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which have implications for the local management of aneurysms and for preventing cardiovascular disease at other levels&#46; Ultrasonography also enables clinicians to&#8230;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">a&#46;</span><p id="par0015" class="elsevierStylePara elsevierViewall">perform a renal assessment for patients with chronic kidney disease or suspected secondary arterial hypertension &#40;AHT&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">b&#46;</span><p id="par0020" class="elsevierStylePara elsevierViewall">detect hepatic steatosis&#44; an imaging indicator of nonalcoholic fatty liver disease&#46;</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Necessary knowledge for applying ultrasonography</span><p id="par0025" class="elsevierStylePara elsevierViewall">The main practical applications of ultrasonography for assessing cardiovascular risk listed in the clinical practice guidelines &#40;CPGs&#41; in our setting<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">1&#8211;4</span></a> are &#40;1&#41; detecting atheromatous plaques &#40;carotid and femoral&#41;&#44; &#40;2&#41; assessing left ventricular hypertrophy and &#40;3&#41; detecting abdominal aortic aneurysms&#46; Other applications with considerable potential but with less evidence to support their use and with undefined roles in the current recommendations include the assessment of local carotid arterial stiffness and left ventricular diastolic function&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Carotid and femoral arteriosclerosis</span><p id="par0030" class="elsevierStylePara elsevierViewall">Ultrasonography helps identify atheromatous plaques in the carotid and femoral arteries&#46; The technique also helps measure carotid intima-media thickness &#40;CIMT&#41; and estimate local arterial stiffness&#46; Currently&#44; 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; Carotid arteries should be examined from the base of the neck to the mandibular angle&#44; visualizing the common carotid artery&#44; carotid bulb and internal carotid artery &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; The femoral arteries are examined in the inguinal region&#44; visualizing the common femoral artery from its entry into Scarpa&#39;s triangle to its bifurcation and the proximal region of the superficial and deep femoral arteries&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Left ventricular hypertrophy</span><p id="par0040" class="elsevierStylePara elsevierViewall">Clinical echocardiography applied to vascular risk is focused on detecting left ventricular hypertrophy &#40;LVH&#41;&#46; There are other parameters with potential prognostic value &#40;left atrium size&#44; diastolic function&#44; 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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