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atheromatous plaques are the main modifier of cardiovascular risk&#44; with the use of CIMT not recommended in clinical practice&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">1&#44;4</span></a> Although data are still scarce&#44; the measurement of local arterial stiffness&#44; as an estimate of arterial stiffness measured by carotid pulse wave velocity&#44; could be a highly relevant parameter in estimating cardiovascular risk and even in monitoring the treatment response&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">For the assessment of the carotid and femoral arterial wall&#44; it is essential to carefully explore the various segments with cross-sectional and longitudinal sweeps&#44; because carotid plaques can locally and asymmetrically affect the vascular wall&#46; In addition&#44; the guidelines recommend repeating each sweep using color Doppler&#44; which can help detect hypo-anechoic plaques that are poorly visualized in B mode&#46; 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valve calcification&#44; aortic root size&#41;&#44; but their value and practical applicability in cardiovascular prevention are not well defined&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Echocardiography is the most widely used technique for diagnosing LVH and confirming LVH detected through electrocardiography&#46; The echocardiographic diagnosis is based on an increase in left ventricular mass &#40;LVM&#41; above certain values&#44; based on which a significant increase in cardiovascular events has been observed in population studies&#46; LVM should be adjusted for body size&#46; Classically&#44; LVM has been adjusted by body surface&#44; but the latest recommendations support adjusting by height&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">1</span></a> The 2 options have their strengths and weaknesses&#59; ideally&#44; both adjustments should be performed&#46; The cutoff points vary according to sex &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">To calculate LVM&#44; the formula proposed by the American Society of Echocardiography is generally employed&#44; which includes the telediastolic thickness of the interventricular septum&#44; left ventricular posterior wall thickness and left ventricular end-diastolic diameter&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">5</span></a> The diagnosis is often simplified to the measurement of the interventricular septal thickness&#44; considering LVH from 10<span class="elsevierStyleHsp" style=""></span>mm in women and 11<span class="elsevierStyleHsp" style=""></span>mm in men&#46; However&#44; the correct diagnosis of LVH should be based on the measurement of the 3 indicated parameters adjusted for body size&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">The recommendation is to perform the measurements in the parasternal long-axis projection&#46; The measurement should be performed at the end of the diastole&#44; at the free margin of the mitral valves&#44; perpendicular to the long axis of the left ventricle&#44; placing the markers accurately on the myocardial&#8211;cavity or myocardial&#8211;pericardial interface&#46; Small variations in the linear measures can result in significant variations in the calculated LVM &#40;in the LVM calculation&#44; a volumetric assumption is performed based on linear measures&#44; raising the inserted values to the third power&#41;&#46; Careful and systematic measurements should therefore be performed&#46; The measurements can be performed in B-mode or M-mode&#46; B-mode makes it easier to avoid measurements in oblique sections of the ventricle&#59; however&#44; the temporal resolution in M-mode is greater&#44; and there is a greater profusion of data &#40;many of the population studies on which the LVH cutoff points are based have been performed with this technique&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Abdominal aortic aneurysm</span><p id="par0060" class="elsevierStylePara elsevierViewall">Abdominal aortic aneurysms &#40;AAA&#41; are defined as dilations of the abdominal aorta with a diameter &#8805;3<span class="elsevierStyleHsp" style=""></span>cm&#46; A diameter of 2&#46;5&#8211;2&#46;9<span class="elsevierStyleHsp" style=""></span>cm constitutes an ectatic or subaneurysmal aorta&#46; Ultrasonography is the initial technique of choice for diagnosing AAA&#46; The ultrasound assessment of the abdominal aorta is simple and has a short learning period and execution time&#46; A transverse sweep should be performed from the epigastric region to the iliac bifurcation&#46; The diameter of the abdominal aorta should be measured in the anteroposterior and transverse direction &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a> and <a class="elsevierStyleCrossRef" href="#sec0130">Video 1 of appendix</a>&#41;&#46; If an aneurysmal dilation is detected&#44; it is advisable to also visualize the aorta in the longitudinal projection to determine the craniocaudal diameter of the aneurysm&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Main clinical scenarios</span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Refine the cardiovascular risk stratification</span><p id="par0065" class="elsevierStylePara elsevierViewall">In the prevention of cardiovascular disease&#44; determining the cardiovascular risk is the cornerstone of preventive interventions&#44; based on the assumption that the greater the estimated risk&#44; the greater the benefit of the intervention&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">6&#44;7</span></a> Thus&#44; while lifestyle measures are generalizable and applicable for the entire population&#44; drug interventions &#40;with their inherent risks and costs&#41; are reserved for patients with greater cardiovascular risk for whom the risk&#8211;benefit balance is more favorable&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The detection of subclinical cardiovascular damage is presented as a support tool for the classical estimation of cardiovascular risk based on identifying the conditions associated with a high to very high risk <span class="elsevierStyleItalic">per se</span> &#40;established cardiovascular disease&#44; chronic kidney disease&#44; familial hypercholesterolemia or diabetes mellitus&#41; and implementing risk equations for the remaining cases &#40;Systematic Coronary Risk