Advance Publication

Journal of Atherosclerosis and Thrombosis1

Journal of Atherosclerosis and Thrombosis 　Vol. 20, No. ●

Committee Report 17 Accepted for publication: July 2, 2013

Published online: December 10, 2013
Diagnosis of Atherosclerosis
Executive Summary of the Japan Atherosclerosis Society (JAS) Guidelines
for the Diagnosis and Prevention of Atherosclerotic Cardiovascular Diseases
in Japan ― 2012 Version

Tamio Teramoto, Jun Sasaki, Shun Ishibashi, Sadatoshi Birou, Hiroyuki Daida, Seitaro Dohi, Genshi Egusa,
Takafumi Hiro, Kazuhiko Hirobe, Mami Iida, Shinji Kihara, Makoto Kinoshita, Chizuko Maruyama,
Takao Ohta, Tomonori Okamura, Shizuya Yamashita, Masayuki Yokode and Koutaro Yokote

Committee for Epidemiology and Clinical Management of Atherosclerosis

From the perspective of preventing atheroscle- useful for making the diagnosis of atherosclerotic renal
rotic cardiovascular disease (CVD), it is essential to artery stenosis 4).
determine the presence or absence and degree of ath-
erosclerosis before the development of clinical symp- 2. Computed Tomography (CT)
toms and to manage or treat risk factors in order to Multidetector row CT (MDCT) offers superior
prevent progression or achieve regression of disease. It imaging speed and spatial resolution and enables visu-
is necessary to diagnose whether atherosclerosis is alization of the coronary arteries following the injec-
present, and if so, to what extent. The diagnostic tech- tion of contrast medium into peripheral veins. This
niques for atherosclerosis employed in the primary technique is starting to replace coronary angiography
prevention of CVD should be noninvasive. In second- as a screening test for CAD. In particular, it is superior
ary prevention, however, the use of invasive diagnostic in specificity 5-8), and if no abnormalities are detected
techniques, including angiography, is necessary. Cur- using this technique, the existence of organic coronary
rently, morphological imaging tests are predominantly stenosis can be almost completely ruled out. In addi-
used to assess the presence and degree of atherosclerosis. tion, this technique allows for visualization of coro-
nary plaques, and the degree of calcification and fat
1. Ultrasonography and fiber content can also be estimated to some extent
Noninvasive imaging tests include body surface based on the CT number.
ultrasonography (a high-frequency probe of ≥ 7 MHz),
which enables observation of the degree of stenosis and 3. Magnetic Resonance Imaging (MRI) and MR
plaque formation (localized atherosclerotic lesions) in Angiography (MRA)
the peripheral arteries, such as the carotid arteries and MRA is used to visualize the cerebral/carotid
arteries of the lower extremities. In particular, in the arteries, aorta and renal arteries and enables the visual-
carotid arteries, ultrasonography is used to determine ization of coronary stenotic lesions.
the degree of stenosis (quantitatively) and detect vul-
nerable plaques that could cause cerebral embolism 4. Angiography
(qualitatively), thereby assessing the degree of systemic Invasive diagnostic imaging techniques include
atherosclerosis and/or functioning as an alternative angiographic evaluations of the degree of stenosis,
predictor of the presence or development of CVD which remains a central diagnostic technique for assess-
(e.g., coronary artery disease (CAD), peripheral arte- ing arterial stenosis. The degree of arterial stenosis (the
rial disease (PAD) or cerebrovascular disease) 1, 2). The stenosis rate) is represented by the formula (D−S)/
existence of plaques and intima-media complex thick- D×100%, where D is the intravascular luminal diam-
ness (IMT) is often used as a measurement index on eter at the site proximal to the site of stenosis that
carotid ultrasonography 3). Ultrasonography is also appears to be normal and S is the luminal diameter at
the site of stenosis. However, because intimal thicken-
Received: May 15, 2013 ing is more or less observed even at sites that appear to
Accepted for publication: July 2, 2013 be normal, the stenosis rate is underestimated consid-
 Advance Publication
2
Journal of Atherosclerosis and Thrombosis
Teramoto et al .

