93). This association remained robust even after adjustment for age, gender and known atherosclerotic disease risk factors (OR = 2.26, 95% CI = 1.02–5.02). In multivariate analysis for risk factors, hypertension was associated with increased presence of embolic material detection in filter EPD (OR = 20.4, 95% CI = 1.28–326.1). The time distance from symptom to CAS was inversely correlated with debris quantity in EPD (Spearman rho −0.716; P = 0.02). Conclusions: Echolucent plaques, smaller time frame from last symptom and hypertension were associated with increased presence of embolic material.

First In Vivo Application of Microwave Radiometry in Human Carotids: A New Noninvasive Method for Detection of Local Inflammatory Activation

This study investigated whether temperature differences: 1) can be measured in vivo noninvasively by microwave radiometry (MR); and 2) are associated with ultrasound and histological findings. Studies of human carotid artery samples showed increased heat production. MR allows in vivo noninvasive measurement of internal temperature of tissues. Thirty-four patients undergoing carotid endarterectomy underwent screening of carotid atherosclerosis by ultrasound and MR. Healthy volunteers were enrolled as a control group. During ultrasound study, plaque texture, plaque surface, and plaque echogenicity were analyzed. Temperature difference (ΔT) was assigned as maximal minus minimum temperature. Association of thermographic with ultrasound and histological findings was performed. ΔT was higher in atherosclerotic carotid arteries compared with the carotid arteries of controls (p < 0.01). Fatty plaques had higher ΔT compared with mixed and calcified (p < 0.01) plaques. Plaques with ulcerated surface had higher ΔT compared with plaques with irregular and regular surface (p < 0.01). Heterogeneous plaques had higher ΔT compared with homogenous (p < 0.01). Specimens with thin fibrous cap and intense expression of CD3, CD68, and vascular endothelial growth factor (VEGF) had higher ΔT compared with specimens with thick cap and low expression of CD3, CD68, and VEGF (p < 0.01). MR provides in vivo noninvasive temperature measurements of carotid plaques, reflecting plaque inflammatory activation.

Association between Plaque Echogenicity and Embolic Material Captured in Filter during Protected Carotid Angioplasty and Stenting

Objectives/designThe aim of the study was to investigate debris captured in filter embolic protection devices (EPDs) during carotid artery stenting (CAS) and its possible correlation with plaque echogenicity and other risk factors. Materials/methodsBetween June 2010 and March 2011, 51 consecutive CAS patients (11 females, mean age 71.2 ± 7, 10 symptomatic) who underwent 53 procedures were included in this prospective study. Ultrasonographic Gray-Weale plaque type (I–V, echolucent to echogenic) characterisation was obtained in all cases. The same type of stent and filter EPD was used. Filters were collected and, after macroscopic evaluation, they were examined using the Thin-Prep® liquid-based cytology (LBC) technique. ResultsTechnical success was 100%. Thirty-day stroke and death rates were 1.8% (1/53) and 0%, respectively. Visible debris was detected in eight (15%) filters, whereas LBC revealed the presence of embolic material particles in 30 filters (56.6%). The presence of embolic material into the filter EPD was 2.38-fold increased for every category change from type IV to type I carotid plaques (OR = 2.38, 95%CI = 1.15–4.93). This association remained robust even after adjustment for age, gender and known atherosclerotic disease risk factors (OR = 2.26, 95%CI = 1.02–5.02). In multivariate analysis for risk factors, hypertension was associated with increased presence of embolic material detection in filter EPD (OR = 20.4, 95%CI = 1.28–326.1). The time distance from symptom to CAS was inversely correlated with debris quantity in EPD (Spearman rho −0.716; p = 0.02). ConclusionsEcholucent plaques, smaller time frame from last symptom and hypertension were associated with increased presence of embolic material.