Evaluation &#91;SCORE&#93; or <span class="elsevierStyleItalic">Registre Giron&#237; del cor</span> &#91;REGICOR&#93; in our setting&#41;&#46; The presence of subclinical cardiovascular damage is associated with a higher incidence of cardiovascular events&#44; regardless of the calculation based on the risk equations&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">8</span></a> In populations with high to very high-risk conditions&#44; various vascular and cardiac damage markers have been associated with a greater risk of a future cardiovascular event&#46;<a class="elsevierStyleCrossRefs" href="#bib0330"><span class="elsevierStyleSup">9&#44;10</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">A high number of cardiovascular events &#40;more than 50&#37; in men and up to 80&#37; in women&#41;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">11</span></a> occur in populations identified as low to moderate risk when applying the cardiovascular risk equations&#46; In addition&#44; the incidence of cardiovascular events varies significantly for patients with the same high to very high-risk condition&#46; Familial hypercholesterolemia is a paradigmatic case in which some patients and families experience early coronary events &#40;often before the age of 40 years in men&#41;&#44; while others develop cardiovascular disease much later &#40;in the sixth or seventh decade of life&#41; or&#44; in exceptional cases&#44; not at all&#46; These patients who are included <span class="elsevierStyleItalic">a priori</span> in the same cardiovascular risk category show a much different actual risk&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Therefore&#44; estimating the cardiovascular risk based on risk equations and conditions has significant room for improvement&#46; In this context&#44; the detection of subclinical cardiovascular damage can play a highly relevant role in identifying patients who can benefit from more intensive preventive measures and avoid the use of these measures in those for whom the benefit is more uncertain&#59; in short&#44; refine the stratification of cardiovascular risk&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Although there is some disagreement between the clinical practice guidelines&#44; there are 2 types of cardiovascular damage assessable by ultrasonography&#44; which are considered modulators of cardiovascular risk according to the current recommendations&#58; carotid or femoral plaques and LVH&#46; In both cases&#44; significant plaques and&#47;or LVH are upward modifiers of vascular risk&#44; placing patients in a high to very high-risk category&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">1&#44;4</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Guiding the treatment&#58; regression of hypertension-mediated damage</span><p id="par0090" class="elsevierStylePara elsevierViewall">Some forms of cardiovascular injury can be reversed with treatment&#44; especially when detected early&#44; the primary example of which is LVH regression with antihypertensive treatment&#46; Echocardiographic LVH regression is associated with a better prognosis and can help identify patients with favorable progress<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">12</span></a> and can even guide the treatment&#46; Intensification of the hypotensive therapy could therefore be proposed for patients with blood pressure readings within the planned objectives but who do not achieve baseline LVH regression&#44; monitoring of course the treatment tolerance&#46; In this context&#44; it is worth noting the new&#44; explicit inclusion in the 2018 European Society of Hypertension &#40;ESH&#41; guidelines of the therapeutic objectives that are below the thresholds that define AHT&#46; According to the latest guidelines&#44; it is not enough to reach blood pressure levels &#60;140&#47;90<span class="elsevierStyleHsp" style=""></span>mmHg&#59; instead&#44; blood pressure readings &#60;130&#47;80<span class="elsevierStyleHsp" style=""></span>mmHg should be attempted&#44; whenever possible&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">In addition to ventricular hypertrophy&#44; regression can be observed with the treatment of atheromatous plaques&#44; vascular remodeling &#40;CIMT&#44; arterial stiffness&#41; and cardiac functionality &#40;diastolic dysfunction parameters&#41;&#46; Although it seems reasonable to assume that regression of any cardiovascular damage is associated with a lower rate of cardiovascular events&#44; not all cases support this hypothesis&#46; In the case of CIMT&#44; for example&#44; 2 meta-analyses were unable to demonstrate the predictive value of treatment-mediated regression&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">13&#44;14</span></a> This finding could be partly due to the fact that the ultrasound techniques with which the results of the meta-analyses were obtained presented a resolution &#40;and thus a sensitivity for CIMT changes&#41; lower than current techniques&#46; In other cases&#44; the data are still limited or inconclusive&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">We should also consider that regression of the organ damage might not be possible even when the risk factors are well-controlled&#44; given that some changes are irreversible&#44; particularly when the organ damage is advanced&#46;</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Screening of abdominal aortic aneurysms</span><p id="par0105" class="elsevierStylePara elsevierViewall">The relevance of detecting AAAs lies in the fact that they are typically asymptomatic&#44; the physical examination is poorly sensitive&#44; and the initial clinical presentation is usually an acute aortic syndrome with very high mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">15</span></a> Early detection helps plan for elective surgery in cases with greater risk of rupture&#44; with much more favorable results&#46; The prevalence of AAAs in the general population is low&#59; in the population with risk factors&#44; however&#44; the prevalence increases &#40;to 8&#37; in the population with high cardiovascular risk in our setting&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">16</span></a> and screening and early detection improve the prognosis &#40;see Section &#8220;Abdominal aortic aneurysm&#8221;&#41;&#46; Ultrasonography is also useful for the follow-up of cases