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B-mode ultrasound measurements of the echolucency of the carotid intima–media may hold information on cardiovascular risk. The information obtained from this measurement may depend on which gain settings are used. We studied the effect of gain settings on echolucency measurements and its consequences on risk factor relations and treatment effects.

Recently, it was demonstrated that information on carotid intima–media thickness (CIMT) and plaque may improve coronary heart disease (CHD) risk prediction through reclassification of some individuals to the correct risk category using the Framingham risk score. Our objective was to assess the currently unknown cost-effectiveness of CIMT measurements in primary prevention.

Whether a change in the rate of carotid intima–media thickness (CIMT) over time that is induced by a pharmaceutical intervention can be directly translated into change in future cardiovascular disease risk is an important issue. As this biomarker is increasingly used as primary outcome in many trials of the evaluation of novel cardiovascular treatments, this has become an important topic in cardiovascular drug development. Two recent meta-analyses using aggregated data from publication have attempted to address the issue. In our view both analyses suffer from considerable flaws. Flaws include the misuse of the concept of the atherosclerosis, pooling of trials carried out with treatments of heterogeneous efficacy and in patients, who had very different risk profiles; pooling of measurements from a wide variety of methodologies that shared a common name, ‘CIMT’; lack of power for detecting relationships using meta-regression techniques, and lastly, the ecologic fallacy. In this article, we discuss the concerns in more detail and offer strategies to get a valid answer on whether therapy-induced change in CIMT indeed relates to change in vascular risk