%% LyX 2.3.3 created this file.  For more info, see http://www.lyx.org/.
%% Do not edit unless you really know what you are doing.
\documentclass[jcdd,article,submit,moreauthors,pdftex]{Definitions/mdpi}
\usepackage[T1]{fontenc}
\usepackage[utf8]{inputenc}
\usepackage{float}
\usepackage{booktabs}
\usepackage{textcomp}
\usepackage{amsmath}

\makeatletter

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% LyX specific LaTeX commands.

\Title{Subclinical Atherosclerosis Progression in Low-Risk Middle-Aged Adults: Carotid Leads Femoral in IMT Increase but not in Plaque Formation}

\newcommand{\orcidauthorA}{0000-0002-7520-0192}


\newcommand{\orcidauthorB}{0000-0002-6986-5753}


\newcommand{\orcidauthorC}{0000-0003-4504-5256}


\Author{Eva Szabóová$^{1,*}$\orcidA{},Alexandra Lisovszki$^{2}$, Alojz Rajnič $^{2}$, Peter
Kolárčik$^{3}$\orcidC{}, Peter Szabó$^{4}$\orcidB{} Tomáš Molnár$^{5}$
and Lucia Kubíková$^{1}$}

\AuthorNames{Eva Szabóová, Alexandra Lisovszki, Alojz Rajnič, Peter Kolárčik, Peter Szabó, Tomáš
Molnár and Lucia Kubíková }

\AuthorCitation{.Szabóová, E.; Lisovszki, A.; Rajnič, A.; Kolárčik, P.; Szabó, P.; Molnár, T.;
Kubíková, L. }


\address{$^{1}$\quad{}Affiliation 1: Pavol Jozef Šafárik University in Košice
and East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine,
Department of Angiology, Slovakia\\
$^{2}$\quad{}Affiliation 2: Pavol Jozef Šafárik University and Louis
Pasteur University Hospital in Košice, Faculty of Medicine, $4^{th}$
Department of Internal Medicine, Slovakia \\
$^{3}$\quad{}Affiliation 3: Pavol Jozef Šafárik University in Košice,
Faculty of Medicine, Department of Health Psychology and Research
Methodology, Slovakia \\
$^{4}$\quad{}Affiliation 4: Technical University of Košice, Department
of Aviation Technical Studies, Slovakia\\
$^{5}$\quad{}Affiliation 5: Pavol Jozef Šafárik University in Košice
and East Slovak Institute of Cardiovascular Diseases, Faculty of Medicine,
Department of Vascular Surgery, Slovakia}



\corres{Correspondence: eva.szaboova@upjs.sk}


\abstract{This study investigated subclinical atherosclerosis progression in low-risk, middle-aged adults (N=141; mean age 49.6±4.7 years) using a 5-year ultrasound follow-up. We compared in-volvement of the carotid and femoral arteries. {Methods}: Clinical data, risk factors, and carotid/femoral intima-media thickness (IMT) and plaque presence were analyzed. Results: Cardiovascular risk factors and scores increased significantly at follow-up. Both carotid and femoral IMT increased (p<0.001) but remained within the normal range. While plaque prev-alence rose and was similar in both arteries (carotid: 4.8\% to 17.9\%, femoral: 3.6\% to 17.7\%, p<0.001 for both), the progression of plaque burden was greater in femorals. Notably, carotid IMT demonstrated a faster yearly progression rate compared to femoral IMT. The age- and sex-adjusted increase in IMT was also more frequent in the carotids (52.9\% to 78.8\%, p<0.001) compared to femorals (23.2\% to 44.7\%, p<0.001). Conclusions: This study demonstrates significant subclinical atherosclerosis progression in low-risk middle-aged adults during 5 years. Carotid arteries showed a faster progression rate and higher prevalence of increased age- and sex-adjusted IMT compared to the femoral arteries. However, plaque burden was similar in both territories, with greater progression in femorals. Identifying carotid and femoral atherosclerosis burden may be a valuable tool for risk stratification in this population. }


\keyword{atherosclerosis; carotid artery plaque; carotid intima media thickness; femoral artery plaque; femoral intima media thickness; short-term progression of atherosclerosis; ultrasound; vascular risk.}


%% Because html converters don't know tabularnewline
%\providecommand{\tabularnewline}{\\}

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% User specified LaTeX commands.
%  LaTeX support: latex@mdpi.com 
%  For support, please attach all files needed for compiling as well as the log file, and specify your operating system, LaTeX version, and LaTeX editor.

%=================================================================


% For posting an early version of this manuscript as a preprint, you may use "preprints" as the journal and change "submit" to "accept". The document class line would be, e.g., \documentclass[preprints,article,accept,moreauthors,pdftex]{mdpi}. This is especially recommended for submission to arXiv, where line numbers should be removed before posting. For preprints.org, the editorial staff will make this change immediately prior to posting.

%--------------------
% Class Options:
%--------------------

%----------
% journal
%----------
% Choose between the following MDPI journals:
% acoustics, actuators, addictions, admsci, adolescents, aerospace, agriculture, agriengineering, agronomy, ai, algorithms, allergies, analytica, animals, antibiotics, antibodies, antioxidants, appliedchem, applmech, applmicrobiol, applnano, applsci, arts, asi, atmosphere, atoms, audiolres, automation, axioms, batteries, bdcc, behavsci, beverages, biochem, bioengineering, biologics, biology, biomechanics, biomedicines, biomedinformatics, biomimetics, biomolecules, biophysica, biosensors, biotech, birds, bloods, brainsci, buildings, businesses, cancers, carbon, cardiogenetics, catalysts, cells, ceramics, challenges, chemengineering, chemistry, chemosensors, chemproc, children, civileng, cleantechnol, climate, clinpract, clockssleep, cmd, coatings, colloids, compounds, computation, computers, condensedmatter, conservation, constrmater, cosmetics, crops, cryptography, crystals, curroncol, cyber, dairy, data, dentistry, dermato, dermatopathology, designs, diabetology, diagnostics, digital, disabilities, diseases, diversity, dna, drones, dynamics, earth, ebj, ecologies, econometrics, economies, education, ejihpe, electricity, electrochem, electronicmat, electronics, encyclopedia, endocrines, energies, eng, engproc, entropy, environments, environsciproc, epidemiologia, epigenomes, fermentation, fibers, fire, fishes, fluids, foods, forecasting, forensicsci, forests, fractalfract, fuels, futureinternet, futuretransp, futurepharmacol, futurephys, galaxies, games, gases, gastroent, gastrointestdisord, gels, genealogy, genes, geographies, geohazards, geomatics, geosciences, geotechnics, geriatrics, hazardousmatters, healthcare, hearts, hemato, heritage, highthroughput, histories, horticulturae, humanities, hydrogen, hydrology, hygiene, idr, ijerph, ijfs, ijgi, ijms, ijns, ijtm, ijtpp, immuno, informatics, information, infrastructures, inorganics, insects, instruments, inventions, iot, j, jcdd, jcm, jcp, jcs, jdb, jfb, jfmk, jimaging, jintelligence, jlpea, jmmp, jmp, jmse, jne, jnt, jof, joitmc, jor, journalmedia, jox, jpm, jrfm, jsan, jtaer, jzbg, kidney, land, languages, laws, life, liquids, literature, livers, logistics, lubricants, machines, macromol, magnetism, magnetochemistry, make, marinedrugs, materials, materproc, mathematics, mca, measurements, medicina, medicines, medsci, membranes, metabolites, metals, metrology, micro, microarrays, microbiolres, micromachines, microorganisms, minerals, mining, modelling, molbank, molecules, mps, mti, nanoenergyadv, nanomanufacturing, nanomaterials, ncrna, network, neuroglia, neurolint, neurosci, nitrogen, notspecified, nri, nursrep, nutrients, obesities, oceans, ohbm, onco, oncopathology, optics, oral, organics, osteology, oxygen, parasites, parasitologia, particles, pathogens, pathophysiology, pediatrrep, pharmaceuticals, pharmaceutics, pharmacy, philosophies, photochem, photonics, physchem, physics, physiolsci, plants, plasma, pollutants, polymers, polysaccharides, proceedings, processes, prosthesis, proteomes, psych, psychiatryint, publications, quantumrep, quaternary, qubs, radiation, reactions, recycling, regeneration, religions, remotesensing, reports, reprodmed, resources, risks, robotics, safety, sci, scipharm, sensors, separations, sexes, signals, sinusitis, smartcities, sna, societies, socsci, soilsystems, solids, sports, standards, stats, stresses, surfaces, surgeries, suschem, sustainability, symmetry, systems, taxonomy, technologies, telecom, textiles, thermo, tourismhosp, toxics, toxins, transplantology, traumas, tropicalmed, universe, urbansci, uro, vaccines, vehicles, vetsci, vibration, viruses, vision, water, wevj, women, world 

%---------
% article
%---------
% The default type of manuscript is "article", but can be replaced by: 
% abstract, addendum, article, book, bookreview, briefreport, casereport, comment, commentary, communication, conferenceproceedings, correction, conferencereport, entry, expressionofconcern, extendedabstract, datadescriptor, editorial, essay, erratum, hypothesis, interestingimage, obituary, opinion, projectreport, reply, retraction, review, perspective, protocol, shortnote, studyprotocol, systematicreview, supfile, technicalnote, viewpoint, guidelines, registeredreport, tutorial
% supfile = supplementary materials

%----------
% submit
%----------
% The class option "submit" will be changed to "accept" by the Editorial Office when the paper is accepted. This will only make changes to the frontpage (e.g., the logo of the journal will get visible), the headings, and the copyright information. Also, line numbering will be removed. Journal info and pagination for accepted papers will also be assigned by the Editorial Office.

%------------------
% moreauthors
%------------------
% If there is only one author the class option oneauthor should be used. Otherwise use the class option moreauthors.

%---------
% pdftex
%---------
% The option pdftex is for use with pdfLaTeX. If eps figures are used, remove the option pdftex and use LaTeX and dvi2pdf.

%=================================================================
% MDPI internal commands
\firstpage{1} 
 
\setcounter{page}{\@firstpage} 

\pubvolume{1}
\issuenum{1}
\articlenumber{1}
\pubyear{2024}
\copyrightyear{2024}
%\externaleditor{Academic Editor: Firstname Lastname} % For journal Automation, please change Academic Editor to "Communicated by"
\datereceived{} 
\dateaccepted{} 
\datepublished{} 
\hreflink{https://doi.org/} % If needed use \linebreak
%------------------------------------------------------------------
% The following line should be uncommented if the LaTeX file is uploaded to arXiv.org
%\pdfoutput=1

%=================================================================
% Add packages and commands here. The following packages are loaded in our class file: fontenc, inputenc, calc, indentfirst, fancyhdr, graphicx, epstopdf, lastpage, ifthen, lineno, float, amsmath, setspace, enumitem, mathpazo, booktabs, titlesec, etoolbox, tabto, xcolor, soul, multirow, microtype, tikz, totcount, changepage, paracol, attrib, upgreek, cleveref, amsthm, hyphenat, natbib, hyperref, footmisc, url, geometry, newfloat, caption

%=================================================================
%% Please use the following mathematics environments: Theorem, Lemma, Corollary, Proposition, Characterization, Property, Problem, Example, ExamplesandDefinitions, Hypothesis, Remark, Definition, Notation, Assumption
%% For proofs, please use the proof environment (the amsthm package is loaded by the MDPI class).