with no initial surgical indication to monitor the size of the AAA and reconsideration of the surgical approach&#44; if necessary&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Dilation of the abdominal aorta &#40;especially above 3<span class="elsevierStyleHsp" style=""></span>cm but also 2&#46;5&#8211;2&#46;9<span class="elsevierStyleHsp" style=""></span>cm&#41; is associated with a greater risk of cardiovascular events in other territories<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">17</span></a> and can have implications in a more intensive management of the cardiovascular risk factors&#46; To date&#44; there have been no randomized clinical trials whose objective was to assess the usefulness of medical treatment in preventing cardiovascular events in patients with AAAs to improve their prognosis&#46; However&#44; the guidelines recommend considering AAAs as a high cardiovascular risk situation and implementing therapeutic measures for secondary prevention&#58; essentially the intensive control of LDL cholesterol and blood pressure&#46; The results regarding the benefit of antiplatelet therapy are controversial&#46; The recommendation is therefore to perform antiplatelet therapy only if the patient is indicated the therapy for other reasons&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">3</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Other scenarios</span><p id="par0115" class="elsevierStylePara elsevierViewall">Other clinical scenarios in the setting of cardiovascular risk in which ultrasonography can be useful include&#8230;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">Renal assessments in patients with suspected secondary AHT&#46; In renovascular AHT&#44; ultrasonography can be especially useful for suspecting the diagnosis&#46; Simply assessing the length of the kidneys can help support the diagnosis of suspected renovascular AHT&#46; A difference in kidney size &#62;1&#46;5&#8211;2<span class="elsevierStyleHsp" style=""></span>cm in a patient with AHT should lead to the suspected presence of renal artery stenosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall">Renal assessment in patients with chronic kidney disease&#46; Ultrasonography is an ideal tool for assessing structural changes related to chronic kidney disease and for ruling out obstructive causes&#46; Several findings represent irreversible changes present in patients with chronic kidney disease&#46; The most studied of these findings are the length of the longitudinal axis&#44; the thickness of the parenchyma and cortex and the echogenicity of the renal cortex&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">The detection of hepatic steatosis in patients with suspected nonalcoholic fatty liver disease&#46; Ultrasonography is of considerable use in diagnosing hepatic steatosis&#44; With its very high accuracy in detecting fat infiltration of the liver when this is at least moderate &#40;more than 30&#37; of the hepatocytes infiltrated&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">19</span></a> Nonalcoholic fatty liver disease is associated with greater cardiovascular risk&#44; although the implications beyond the treatment of the cardiovascular risk factors according to the estimate of overall cardiovascular risk are uncertain at present&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">20</span></a></p></li></ul></p></span></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Key aspects and real-life use</span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Left ventricular hypertrophy and carotid plaques</span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Who should undergo carotid echocardiography or ultrasonography&#63;</span><p id="par0135" class="elsevierStylePara elsevierViewall">Although the recommendations differ among the various scientific societies and have evolved with successive updates of the CPGs&#44; in general and leaving aside symptomatic patients &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span>&#44; those with stroke&#44; ischemic heart disease&#44; heart failure&#41;&#44; the recommendation is to perform carotid or cardiac ultrasonography to refine the cardiovascular risk stratification for patients close to the decision threshold&#46; This recommendation is typically for asymptomatic patients in whom the finding of cardiovascular damage affects the decision to start drug treatment and the control objectives to employ&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">In addition to the technique&#39;s prognostic value&#44; the indication to search for subclinical cardiovascular damage depends on the availability&#44; risks and costs of the technique&#46; For this reason&#44; searching for subclinical arteriosclerosis through imaging techniques has typically been recommended for patients with intermediate cardiovascular risk &#40;effect on decision making with greater pretest probability of finding disease and greater cost-effectiveness&#41;&#46; However&#44; with the widespread use of clinical ultrasonography and considering its safety and low cost&#44; the range of patients who should undergo screening for subclinical cardiovascular damage should probably be widened&#46; For patients with cardiovascular risk factors but low overall cardiovascular risk&#44; especially in cases with coexistent diseases associated with a greater actual risk than that estimated by classical factors &#40;<span class="elsevierStyleItalic">e&#46;g&#46;</span>&#44; autoimmune systemic diseases and HIV infection&#41;&#44; ultrasonography can help identify patients with a greater likelihood of experiencing a cardiovascular event and start preventive measures that otherwise would be ignored&#46; This approach has started to be recognized in the recent guidelines developed by the European Cardiology Society and the European Atherosclerosis Society &#40;EAS&#41;&#44; which proposed considering carotid and femoral atheromatosis as a risk modifier in patients with low or moderate cardiovascular risk&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">4</span></a> The usefulness of ultrasonography in assessing cardiovascular risk early in the cardiovascular continuum is equally based on recent evidence indicating that&#44; for example&#44; 47&#37; of patients who debut with AHT present subclinical organ injury&#44; becoming by definition patients with high cardiovascular