ATHEROTHROMBOSE Stratification du risque vasculaire Marqueurs carotidiens. Emphase sur

1
ATHEROTHROMBOSEStratification du risque
vasculaireMarqueurs carotidiens. Emphase sur
IMTApplication pratique et Consensus canadien
2006
André Roussin MD, FRCP, Internal
medicine Director, Vascular Lab, Notre-Dame
Hospital (CHUM) Associate Professor of medicine
and Researcher University of Montreal
Chair
President
TIGC.ORG
SSVQ.ORG
2
André Roussin MDDisclosures
I have been on advisory boards or received
honorarium as consultant or speaker or received
research funds from the following companies

• AstraZeneca
• Bristol-Myers Squibb
• Boeringher-Ingelheim
• GlaxoSmithKline
• Leo Pharma

• Merck Frosst
• Pfizer
• Roche Diagnostics
• Schering Canada
• sanofi aventis

3
HUMAN ATHEROGENESISFrom yellow streak to plaque
and thrombosis
1
2
3
4
5
6
7
Libby P. Circulation. 2001104365-372
4
Inflammation markers
Koenig W, Khuseyinova N. ATVB 2007 27 15-26
5
ASO and Drug Interventions
Napoli C et al. Circulation 2006 114 2517-27
6
Cardiovascular disease worldwide

• CVD (CAD, Stroke and PAD) is the leading cause of
  death worldwide1
• CVD contributed in 2001 nearly one third of all
  global deaths1-2
• 3 Risk factors are responsible for gt 75 of all
  CVD worldwide1
• Elevated cholesterol
• Smoking
• High blood pressure
• Of the three, elevated cholesterol carries the
  greatest attributable risk for CAD3

1. WHO. World Health report 2002
2. American Heart Association statistical fact
   sheet 2003
3. Wilson P et al. Circ 1998 971837-1847

7
Risque de développer MCAS pendant la vie
Femme
Homme
0.5
0.5
0.2
0.2
1/10
1/10
65
55
40
40
50
50
60
60
70
70
80
90
Age (années)
Age (années)
Lloyd-Jones, Lancet 1999 353 89-92
8
Notion  traditionnelle  de risque
vasculaireConsensus Canadien sur les
Dyslipidémies Calcul du risque de coronaropathie
à 10 ans

• ASO présente
• Coronaropathie (MCAS)
• Maladie artérielle périphérique
• ASO carotidienne (ICT, AVC isch. , plaque)
• Patients gt 30 ans avec Diabète sucré
• Dyslipidémie sévère
• Hypercholestérolémie familiale (LDL)
• Hypoalphalipoprotéinémie familiale (HDL)
• Tous les autres
• Préciser le risque avec les tables de Framingham
  du NCEP III