%=================================================================
% The fields PACS, MSC, and JEL may be left empty or commented out if not applicable
%\PACS{J0101}
%\MSC{}
%\JEL{}

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
% Only for the journal Diversity
%\LSID{\url{http://}}

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
% Only for the journal Applied Sciences:
%\featuredapplication{Authors are encouraged to provide a concise description of the specific application or a potential application of the work. This section is not mandatory.}
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
% Only for the journal Data:
%\dataset{DOI number or link to the deposited data set in cases where the data set is published or set to be published separately. If the data set is submitted and will be published as a supplement to this paper in the journal Data, this field will be filled by the editors of the journal. In this case, please make sure to submit the data set as a supplement when entering your manuscript into our manuscript editorial system.}

%\datasetlicense{license under which the data set is made available (CC0, CC-BY, CC-BY-SA, CC-BY-NC, etc.)}

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
% Only for the journal Toxins
%\keycontribution{The breakthroughs or highlights of the manuscript. Authors can write one or two sentences to describe the most important part of the paper.}

%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%
% Only for the journal Encyclopedia
%\encyclopediadef{Instead of the abstract}
%\entrylink{The Link to this entry published on the encyclopedia platform.}
%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%

\makeatother

\usepackage{babel}
\begin{document}
\maketitle


%\end{paracol}\nointerlineskip{}
\section{Introduction }

Atherosclerosis (ATS) burden is a strong risk for new cardiovascular
(CV) events and is related to poor outcome after CV events \citep{Roquer2010}.
A large proportion of the asymptomatic population stratified by various
validated multivariable risk prediction tools is at low-to moderate
CV disease (CVD) risk \citep{Muntendam2010}, with missed opportunities
for early detec-tion and appropriate management of underlying ATS
\citep{Sillesen2018}. Identification of subclinical ATS is
an important step in the management of patients in primary CVD prevention.
There are several methods to evaluate the presence and progression
of subclinical ATS \citep{Szaboova2012,Perk2012}.
Coronary artery calcification (CAC), carotid intima-media thickness
(CIMT), carotid plaque and ankle-brachial index (ABI) were proposed
as valuable markers of subclinical ATS and predictors of CV events
\citep{Geisel2017}, however, with not equal risk redefinition
\citep{Yeboah2012}. According to the current European guidelines,
CAC scoring, or as alternative when CAC scoring is not feasible,
plaque detection by carotid ultrasound (USG) may be considered to
improve risk classification around treatment decision thresholds with
IIb B level of evidence \citep{Visseren2021}. Since ATS is
a global disease, the study of ATS requires a multimodal and multiterritorial
approach. Several studies support the value of measuring subclinical
ATS in multiple arterial territories for a more accurate CV risk stratification
\citep{Belcaro2001,Laclaustra2016}. Subclinical
ATS is highly prevalent in middle-aged asymptomatic population
\citep{FernandezFriera2015,Mitu2017,Szaboova2024},
in addition, clinical data documented extensive ATS in a substantial
number of low-risk individuals \citep{FernandezFriera2015}.
Except for the preferentially screened carotid and coronary area,
the iliofemoral arteries and abdominal aorta are also frequently affected.
Results from the Progression of Early Subclinical Atherosclerosis
Study (PESA) documented even higher prevalence of ATS plaque in the
iliofemoral arteries, compared with the carotid, abdominal, and coronary
arteries \citep{FernandezFriera2015}. Identification of global
atherosclerotic burden is a useful tool to identify patients at high
CVD risk. There are limited numbers of studies comparing presence
and progression of subclinical ATS in different arterial regions \citep{Mendieta2023}.
Ultrasound-based techniques are non-invasive, accessible, with quick
measures, easy training, reduced cost, and no radiation \citep{Darabian2013},
and so they are suitable for population screening. We aimed to study
the short-time progression rate of carotid and femoral subclinical
atherosclerosis in middle-aged, apparently healthy individuals and
to evaluate their potential use in primary prevention. 

\section{Patients and methods }

The present study is an observational, prospective, real-life study
in a target population of 400-450 apparently healthy subjects. Study
subjects were 141 participants of Caucasian origin without established
CVD, 56,7\% women and 43,3\% men, aged 49.6\textpm 4.7 years, who
underwent baseline and 5-year follow-up (4.67\textpm 0.95 years) visit
between February 2010 and October 2017. The study design has been
reported elsewhere \citep{Szaboova2024}. Briefly, males or females 35-55 years
of age, non-diabetics, inhabitants of the East Slovak Region, with
obtained written informed consent were included. Subjects with established
CVD, European Systematic Coronary Risk Evaluation (SCORE) risk \ensuremath{\ge}5\%,
chronic kidney, respiratory or hepatic disorders, neoplasia, severe
obesity (body mass index (BMI) >35 kg/m$^2$), alcoholism, non-compliance,
pregnancy, as well as acute inflammatory disorders were excluded.
Out of the target population, only 256 persons met the inclusion criteria,
we excluded 69 patients. Finally, 187 individuals were enrolled into
the study, 141 of them (75,4\%) finished the follow-up. During follow-up,
we observed one sudden cardiac death (0.53\%), one suicidal death,
and one nonfatal CV event (unstable angina pectoris). This study
was conducted in accordance with the Declaration of Helsinki, and
the protocol was approved by the Ethical Committee of the L. Pasteur
University Hospital in Košice (approval number 2020/EK/02018).

\section{Data collections and statistics}

\subsection{Data collection}

Participants were examined in the Outpatient Department of the 4th
Clinic of Internal Medicine at L. Pasteur University Hospital in
Košice, in the morning, under basal conditions. The examination itself
consisted of the blood and urine collection for biochemical analysis,
detection of morphological markers of subclinical ATS, interviews
for medical history with the focus on classical risk factors (RFs)
for ATS and current medications, measurements of body size, waist
circumference and office blood pressure, determination of 10-year
fatal and total CV risk (European SCORE) and resting 12-lead electrocardiogram
recording. Blood and urine samples were analysed in the relevant subdivisions
of the department of laboratory medicine at the same hospital. Metabolic
parameters used in our work \{fasting glucose, glycated haemoglobin
(HbA1c), uric acid, serum total cholesterol (T-C), high-density lipoprotein
cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C),
triglycerides (TAG), serum creatinine\} have been directly determined
by standard laboratory tests; estimated glomerular filtration rate
(eGFR) were calculated according to the Modification of Diet in Renal
Disease (MDRD) formula  \citep{Hallan2004}. The following
values were considered pathological: creatinine > 90\textmu mol/L,
eGFR < 1.5mL/s/m$^2$, uric acid > 357/428\textmu mol/L (males/females).
Non-modifiable RFs for ATS as well as arterial hypertension (AH),
dyslipoproteinemia (DLP), obesity/central obesity, diabetes mellitus
(DM), impaired fasting glucose, metabolic syndrome (MetS) have been
defined according to current recommendations \citep{Piepoli2016,Cosentino2020}.
Smoking status was characterized as current smoking \ensuremath{\ge}1cigarette/day.
To estimate a person´s 10-year risk of CV death we used the SCORE
chart for high-risk countries (low risk <1\%/moderate risk \ensuremath{\ge}1\%
and <5\%), total 10-year CV event risk was calculated by multiplying
fatal risk (3x for men and 4x for women) \citep{Piepoli2016}.
The targeted dietary and pharmacological management of AH and DLP
was satisfactory at the time of patient enrollment into the study.
Based on personalized CV risk assessment, preventive measures (lifestyle
modifications and/or pharmacological treatment) were recommended
for each subject, to which they agreed. Adherence to instructions
was regularly checked by family doctors and study investigators. 

\subsection{Morphological markers of subclinical atherosclerosis}

\subsubsection{Carotid IMT and plaque assessment}

Ultrasonography was performed by one experienced sonographer with
acceptable intraobserver variability of measurements, blinded to subjects’
health status and RFs. Details of the USG methodology and quality
control have been reported previously \citep{Szaboova2024,Bunting2019}.
CIMT and carotid plaque were defined according to the Mannheim consensus
 \citep{Touboul2012,Salonen1991}. Bilateral carotid
arteries were scanned using high-resolution B-mode USG (Philips HD
15) with the 7.5-MHz probe in real-time, at 5x magnification. IMT
was defined as the distance from the leading edge of the lumen--intima
interface to the leading edge of the media--adventitia interface
and was measured on distinct plaque-free segment of the common carotid
artery (CCA) far wall, 1 cm from the flow divider, in the end-diastole,
at its presumed maximum thickness. Examinations were made automatically.
ATS plaque was defined as an endoluminal protrusion of at least 1.5
mm or a >50\% focal thickening of the IMT relative to the adjacent
wall segment. Plaque presence on both transverse and longitudinal
planes was recorded in the CCA, bulb, internal (ICA) and external
(ECA) carotid arteries. Generally, carotid plaques were stable, isoechogenic,
with smooth surface and normal peak systolic velocity (PSV) at baseline
and during follow-up. CCA parameters evaluated in our work: mean value
of CIMT on the right, left (CIMTdx, sin), maximum value of CIMT right
or left (CIMTmax), CIMT>0.9mm right or left (CIMTbilat>0.9), pathological
mean right or left CIMT by age and sex (asCIMTbilat), i.e., in males/females
on the left side: 31-40 years: >0.57/0.51 mm, 41--50 years: >0.61/0.57
mm, and over 50 years: >0.70/0.64 mm; on the right side: 31-40 years:
>0.5/0.49 mm, 41-50 years: >0.57/0.53 mm, over 50 years: >0.62/0.59
mm \citep{Stein2008,Denarie2000}, CCA-IMT progression
(mm/year) and presence of carotid plaque.

\subsubsection{Femoral IMT and plaque assessment}

The literature diverges on the issue of the reference measurement
site and methodology of IMT (especially in other than carotid area),
even the pathological values of IMT in the carotid or femoral area
are not uniform. Considering the need to use the same methodology,
we proceeded with the assessment of subclinical ATS of the femoral
artery as in the carotid area. The definition of IMT and plaque was
identical for both arterial territories. Bilateral common femoral
arteries (CFA) were scanned, femoral IMT (FIMT) was obtained 1-2 cm
proximal from the bifurcation, on the far wall of CFA \citep{Koc2018}.
For the plaque presence, the CFA, the superficial and profundal femoral
arteries were examined for a length of 3 cm (1.5 cm proximally and
distally to the flow divider) \citep{Belcaro2001}. CFA parameters
evaluated in our work: mean value of FIMT on the right, left (FIMTdx,
sin), maximum value of FIMT right or left (FIMTmax), FIMT>0.9mm right
or left (FIMTbilat>0.9) \citep{Langlois2008}, FIMT>1.1mm
right or left (FIMTbilat>1.1) \citep{Koc2018}, pathological
mean right or left FIMT by age and sex (asFIMTbilat), i.e., in white
males/females 24-43 years: >0.75/0.64 mm \citep{Paul2011},
CFA-IMT progression (mm/year) and presence of femoral plaque. 

\subsection{Statistical analysis}

Patient’s data are summarized at baseline and at the end of follow-up
and analysed by means of descriptive statistical methods. Continuous
variables are shown in the tables in the form of arithmetic mean
and standard deviation (SD), and the categorical variables as an absolute
number and its relative representation (\%) in the sample. Analysis
of differences in the continuous clinical parameters investigated,
including markers of subclinical ATS between patients at baseline
and at follow-up visit was carried out using a paired samples t-test.
A McNemar’s test was used to compare the frequencies of categorical
variables in time between paired samples. During the follow-up a
progression rate of CIMT and FIMT was also calculated. A value of
p<0.05 was considered statistically significant. The analyses were
performed using the IBM SPSS 23.0 statistical software package (IBM
Corp., Armonk, NY, USA).

\section{Results}

\subsection{Characteristics of the study group }

Out of the study sample of 187 clinically healthy, non-diabetic, 35--55-year-old
individuals (mean age 45,6\textpm 5 years at baseline) in the Eastern
Slovak Region, 141 persons were checked after a follow-up of 4.67\textpm 0.95
years. Demographic, clinical and laboratory data at baseline and after
follow-up are shown in Table 1. 