risk&#46;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">21</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">For populations with high risk or very high risk conditions &#40;previous cardiovascular event&#44; diabetes mellitus&#44; familial hypercholesterolemia&#44; chronic kidney disease&#41;&#44; the presence of carotid plaques or LVH identifies a patient subgroup with greater risk&#44; with potential therapeutic implications&#58; risk re-stratification and adjustment of therapeutic objectives &#40;from high to very high risk and even an extreme risk category&#44; which a number of CPGs already propose&#41;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">22</span></a> or consideration for new therapies such as proprotein convertase subtilisin&#47;kexin type 9 inhibitors&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Should the technique be repeated periodically&#63;</span><p id="par0150" class="elsevierStylePara elsevierViewall">Serial arterial ultrasonography is not recommended for asymptomatic patients&#44; except for the follow-up of significant carotid stenosis&#46; The sensitivity to changes in carotid and femoral atheromatosis is low and should not be employed for monitoring treatment response of the cardiovascular risk factors&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">The case of LVH measured by echocardiography is completely different&#46; LVH sensitivity to changes measured by echocardiography is good&#44; and echocardiographic LVH regression has been shown to be associated with a better prognosis&#46; However&#44; there is relevant variability between the measures performed at different times&#44; as well as between different observers&#44; and should be considered when interpreting the changes&#46; It is essential to establish a safety margin to determine that an actual change in ventricular mass has been produced between 2 measurements separated by time&#46; It is estimated that the change in ventricular mass between 2 measurements should exceed 10&#37; to ensure &#40;with a 90&#37; probability&#41; that the change is real and not an expression of variability&#46; Therefore&#44; all variations in ventricular mass &#60;10&#37; and measured by the same operator should be considered nonsignificant&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">23</span></a> When certifying changes in LVH when comparing echocardiograms performed by different operators&#44; further caution is warranted&#44; because the interobserver variability can be much greater&#46; There are no specific recommendations on the periodicity of cardiac ultrasounds to assess whether there is LVM regression&#44; an aspect that once again depends largely on the availability of the technique&#46; In any case&#44; the test should not be repeated before 6 months&#44; the time needed to begin to observe changes in the LVM&#46;</p></span></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Abdominal aortic aneurysm</span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Who should undergo ultrasound screening of abdominal aortic aneurysms&#63;</span><p id="par0160" class="elsevierStylePara elsevierViewall">Several CPGs recommend ultrasound screening for AAA in at-risk populations&#46; Although the matrices vary by CPG&#44; the main scenario in which ultrasound screening is recommended is for men older than 65 years&#44; especially if they have been exposed to tobacco or have a family history of AAA&#46; In women older than 65 years with exposure to tobacco or a family history of AAA&#44; the evidence is less consistent&#44; and the recommendation is to individualize the approach&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the recommendations of the European Society of Cardiology on the ultrasound screening of AAAs&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Due to the practical difficulty of performing screening&#44; there is also the option of performing opportunistic screening when the patient is admitted to the doctor&#39;s office or undergoes ultrasonography for another reason&#44; including an echocardiography &#40;the diameter of the abdominal aorta can be assessed with the sector probe&#41;&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">Moreover&#44; the presence of an AAA requires a complete assessment of the entire aorta&#44; including the aortic valve&#44; given that tandem lesions can be found&#44; and requires screening for peripheral arterial disease&#44; a comorbidity that frequently coexists with AAA&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">3</span></a> Although the CPGs do not make specific recommendations&#44; peripheral arterial disease is an indicator associated with a greater likelihood of presenting AAA&#44; and therefore the search for AAAs should be considered for patients with peripheral arterial disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">16&#44;24</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Should the technique be repeated periodically&#63;</span><p id="par0175" class="elsevierStylePara elsevierViewall">The recommendation is to perform ultrasound screening only once&#44; with ultrasound follow-up only in pathological cases&#46; For patients in whom aneurysmal dilation of the abdominal aorta is detected but do not have a surgical indication at the time &#40;diameter of 30&#8211;55<span class="elsevierStyleHsp" style=""></span>mm for men or 30&#8211;50<span class="elsevierStyleHsp" style=""></span>mm for women&#41;&#44; the recommendation is periodic follow-up through ultrasound or another imaging test&#46; The periodicity should be shorter the greater the size of the AAA and&#44; thus&#44; the risk of rupture &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; If the AAA grows faster than 10<span class="elsevierStyleHsp" style=""></span>mm&#47;year&#44; the recommendation is elective surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">3</span></a></p></span></span></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Existing evidence</span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Carotid and femoral plaques</span><p id="par0180" class="elsevierStylePara elsevierViewall">The presence of plaques and the increase in CIMT assessed by ultrasonography predict the incidence of cardiovascular events independently of the classical cardiovascular risk factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">8&#44;25&#44;26</span></a> Even