Risque Élevé
9
Risque cardiovasculaire Framingham modifié NCEP
IIIPour calculer le risque dIM et de mortalité
CVPoints pour un homme
1. Age
2. Total Cholesterol (mmol/L) according to age
Age Points
20-34 -9
35-39 -4
40-44 0
45-49 3
50-54 6
55-59 8
60-64 10
65-69 11
70-74 12
75-79 13
Points Points
Total Cholesterol Age 20-39 Age 40-49 Age 50-59 Age 50-59 Age 60-69 Age 70-79
lt4.14 0 0 0 0 0 0
4.15-5.19 4 3 2 2 1 0
5.2-6.19 7 5 3 3 1 0
6.2-7.2 9 6 4 4 2 1
gt7.21 11 8 5 5 3 1
10
Risque cardiovasculaire Framingham modifié NCEP
IIIPour calculer le risque dIM et de mortalité
CVPoints pour un homme
3. Smoking according to age
Points Points
Age 20-39 Age 40-49 Age 50-59 Age 50-59 Age 60-69 Age 70-79
Non-Smoker 0 0 0 0 0 0
Smoker 8 5 3 3 1 1
5. Blood Pressure according to treatment
4. HDL-C
Sys BP Untreated Treated
lt120 0 0
120-129 0 1
130-139 1 2
140-159 1 2
gt160 2 3
HDL-C Points
gt1.55 -1
1.30-1.54 0
1.04-1.29 1
lt1.04 2
11
Pour calculer le risque dIM et de mortalité CV
Points 10-year Risk
0 1
1 1
2 1
3 1
4 1
5 2
6 2
7 3
8 4
9 5
10 6
11 8
12 10
13 12
14 16
15 20
16 25
gt17 gt30
Low Risk lt 10
Pour un homme
?
Medium Risk 10-20
?
High Risk gt 20
12
INTERHEARTRisk of AMI associated with Risk
Factors in the Overall PopulationODDS RATIO
Risk factor Cont Cases Cont Cases OR (99 CI) adj for age, sex, smok OR (99 CI) adj for all
ApoB/ApoA-1 (5 v 1) 20.0 33.5 3.87 (3.39, 4.42) 3.25 (2.81, 3.76)
Curr smoking 26.8 45.2 2.95 (2.72, 3.20) 2.87 (2.58, 3.19)
Diabetes 7.5 18.4 3.08 (2.77, 3.42) 2.37 (2.07, 2.71)
Hypertension 21.9 39.0 2.48 (2.30, 2.68) 1.91 (1.74, 2.10)
Abd Obesity (3 v 1) 33.3 46.3 2.22 (2.03, 2.42) 1.62 (1.45, 1.80)
Psychosocial - - 2.51 (2.15, 2.93) 2.67 (2.21, 3.22)
Veg fruits daily 42.4 35.8 0.70 (0.64, 0.77) 0.70 (0.62, 0.79)
Exercise 19.3 14.3 0.72 (0.65, 0.79) 0.86 (0.76, 0.97)
Alcohol Intake 24.5 24.0 0.79 (0.73, 0.86) 0.91 (0.82, 1.02)
All combined - - 129.2 (90.2, 185.0) 129.2(90.2, 185.0)
All combined (extremes) 333.7 (230.2, 483.9) 333.7 (230.2, 483.9)
Yusuf S et al. Lancet 2004 364 937-52
13
INTERHEARTRisk of AMI associated with Risk
Factors in the Overall PopulationPOPULATION
ATTRIBUTABLE RISK
Risk factor Cont Cases Cont Cases PAR 1 (99 CI) PAR 2 (99 CI)
ApoB/ApoA-1(5 v 1) 20.0 33.5 54.1 (49.6, 58.6) 49.2 (43.8, 54.5)
Curr smoking 26.8 45.2 36.4(33.9,39.0) 35.7,(32.5,39.1)
Diabetes 7.5 18.5 12.3 (11.2, 13.5) 9.9 (8.5, 11.5)
Hypertension 21.9 39.0 23.4 (21.7, 25.1) 17.9 (15.7, 20.4)
Abd Obesity (3 v 1) 33.3 46.3 33.7 (30.2, 37.4) 20.1 (15.3, 26.0)
Psychosocial - - 28.8 (22.6, 35.8) 32.5 (25.1, 40.8)
Veg fruits daily 42.4 35.8 12.9 (10.0, 16.6) 13.7 (9.9, 18.6)
Exercise 19.3 14.3 25.5 (20.1, 31.8) 12.2 (5.5, 25.1)
Alcohol 24.5 24.0 13.9 (9.3, 20.2) 6.7 (2.0, 20.2)
Combined - - 90.4 (88.1, 92.4) 90.4 (88.1, 92.4)
Yusuf S et al. Lancet 2004 364 937-52
14
INTERHEARTRisk of AMI with Multiple Risk Factors
Smk
DM
HTN
ApoB/A
123
All 4
Ob
PS
All RFs
Yusuf S et al. Lancet 2004 364 937-52
15
Notion  élargie  risque vasculaireIncluant le
Consensus Canadien sur les Dyslipidémies
Ajoutant les facteurs de risque  émergents 