\subsection{Risk profile, subclinical carotid or femoral atherosclerosis burden
at baseline and at follow-up}

Changes in the persons´ risk profile including analysed structural
markers of subclinical ATS after 5 years are listed in Table 2. After
follow-up we documented a significantly higher prevalence of modifiable
RFs: DLP, central obesity, AH, as well as a corresponding increase
of SCORE risk (1.2\textpm 1.61; p < 0.001) and number of RFs (3.72\textpm 5.82;
p < 0.05). The mean values of CIMT right and left (0.62\textpm 0.10
mm; p<0.001, both) were significantly increased, but remained under
the „cut off level of 0.9 mm“ at follow-up. The increase in mean (0.07-0.08\textpm 0.12
mm) and maximum (0.07\textpm 0.13 mm) values of CIMT was significant.
The mean and maximum values of IMT at baseline and at follow-up were
almost identical at carotid and femoral sites (Table 2). The mean
right and left CCA-IMT change/year was the same: 0.017\textpm{} (0.027-0.029)
mm. The FIMT progression was slower in comparison with CIMT, with
the lowest rate for FIMTdx (right: 0.0085\textpm 0.035mm/year; left:
0.012\textpm 0.044 mm/year). The occurrence of CIMT>0.9 mm was rare
(2.1\%) and not significantly changed during the follow-up. In comparison
with carotid region, the FIMT>0.9 mm was more frequent at the first
and last visit, on the other hand, the presence of the other femoral
IMT cut-off value, FIMT >1.1 mm, was similarly to carotid region,
rare. However, the prevalence of asCIMTbilat was higher (78.8\%) with
greater increase (+25.9\%) at the end of follow-up in comparison
with the occurrence and increase rate of asFIMTbilat (44.7\% and +21.5\%
resp.). Similar significant increase in the rate of carotid and femoral
plaque burden was also observed (from 4.8\% to 17.9\% and 3.6\% to
17.7\% resp.; p< 0.001, both), but with higher progression in femorals
(13.1\% vs. 14.1\%). Initially in 8.4\% of subjects we found carotid
or femoral plaque, at the end of the follow-up it was 26.9\% (in 12
subjects’ plaques were present in both, the carotid and femoral regions).
If only the carotid area was examined, the ATS plaque on the femoral
artery would be missed in approximately 9\% of patients at the end
of follow-up.

\begin{table}[H]

\caption{Comparison of mean values, standard deviations (SD) and changes (\ensuremath{\Delta})
of continuous anthropometric, clinical and biochemical data at baseline
and after follow-up assessed with paired t-test.}

\noindent \begin{centering}
\begin{tabular}{lcccc}
\toprule 
\textbf{Parameters} & \textbf{Baseline} & \textbf{Follow-up} & \textbf{$\varDelta$} & \textbf{p}\tabularnewline
 & \textbf{N=141 Mean (SD)} & \textbf{N=141 Mean (SD)} & \textbf{Mean (SD)} & \tabularnewline
\midrule
Age (yr) & 45.64 (5.02) & 49.64 ( 4.67) & 4.35 (1.6) & <0.001\tabularnewline
Waist circumference (cm) & 87.63 (13.07) & 92.33 ( 12.87) & 4 (5.39) & <0.001\tabularnewline
BMI (kg/m$^{2}$) & 25.28 (3.89) & 25.67 (4.55) & 0.38 (1.48) & 0.003\tabularnewline
Total cholesterol (mmol/L) & 5.47 (0.93) & 6.00 (1.09) & 0.48 (0.88) & <0.001\tabularnewline
LDL-C (mmol/L) & 3.24 (0.79) & 3.91 (0.83) & 0.63 (0.75) & <0.001\tabularnewline
HDL-C (mmol/L) & 1.5 ( 0.35) & 1.47 (0.36) & -0.01 (0.21) & NS\tabularnewline
Triglycerides (mmol/L) & 1.26 (0.74) & 1.47 (0.86) & 0.15 (0.56) & 0.002\tabularnewline
Plasma glucose (mmol/L) & 5.01 (0.47) & 5.13 (0.49) & 0.11 (0.4) & 0.001\tabularnewline
HbA1c (IFCC) (mmol/mol) & 34.4 (3.6) & 32.4 (3.5) & -1.9 (3.4) & <0.001\tabularnewline
Uric acid (\textmu mol/L) & 297.27 (80.09) & 312.16 (81.9) & 13.97 (45.31) & 0.001\tabularnewline
Creatinine (\textmu mol/L) & 86.45 (10.64) & 71.36 (11.91) & -16.36 (5.63) & <0.001\tabularnewline
eGFR (mL/min/1.73m$^{2}$) & 70.2 (7.8) & 96.6 (11.4) & 26.4 (9.0) & <0.001\tabularnewline
\bottomrule
\end{tabular}
\par\end{centering}
\medskip{}

Remarks: BMI, body mass index; LDL-C, low-density lipoprotein cholesterol;
HDL-C, high-density lipoprotein cholesterol; HbA1c, glycated hemoglobin;
IFCC, International Federation of Clinical Chemistry and Laboratory
Medicine; eGFR, estimated glomerular filtration rate; NS, statistically
nonsignificant difference; N, number; SD, standard deviation; \ensuremath{\Delta},
change; p, statistical significance; yr, years.
\end{table}

\begin{table}[H]

\caption{Comparison of prevalence and mean values of cardiovascular risk factors
and morphological markers of subclinical carotid/femoral atherosclerosis
at baseline and after follow-up assessed with McNemar´s or paired
t-test.}

\noindent \begin{centering}
\begin{tabular}{lcccc}
\toprule 
\textbf{Parameter} & \textbf{Baseline} & \textbf{Follow-up} & \textbf{$\varDelta$} & \textbf{p}\tabularnewline
 & \textbf{N=187/141 Mean (SD)} & \textbf{N=141 Mean (SD)} & \textbf{Mean (SD)} & \tabularnewline
\midrule
Risk age (N/ \%) & 41/ 21.9 & 65/ 46.1 & 24/ 24.2 & NS{**}\tabularnewline
Sex (male) (N/ \%) & 75/ 40.1 & 61/ 43.3 & -14/ 3.2  & NS{**}\tabularnewline
Positive family history (N/ \%) & 33/ 17.8 & 31/ 22.1 & -2/ 4.3  & NS{**}\tabularnewline
DLP (N/ \%) & 132/ 71 & 126/ 89.4 & -6/ 18.4 & <0.001{**}\tabularnewline
AH (N/ \%) & 48/ 25.8 & 54/ 38.6 & 6/ 12.8 & <0.001{**}\tabularnewline
Duration of AH (years) & 0.78 (2.12) & 2.1 (4.57) & 1.32/ (2.45)  & <0.001{*}\tabularnewline
Smoking (N/ \%) & 38/ 20.3 & 28/ 19.9 & -10/ -0.4 & NS{**}\tabularnewline
MetS (N/ \%) & 31/ 16.8 & 40/ 28.4 & 9/ 11.6  & NS{**}\tabularnewline
Central obesity (N/ \%) & 105/ 57.4 & 103/ 74.6 & -2/ 17.2  & <0.001{**}\tabularnewline
SCORE fatal & 0.57 (0.93) & 1.16 (1.56) & 0.59/ (0.63)  & <0.001{*}\tabularnewline
SCORE total & 1.81 (2.70) & 3.71 (4.72) & 1.9/ (2.02)  & <0.001{*}\tabularnewline
Number of RFs & 2.61 (1.63) & 3.78 (6.06) & 1.17/ (4.43)  & <0.027{*}\tabularnewline
Treatment of DLP (N/\%) & 12/ 6.4 & 12/ 8.5 & 0/ 2.1  & NS{*}{*}\tabularnewline

\midrule
CIMT sin (mm) & 0.54 (0.09) & 0.62 (0.10) & 0.08 /(0.11) & <0.001{*}\tabularnewline
CIMT dx (mm) & 0.54 (0.09) & 0.62 (0.10) & 0.08 /(0.12) & <0.001{*}\tabularnewline
CIMT max (mm) & 0.67 (0.11) & 0.74 (0.11) & 0.07 /(0.12) & <0.001{*}\tabularnewline
CIMT bilat 0.9 mm (N/ \%) & 2/ 1.1 & 3/ 2.1 & 1/ 1.0 & NS{*}{*}\tabularnewline
asCIMT bilat (N/ \%) & 99/ 52.9 & 111/ 78.8 & 12/ 25.9 & <0.001{*}{*}\tabularnewline
Carotid plaque (N/ \%) & 9/ 4.8 & 25/ 17.9 & 16/ 13.1 & <0.001{*}{*}\tabularnewline
FIMT sin (mm) & 0.56 (0.13)  & 0.64 (0.14) & 0.08/(0.17) & <0.001{*}\tabularnewline
FIMT dx (mm)  & 0.56 (0.14)  & 0.63 (0.15) & 0.07/(0.15) & <0.001{*}\tabularnewline
FIMT max (mm) & 0.70 (0.15)  & 0.79 (0.17) & 0.09/(0.18) & <0.001{*}\tabularnewline
FIMT bilat >0.9 (N/ \%) & 7/ 5.1 & 16 / 11.4 & 9/6.3 & NS{*}{*}\tabularnewline
FIMT bilat >1.1 (N/ \%) & 3/2.2 & 4 / 2.9 & 1/0.7 & NS{*}{*}\tabularnewline
asFIMT bilat (N/ \%) & 32 / 23.2 & 63/ 44.7 & 31/21.5 & <0.001{*}{*}\tabularnewline
Femoral plaque (N/ \%) & 5/3.6 & 25/ 17.7  & 20/14.1 & <0.001{*}{*}\tabularnewline
\end{tabular}
\par\end{centering}
\medskip{}

Remarks: DLP, dyslipoproteinemia; AH, arterial hypertension; MetS,
metabolic syndrome; RFs, risk factors; CIMT or FIMT: dx/sin/max, mean
common carotid or femoral artery intima-media thickness: right/left/maxium
value; CIMT or FIMT bilat >0.9 mm, common carotid or femoral artery
intima-media thickness >0.9 mm bilaterally; FIMT bilat >1.1 mm, common
femoral artery intima-media thickness >1.1 mm bilaterally; asCIMT
or FIMT bilat, pathological common carotid or femoral artery intima-media
thickness by age and sex on the right or left; SD, standard deviation;
NS, statistically nonsignificant difference; N, number; p, statistical
significance; {*}, paired t-test; {*}{*}, McNemar´s test; \ensuremath{\Delta},
change, difference. In paired t-test (N= 141 at baseline and follow-up),
in McNemar´s test (N=187 at baseline and N=141 at follow-up).
\end{table}


\section{Discussion}

Early detection of subclinical ATS has received increased attention
in CVD prevention in the last decades. Clinical studies on subclinical
ATS are heterogeneous, performed mostly in elderly populations. Less
data is available in younger “low risk” populations using multiple
phenotypes across multiple arterial sites. Examination of different
arterial segments may complement each other in the evaluation of the
presence and extent of ATS and in the modification of CV risk \citep{Touboul2005}.
There are also limited numbers of studies comparing progression of
subclinical ATS in different regions \citep{Mendieta2023}
with impact on the timing of population screening. 

In our 5-year prospective study, in clinically healthy, 35--55-year-old, nondiabetic, predominantly
non-hypertensive individuals, without known CVD, with low-to moderate
calculated fatal risk SCORE, the increase in mean and maximum values
of CIMT and FIMT was significant, with almost identical CIMT and FIMT
values. The yearly progression rate of IMT was slower in femoral region
in comparison with the carotids. IMT>0.9mm (previously identified
as hypertension-mediated organ damage) was 5x more frequent in femoral
region in comparison with the carotids. On the other hand, the occurrence
of FIMT >1.1mm (predictive value of CIMT>0.9mm) \citep{Koc2018}
was as low, as CIMT>0.9mm. The presence of age- and sex-adjusted abnormal
mean CIMT and FIMT was surprisingly high (mainly carotid) and compared
to the beginning of the study, the prevalence was significantly higher
by 25.9\%. Similarly, a relatively high and similar prevalence of
carotid (17.9\%) and femoral (17.7\%) plaque burden was documented
at the end of follow-up, with a more pronounced progression during
the follow-up in femoral region.