the latest updates of the European guidelines regarding cardiovascular prevention have proposed the use of CIMT as a modifier of cardiovascular risk&#46; Numerous studies have demonstrated the association between CIMT and incident cardiovascular events&#44; but the additional usefulness of CIMT to stratification based on cardiovascular risk factors has been questionable&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">27</span></a> In contrast&#44; carotid plaques more accurately predict the incidence of coronary events when compared with CIMT<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">28</span></a> and improve the prediction based on cardiovascular risk factors&#44; with a reclassification rate of 7&#46;3&#37; in the Framingham cohort&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">25</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">Although they have less of a profusion of data&#44; atheromatous plaques in femoral arteries have also been shown to predict the incidence of cardiovascular events<a class="elsevierStyleCrossRefs" href="#bib0430"><span class="elsevierStyleSup">29&#44;30</span></a> and complement the search for carotid plaques&#44; showing an equivalent predictive value &#40;CAFES-CAVE study&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">31</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">It is important to note that the presence of carotid plaques <span class="elsevierStyleItalic">per se</span> has independent prognostic value&#59; however&#44; the recent 2018 ESH&#47;ESC guidelines consider carotid plaques as risk modifiers only if they cause stenosis of &#60;50&#37;&#44; while the 2019 ESH&#47;EAS guidelines do not refer to this issue&#46; Considering the available evidence&#44; it is the opinion of the authors of this review that the presence of carotid or femoral plaques <span class="elsevierStyleItalic">per se</span> should be assessed as an upwards modifier of cardiovascular risk&#44; although the degree of stenosis&#44; the morphological characteristics and the atheroma burden can refine the prognostic value of these plaques&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">32&#44;33</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Left ventricular hypertrophy</span><p id="par0195" class="elsevierStylePara elsevierViewall">Numerous studies have demonstrated the association between LVH and the incidence of cardiovascular events and death&#46;<a class="elsevierStyleCrossRefs" href="#bib0455"><span class="elsevierStyleSup">34&#8211;36</span></a> Both in the hypertensive and general populations&#44; patients with increased left ventricular mass and&#47;or an echocardiographic diagnosis of LVH have a higher incidence of stroke&#44; acute myocardial infarction and cardiovascular death&#46;<a class="elsevierStyleCrossRefs" href="#bib0470"><span class="elsevierStyleSup">37&#44;38</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">In addition&#44; LVH regression in patients with hypertension after the start of treatment is associated with a reduction in cardiovascular events&#46; In a meta-analysis by Verdecchia et al&#46;&#44; patients who experienced a reduction in LVM presented a lower incidence of cardiovascular events &#40;OR&#44; 0&#46;41&#59; 95&#37; CI 0&#46;21&#8211;0&#46;78&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;007&#41;&#44; compared with those who experienced an increase in LVM or developed <span class="elsevierStyleItalic">de novo</span> LVH&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">39</span></a> A subanalysis of the Losartan Intervention For Endpoint Reduction in Hypertension study observed that patients with baseline LVH who experienced a reduction in LVM during follow-up presented a lower incidence of death&#44; stroke&#44; acute myocardial infarction and all-cause mortality&#44; regardless of the treatment received and the reduction in blood pressure&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">40</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Additional parameters such as the geometry of the left ventricle&#44; the size of the left atrium and the diastolic function of the LV have been associated with a greater risk of cardiovascular events<a class="elsevierStyleCrossRefs" href="#bib0490"><span class="elsevierStyleSup">41&#44;42</span></a> and atrial fibrillation&#44;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">43</span></a> but unlike LVH&#44; the specific usefulness of these parameters for refining the cardiovascular risk is uncertain&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Abdominal aortic aneurysm</span><p id="par0210" class="elsevierStylePara elsevierViewall">An increase in abdominal aortic diameter is associated with an increase in all-cause mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0505"><span class="elsevierStyleSup">44&#8211;46</span></a> Abdominal aortic dilation is associated with a greater risk of acute aortic events &#40;mainly rupture&#41; with poor prognoses&#44; while elective surgery has a survival rate &#62;90&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">47</span></a> In this context&#44; several clinical trials and meta-analyses have shown that ultrasound AAA screening for men 65 years or older decreased mortality related to aneurysm complications&#44; with relative reductions in risk of approximately 50&#37;&#44; which extends to 10 years after the surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0525"><span class="elsevierStyleSup">48&#8211;52</span></a> There have also been studies that claim that population screening for men 65 years or older is cost-effective&#44; while not being cost-effective for women&#46;<a class="elsevierStyleCrossRefs" href="#bib0550"><span class="elsevierStyleSup">53&#44;54</span></a> Recently&#44; 2 studies in a Swedish and Australian population have questioned the benefits of population screening in a context in which the prevalence of AAA and AAA-related mortality have decreased&#44; probably due to the lower rate of tobacco use&#46;<a class="elsevierStyleCrossRefs" href="#bib0560"><span class="elsevierStyleSup">55&#44;56</span></a> In terms of scientific evidence&#44; more studies are needed in this new populational context&#44; focusing the screening on subgroups at greater risk &#40;essentially men 65 years or old who are active smokers or ex-smokers&#44; a group that the