Femoral Plaque Echogenicity and Cardiovascular Risk in Claudicants

The present study was designed to verify whether the evaluation of femoral plaque echogenicity might be a useful tool for cardiovascular risk assessment in patients affected by lower extremity peripheral arterial disease. Lower extremity peripheral arterial disease is a common manifestation of atherosclerosis and is associated with a high risk of developing major cardiovascular events. Vulnerable atherosclerotic plaque plays a central role in the occurrence of acute ischemic events in different vascular territories. Furthermore, atherosclerosis is a systemic disease, and the presence of an unstable atherosclerotic plaque in a certain vascular district, characterized by low echogenicity at B-mode ultrasound, is associated to a greater prevalence of unstable plaques in other vascular beds. Femoral plaque echogenicity of 246 claudicants with ankle/brachial index ≤0.90 was evaluated at B-mode ultrasound by visual analysis and by calculating the grayscale median (GSM) value. In these patients, the occurrence of myocardial infarction and stroke was prospectively assessed. Femoral GSM values and plaque types assessed by visual analysis were highly correlated by Spearman analysis (rho = 0.905, p < 0.001). During a median follow-up of 30 months, 32 patients (13%) had a major cardiovascular event. Compared with patients without events, those who experienced an event during the follow-up had a lower femoral plaque GSM value (42.9 ± 26.2 vs. 58.8 ± 19.3, p = 0.002) and a higher prevalence of hypoechoic femoral plaque at visual analysis (68.8% vs. 19.6%, p < 0.001). At Cox analysis, femoral GSM showed an inverse relationship with cardiovascular risk, even after adjustment for possible confounders (hazard ratio: 0.96, 95% confidence interval [CI]: 0.95 to 0.98, p < 0.001). Furthermore, patients with hypoechoic femoral plaques at visual analysis had a 7.24-fold increased cardiovascular risk compared with patients with hyperechoic plaques after adjustment for possible confounders (95% CI: 3.23 to 16.22, p < 0.001). This study demonstrates that the presence of hypoechoic atherosclerotic femoral plaques is associated with higher cardiovascular risk in lower extremity peripheral arterial disease patients.

Influence of plaque volume on hemodynamic response and stress hormone release in patients undergoing carotid artery stenting.

Carotid artery stenting (CAS) may cause bradycardia and hypotension due to barostimulation. The impact of periprocedural hypotension on CAS outcome remains controversial. The role of carotid plaque volume and catecholamine hormone release during CAS on hemodynamic changes has not been investigated so far. The aim of this prospective study was to evaluate if carotid artery plaque characteristics are predictive for stress hormone release or for postprocedural hemodynamic instability. In 26 patients undergoing CAS, carotid plaque volume and morphology were assessed by two- and three-dimensional (3D)-Duplex sonography prior to the procedure. Arterial plasma adrenaline, noradrenaline and renin concentrations were measured at the time of sheath insertion and 5 minutes after stent placement. ECG, heart rate, and invasive blood pressure were monitored throughout the procedure. CAS caused no significant changes in hormone release, but increasing plaque volume was related to the degree of bradycardia following stent deployment (r=0.57; P=0.01). Plaque size was not associated with postprocedural hypotension. Plaque echogenicity (echolucent, heterogeneous or echogenic) did not correlate with changes in systolic blood pressure, heart rate or catecholamine hormone release. CAS caused bradycardia in relation to plaque size, but did not cause catecholamine release which may indicate that the endovascular procedure is not associated with a relevant stress reaction.

The Relation Between Carotid Plaque Echogenicity and Oxidative Stress Marker 8-iso-Prostaglandin F2α

Echolucent plaques are associated with high risk of ischemic cerebrovascular events. Oxidative stress has been implicated in the process of atherosclerotic plaque development from initiation to progression. We assessed the relation between carotid plaque echogenicity and urinary 8-iso-prostaglandin F2α, as an index of oxidative stress. This cross-sectional study was conducted prospectively on 290 consecutive outpatients. Each patient was evaluated for carotid plaque echogenicity using the gray-scale median at the maximal thickness plaque and urinary 8-iso-prostaglandin F2α using enzyme linked immunosorbent assay. By Pearson correlation analysis, we found significant negative linear relation between gray-scale median values and the urinary 8-iso-prostaglandin F2α levels (r = −0.133, p = 0.023). This correlation remained significant after adjustment for atherosclerotic risk factors, thickness of the maximal plaque and medication use (β = −0.137, p = 0.031). We herein show that higher levels of urinary 8-iso-prostaglandin F2α is associated with lower plaque echogenicity.