\subsection{Risk profile}

The risk profile of our study group is comparable with the literature
 \citep{Mackinnon2004,Mitu2017}, and was commented
in our previous study \citep{Szaboova2024}. Obesity and DLP
were increased due to the fact, that we followed central obesity and
tighter cut-offs for DLP. In the large on-going PESA study with enrollment
of participants without CVD, with no exclusion of diabetics, the study
group had a better risk profile in term of DLP (40.9\%) and obesity
(13.3\%), but the proportion of lipid-lowering therapy was similar
(6.6\%)  \citep{LopezMelgar2020}. 

\subsection{CIMT and FIMT progression }

Increased CIMT represents subclinical vascular disease and CVD risk
marker \citep{Bots1997,Herder2012}, may be related
to intimal and/or medial hypertrophy, and may be an adaptive response
to changes. Increased CIMT is related to (not clearly synonymous with)
subclinical ATS due to similar alterations in the progression of
both processes \citep{Bots1997}. The initiation, progression
and expression of ATS lesions are mainly artery-related \citep{Dalager2007}.
Shared common risk factors have different impact in different arterial
territories \citep{Kannel1994,Meer2003}. Autopsy
studies revealed, that in different vascular segments there is no
uniform involvement of ATS  \citep{Boesing2001}. ATS plaques
in different segments of the arterial tree have similar cell types,
but their relative numbers and amount of connective tissue and lipids
can vary considerably  \citep{Ross1984}. Twin studies also
reported a heritable component on carotid and femoral IMT 
\citep{Lee2011,Tarnoki2015,Medda2014}. Like carotid,
femoral artery wall morphology is correlated with subclinical ATS
 \citep{Bedi2014}, is associated with CAC score (CACS) \citep{Laclaustra2016},
and is an independent predictor of future CV events 
\citep{Davidsson2010,Yerly2015,Kirhmajer2011,Griffin2009,Giannoukas2009}.
Some studies have reported that ATS changes are more advanced in the
femoral artery than carotid artery \citep{Wendelhag1993,Kocyigit2020},
another ones revealed that IMT of femoral artery is a better indicator
of extent and severity of coronary artery ATS than in carotid arteries
 \citep{Lekakis2005,Sosnowski2007}. Examination of various
arterial segments may complement each other in the evaluation of the
extent of ATS \citep{Touboul2005}. The majority of studies
have assessed only common carotid artery IMT, USG of femoral arteries
for CV risk modification has not become a part of the routine, moreover,
comparative data from the presence and dynamics of vascular target
organ damage phenotypes in carotid and femoral arterial segments are
scarce  \citep{Kocyigit2020}. 

A systematic review reported
the mean CIMT between 0.62-1.07 mm, and CIMTmax between 0.78-1.8 mm
in low-to-intermediate risk individuals aged 60\textpm 7.6 years \citep{AzcuiAparicio2021}.
In the PESA study, with a comparable mean age of study population,
similar to our results \citep{Szaboova2024} the mean CIMT
value was 0.59 mm \citep{FernandezFriera2015,LopezMelgar2020}.
The varying progression rate of the mean CCA-IMT was published in
different population-based studies, ranged between 0.0038-0.060 mm/year
 \citep{Lynch1997,Wagenknecht2003}, other studies
detected comparable progression rate to ours  \citep{Chen2016,Sturlaugsdottir2018}.
A mildly higher rate of CCA-IMT (0.025 mm/year) was observed in the
large Atherosclerosis Risk in Communities (ARIC) Study \citep{Chambless2000},
lower progression rate of the CCA-IMT was documented in the Carotid
Atherosclerosis Progression Study (CAPS) (0.001 mm/year) \citep{Mackinnon2004}.

For CVD risk assessment, instead of normative values (i.e. pathological
IMT>0.9 mm, reflecting primarily ATS at the carotid bifurcation and
hypertension mediated hypertrophy at the level of CCA), carotid USG
imaging and measurements should follow protocols with CIMT values
in percentiles by age, sex, race/ethnicity and mostly also by side
 \citep{Stein2008,Denarie2000,Johri2020}.
In comparison with previous data \citep{Mitu2017,Novo2019},
the occurrence of CIMT>0.9 mm was rare in our study and not significantly
changed after 5-year follow up \citep{Szaboova2024}. Similarly
to us, CIMT>0.9 mm was detected in 1\% of participants in the PESA
study \citep{FernandezFriera2015,LopezMelgar2020}.
In contrast, there was a 36.7\% incidence of CIMT>0.9mm reported by
Mitu et al. among apparently healthy individuals, classified mainly
in high-risk SCORE \citep{Mitu2017} and an incidence of 34\%
was reported by Novo et al. in an older study group, with a relatively
high prevalence of diabetics and hypertensives \citep{Novo2019}.

Similarly to our results \citep{Szaboova2024} the 75th percentile
of the CCA-IMT distribution was established at 0.58 and 0.59 mm in
healthy females and males without CV RFs, over 40 years of age 
\citep{KablakZiembicka2021,Engelen2013}. In a recent study
of an apparently healthy population aged 57.7\textpm 10.4 years, without
exclusion of diabetics, the distribution of pathological CIMT>0.74
mm (75th percentile) was 25.96\% (lower than in our study), but it
followed a higher cut-off level in comparison with us \citep{Alizargar2019}.The
prevalence of CIMT>75th percentile for the patient’s age, sex and
race/ethnicity was approximately 12\% across the Framingham Heart
Study, but at intermediate Framingham risk score (FRS), 22--58\%
of patients had increased CIMT  \citep{Gepner2006}. However,
no data are available on the progression rate of pathological age-
and sex-adjusted CIMT in the literature. 

Very similar to our mean
FIMT values were found by Deparion et al. \citep{Depairon2000}
in healthy subjects aged 20-60 years, without CV RFs: 0.543\textpm 0.063
mm and 0.562\textpm 0.074 mm for women and men resp. The estimated
increase per year was less than in our study, (0.0031 mmm for men
and 0.0012 for women), probably because the fact, that they screened
subjects without CV RFs, in our study the presence of RFs was not
an exclusion criterion. In some studies the mean CFA IMT was higher
than in our: in size and risk profile similar study to our, regardless
of sex, the FIMT was 0.80\textpm 0.2mm \citep{Kocyigit2020}; in another one the
FIMT was 0.72/0.73mm (left/ right), probably due to the effect of
older age and presence of DM \citep{Lucatelli2016}. A bit
higher value of mean FIMT (0.64mm females /0.75mm males) was measured
in healthy participants of the Bogalusa Heart Study (71\% white, aged
24--43 years), but only single measurement of the left common femoral
artery was provided  \citep{Paul2011}. The population based
French (low-risk country) AXA Study (Sex and Topographic Differences
in Associations Between Large-Artery Wall Thickness and Coronary
Risk Profile in a French Working Cohort) in subjects (employees of
an insurance company AXA, Paris La Défense, France) aged 17-65 years,
with no exclusion of CVD and CV RFs, documented mean FIMT 0.43\textpm 0.06
mm for women and 0,50\textpm 0.11mm for men (thinner than FIMT in
our study) with progression rate 0.003 and 0.005mm/year for women
and men, resp. \citep{Gariepy1998}. The Asclepios Study in
apparently healthy population aged 35-55 years without exclusion of
DM documented thinner FIMT than in our cohort in females (0.49 mm)
but not in males \citep{Langlois2008} (due to thickened
femoral IMT measurement site, incorrectly classified as plaque, however,
we did not evaluate separately IMT for females and males). 

FIMT>0.9mm,
age and sex adjusted pathological FIMT occurrence have received less
attention to date in the literature. Langlois et al. found the maximal
FIMT 0.59 (0.51--0.70) mm in females and 0.71 (0.60--0.87) mm in
males \citep{Langlois2008}, which is similar to our results,
even though we did not determine FIMT separately for men and women,
but the presence of age- and sex-adjusted FIMT. In the same cohort,
 \citep{Langlois2008} with no exclusion of DM, 26,3\% of
subjects had FIMT>0.9mm, more than in our study. 

Rietzschel et al.
in a population of 156 apparently healthy normotensive Caucasian
volunteers between 18 and 65 years revealed, similarly to us, identical
right common femoral and carotid mean IMT (0.52 mm) \citep{Rietzschel2001}.
In above mentioned studies \citep{Kocyigit2020,Lucatelli2016}
the mean and maximal femoral IMT were greater than the mean and maximal
carotid IMT. In accordance with us, the CIMT was greater in other
studies \citep{Langlois2008,Paul2011}, also the
progression rate was higher for CIMT than for FIMT in the AXA study
and in the study conducted by Markus \citep{Gariepy1998,Markus1997}. 

\subsection{Carotid and femoral plaque progression}

Carotid IMT and plaque are markers for measuring ATS burden and strongly
associated with vascular RFs and the incidence of CV events \citep{Herder2012}.
ATS progression predicts CV events \citep{Polak2011}. The
occurrence of carotid plaques is variable in the general population
and might be explained by age, CV RFs and geographical influence \citep{Mitu2017}.
According to a systematic review \citep{AzcuiAparicio2021}, the occurrence of plaque
in asymptomatic, low-to-intermediate risk cohorts, with different
age and risk profile was an average of 35\%. Some studies \citep{Mitu2017,Novo2019,Alizargar2019,Sillesen2012}
in comparison to our results, reported a higher prevalence of carotid
plaque (40\%, 25\%, 34\%, 78\%, resp.) probably due to the enrollment
of older subjects. Studies with asymptomatic, middle-aged individuals
documented higher occurrence of carotid plaques (29.3\% in subjects
with risk SCORE <5\% \citep{Mitu2017}, 31\% in the PESA Study
\citep{LopezMelgar2020}). In the Refine study among 50--69-year-old
participants, after a 4.2-year follow-up, in those patients without
plaque at the first visit, the rate of plaque burden was 29.7\%, which
is a higher progression than in our study, but in a population with
worse risk profile, with no exclusion of CVD \citep{Sturlaugsdottir2018}.
Similar to our data, 20.5\% of subjects developed new carotid artery
plaques during a 5-year follow-up in a community in Taiwan (older
subjects, no exclusion of DM) \citep{Chen2016}. 

There is
a slight difference in the genesis of ATS plaques in CCA and CFA,
supported by pathology \citep{Ross1984}, biochemical studies
 \citep{Langlois2008}, different distribution of plaques in
carotid and femoral sites \citep{Ross1984}, as well as by
significant side-difference in IMT of CFA but not of CCA 
, underlining a possible role of local geometry
in the development of ATS \citep{Bossuyt2014}. However, this
side difference was not observed by Lucatelli at al. \citep{Lucatelli2016}
by us not even in carotid area. 

Although ATS is considered a generalized
disease process, the extent of ATS and its underlying risk factors
differ among arterial sites \citep{Fukudome1997}, confirmed
by autopsy studies \citep{Boesing2001}. It has been shown
that ATS lesions are more frequent and advanced in femoral arteries
than in carotid arteries independent of increasing number of risk
factors \citep{Lisowska2005,Kroeger1999,Gariepy1996}.
ATS in femoral arteries occurred earlier than carotid arteries \citep{Kroeger1999}
and femoral artery is more susceptible to the atherogenic influence
of risk factors \citep{Gariepy1996}. 