• MCAS familiale précoce RR 1.7 à 2
• ApoB, Lp(a), LDL dense, ApoA1
• Syndrome métabolique
• Marqueurs sub-cliniques d'ASO
• ITH, ECG effort, Plaques et Intima-media
• Facteurs de risque émergents
• hsCRP, homocystéine

16
Risk factors markers and / or activators
Atherosclerosis
Atherothrombosis Stroke - MI - Death
IM ? ? Plaque ? Stenosis ? Thrombosis
Triggering Factors
Smoking, Diabetes, LDL/oxLDL, HBP, AgII/AT1,
Shear stress
Endothelial Factors
Inflammation Factors
Cells, Intercellular intracellular signaling,
proteins-enz. actions
Procoagulant Factors
TF, PAI-1 / tPA and TxA2 / Prostacycline
imbalances
17
New insights What has been improved
1970-1980 1990 2000
Weight BMI Waist circumference
HBP gt 160 HBP goal 140 Ideal BP 120
Chol TG LDL HDL TG LDL TC/HDL ApoB
Diabetes Diabetes Diabetes Met. Syndrome
Smoking Smoking Smoking
Sedentarism Sedentarism Fitness
CAD CAD Stroke CAD Stroke PAD
18
New insights What has been added

• Sub-clinical markers
• Ankle-Brachial Index
• Micro-albuminuria
• Carotid intima-media thick.
• Coronary calcification

• Serological markers
• hs-CRP
• Lipoprotein(a)
• Homocysteine
• Insulinemia
• sLp-PLA2

-/

19
CCS position statement 2006Treatment of
dyslipidemia and prevention of CVD
Niveau de risque Risque MCAS en 10 ans Recommendations Recommendations But du traitement Objectif accessoire
LDL-C mmol/L CT/HDL Baisse de LDL-C Apo B
Élevé 20 ou ASO ou Diabète Cible primaire lt 2.0 Cible secondaire lt 4.0 gt 50 lt 0.85
Modéré 10 - 19 Traiter si 3.5 Traiter si 5.0 gt 40 lt 1.05
Bas lt 10 Traiter si 5.0 Traiter si 6.0 gt 40 lt 1.2
Adapté de Can J Cardiol 2006 22 (11) 913-927
20
Ultrasonographie carotidienneÉvaluation de lASO
et stratification de risque CV

• Faible coût
• Accessible
• Non-invasive
• Imagerie excellente
• Quantitative
• Reproductible
• Mesure lASO intimale avant la sténose
  angiographique

• Épaisseur Intima-Media
• Intima-media thickness
• IMT
• Épaisseur de plaque
• Surface de plaque
• Volume de plaque
• Sténose
• Type de plaque
• Échogénicité
• Homogénéité

21
Ultrasound Examination of the Carotid Artery
External carotid
Internal carotid
Skin
1.0 cm
0.5-1.0 cm
Bifurcation
Commoncarotid
1.0 cm
Near Wall
Far Wall
B-modeultrasound
Periadventitia-adventitia Adventitia-media Intima-
lumen
Adventitia-periadventitia Media-adventitia Lumen-i
ntima
Smilde TJ et al. Lancet 2001 357 577-581
22
Façons de déterminer la valeur dun marqueur de
risqueVasan R S. Circ 2006 113 2335-2362
23
Considérations avant ladoption dun marqueur de
risque CVVasan R S. Circ 2006 113 2335-2362
24
Marqueurs structurels et fonctionnels de risque CV
Vasan R S. Circ 2006 113 2335-2362
25
Reproducibility of non-invasive ultrasonic
measurement of carotid atherosclerosisThe
Asymptomatic Carotid Artery Plaque Study (ACAPS)

• 858 patients
• 12 measurements in each patient
• Repeated at 1 month
• Within and between sonographer variation

• Mean IMT difference (exam 2-exam 1) 0.13 mm
• 90 of patients mean difference lt 0.2 mm
• Result
• Highly reproducible measurement
• B-mode ultrasound can monitor small rates of
  lesion progression

Stroke 1992, Aug 23 (8), 1062-8
26
Protocoles pour Épaisseur Intima-Media (IMT)