Early Improvement in Carotid Plaque Echogenicity by Acarbose in Patients With Acute Coronary Syndromes

The resolution of hyperglycemia is associated with suppression of in-hospital cardiac complications in patients with acute coronary syndromes (ACS). This study evaluated carotid artery plaque echolucency using ultrasound in patients with ACS and type 2 diabetes mellitus (DM) to determine whether acarbose, an α-glucosidase inhibitor, may rapidly stabilize unstable atherosclerotic plaques. ACS patients with type 2 DM and carotid plaques (n=44) were randomly assigned to treatment with acarbose (150 or 300 mg/day, n=22) or a control group (no acarbose, n=22). Acarbose treatment was initiated within 5 days after the onset of ACS. Unstable carotid plaques were assessed by measuring plaque echolucency using carotid ultrasound with integrated backscatter (IBS) before, and at 2 weeks, 1 and 6 months after the initiation of treatment. An increase in the IBS value reflected an increase in carotid plaque echogenicity. As results, the IBS value of echolucent carotid plaques showed a significant increase at 1 month and a further increase at 6 months after treatment in the acarbose group, but there was minimal change in the control group. The increase in IBS values was significantly correlated with a decrease in C-reactive protein levels. Acarbose rapidly improved carotid plaque echolucency within 1 month of therapy in patients with ACS and type 2 DM.

Changes in Carotid Plaque Echogenicity with Time Since the Stroke Onset: An Early Marker of Plaque Remodeling?

Carotid plaques undergo histologic changes early after an ischemic stroke. However, the evolution of carotid plaques echolucency after a recent brain ischemia is not well known. A prospective observational study that included consecutive stroke patients and asymptomatic individuals with plaques showing ≥50% stenosis on duplex ultrasound was conducted. Plaque echogenicity was measured with the standardized gray-scale median (GSM) and compared with respect to symptoms presence and time from stroke onset. One hundred twenty-six carotid plaques in 124 patients were studied and four groups of plaques were analyzed: (1) plaques seen within 24 h of stroke onset (32); (2) between 1–7 days (50); (3) more than 7 days after stroke onset (22) and; (4) plaques without associated symptoms (22). Plaques of group 1 had less echogenicity than those of groups 2–4: median GSM (interquartile range) 14 (16), 19.5 (19), 22.5 (21), 26.5 (16) respectively ( p = 0.001). In conclusion, carotid plaque echogenicity is increased with time from stroke onset and could be an early marker of plaque remodeling.

Circulating levels of metals are related to carotid atherosclerosis in elderly

The aim of this study was to investigate if blood levels of trace and/or heavy metals are related to atherosclerosis in a cross-sectional study in elderly.In the population-based Prospective Investigation of the Vasculature in Uppsala Seniors (PIVUS) study (1016 subjects, all aged 70), the prevalence of carotid artery plaques was recorded by ultrasound. The numbers of carotid arteries with plaques (0, 1 or 2) were recorded. Also the thickness (IMT) and gray scale (IM-GSM) of the intima-media complex were measured together with plaque echogenicity. Eleven heavy metals and trace elements were analyzed in whole blood, using inductively coupled plasma-sector field mass spectrometry.Nickel levels were related to the number of carotid arteries with plaques in an inverted U-shaped manner after multiple adjustment for gender, waist circumference, body mass index, fasting blood glucose, systolic and diastolic blood pressure, HDL and LDL cholesterol, serum triglycerides, smoking, antihypertensive treatment and statin use (p=0.026). IM-GSM and plaque echogenicity were both inversely related to chromium in a linear fashion, and to aluminum in an inverted U-shaped manner (both p<0.0001 for IM-GSM). The relationships between metals and IMT were modest.Circulating levels of some metals, like nickel, aluminum and chromium, were related to atherosclerotic plaques or the echogenicity of the IM-GSM and overt plaques independently of cardiovascular risk factors, including lipids.