In our study the occurrence
of carotid plaque was slightly higher than femoral plaque, mainly
at baseline, the difference practically disappeared at the end of
follow-up due to higher progression rate in femoral region. Generally,
high plaque frequency was documented among participants aged 45--64
years, with 17.5\% diabetics, in study conducted by Yerly at al. \citep{Yerly2012}:
73.4 \% of participants had \ensuremath{\ge}1 plaque (defined as IMT
\ensuremath{\ge}1.2 mm) at carotid level and 67.5 \% at femoral level.
In contrast, among healthy adults (subpopulation of international
twin study), aged 20-78 years, with 4.1\% presence of DM, with higher
prevalence of smokers, the plaque prevalence was significantly higher
in the CFA compared to the CCA (40.7\% vs 30.4\%), the progression
rate was not followed \citep{Lucatelli2016}. Among PESA participants,
plaques were most common in the iliofemorals (44\%), followed by
the carotids (31\%) aorta (25\%) and coronary arteries (18\%). Interestingly,
among participants with low Framingham Heart Study (FHS) 10-year risk,
subclinical disease at all was detected in 58\% (higher than in our
study, but in mul-titerritorial location). Nearly 60\% of those, with
CACS=0, had plaques at other vascular sites implying, that in low-risk
sample, the absence of CAC does not necessarily indicate that a participant
is disease free \citep{FernandezFriera2015}. In the large
Asklepios Study cohort of asymp-tomatic subjects aged 35 to 55 years
without exclusion of DM/impaired fasting glucose (21.4\%) the occurrence
of carotid and femoral plaque was generally high, 43.6\% in ca-rotid
and 54.9\% in femoral region  \citep{Langlois2008}. In the
Cafes-Cave 10-year, prospective study with 10 000 healthy, low risk
individuals without AH, DM and DLP, aged 35-65 years, 10.8\% of study
population had ATS plaque either at the femoral, or carotid level
(less than in our study, but their study population was free of 3
main modifiable RFs). Moreover, the authors documented a difference
in morphology between carotid and femoral arteries: in 51\% of subjects
the carotid was the most advanced artery and in 52.4\% the right (carotid
or femoral) arteries were more advanced than the left \citep{Belcaro2001}.
We observed almost the same prevalence on both arterial sites but
did not evaluate side difference. 

\section{Limitations}

Limitations of our study are a small study group and lower response
rate (75\%). Moreover, the lack of methodological standardization,
measurement difficulties and publication bias make it difficult to
compare our results with other studies. In addition, there are limited
data focusing on the comparison of subclinical ATS progression in-corporating
2 peripheral arterial sites concurrently in similarly selected subjects
and using markers. Due to these limitations, there is a need for cautious
interpretation of our results. Additional research in a larger sample
of asymptomatic individuals is needed to quantify the impact of imaging
in different arterial territories for subclinical ATS in CV risk management
before applying them in clinical practice.

\section{Conclusion}

In middle-aged, non-diabetic, low-to moderate CV risk individuals,
during a short follow-up, a relatively high prevalence and significant
progression of subclinical carotid and femoral ATS was detected by
standardized ultrasound techniques, expressed mainly as the presence
of plaque and age- and sex-adjusted increase of IMT. Carotid arteries
showed a faster progression rate and higher prevalence of increased
age- and sex-adjusted IMT compared to the femoral arteries. However,
plaque burden was similar in both territories, with higher progression
rate in femorals. The high prevalence, short-term different dynamics
of subclinical ATS in the carotid and femoral regions (between 45
and 50 years of patients’ age), may underline the rationale for carotid
and femoral ATS screening and optimal timing for personalized CV risk
stratification in middle-aged subjects with low-to moderate calculated
CV risk, especially in those over 50 years old with several RFs.

\bigskip{}
\noindent
\textbf{Author Contributions}: Conceptualization, ES; methodology, ES, AL;
software, PK, PS; formal analysis, ES, PK; investigation, ES, AL,
AR; resources, TM, LD; data collection, AL, AR, TM, LD; writing---original
draft preparation, ES, writing---review and editing, ES, PS; visualization,
PS, PK; supervision, ES. All authors have read and agreed to the published
version of the manuscript. 

\noindent
\textbf{Funding}: This research received no external funding. 

\noindent
\textbf{Institutional Review Board Statement}: The study was conducted according
to the guidelines of the Declaration of Helsinki, and approved by
the Ethics Committee of the L. Pasteur University Hospital in Košice
for studies involving humans. 

\noindent
\textbf{Informed Consent Statement}: Informed consent was obtained from all
subjects involved in the study. 

\noindent
\textbf{Data Availability Statement}: The data presented in this study are
available on request from the corresponding author. 

\noindent
\textbf{Conflicts of Interest}: The authors declare no conflict of interest. 


\noindent
\textbf{Acknowledgements}: The authors thank the participants in Košice region
for their valuable contribution.

\bibliographystyle{unsrt}
%\phantomsection\addcontentsline{toc}{section}{\refname}\bibliography{Diagnostics_24}

\bigskip{}
\noindent 
\begin{flushleft}
\textbf{References}
\par\end{flushleft}

\begin{thebibliography}{999}

\bibitem{Roquer2010}
Roquer, J;  Ois, A.
\newblock {Atherosclerotic Burden and Mortality}.
\newblock In {\em Handbook of Disease Burdens and Quality of Life Measures; }
\newblock Preedy, V.R., Watson, R.R.,  Eds.;  Springer, New York, NY, 2010; pp 899--918.
\url {https://doi.org/10.1007/978-0-387-78665-0\_51}

\bibitem{Muntendam2010}
Muntendam, P.; McCall, C.; Sanz, J.; Falk, E.; Fuster, V.;  and
  High-Risk~Plaque Initiative.
\newblock The BioImage Study: novel approaches to risk assessment in the
  primary prevention of atherosclerotic cardiovascular disease--study design
  and objectives.
\newblock {\em Am Heart J} \textbf{2010},  {\em 160}, 49--57. 
\url {https://doi.org/10.1016/j.ahj.2010.02.021}

\bibitem{Sillesen2018}
Sillesen, H; Sartori, S.; Sandholt, B.; Baber, U.; Mehran, R.; Fuster, V.  
\newblock Carotid plaque thickness and carotid plaque burden predict future
  cardiovascular events in asymptomatic adult americans.
\newblock {\em Eur Heart J. Cardiovascular Imaging} \textbf{2018},  {\em 19}, 1042--1050.
\url {https://doi.org/10.1093/ehjci/jex239}

\bibitem{Szaboova2012}
Szab{\'o}ov{\'a}, E.
\newblock Individualized cardiovascular risk assessment.
\newblock In {\em Coronary artery disease - New insights and novel approaches},
 IntechOpen Book Series, 2012; pp 169--206.
\url {https://doi.org/10.5772/31500}

\bibitem{Perk2012}
Perk,  J.;   De Backer,  G.;  Gohlke, H.; Graham, I.;  Reiner, Z.;  Verschuren, M.;
Albus, Ch.; Benlian, P.;   Boysen, G.; Cifkova, R.;  Deaton,  Ch.; 
Ebrahim, S.;  Fisher,  M.; Germano, G.;  Hobbs, R.;  Hoes, A.;  Karadeniz, S.;
 Mezzani, A.; Prescott, E.;  Ryden,L.;  Scherer, M.; Syvänne, M.; 
Scholte op Reimer, W, J.M.; Vrints,  Ch.; Wood, D.;  Zamorano, J.L.;  Zannad, F.
European Association for Cardiovascular Prevention {\&} Rehabilitation (EACPR), and
E.S.C. Committee for Practice Guidelines (CPG). 
\newblock European Guidelines on cardiovascular disease prevention in clinical
  practice (version 2012). The Fifth Joint Task Force of the European Society
  of Cardiology and Other Societies on Cardiovascular Disease Prevention in
  Clinical Practice (constituted by representatives of nine societies and by
  invited experts).
\newblock {\em Eur Heart J} \textbf{2012},   {\em 33}, 1635--1701.
\url {https://doi.org/10.1093/eurheartj/ehs092}

\bibitem{Geisel2017}
Geisel, M.H.;  Bauer, M.;  Hennig, F.; Hoffmann, B.;  Lehmann, N.; Stefan
Möhlenkamp, S.; Kröger, K.;  K ara, K.;  Müller, T.;  Moebus, S.; Erbel, R.;
Scherag, A.; Jöckel, K.H.;  Mahabadi, A.A.  The Heinz Nixdorf Recall study.
\newblock Comparison of coronary artery calcification, carotid intima-media
  thickness and ankle-brachial index for predicting 10-year incident
  cardiovascular events in the general population.
\newblock {\em Eur Heart J} \textbf{2017},  {\em 38}, 1815--1822.
\url {https://doi.org/10.1093/eurheartj/ehx120}

\bibitem{Yeboah2012}
Yeboah, J.; McClelland, R.L.; Polonsky, T.S.; Burke, G.L.; 
Sibley,  Ch.T.;  O’Leary, D.;   Carr, J.J.; Goff,  D.C.; Greenland, Ph.; Herrington, D.M.
\newblock Comparison of novel risk markers for improvement in cardiovascular
  risk assessment in intermediate-risk individuals.
\newblock {\em JAMA} \textbf{2012},  {\em 308}, 788--795.
\url {https://doi.org/10.1001/jama.2012.9624}

\bibitem{Visseren2021}
Visseren, F.L.J.;  Mach,  F.; Smulders,  Y.M.; Carballo, D.; Koskinas, K.C.; 
Bäck, M.;  Benetos, A.;  Biffi, B.; Boavida, J.M.; Capodanno, D.;  
Cosyns, B.;  Crawford, C.;   Davos, C.H.;  Desormais, I.; 
Di Angelantonio, E.; Franco, O.H.;  Halvorsen, S.; Hobbs, F.D.R.;  Hollander, M.; 
Jankowska, E.A.;  Michal, M.;   Sacco, S.;  Sattar, N.; Tokgozoglu, L.; 
Tonstad,  S.;  Tsioufis, K.P.;   van Dis, I.; van Gelder, I.C.;  Christoph Wanner, Ch.;
Williams, B. E.S.C. National Cardiac Societies, and E.S.C. Scientific Document Group.
\newblock 2021 ESC Guidelines on Cardiovascular Disease Prevention in Clinical Practice.
\newblock {\em Eur Heart J} \textbf{2021}, 42, 3227--3337.
\url {https://doi.org/10.1093/eurheartj/ehab484}

\bibitem{Belcaro2001}
Belcaro, G.; Nicolaides, A. N.; Ramaswami, G.;   Cesarone, M.R.; De Sanctis, M.; Incandela,L.; 
Ferrari, P.;  G. Geroulakos, G.;  Barsotti,  A.; Griffin, M.; Dhanjil, S.;  Sabetai, M.;   Bucci, M.; Martines, G. 
\newblock Carotid and femoral ultrasound morphology screening and
  cardiovascular events in low risk subjects: a 10-year follow-up study (the
  CAFES-CAVE study(1)).
\newblock {\em Atherosclerosis} \textbf{2001},  {\em 156}, 379--387.
\url {https://doi.org/10.1016/s0021-9150(00)00665-1}

\bibitem{Laclaustra2016}
Laclaustra, M.;  Casasnovas, J.A.; Fernández-Ortiz, A.; Fuster, V.; 
León-Latre, M.;   Jiménez-Borreguero, L.J.;  Pocovi, M.;  Hurtado-Roca, Y.;   Ordovas, J.M.; 
Jarauta, E.; Guallar, E.; Ibañez, B.;   Civeira, F. 
\newblock Femoral and Carotid Subclinical Atherosclerosis Association with Risk
  Factors and Coronary Calcium: The AWHS Study.
\newblock {\em J Am Coll Cardiol } \textbf{2016},  {\em 67}, 1263--1274.
\url {https://doi.org/10.1016/j.jacc.2015.12.056}