• 12 point manual measurement
• Near and far wall of CCA, ICA, Bulb
• Near and far wall of CCA, ICA
• Far wall of CCA
• Mean of maximal IMT measurement
• Mean of mean IMT measurement
• Manual VS automated edge detection
• Plaque thickness summed
• Plaque area summed
• Plaque volume summed

Adapted from Weingert M SSVQ 2006
27
IMTReproducibility of Measurement

• Intra observer variability lower in studies
  limited to common carotid artery far wall ( 0.02
  mm) VS multiple measurements at different carotid
  sites ( 0.06 mm)
• Studies using automated computerized IMT
  measurement rather than manual cursor placement
  have best reproducibility.

Adapted from Weingert M SSVQ 2006
28
IMT quantitative vs caliper
29
IMT and 70 Coronary StenosisSensitivity vs
Specificity

• IMT of Sensitivity Specificity
• 0.6 mm 95 20
• 0.8 mm 55 60
• 1.0 mm 20 90

Aminbaklish A. et al. Clin. Invest. Med 1999
22265-274
30
Evaluating Atherosclerosis by IMT
measurementAnatomy
Courtesy E. Braunwald
Buithieu J /
31
Evaluating Atherosclerosis by IMT
measurementMethodology

• 12 point manual measurement
• Far wall of Common Carotid Artery
• Near and far wall of CCA, ICA
• Near and far wall of CCA, ICA, Bulb
• Mean of maximal IMT measurement
• Mean of mean IMT measurement
• Manual / automated edge detection
• Summation of plaque thickness
• Summation of plaque area
• Summation of plaque volume

ICA
ECA
ICA
10 mm
Bulb
10 mm
CCA
10 mm
CCA
Buithieu J /
32
Evaluating Atherosclerosis by computerized IMT
measurement
Automated Computerized method

• ECG gating
• Diastole
• distal CCA
• Mean IMT over
• 100 pts along at least 1 cm
• Avoids pulsatile deformation of wall thickness
• Observer independent
• Better precision/reproducibility
  Intermeasurement ? 3

Buithieu J /
33
The Atherosclerosis Risk in Communities (ARIC)
Study Predictive Value of CIMT Methodology

• Prospective, multicenter study
• N 12841 aged 45 - 64 y (72.5 5.5)
• 7289 women, 5552 men
• No evidence of CV disease at enrollment
• Median follow-up 5.2 years
• Mean CIMT over 1 cm - far walls of Right Left
  CCA-Bulb-ICA

ECA
ICA
10 mm
Bulb
10 mm
CCA
10 mm
Chambless LE al. Am J Epidemiol 1997.
146483-494
Buithieu J /
34
The Atherosclerosis Risk in Communities (ARIC)
Study Predictive Value of CIMT for Myocardial
Infarct / Death
Mean F-up 5.2 y
Age and Gender adjusted CHD incidence/1000
patient-year
CIMT (mm)
Chambless LE al. Am J Epidemiol 1997.
146483-494
Buithieu J /
35
The Atherosclerosis Risk in Communities (ARIC)
Study Predictive Value of CIMT for Stroke
Mean F-up 7.2 y
Age and Gender adjusted Stroke incidence/1000
patient-year
CIMT (mm)
Chambless LE al. Am J Epidemiol 2000.
151478-487
Buithieu J /
36
The Atherosclerosis Risk in Communities (ARIC)
Study Predictive Value of CIMT by incremental
value

• CIMT (mean of CCA-Bulb-ICA) increment is
  associated with increased hazard rate ratio (HRR)

Increment CHD CHD Stroke Stroke
Increment Men Women Men Women
0.19 mm 1.17 1.38
0.18 mm 1.21 1.36
Chambless LE al. Am J Epidemiol 1997.
146483-494 Chambless LE al. Am J Epidemiol
2000. 151478-487
Buithieu J /
37
The Atherosclerosis Risk in Communities (ARIC)
Study Predictive Value of CIMT by strata

