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Carotid atherosclerosis and vascular age in the assessment of coronary heart disease risk beyond the Framingham Risk Score

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Title: Carotid atherosclerosis and vascular age in the assessment of coronary heart disease risk beyond the Framingham Risk Score


1
Carotid atherosclerosis and vascular age in the
assessment of coronary heart disease risk beyond
the Framingham Risk Score
  • Mireia Junyent, Daniel Zambón, Rosa Gilabert,
    Isabel Núñez, Montserrat Cofán, Emilio Ros
  • Unitat de Lípids, Servei dEndocrinologia i
    Nutrició (M.J., D.Z., M.C., E.R.) and Secció
    dEcografia, Centre de Diagnòstic per lImatge
    (R.G., I.N.), Institut dInvestigacions
    Biomèdiques August Pi i Sunyer, Hospital Clínic,
    Barcelona, Spain.

Junyent M et al, Atherosclerosis 2007 (Epub ahead
of print)
2
Cardiovascular Health StudyEvent-free rates by
quintiles of carotid IMT
4.476 asymptomatic individuals Age 65
years Follow-up 6.2 years 267 MI/284 strokes
OLeary DH, et al. N Engl J Med 199934014-22.
3
Relative risk of myocardial infarction (MI) or
stroke (CI 95) by quintiles of carotid IMT in
the Cardiovascular Health Study (OLeary DH, et
al. N Engl J Med 1999340 14-22.)
4
Atherosclerosis Risk in Communities (ARIC) Study
Longitudinal population based study of 10.841
asymptomatic individuals Age 45 to 64 years
Follow-up 5.2 years CHD
events 290
Carotid IMT adjusted for age, center and race.
Chambless LE, et al. Am J Epidemiol
1997146483-94.
5
The Rotterdam Study
Nonfatal MI stroke. Nested case-control study
Cases 98 MI, 95 stroke Controls 1373
Follow-up 2.7 y
Bots ML, et al. Circulation 1997961432-7.
6
Meta-Analysis of CVD outcomes by carotid IMT
Lorenz MW, et al. Circulation 2007115459-67 .
7
Background
  • The Framingham risk score (FRS) provides a
    logical approach to cardiovascular risk
    stratification and therapeutic targeting.
    However, reassessment of risk based on imaging
    techniques of preclinical atherosclerosis, such
    as carotid ultrasound, is recommended,
    particularly in individuals classified at
    intermediate risk by the FRS.
  • The aim of this study was to assess the effect of
    carotid intima-media thickness (IMT) measurements
    on FRS stratification (10-year risk 5 low
    risk, 6-20 intermediate risk, gt20 high
    risk) in a sizeable sample of asymptomatic
    hyperlipidemic subjects.

8
Methods. I
  • Risk factors were determined in 250 control and
    540 dyslipidemic subjects (131 patients with
    prior coronary heart disease). We excluded
    subjects with diabetes, familial
    hypercholesterolemia, and dysbetalipoproteinemia
    because of their inherent high cardiovascular
    risk. The asymptomatic subjects were the study
    target and were classified into 3 categories of
    the FRS low-risk (n191), intermediate-risk
    (n176), and high-risk (n42).
  • The risk status of each patient was reclassified
    as low, intermediate or high () on the basis of
    age and gender-adjusted percentiles (P) of
    carotid IMT and plaque presence and height in 250
    control subjects.
  • () lt25 P, 25-75 P,
    gt75 P, respectively

9
Methods. II
  • B-mode ultrasound of the right and left carotid
    arteries was performed using SSA 140 A
    Powervision and Applio instruments (Toshiba,
    Nasu, Japan). We determined mean common carotid
    IMT (mean CC-IMT) and the highest plaque height
    in patients with plaques.
  • We also estimated vascular age in dyslipidemic
    patients from regression equations of carotid
    IMT vs age in a control population (Junyent M, et
    al. Med Clin (Barc). 2005125770-774).

10
Characteristics of subjects by FRS category
Junyent M et al, Atherosclerosis 2007 (Epub ahead
of print)
11
Concordance betweenFRS and carotid IMT
Junyent M et al, Atherosclerosis 2007 (Epub ahead
of print)
12
Differences between chronological and estimated
vascular ages according to FRS and carotid IMT
Junyent M et al, Atherosclerosis 2007 (Epub ahead
of print)
13
Adjusted carotid IMT in study groups
Junyent M et al, Atherosclerosis 2007 (Epub ahead
of print)
14
Carotid plaque in study groups
80
70
Plt0.001 for trend
60
50
Plaque frequency,
40
30
20
10
0
CTRL
FRS

5
FRS 6-20
FRSgt20
Study groups
Junyent M et al, Atherosclerosis 2007 (Epub ahead
of print)
15
Scatterplots of 10-yr CHD risk from FRS against
CIMT
Symbols denote differences between
chronological and estimated vascular age
? lt 0 years ? 0 to 10 years gt10 years
Junyent M et al, Atherosclerosis 2007 (Epub ahead
of print)
16
Conclusions
  • The direct assessment of carotid atherosclerosis
    by sonography in asymptomatic hyperlipidemic
    subjects revealed wide discrepancies with the
    FRS.
  • Close to 60 of subjects were misclassified by
    FRS after individual CIMT and plaque burden
    imaging, and four out of five showed more
    atherosclerosis than expected (vulnerable
    patients).
  • Estimated vascular age was older than
    chronological age in two-thirds of the overall
    study subjects.

Junyent M et al, Atherosclerosis 2007 (Epub ahead
of print)
17
Implications
  • The results support the use of carotid sonography
    as a first-line tool for cardiovascular risk
    prediction.
  • The information from carotid sonography may be a
    useful guide for both patient feedback and
    tailoring treatment to new goals.

Junyent M et al, Atherosclerosis 2007 (Epub ahead
of print)
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