\bibitem{FernandezFriera2015}
Fernández-Friera, L.; Peñalvo, J.L.; Fernández-Ortiz, A.;  Ibañez,B.;   López-
Melgar,  B.;  Laclaustra, M.;  Oliva, B.;  Mocoroa, A.;  Mendiguren, J.; de
Vega, V.M.;  García, L.;  Molina, J.;  Sánchez-González, J.;  Guzmán,  G.; Alonso-
Farto,  J.C.; Guallar, E.;  Civeira, F.;   Sillesen, H.;   Pocock, S.;  Ordovás, J.M.; 
Sanz, G.;  Jiménez-Borreguero, L.J.;   Fuster, F. 
\newblock Prevalence, Vascular Distribution, and Multiterritorial Extent of
  Subclinical Atherosclerosis in a Middle-Aged Cohort: The PESA (Progression of Early Subclinical Atherosclerosis) Study.
\newblock {\em Circulation} \textbf{2015},  {\em 131}, 2104--2113.
\url {https://doi.org/10.1161/CIRCULATIONAHA.114.014310}

\bibitem{Mitu2017}
Mitu, O.;  Roca, M.;  Floria, M.; Petris, A. O.;   Graur, M.; Mitu, F.
\newblock Subclinical cardiovascular disease assessment and its relationship
  with cardiovascular risk SCORE in a healthy adult population: A
  cross-sectional community-based study.
\newblock {\em Clinica e investigacion en arteriosclerosis : publicacion
  oficial de la Sociedad Espanola de Arteriosclerosis} \textbf{2017},  {\em 29}, 111--119.
\url {https://doi.org/10.1016/j.arteri.2016.10.004}

\bibitem{Szaboova2024}
Szabóová, E.;  Lisovszki, A.;  Kolarčik, P.;  Fatľová, E.; Molnár, T.;  Szabó, P.
\newblock Impact of Classical Risk Factors on Subclinical Carotid
  Atherosclerosis Progression: Insights from a Non-Diabetic Cohort.
\newblock {\em RCM} \textbf{2024},  {\em 25}, 103.
\url {https://doi.org/10.31083/j.rcm2503103}

\bibitem{Mendieta2023}
%Guiomar Mendieta, Stuart Pocock, Virginia Mass, Andrea Moreno, Ruth Owen, Inés
%  García-Lunar, Beatriz López-Melgar, Jose~J. Fuster, Vicente Andres,
%  Cristina Pérez-Herreras, Hector Bueno, Antonio Fernández-Ortiz, Javier
%  Sanchez-Gonzalez, Ana García-Alvarez, Borja Ibáñez, and Valentin Fuster.
Mendieta, M.;  Pocock, S.;  Mass, V.;  Moreno, A.;   Owen, R.;  García-
Lunar,  I.;   López-Melgar,  B.;  Fuster, J.J.;  Andres, V.;  Pérez-Herreras,  Ch.; 
Bueno, H.; Fernández-Ortiz, A.;   Sanchez-Gonzalez,  J.; García-Alvarez,  A.; Ibáñez, B.; Fuster, V.
\newblock Determinants of Progression and Regression of Subclinical
  Atherosclerosis Over 6 years.
\newblock {\em JACC} \textbf{2023},
   {\em 82}, 2069--2083.
\url {https://doi.org/10.1016/j.jacc.2023.09.814}

\bibitem{Darabian2013}
Darabian, S.;  Hormuz, M.;  Latif, M.A.;  Pahlevan,  S.; Budoff, M.J..  
\newblock The role of carotid intimal thickness testing and risk prediction in
  the development of coronary atherosclerosis.
\newblock {\em Curr  Atheroscler  Rep} \textbf{2013},  {\em 15}, 306.
\url {https://doi.org/10.1007/s11883-012-0306-4}

\bibitem{Hallan2004}
Hallan,  S.; Arne Asberg, A.;  Lindberg, M.;  Johnsen, H. 
\newblock Validation of the Modification of Diet in Renal Disease formula for
  estimating GFR with special emphasis on calibration of the serum creatinine
  assay.
\newblock {\em Am J Kidney Dis} \textbf{2004},  {\em 44}, 84--93.
\url {https://doi.org/10.1053/j.ajkd.2004.03.027}

\bibitem{Piepoli2016}
Piepoli, M.F.;   Hoes,  A.W.;  Agewall, S.; Albus, Ch.;  Brotons,  C.; 
Catapano,  A.L.; Cooney, M.T.;  Corrà, U.;  Cosyns, B.;  Deaton, Ch.;   Graham, I.; 
Hall, M.S.; Hobbs, F.D.R.;  Løchen, M.L.;   Löllgen, H.; Marques-
Vidal, P.;  Perk,  J.; Prescott, E.;  Redon, J.; . Richter, D.J.;  Sattar, N.; Smulders, Y.;
Tiberi, M.; van der Worp, H.B.;  van Dis, I.;  Verschuren, W:M:M.;  Binno, S.; 
E.S.C. Scientific~Document Group.
\newblock 2016 {E}uropean {G}uidelines on cardiovascular disease prevention in
  clinical practice: {T}he {S}ixth {J}oint {T}ask {F}orce of the {E}uropean
  {S}ociety of {C}ardiology and {O}ther {S}ocieties on {C}ardiovascular
  {D}isease {P}revention in {C}linical {P}ractice (constituted by
  representatives of 10 societies and by invited experts) {D}eveloped with the
  special contribution of the {E}uropean {A}ssociation for {C}ardiovascular
  {P}revention {\&} {R}ehabilitation {(EACPR)}.
\newblock {\em Eur Heart J} \textbf{2016}, {\em 37}, 2315--2381.
\url {https://doi.org/10.1093/eurheartj/ehw106}

\bibitem{Cosentino2020}
Cosentino,  F.;   Grant, P.J.;  Aboyans, V.;   Bailey, C.J.;   Ceriello,  A.; 
Delgado, V.;  Federici, M.;  Filippatos, G.;   Grobbee, D.E.;  Hansen, T.B.; 
Huikuri, H.V.;  Johansson, I.;  Jüni,  P.; Lettino, M.;  Marx,  N.;
Mellbin,  L.G.;  Östgren, C.J.;  Rocca, B.;  Roffi, M.; Sattar, N.; Seferovic´, P.M.; 
Sousa-Uva, M.;  Valensi, P.;  Wheeler, D.C.; E.S.C. Scientific Document Group. 
\newblock 2019 {ESC G}uidelines on diabetes, pre-diabetes, and cardiovascular
  diseases developed in collaboration with the {EASD}.
\newblock {\em Eur Heart J} \textbf{2020},  {\em 41}, 255--323.
\url {https://doi.org/10.1093/eurheartj/ehz486}

\bibitem{Bunting2019}
Bunting, K.V.; Steeds,  R.P.;  Slater, L.T.;   Rogers, J.K.;   Gkoutos, G.V.; 
Kotecha, D.
\newblock A Practical Guide to Assess the Reproducibility of Echocardiographic
  Measurements.
\newblock {\em J Am Soc Echocardiogr} \textbf{2019}, 32, 1505--1515.
\url {https://doi.org/10.1016/j.echo.2019.08.015}

\bibitem{Touboul2012}
Touboul, P.J.;  Hennerici, M.G.;   Meairs, S.; Adams, H.;  Amarenco,  P.; Bornstein, N.;   Csiba,
L.; Desvarieux,  M.; Ebrahim, S.;  Hernandez Hernandez,  R.;  Jaff,  M.;  Kownator, S.; Naqvi,  T.; Prati, P.; 
Rundek, T.; Sitzer, M.; Schminke, U.; Tardif, J.C.; Taylor, A.;  Vicaut, E.;   Woo, K.S.. 
\newblock Mannheim carotid intima-media thickness and plaque consensus
  (2004-2006-2011). {A}n update on behalf of the advisory board of the 3rd, 4th
  and 5th watching the risk symposia, at the 13th, 15th and 20th {E}uropean
  {S}troke {C}onferences, {M}annheim, {G}ermany, 2004, {B}russels, {B}elgium,
  2006, and {H}amburg, {G}ermany, 2011.
\newblock {\em Cerebrovasc Dis} \textbf{2012},  {\em 34}, 290--296.
\url {https://doi.org/10.1159/000343145}

\bibitem{Salonen1991}
Salonen,  R.; Haapanen,  A.; Salonen, J.T.
\newblock Measurement of intima-media thickness of common carotid arteries with
  high-resolution b-mode ultrasonography: inter- and intra-observer
  variability.
\newblock {\em Ultrasound Med Biol} \textbf{1991}, 17, 225--230.
\url {https://doi.org/10.1016/0301-5629(91)90043-v}

\bibitem{Stein2008}
James H. Stein, J,H.;   Korcarz,  C.E.;  Hurst, R.T.;   Lonn, E.;  Kendall,  Ch. B.;
Mohler, E.R.;  Najjar, S.S.;   Rembold,  Ch.M.;  Post,  W.S.;  American Society
of Echocardiography Carotid Intima-Media Thickness Task Force. 
\newblock 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.
\newblock {\em J Am Soc Echocardiogr} \textbf{2008},  {\em 21}, 93--111.
\url {https://doi.org/10.1016/j.echo.2007.11.011}

\bibitem{Denarie2000}
Denarié, N.;   Gariepy, J.;   Chironi, G.;   Massonneau,  M.; Laskri,  F.; Salomon,  G.J.;  Levenson, J.; 
Simon, A.
\newblock Distribution of ultrasonographically-assessed dimensions of common
  carotid arteries in healthy adults of both sexes.
\newblock {\em Atherosclerosis} \textbf{2000}, 148, 297--302.
\url {https://doi.org/10.1016/s0021-9150(99)00276-2}

\bibitem{Koc2018}
Koç, A.S.; Peköz, B.C.
\newblock B-mode ultrasound assessment of intima-media thickness of common
  carotid, internal carotid, brachial, femoral arteries and abdominal aorta in
  patients with cardiovascular risk factor.
\newblock {\em J Surg Med } \textbf{2018},  {\em 2}, 244--248.
\url {https://doi.org/10.28982/josam.421768}

\bibitem{Langlois2008}
Langlois, M.R.;  Rietzschel, E.R.;  De Buyzere, M.L.;  De Bacquer,  D.; Bekaert, S.;
 Blaton, V.;  De Backer, G.G;  Gillebert, T.C.	
\newblock  Femoral Plaques Confound the Association of Circulating Oxidized 
Low-Density Lipoprotein With Carotid Atherosclerosis in a General Population 
Aged 35 to 55 Years: The Asklepios Study.
\newblock {\em Arterioscler Thromb Vasc Biol}
  \textbf{2008}, 28(8), 1563--1568.
\url {https://doi.org/10.1161/atvbaha.108.167346}

\bibitem{Paul2011}
Paul, T.K.; Chen, W.; Sathanur R. Srinivasan,  S.R.; He, J.;   Berenson, G.S. 
\newblock Contrast of the impact of multiple cardiovascular risk factors on the
  femoral and carotid intima-media thickness in asymptomatic young adults: The
  Bogalusa Heart Study.
\newblock {\em Atherosclerosis} \textbf{2011},  {\em 216}, 359--364.
\url {https://doi.org/10.1016/j.atherosclerosis.2011.02.023}

\bibitem{Touboul2005}
Touboul,  P.J.; Labreuche, J.; Vicaut, E.;  Amarenco, P.;  G. E. N. I. C.
Investigators.	
\newblock Carotid intima-media thickness, plaques, and Framingham risk score as
  independent determinants of stroke risk.
\newblock {\em Stroke} \textbf{2005},  {\em 36}, 1741--1745.
\url {https://doi.org/10.1161/01.STR.0000174490.23495.57}

\bibitem{Mackinnon2004}
Mackinnon,  A.D.;  Jerrard-Dunne,  P.;  Sitzer, M.;  Buehler, A.;  von
Kegler, S.;  Markus, H.S. 
\newblock Rates and determinants of site-specific progression of carotid artery
  intima-media thickness: the carotid atherosclerosis progression study.
\newblock {\em Stroke} \textbf{2004},  {\em 35}, 2150--2154.
\url {https://doi.org/10.1161/01.STR.0000136720.21095.f3}