recommendation for ultrasound screening for AAA is already focused on by organizations such as the US Preventive Service Task Force&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">57</span></a></p><p id="par0215" class="elsevierStylePara elsevierViewall">Abdominal aortic dilation is also associated with a higher incidence of cardiovascular events in other territories&#44; which occurs especially when the dilation exceeds 3<span class="elsevierStyleHsp" style=""></span>cm in diameter but can also occur between 2&#46;5 and 3<span class="elsevierStyleHsp" style=""></span>cm&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">17&#44;44&#44;45</span></a> In addition&#44; the risk of progression to aneurysm is greater between 2&#46;5 and 3<span class="elsevierStyleHsp" style=""></span>cm&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">46</span></a></p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Limitations</span><p id="par0220" class="elsevierStylePara elsevierViewall">The limitations of ultrasonography in managing cardiovascular risk include those intrinsic to the technique&#44; essentially interobserver variability and lack of visualization in patients with a poor ultrasound window&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Another important limitation is the lack homogeneity in the recommendations and the gaps in understanding when using subclinical cardiovascular damage as a marker in clinical practice&#46; Ultrasonography is applied to several organs and by various disciplines&#44; making it difficult to find consensus&#44; and there is frequently a lack of solid evidence on which to base recommendations&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Lastly&#44; two important points that limit the application of ultrasonography are training and equipment availability&#46; Assessing ventricular mass in repeated measures and detecting carotid plaques are well-established methods for better stratifying cardiovascular risk in patients&#44; but this is possible only in units that have the ability to perform ultrasounds by themselves&#46; In a healthcare system with waiting lists even for patients with acute disease&#44; it is infeasible to perform interconsultations with other specialties to measure left ventricular mass&#44; search for carotid plaques and determine pulse wave velocity&#46; Thus&#44; we have the need for appropriate extensive training that covers and integrates the various ultrasonography settings and symptoms with sufficient depth&#44; which are characteristics of internal medicine&#46; It is an open question as to what extent proper training will be accompanied by the sufficient means to provide internists with the essential devices to properly manage cardiovascular risk&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Areas for future development</span><p id="par0235" class="elsevierStylePara elsevierViewall">There are numerous techniques based on ultrasonography that&#44; with maturity and results to support them&#44; could improve the assessment of cardiovascular risk and help prevent cardiovascular disease&#46;</p><p id="par0240" class="elsevierStylePara elsevierViewall">The study of local arterial stiffness is a technique with considerable potential that has begun to be applied in clinical practice&#44; although the profusion of data on its predictive value is still less than that for carotid-femoral pulse wave velocity&#44; the gold standard for assessing arterial stiffness&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">Another area of considerable interest is the ultrasound characterization of atheromatous plaques and the prognostic value that can be derived from parameters such as plaque composition&#44; atheroma burden &#40;volume calculation by 3D ultrasonography and indirect methods for estimating the atheroma burden&#58; number of segments&#44; plaque height&#41; and intraplaque vascularization&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">Lastly&#44; the assessment of left ventricular diastolic function is a widely used tool in the diagnosis and follow-up of heart failure&#59; however&#44; its value in estimating cardiovascular risk and controlling vascular risk factors is currently being assessed&#46;</p></span><span id="sec0120" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0255" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Background"
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          "titulo" => "Necessary knowledge for applying ultrasonography"
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              "titulo" => "Carotid and femoral arteriosclerosis"
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              "titulo" => "Left ventricular hypertrophy"
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              "titulo" => "Abdominal aortic aneurysm"
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          "titulo" => "Main clinical scenarios"
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              "titulo" => "Refine the cardiovascular risk stratification"
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              "titulo" => "Guiding the treatment&#58; regression of hypertension-mediated damage"
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              "identificador" => "sec0045"
              "titulo" => "Screening of abdominal aortic aneurysms"
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              "titulo" => "Carotid and femoral plaques"
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              "titulo" => "Left ventricular hypertrophy"
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              "titulo" => "Abdominal aortic aneurysm"
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    "fechaRecibido" => "2019-10-27"
    "fechaAceptado" => "2019-11-09"
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            2 => "Ultrasonography"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:3 [
            0 => "Estratificaci&#243;n del riesgo"
            1 => "Arteriosclerosis"