• CIMT (mean of CCA-Bulb-ICA) increased hazard
  rate ratio (HRR) vs CIMT lt 0.6 mm

CIMT CHD CHD Stroke Stroke
CIMT Men Women Men Women
gt 1.0 mm (Yes/No) 1.20 2.62 1.78 2.02
gt 1.0 mm 2.15 7.40 2.59 4.32
0.80 - 0.99 mm 2.44 3.35 2.08 3.14
0.70 - 0.79 mm 1.56 3.56 1.26 1.73
0.60 - 0.69 mm 1.21 2.53 0.79 2.07
Chambless LE al. Am J Epidemiol 1997.
146483-494 Chambless LE al. Am J Epidemiol
2000. 151478-487
Buithieu J /
38
The Atherosclerosis Risk in Communities (ARIC)
Study Predictive Value of CIMT Conclusions

• N 15 792 patients
• CIMT measurements
• Reproducible
• Independent predictor of adverse cardiovascular
  eventsafter adjustment for
• Age, sex, race, center, BMI, waist-hip ratio,
  sporting activity
• Diabetes, LDL, HDL, hypertension, smoking
• Fibrinogen, WBC, LVH

Chambless LE al. Am J Epidemiol 1997.
146483-494 Chambless LE al. Am J Epidemiol
2000. 151478-487
39
Predicting clinical coronary events role of
Carotid IMTCLAS Sub-Study

• 133 patients 8.8 year follow-up
• Close correlation between far wall CCA-IMT and
  changes in catheterization
• Progression of IMT correlated with
• Progression of CAD
• Increased coronary events
• Absolute IMT thickness and progression of IMT
  more strongly correlated with coronary events
  than
• Changes in lipid levels
• Lesion changes on coronary catheterization
• Result every 0.03 mm increase in IMT increases
  risk of coronary event 3.1

Hodis H.N. et al Ann Int Med 1998 128262-269
40
Predicting clinical coronary events role of
Carotid IMTCLAS Sub-Study

• CIMT directly associated withhigher risk for
  future MI and CHD death

N 146 CABG
p lt 0.001
CHD Risk Non fatal MI, Coronary Death,
Revascularization
Carotid Intima-Media Thickness (mm)
Hodis HN al. Ann Intern Med 1998. 128262-269
Buithieu J /
41
Predicting clinical coronary events role of
Carotid IMT progressionCLAS Sub-Study

• CIMT progression directly associated withhigher
  risk for future MI and CHD death

N 146 CABG
p lt 0.001
CHD Risk Non fatal MI, Coronary Death,
Revascularization
CIMT progression (mm/y)
Hodis HN al. Ann Intern Med 1998. 128262-269
Buithieu J /
42
Cardiovascular Health Study (NHLBI) Predictive
Value of CIMT methodology

• Prospective, multicenter study
• N 4476 aged gt 65 y (72.5 5.5)
• Male 38.8 , Caucasian 84.8
• No evidence of CV disease at enrollment
• Median follow-up 6.2 years
• Maximal CIMT mean of near far walls of R L
  CCA
• Maximal CIMT mean of near far walls of R L ICA

OLeary D al N Eng J Med 1999.340 14-22
Buithieu J /
43
Cardiovascular Health Study (NHLBI) Predictive
Value of CIMT for Myocardial Infarction Stroke
5
25
OLeary D al N Eng J Med 1999.340 14-22
Buithieu J /
44
Cardiovascular Health Study (NHLBI) Predictive
Value of CIMT for Myocardial Infarction Stroke
Myocardial Infarction or Stroke (Rate per 1000
Person-Years)
Quintiles
OLeary D al N Eng J Med 1999.340 14-22
Buithieu J /
45
Cardiovascular Health Study (NHLBI) Predictive
Value of CIMT for Myocardial Infarction Stroke
CIMT - CCA Quintile CIMT - CCA Thickness (mm) MI-CVA Rate () at 7 y Adjusted Relative Risk Adjusted Relative Risk Adjusted Relative Risk
CIMT - CCA Quintile CIMT - CCA Thickness (mm) MI-CVA Rate () at 7 y MI - CVA MI CVA
1 lt 0.87 5.2 1.00 1.00 1.00
2 0.87 - 0.96 9.3 1.49 1.79 1.33
3 0.97 - 1.05 9.0 1.29 1.40 1.21
4 1.06 - 1.17 13.2 1.76 2.07 1.39
5 gt 1.18 18.7 2.22 2.46 2.13
Relative Risk adjusted for age, sex, sBP, HTN,
Atrial fibrillation, Diabetes
OLeary D al N Eng J Med 1999.340 14-22
Buithieu J /
46
The Rotterdam Study Comparative Predictive Value
for Incident Myocardial Infarction