\bibitem{LopezMelgar2020}
López-Melgar, B.; Fernández-Friera, L.; Oliva, B.; García-Ruiz, J.M.;  
Sánchez-Cabo, F.; Bueno, H.;  Mendiguren,  J.M.; Lara-Pezzi,  E.; Andrés, V.;
Ibáñez, B.; Fernández-Ortiz, A.; Sanz, J.; Fuster, V. 
\newblock Short-Term Progression of Multiterritorial Subclinical
  Atherosclerosis.
\newblock {\em J Am Coll  Cardiol } \textbf{2020},  {\em 75}, 1617--1627.
\url {https://doi.org/10.1016/j.jacc.2020.02.026}

\bibitem{Bots1997}
Bots, M.L.;  Hofman, A.;  Grobbee, D.E.  
\newblock Increased common carotid intima-media thickness. Adaptive response or
  a reflection of atherosclerosis? Findings from the Rotterdam Study.
\newblock {\em Stroke} \textbf{1997}, {\em 28}, 2442--2447.
\url {https://doi.org/10.1161/01.str.28.12.2442}

\bibitem{Herder2012}
Herder, M.; Johnsen, S.H.;  Arntzen,  K.A.;  Mathiesen, E.B.  
\newblock 
Risk Factors for Progression of Carotid Intima-Media Thickness and Total 
Plaque Area: A 13-Year Follow-Up Study
: The Tromsø Study.
\newblock {\em Stroke} \textbf{2012}, {\em 43}, 1818--1823.
\url {https://doi.org/10.1161/STROKEAHA.111.646596}

\bibitem{Dalager2007}
Søren Dalager, William~P. Paaske, Ingrid Bayer~Kristensen, Jacob
  Marsvin~Laurberg, and Erling Falk.
Dalager, S.; Paaske,  W.P.; Kristensen,  I.B.; Laurberg, J.M.; 
Falk, E.  
\newblock 
Artery-Related Differences in Atherosclerosis Expression: Implications for Atherogenesis 
and Dynamics in Intima-Media Thickness
\newblock {\em Stroke} \textbf{2007}, {\em 38 }, 2698--2705.
\url {https://doi.org/10.1161/strokeaha.107.486480}

\bibitem{Kannel1994}
Kannel, W.B. 
\newblock Risk factors for atherosclerotic cardiovascular outcomes in different
  arterial territories.
\newblock {\em J Cardiovasc Risk} \textbf{1994},{\em 1}, 333--339.

\bibitem{Meer2003}
van der Meer, I.M.; Iglesias del Sol, A.;  Hak, E.;  Bots,  M.L.; 
Hofman,  A.; Witteman, J.C.M.
\newblock Risk factors for progression of atherosclerosis measured at multiple
  sites in the arterial tree: the Rotterdam Study.
\newblock {\em Stroke} \textbf{2003}, {\em 34}, 2374--2379.
\url {https://doi.org/10.1161/01.STR.0000088643.07108.19}

\bibitem{Boesing2001}
Bösing, N.; Hort, W.;  Losch-Coche,U. 
\newblock The site and extent of arteriosclerosis. comparative planimetric
  studies of the left descending coronary artery, internal carotid artery,
  superficial femoral artery and abdominal aorta in 104 cadavers.
\newblock {\em Kardiol} \textbf{2001}, {\em 90}, 327--338.
\url {https://doi.org/10.1007/s003920170162}

\bibitem{Ross1984}
Ross,  R.; Wight, T.N; Strandness, E.; Thiele,B.  
\newblock Human atherosclerosis. I. Cell constitution and characteristics of
  advanced lesions of the superficial femoral artery.
\newblock {\em Am J Pathol} \textbf{1984},  {\em 114}, 79--93.

\bibitem{Lee2011}
Lee,  K.; Sung, J.; Lee, S.Ch.;  Park, S.W.; Kim,  Y.S.;  Lee,  J.Y.; Ebrahim,  S.;   Song,Y.M.  
\newblock Segment-specific carotid intima-media thickness and cardiovascular
  risk factors in Koreans: the Healthy Twin Study.
\newblock {\em Eur J Prev Cardiol} \textbf{2011}, {\em 19}, 1161--1172.
\url {https://doi.org/10.1177/1741826711422763}

\bibitem{Tarnoki2015}
A.~Tarnoki, D.L. Tarnoki, B.~Fejer, E.~Godor, A.A. Molnar, P.~Maurovich Horvat,
  E.~Medda, C.~Fagnani, M.A. Stazi, B.~Merkely, F.~Farina, C.~Baracchini,
  G.~Pucci, G.~Schillaci, and G.~Jermendy.
Tarnoki, A.; Tarnoki, D.L.; Fejer, B.;   Godor, E.;  Molnar, A.A.;  Maurovich Horvat, P.;   Medda,E.;
Fagnani, C.;  Stazi,  M.A.; Merkely, B.; Farina, F.;  Baracchini, C.; Pucci, G.; Schillaci, G.; 
Jermendy,G.
\newblock 
1A.12
GENETIC BACKGROUND OF FEMORAL ATHEROSCLEROTIC PLAQUE FORMATION
\newblock {\em J Hypertens} \textbf{2015}, {\em 33} (suppl 1):e4.
\url {https://doi.org/10.1097/01.hjh.0000467362.35205.d1}

\bibitem{Medda2014}
Medda, E.; Fagnani, C.;  Schillaci, G.; Tarnoki, A.D; Tarnoki, D.L.; Baracchini,  C.; Meneghetti,
G.;  Fanelli, F.;  Alaeddin, A.;  Pucci, G.; Alviti,  S.; Cotichini,  R.; Brescianini,   S.;  Boatta, E.; Lucatelli, P.;
Nisticò, L.; Penna, L.;  Salemi,  M.; Toccaceli, V.; Zini, C.; Garami, Z.;   Stazi, M.A. 
\newblock Heritability of arterial stiffness and carotid intima-media
  thickness: An Italian twin study.
\newblock {\em Nutr Metab Cardiovasc Dis}
 \textbf{2014},  {\em 24}, 511--517.
\url {https://doi.org/10.1016/j.numecd.2013.10.031}

\bibitem{Bedi2014}
Bedi, R.; Nagra, A.;  Fukumoto, T.; Lynum, S.; Sengupta, P.;  Aw, J.; 
Mefford, I.;  Panwar, S.R.;  Bansal, N.; Insaan, P.;  Singh, S.;
Panwar, R.; Vedanthan, R.; Fuster, V.;   Narulam, J.
\newblock 
Detection of Subclinical Atherosclerosis in Peripheral Arterial Beds With 
B-Mode Ultrasound: A Proposal for Guiding the Decision for Medical Intervention 
and an Artifact-Corrected Volumetric Scoring Index
\newblock {\em Glob Heart}, \textbf{2014}, {\em 9}, 367.
\url {https://doi.org/10.1016/j.gheart.2014.10.007}

\bibitem{Davidsson2010}
Davidsson, L.; Fagerberg, B.; Bergström, G.;  Schmidt, C.
\newblock Ultrasound-assessed plaque occurrence in the carotid and femoral
  arteries are independent predictors of cardiovascular events in middle-aged
  men during 10 years of follow-up.
\newblock {\em Atherosclerosis} \textbf{2010},  {\em 209}, 469--473.
\url {https://doi.org/10.1016/j.atherosclerosis.2009.10.016}

\bibitem{Yerly2015}
Yerly, P.; Marquès-Vidal, P.; Owlya, R.;  Eeckhout, E.; Kappenberger, L.; 
Darioli, R.;  Depairon, M. 
\newblock The atherosclerosis burden score (ABS): a convenient ultrasound-based
  score of peripheral atherosclerosis for coronary artery disease prediction.
\newblock {\em Cardiovasc Transl Res } \textbf{2015}, {\em 8}, 138--147.
\url {https://doi.org/10.1007/s12265-015-9617-5}

\bibitem{Kirhmajer2011}
Kirhmajer,  M.V.; Banfic, L.;  Vojkovic, M.;  Strozzi, M.;  Bulum, J.; 
Miovski, Z. 
\newblock Correlation of femoral intima-media thickness and the severity of
  coronary artery disease.
\newblock {\em Angiology} \textbf{2011}, {\em 62}, 134--139.
\url {https://doi.org/10.1177/0003319710375087}

\bibitem{Griffin2009}
Griffin, M.; Nicolaides, A.; Tyllis, T.;  Georgiou, N.; Martin, R.M.; 
Bond, D.;  Panayiotou, A.; Tziakouri, C.;  Doré, C.J.; Fessas, C. 
\newblock Carotid and femoral arterial wall changes and the prevalence of
  clinical cardiovascular disease.
\newblock {\em Vasc Med} \textbf{2009}, {\em 14}, 227--232.  
\url {https://doi.org/10.1177/1358863X08101542}

\bibitem{Giannoukas2009}
Giannoukas, A.D.; Antoniou, G.A.; Saleptsis, V.; Baros, C.; Griffin, M.;   Nicolaides, A.N.
\newblock Common femoral artery intima-media thickness as marker for
  cardiovascular disease in asymptomatic adults.
\newblock {\em VASA} \textbf{2009}, {\em 38}, 147--154.
\url {https://doi.org/10.1024/0301-1526.38.2.147}

\bibitem{Wendelhag1993}
Wendelhag, I.; Wiklund, O.; Wikstrand, J.
\newblock Atherosclerotic changes in the femoral and carotid arteries in
  familial hypercholesterolemia. Ultrasonographic assessment of intima-media
  thickness and plaque occurrence.
\newblock {\em Arterioscler Thromb} \textbf{1993},  {\em 13}, 1404--1411.
\url {https://doi.org/10.1161/01.atv.13.10.1404}

\bibitem{Kocyigit2020}
Kocyigit, D.;  Gurses, K.M.; Taydas, O.;  Poker, A.; Ozer, N.; Hazirolan, T.;
Tokgozoglu,L. 
\newblock Role of femoral artery ultrasound imaging in cardiovascular event
  risk prediction in a primary prevention cohort at a medium-term follow-up.
\newblock {\em J Cardiol} \textbf{2020}, {\em 75}, 537--543.
\url {https://doi.org/10.1016/j.jjcc.2019.09.012}

\bibitem{Lekakis2005}
Lekakis,  J.P.; Papamichael, C.;  Papaioannou, T.G.;  Stamatelopoulos, K.S.;
Cimponeriu, A.; Protogerou, A.D.; Kanakakis, J.;	 
\newblock Intima-media thickness score from carotid and femoral arteries
  predicts the extent of coronary artery disease: intima-media thickness and
  CAD.
\newblock {\em Int I Card Imaging }
  \textbf{2012}, {\em 21}, 495--501.
\url {https://doi.org/10.1007/s10554-004-8165-x}

\bibitem{Sosnowski2007} 
Sosnowski, C.;  Pasierski, T.; Janeczko-Sosnowska, E.; Szulczyk, A.;
Dabrowski, R.;  Woz´niak, J.;  Sumin´ski, A.; Ruzyłło, W. 
\newblock Femoral rather than carotid artery ultrasound imaging predicts extent
  and severity of coronary artery disease.
\newblock {\em Kardiol} \textbf{2007}, {\em 65} 760--766.