            2 => "Ecograf&#237;a"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">In the prevention of cardiovascular disease&#44; determining the cardiovascular risk is the cornerstone of preventive interventions&#46; In this risk estimation&#44; detecting subclinical cardiovascular damage represents a complementary tool to classic stratification based on risk factors&#46; The versatility&#44; availability&#44; speed&#44; low cost and safety of ultrasonography place it ahead of other techniques employed in detecting subclinical cardiovascular damage&#46; The clinical practice guidelines for cardiovascular risk prevention recommend the use of ultrasonography for assessing atheromatous plaques and left ventricular hypertrophy as modulators of cardiovascular risk&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Ultrasonography also has other relevant applications in cardiovascular risk&#44; including the diagnosis of abdominal aortic aneurysms&#44; kidney assessments for patients with chronic kidney disease or suspected secondary arterial hypertension and the detection of steatosis when nonalcoholic fatty liver disease is suspected&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">En la prevenci&#243;n de la enfermedad cardiovascular&#44; la estimaci&#243;n del riesgo cardiovascular es la piedra angular sobre la que se sustentan las intervenciones preventivas&#46; En esta estimaci&#243;n del riesgo&#44; la detecci&#243;n de da&#241;o cardiovascular subcl&#237;nico supone una herramienta complementaria a la estratificaci&#243;n cl&#225;sica basada en factores de riesgo&#46; Por su versatilidad&#44; disponibilidad&#44; rapidez&#44; bajo coste e inocuidad&#44; la ecograf&#237;a se ha situado con ventaja respecto a otras t&#233;cnicas usadas en la detecci&#243;n de da&#241;o cardiovascular subcl&#237;nico&#46; Las gu&#237;as de pr&#225;ctica cl&#237;nica del &#225;mbito de la prevenci&#243;n cardiovascular recomiendan su uso para la valoraci&#243;n de placas de ateroma e hipertrofia del ventr&#237;culo izquierdo como moduladores del riesgo cardiovascular&#46;</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Adem&#225;s&#44; la ecograf&#237;a tiene otras aplicaciones relevantes en el &#225;mbito del riesgo cardiovascular como son el diagn&#243;stico del aneurisma de aorta abdominal&#44; la valoraci&#243;n renal en pacientes con enfermedad renal cr&#243;nica o sospecha de hipertensi&#243;n arterial secundaria y la detecci&#243;n de esteatosis cuando se sospecha enfermedad por h&#237;gado graso no alcoh&#243;lico&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Beltr&#225;n LM&#44; Rodilla E&#44; Clinical Ultrasound and Vascular Risk Working Group&#46; Ecograf&#237;a cl&#237;nica en el riesgo cardiovascular&#46; Rev Clin Esp&#46; 2020&#59;220&#58;364&#8211;373&#46;</p>"
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            "apendice" => "<p id="par0265" class="elsevierStylePara elsevierViewall">The following are the supplementary data to this article&#58;<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix A"
            "titulo" => "Supplementary data"
            "identificador" => "sec0130"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Longitudinal projection of carotid artery&#46; &#40;A&#41; Artery of healthy model&#46; &#40;B&#41; Artery with hypo-anechoic plaque &#40;crosses&#41; in the posterior wall of the bulb in a patient with hypercholesterolemia&#46; <span class="elsevierStyleItalic">Abbreviations</span>&#58; CCA&#44; common carotid artery&#59; ECA&#44; external carotid artery&#59; ICA&#44; internal carotid artery&#46;</p>"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Parasternal long-axis projection&#58; measure of the left ventricular mass&#46; &#40;A&#41; B mode and &#40;B&#41; M-mode&#46; Note that the measurements used to calculate the left ventricular mass are the end-diastolic interventricular septum diameter &#40;IVSd&#41;&#44; the end-diastolic left ventricular diameter &#40;LVD&#41; and the end-diastolic posterior wall diameter &#40;PWd&#41;&#46; <span class="elsevierStyleItalic">Abbreviations</span>&#58; IVS&#44; intraventricular septum&#59; IVSd&#44; intraventricular septum in diastole&#59; IVSs&#44; intraventricular septum in systole&#59; LA&#44; left atrium&#59; LV&#44; left ventricle&#59; LVDd&#44; left ventricular diameter in diastole&#59; LVDs&#44; left ventricular diameter in systole&#59; PW&#44; posterior wall&#59; PWd&#44; posterior wall in diastole&#59; PWs&#44; posterior wall in systole&#59; RV&#44; right ventricle&#59; RVDd&#44; right ventricular diameter in diastole&#46;</p>"
        ]
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        "etiqueta" => "Figure 3"
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        "mostrarFloat" => true
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        "descripcion" => array:1 [
          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Transverse and longitudinal projections of a complicated abdominal aortic aneurysm&#46; Note the periaortic collections and disruption of the mural thrombus &#40;courtesy of Dr&#46; Gonzalo Garc&#237;a of Casasola&#41;&#46;</p>"
        ]
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          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Sources&#58; Williams et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">1</span></a> Erbel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">3</span></a> and Mach et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">4</span></a></p>"
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Technique&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Definition&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Prognostic value&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Carotid and femoral ultrasound</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