• Population-based cohort
• N 6389 aged gt 55 (69.3 9.2)
• Male 38.1 , Caucasian 100
• No prior MI or revascularization
• Mean Follow-up 4.2 years

van der Meer IM al. Circ 2004. 1091089-1094
47
The Rotterdam Study Comparative Predictive Value
for Incident Myocardial Infarction
Composite atherosclerosis score

• Carotid - Ultrasonography
• Maximal CIMT mean of near and far wall of left
  right CCA
• Carotid plaque - weighted score
• Aorta - Lateral abdominal X-ray
• Calcifications - length of affected area
• 0cm, lt1.0, 1.0-2.5, 2.5-4.9, 5.0-9.9, 10.0cm
• Lower extremities - Ankle-Brachial Index (ABI)
• 1.50-1.21, 1.21-1.10, 1.10-0.97, 0.97-0.00

?
van der Meer IM al. Circ 2004. 1091089-1094
48
The Rotterdam Study Comparative Predictive Value
for Incident Myocardial Infarction
Incident MI 258 / 6389 4.0
van der Meer IM al. Circ 2004. 1091089-1094
49
Carotid PlaquePredictive value

• 76 asymptomatic patients
• Aged 35-65
• TC gt 6.5
• Stress test, cath, carotid ultrasound
• 1 Plaque 64
• 57 had critical CAD
• Positive predictive value for coronary
  atherosclerosis 76
• No Plaque
• Women none had CAD
• Men - with positive stress test 21
  significant CAD

Giral P. et al. Am J Card 1999 84 14-17
50
PLAQUE AREACAD rather than Stroke prediction
Spence JD al. Stroke 2002. 33(12)2910-2922
Buithieu J /
51
PLAQUE AREAStoke and MI risk
Plaque Area (cm2) Stroke alone Stroke alone Stroke and MI Stroke and MI
Plaque Area (cm2) 5 y Risk () RR 5 y Risk () RR
0.00 - 0.11 1.6 1.0 4.8 1.0
0.12 - 0.45 2.3 1.4 9.3 1.9
0.46 - 1.18 3.9 2.4 12.3 2.5
1.19 - 6.73 4.0 2.4 14.0 2.9
Spence JD al. Stroke 2002. 33(12)2910-2922
Buithieu J /
52
PLAQUE AREARegression vs Progression
Spence JD al. Stroke 2002. 33(12)2910-2922
Buithieu J /
53
PLAQUE AREAProgression
Spence JD al. Stroke 2002. 33(12)2910-2922
Buithieu J /
54
PLAQUE AREA Predictor for MI and CVA

• CIMT mostly medial thicknessMedial
  hypertrophyrelated to HTNCorrelation w LVH gt
  CADpredicts CVA gt MI
• Plaque area intimal processrelated to ASOHigh
  associated with coronary plaquepredicts MI more
  strongly

Spence JD al. Stroke 2002. 33(12)2910-2922
55
PLAQUE VOLUME
Ainsworth CD al. Stroke 2005. 36-1904-1909
Buithieu J /
56
IMT vs Plaque area vs Plaque volume

• CIMT
• Hypertension
• Total Plaque Area
• Smoking
• Plasma cholesterol
• Total Plaque Volume
• Diabetes