\bibitem{AzcuiAparicio2021}
Azcui Aparicio,R.E.; Ball, J.;  Yiallourou, S.;  Venkataraman, P.;
Marwick, T.; Carrington, M.J.	
\newblock Imaging-guided evaluation of subclinical atherosclerosis to enhance
  cardiovascular risk prediction in asymptomatic low-to-intermediate risk
  individuals: A systematic review.
\newblock {\em Prev Med} \textbf{2021},  {\em 153}, 106819.
\url {https://doi.org/10.1016/j.ypmed.2021.106819}

\bibitem{Lynch1997}
Lynch, J.;  Kaplan, G.A,; Salonen, R.; Salonen, J.T. 
\newblock 
Socioeconomic Status and Progression of Carotid Atherosclerosis : Prospective
 Evidence From the Kuopio Ischemic Heart Disease Risk Factor Study.
\newblock {\em Arterioscler Thromb Vasc Biol }
 \textbf{1997} {\em 17}, 513--519.
\url {https://doi.org/10.1161/01.atv.17.3.513}

\bibitem{Wagenknecht2003}
Wagenknecht, L.E.;  Zaccaro, D.;  Espeland, M.A.;  Karter, A.J.; O’Leary, D.H.;
Haffner, S.M. 
\newblock Diabetes and progression of carotid atherosclerosis: the insulin
  resistance atherosclerosis study.
\newblock {\em Arterioscler Thromb Vasc Biol }
  \textbf{2003}, {\em 23}, 1035--1041.
\url {https://doi.org/10.1161/01.ATV.0000072273.67342.6D}

\bibitem{Chen2016}
Chen,  P-C.; Jeng, J.S.; Hsu, H.C.;  Su, T.C.;  Chien,  K.L.; Lee, Y.T.   
\newblock 
Carotid Atherosclerosis Progression and Risk of Cardiovascular Events in a Community in Taiwan.
\newblock {\em Sci Rep} \textbf{2016}, {\em 6}, 25733.
\url {https://doi.org/10.1038/srep25733}

\bibitem{Sturlaugsdottir2018}
Sturlaugsdottir, R.;  Aspelund, T.; Bjornsdottir, G.;  Sigurdsson, S.; Thorsson,B.;
Eiriksdottir, G.; Gudnason, V. 
\newblock Predictors of carotid plaque progression over a 4-year follow-up in
 the Reykjavik REFINE-study. 
\newblock {\em Atherosclerosis} \textbf{2018}, {\em 269}, 57--62.
\url {https://doi.org/10.1016/j.atherosclerosis.2017.12.005}

\bibitem{Chambless2000}
Chambless, L.E.; Folsom, A.R.; Clegg, L.X.; Sharrett, A.R.; Shahar, E.; Nieto, F.J.; Rosamond, W.D.;
Evans, G. 
\newblock Carotid wall thickness is predictive of incident clinical stroke: the
  Atherosclerosis Risk in Communities (ARIC) study.
\newblock {\em Am J  Epidemiol} \textbf{2000},  {\em 151}, 478--487.
\url {https://doi.org/10.1093/oxfordjournals.aje.a010233}

\bibitem{Johri2020}
Johri, A.M.; Nambi, V.;  Naqvi, T. Z.;   Feinstein,  S.B.;  Kim, E.S.H.;
Park, M.M.;  Becher, H.;  Sillesen, H. 
\newblock 
Recommendations for the Assessment of Carotid Arterial Plaque by Ultrasound for the Characterization of Atherosclerosis and Evaluation of Cardiovascular Risk: From the American Society of Echocardiography.
\newblock {\em J Am Soc of Echocardiogr } \textbf{2020},  {\em 33}, 917--933.
\url {https://doi.org/10.1016/j.echo.2020.04.021}

\bibitem{Novo2019}
Novo, S.; Carità, P.;  Lo Voi, A.;  Muratori, I.; Tantillo, R.; Corrado, E.;
Kalodiki, E.; Novo, G. 
\newblock Impact of preclinical carotid atherosclerosis on global
  cardiovascular risk stratification and events in a 10-year follow-up:
  comparison between the algorithms of the Framingham Heart Study, 
the European Score and the Italian ’Progetto Cuore’.
\newblock {\em J Cardiovasc Med }
  \textbf{2019}, {\em 20}, 91--96.
\url {https://doi.org/10.2459/JCM.0000000000000740}

\bibitem{KablakZiembicka2021}
Kabłak-Ziembicka, A.; Przewłocki, T.
\newblock 
Clinical Significance of Carotid Intima-Media Complex and Carotid Plaque 
Assessment by Ultrasound for the Prediction of Adverse Cardiovascular Events 
in Primary and Secondary Care Patients.
\newblock {\em J Clin Med } \textbf{2021}, {\em 10}, 4628.
\url {https://doi.org/10.3390/jcm10204628}

\bibitem{Engelen2013}
Lian Engelen, Isabel Ferreira, Coen~D. Stehouwer, Pierre Boutouyrie, Stéphane
  Laurent, and Reference~Values for Arterial Measurements~Collaboration.
Engelen, L.; Ferreira, I.;  Stehouwer, C.D.;  Boutouyrie, P.;  Laurent, A.; 
Reference Values for Arterial Measurements Collaboration. 
\newblock Reference intervals for common carotid intima-media thickness
  measured with echotracking: relation with risk factors.
\newblock {\em Eur Heart J} \textbf{2013}, {\em 34}, 2368--2380.
\url {https://doi.org/10.1093/eurheartj/ehs380}

\bibitem{Alizargar2019}
Alizargar J.;  Bai, C.H. 
\newblock Value of the arterial stiffness index and ankle brachial index in
  subclinical atherosclerosis screening in healthy community-dwelling
  individuals. 
\newblock {\em BMC Public Health} \textbf{2019}, {\em 19}, 65.
\url {https://doi.org/10.1186/s12889-019-6398-9}

\bibitem{Gepner2006}
Adam~D. Gepner, Jon~G. Keevil, Rachael~A. Wyman, Claudia~E. Korcarz, Susan~E.
  Aeschlimann, Kjersten~L. Busse, and James~H. Stein.
Gepner, A.D.; Keevil, J.G.;  Wyman, R.A.;  Korcarz, C.E.;  Aeschlimann, S.E.;
Busse, K.L.; Stein., J, H.
\newblock Use of carotid intima-media thickness and vascular age to modify
  cardiovascular risk prediction.
\newblock {\em J Am Soc Echocardiogr } \textbf{2006}, {\em 19}, 1170--1174.
\url {https://doi.org/10.1016/j.echo.2006.04.009}

\bibitem{Depairon2000}
Depairon, M.; Tutta,  P.;  van Melle, G.; Hayoz, D.; Kappenberger, L.;  Darioli, R.
\newblock Reference values of intima-medial thickness of carotid and femoral
  arteries in subjects aged 20 to 60 years and without cardiovascular risk
  factors.
\newblock {\em Arch Mal Coeur Vaiss } \textbf{2000}, {\em 93}, 721--726.

\bibitem{Lucatelli2016}
Lucatelli,P.; Fagnani, C.; Tarnoki, A.D.; Tarnoki, D.L.;
Stazi, M.A.; Salemi, M.;  Cirelli, C.; Sacconi, B.; d’Adamo, A.;
Fanelli, F.; Catalano, C.; Pucci, G.; Schillaci, G.;  Baracchini, C.;
Medda, E.
\newblock 
Femoral Artery Ultrasound Examination: A New Role in Predicting Cardiovascular Risk.
\newblock {\em Angiology} \textbf{2016},  {\em 68}, 257--265.
\url {https://doi.org/10.1177/0003319716651777}

\bibitem{Gariepy1998}
Gariepy,  J.; Salomon, J.; Denarié, N.; Laskri, F.;  Mégnien, J.L.; Levenson, J.; A. Simon, A. 
\newblock Sex and topographic differences in associations between large-artery
  wall thickness and coronary risk profile in a French working cohort: the AXA
  Study.
\newblock {\em Arterioscler Thromb Vasc Biol}
  \textbf{2012}, {\em 18}, 584--590.
\url {https://doi.org/10.1161/01.atv.18.4.584}

\bibitem{Rietzschel2001}
Rietzschel, E.R.; De Buyzere, M.L.; Duprez, D.A.;   Clement, D.L. 
\newblock Interchangeability of carotid and femoral intima-media thickness in
  risk stratification. 
\newblock {\em Int Angiol} \textbf{2001}, {\em 20}, 38--46.

\bibitem{Markus1997}
Markus, R.A.;  Mack, W.J.; Azen, S.P.;  Hodis, H.N. 
\newblock Influence of lifestyle modification on atherosclerotic progression
  determined by ultrasonographic change in the common carotid intima-media
  thickness.
\newblock {\em Am J Clin Nutr } \textbf{1997}, {\em 65},1000--1004.
\url {https://doi.org/10.1093/ajcn/65.4.1000}

\bibitem{Polak2011}
Polak, J.F.; Pencina, M.J.; O’Leary, D.H.; D’Agostino, R. B. 
\newblock Common carotid artery intima-media thickness progression as a
  predictor of stroke in multi-ethnic study of atherosclerosis.
\newblock {\em Stroke} \textbf{2011},  {\em 42}, 3017--3021.
\url {https://doi.org/10.1161/STROKEAHA.111.625186}

\bibitem{Sillesen2012}
Sillesen, H.; Muntendam, P.; Adourian, A.; Entrekin, R.;  Garcia, M.; 
Falk, E.; Fuster, V. 
\newblock Carotid plaque burden as a measure of subclinical atherosclerosis:
  comparison with other tests for subclinical arterial disease in the High Risk
  Plaque Bioimage Study.
\newblock {\em JACC. Cardiovascular imaging} \textbf{2012}, {\em 5}, 681--689.
\url {https://doi.org/10.1016/j.jcmg.2012.03.013}

\bibitem{Bossuyt2014}
Bossuyt, J.; Van Bortel, L.M.; De Backer, T.J.M.;  Van De Velde,  S.;
Azermai, M.; Segers, S.;  De Buyzere, M.;  Van Daele, C.; Rietzschel, E.; Asklepios
Investigators.
\newblock Asymmetry in prevalence of femoral but not carotid atherosclerosis.
\newblock {\em J Hypertens} \textbf{2014}, {\em 32}, 1429--1434.
\url {https://doi.org/10.1097/HJH.0000000000000205}

\bibitem{Fukudome1997}
Fukudome, Y.; Fujii, K.; Abe, I.;  Ohya, Y.; Fukuhara, M.;  Kaseda, S.;  Onaka, U.; 
Tsuchihashi, T.; Fujishima, M. 
\newblock Ultrasonographic assessment of regional differences in
  atherosclerotic lesions in patients with hypertension, diabetes mellitus, or
  both.
\newblock {\em Hypertens Res } \textbf{1997}, {\em 20}, 175--181.
\url {https://doi.org/10.1291/hypres.20.175}

\bibitem{Lisowska2005}
Lisowska,A.;  Musiał, W.J.;  Knapp, M.; Prokop, J.; 
Dobrzycki, S.   
\newblock Carotid and femoral atherosclerotic lesions in patients with coronary
  heart disease confirmed by angiography.
\newblock {\em Kardiol} \textbf{2005}, {\em 63}, 636--642.

\bibitem{Kroeger1999}
Kröger,  K.; Kucharczik, A.; Hirche, H.;  Rudofsky, G. 
\newblock Atherosclerotic lesions are more frequent in femoral arteries than in
  carotid arteries independent of increasing number of risk factors.
\newblock {\em Angiology} \textbf{1999}, {\em 50}, 649--654.
\url {https://doi.org/10.1177/000331979905000805}

\bibitem{Gariepy1996}
Gariepy, J.; Simon, A.;  Massonneau, M.;  Linhart, A.; Segond, P.; Levenson, J.
\newblock Echographic assessment of carotid and femoral arterial structure in
  men with essential hypertension. Group PCVMETRA.
\newblock {\em Am J Hyperten} \textbf{1996}, {\em 9}, 126--136.
\url {https://doi.org/10.1016/0895-7061(95)00262-6}

\bibitem{Yerly2012}
Yerly, P.;  Rodondi, N.; Viswanathan, B.; Riesen,W.; Vogt, P.; 
Bovet, P. 
\newblock Association between conventional risk factors and different
  ultrasound-based markers of atherosclerosis at carotid and femoral levels in
  a middle-aged population.
\newblock {\em Int J Cardiovasc Imaging },
  \textbf{2012} {\em 29}, 589--599.
\url {https://doi.org/10.1007/s10554-012-0124-3}

\end{thebibliography}

\end{document}