Accepted for publication: July 2, 2013

Published online: December 10, 2013
ering the amount of the plaque volume. Because at a low cost, it is widely used. Because myocardial
plaques are usually eccentric and the intravascular ischemia can be induced, it is important to keep in
luminal diameter is therefore not a precise circle, there mind the risk of possible cardiac events, including
are limitations in the ability to determine the stenosis ventricular fibrillation and sudden death, when per-
rate based on one cross-section. If there is compensa- forming this technique.
tory vascular remodeling, the blood vessel may not be
considered to exhibit luminal stenosis even if the 9. Myocardial Perfusion Scintigraphy
plaques are well-formed; thus, there are severe limita- This technique is widely used in the diagnosis of
tions in establishing the plaque volume using this CAD to assess disease severity, myocardial viability
technique. and the prognosis and aids in decision making con-
cerning therapeutic strategies. It is also used to screen
5. Intravascular Ultrasound (IVUS) for significant coronary stenosis, is relatively mini-
IVUS is a technique used to observe the arterial mally invasive and may be a useful monitoring test for
wall from the arterial lumen using an ultrasound device. preventing atherosclerosis. Stressors include exercise
It enables the evaluation of both the plaque volume stress, dipyridamole stress and adenosine stress. This
and the properties of the plaques. technique has been shown to have a sensitivity of 80%
to 90% and a specificity of 70% to 95% for detecting
6. Angioscopy significant coronary stenosis 10).
Angioscopy is a technique used to observe the At present, ultrasonography is a minimally inva-
color and estimate the properties of plaques. sive, simple and easy-to-use test for diagnosing athero-
sclerosis. Coronary CT, exercise electrocardiography
7. Physiological Tests and myocardial perfusion scintigraphy are noninvasive
Diagnostic techniques other than morphological and useful diagnostic techniques in cases in which a
tests include physiological tests, such as the brachial- diagnosis of CAD is suspected.
ankle pulse wave velocity (baPWV) and cardio-ankle
vascular index (CAVI). Although these parameters are
easily determined by measuring the pulse wave in the Footnotes
extremities using a dedicated device, it should be This is an English version of the guidelines of the
noted that the values function as indices of artery stiff- Japan Atherosclerosis Society (Chapter 17) published
ness and do not always reflect the presence of athero- in Japanese in June 2012.
sclerosis. The ankle-brachial blood pressure index
(ABI), which is measured simultaneously, can be used
to diagnose PAD in the lower extremities ( ＜ 0.9 or Acknowledgements
≥ 1.3). The techniques used to measure the vascular We are grateful to the following societies for their
endothelial function impaired in the early stage of ath- collaboration and valuable contributions: Dr. Hide-
erosclerosis include flow-mediated vasodilation nori Arai (The Japan Geriatrics Society), Dr. Kiminori
(FMD), which measures and calculates changes in the Hosoda (Japan Society for the Study of Obesity), Dr.
vascular diameter following ischemic reactive hyper- Hiroyasu Iso (Japan Epidemiological Association), Dr.
emia of the extremities using ultrasound, and strain Atsunori Kashiwagi (Japan Diabetes Society), Dr.
gauge plethysmography, which electrically observes Masayasu Matsumoto (The Japan Stroke Society), Dr.
and measures changes in the volume of the arterial Hiromi Rakugi (The Japanese Society of Hyperten-
blood flow in the extremities as changes in the circum- sion), Dr. Tetsuo Shoji (Japanese Society of Nephrol-
ference using a strain gauge. However, the use of these ogy) and Dr. Hiroaki Tanaka (Japanese Society of
techniques is quite limited in general practice. Physical Fitness and Sports Medicine). We also thank
If a diagnosis of CAD, particularly effort angina, Dr. Shinji Koba, Dr. Manabu Minami, Dr. Tetsuro
is suspected, the following noninvasive tests are useful. Miyazaki, Dr. Hirotoshi Ohmura, Dr. Mariko Harada-
Shiba, Dr. Hideaki Shima, Dr. Daisuke Sugiyama, Dr.
8. Exercise Electrocardiography Minoru Takemoto and Dr. Kazuhisa Tsukamoto for
Exercise electrocardiography has been shown to supporting this work.
have a sensitivity of approximately 70% and a speci-
ficity of approximately 75% for detecting significant
coronary stenosis 9), neither of which are superior; References
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 Advance Publication
Journal of Atherosclerosis and Thrombosis3
Diagnosis of Atherosclerosis

Accepted for publication: July 2, 2013

Published online: December 10, 2013
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