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                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Atheromatous plaque&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">- Focal thickening of the carotid wall exceeding &#8805;50&#37; of the thickness of the surrounding wall or that penetrates &#8805;0&#46;5<span class="elsevierStyleHsp" style=""></span>mm into the lumen&#46;- Localized area with intima-media thickness &#8805;1&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#44; which penetrates the lumen and that is identified by differentiating the surrounding area&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2018 ESH&#47;ESC&#58; very high cardiovascular risk if significant carotid plaques &#40;stenosis &#62;50&#37;&#41;2019 EAS&#47;ESC&#58; carotid or femoral plaques should be considered an upward modifier of cardiovascular risk in asymptomatic patients with low-moderate risk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Women &#62;95<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span>Men &#62;115<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">High cardiovascular risk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LVM adjusted according to height &#40;g&#47;m<span class="elsevierStyleSup">2&#46;7</span>&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Women &#62;47<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2&#46;7</span>Men &#62;50<span class="elsevierStyleHsp" style=""></span>g&#47;m<span class="elsevierStyleSup">2&#46;7</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="3" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Abdominal aortic ultrasonography</span></td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Aneurysm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Dilation of abdominal aorta &#8805;3<span class="elsevierStyleHsp" style=""></span>cm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Equivalent of cardiovascular disease &#8211; very high cardiovascular risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Ultrasound diagnosis of subclinical cardiovascular damage according to the recommendations of the European Society of Hypertension&#44; European Atherosclerosis Society and European Society of Cardiology&#46;</p>"
        ]
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        "identificador" => "tbl0010"
        "etiqueta" => "Table 2"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Abbreviations</span>&#58; AAA&#44; abdominal aortic aneurysm&#59; LVH&#44; left ventricular hypertrophy&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Sources&#58; Williams et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">1</span></a> Erbel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">3</span></a> and Mach et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">4</span></a></p>"
          "tablatextoimagen" => array:1 [
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              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Technique&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Parameter assessed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Recommendations on the use of ultrasonography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Grade&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Class&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Carotid and femoral ultrasonography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Atheromatous plaques&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Should be considered a modifier of cardiovascular risk for patients with low-moderate risk&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Should be considered in patients with documented vascular disease at other levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Echocardiogram&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">LVH&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Should be considered when the detection of LVH could affect the treatment decisions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Abdominal aortic ultrasonography&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Screening and follow-up of AAA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Recommended for all men older than 65 years&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleSmallCaps">I</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">May be considered for women older than 65 years who are smokers or ex-smokers or who have a family history of cardiovascular risk&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIb&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Not recommended for women who are nonsmokers and who do not have a family history of cardiovascular risk&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleSmallCaps">III</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">C&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Should be considered for first-degree relatives of patients with abdominal aortic aneurysms&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">For patients with abdominal aortic aneurysms with a diameter of 30&#8211;39<span class="elsevierStyleHsp" style=""></span>mm&#44; the recommendation is an imaging check-up every 3 years&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">For patients with abdominal aortic aneurysms with a diameter of 40&#8211;44<span class="elsevierStyleHsp" style=""></span>mm&#44; the recommendation is an imaging check-up every 2 years&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">For patients with abdominal aortic aneurysms with a diameter of 45&#8211;50<span class="elsevierStyleHsp" style=""></span>mm&#44; the recommendation is an imaging check-up every year&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">IIa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">B&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Current recommendations on the use of ultrasonography in the setting of cardiovascular risk issued by the European Society of Hypertension&#44; European Atherosclerosis Society and European Society of Cardiology&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:57 [
            0 => array:3 [
              "identificador" => "bib0290"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2018 ESC&#47;ESH Guidelines for the management of arterial hypertension"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46; Williams"
                            1 => "G&#46; Mancia"
                            2 => "W&#46; Spiering"
                            3 => "E&#46; Agabiti Rosei"
                            4 => "M&#46; Azizi"
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Special article
Clinical ultrasonography in cardiovascular risk
Ecografía clínica en el riesgo cardiovascular
L.M. Beltrána,
Corresponding author
luism.beltranromero@gmail.com

Corresponding author.
, E. Rodillab,c, Clinical Ultrasound and Vascular Risk Working Group
a Unidad de Riesgo Vascular, Servicio de Medicina Interna, Hospital Virgen del Rocío, Sevilla, Spain
b Unidad de Hipertensión Arterial y Riesgo Vascular, Servicio de Medicina Interna, Hospital Universitario de Sagunto, Sagunto, Valencia, Spain
c Universidad Cardenal Herrera-CEU, CEU Universities, Valencia, Spain

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