Al-Shali al. Atherosclerosis 2005-178319-325
Buithieu J /
57
Plaque roughness

• IMT roughness
• N 15 healthy (24.9 2.3)N 22 healthy
  (62.9 3.5)N 46 CAD (62.0 9.2)

AUC SE p level
CIMT mean 0.66 0.07 0.03
CIMT max 0.71 0.07 0.01
IMT roughness 0.80 0.07 0.00
Young healthy Older healthy CAD
CIMT mean 0.55 0.77 0.88
CIMT max 0.65 0.87 1.01
IMT roughness 0.035 0.040 0.075
p lt 0.05 p lt 0.01
Schmidt-Trucksass A al. Atherosclerosis 2003.
16657-65
Buithieu J /
58
Reference Values for CIMT (75th percentile)
1.2
1.0
0.8
0.6
CIMT (mm)
0.4
0.2
0.0
Age (years)
Redberg R al. JACC Task Force 3. J Am Coll
Cardiol 2003. 411886-1898
Buithieu J /
59
IMT selon lâge
Age IMT (years) (mm) 10 0.53 20 0.55 30
0.58 40 0.60 50 0.64 60 0.73 70 0.78 80
0.80
Familial HC
Normal controls
From Weingert M, SSVQ 2006

• De Groot Circ. 2004 109 (suppl) 11133-38

60
IMT conclusion 1Atherosclerosis is a diffuse
disease

• Detection in one vascular bed highly associated
  with atherosclerosis in other beds
• Carotid atheroma associated with increased risk
  of vascular events in direct relationship to
  extent of atherosclerosis
• IMT 1 mm vs. lt 1 mm, associated with 5-fold
  increased risk of CAD
• Risk for CVA and MI correlate with carotid IMT
  independent of standard risk factors (ARIC)

Adapted from Weingert M SSVQ 2006
61
IMT conclusion 2Progression and relations

• Normal progression is 0.02-0.05 mm/year
• Direct relationship between number of risk
  factors and IMT
• Direct relationship between IMT and CAD and
  cardiac events as well as stroke
• Burk, G.I. et al Stroke 1995 26386-391
• OLeary, D.H. et al NEJM, 1999 34014-25
• Mannami, T. et al Arch.-Int. Med 2000 160
  2297-2303
• Hodes, H.N. et al Ann Int Med 1998 128 262-269

62
IMT conclusion 3? Carotid IMT Associations

• IMT augmentation is associated with
• White matter lesions on MRI
• Coronary disease on catheterization
• EBCT coronary artery calcification
• LVH on echocardiogram
• Microalbuminuria in diabetics
• Peripheral Vascular Disease

Adapted from Weingert M SSVQ 2006
63
IMT conclusion 4Carotid IMT Usefulness

• Reflects impact of multiple risk factors
• Mirrors atherosclerotic burden
• Predictor of cardiovascular and neurological
  events
• Can reclassify patient to higher risk category,
  worthy of more aggressive treatment

64
Recommendations for the Management of
Dyslipidemia and the Prevention of Cardiovascular
Disease 2003 Update Diagnosis of Asymptomatic
Atherosclerosis

• Recommended
• Physical examination
• Ankle-brachial index
• Possibly useful in subjects at moderate risk
• Carotid ultrasonography
• Electrocardiography
• Graded exercise testing in Men gt 40 with risk
  factors

Genest JG al. Can Med Assoc J 2003.
168(9)921-924
65
Recommendations for the Management of
Dyslipidemia and the Prevention of Cardiovascular
Disease 2003 Update Diagnosis of Asymptomatic
Atherosclerosis

• Not currently recommended based on available
  evidence
• Flow-mediated vasodilatation
• Plethysmography
• Arterial compliance
• Electron beam CT scanning
• MRI scanning
• Intravascular ultrasonography

Genest JG al. Can Med Assoc J 2003.
168(9)921-924
66
2006 Position Statement Recommendations for the
Diagnosis and Treatment of Dyslipidemia and
Prevention of Cardiovascular Disease

• Useful non-invasive investigations in the
  intermediate risk category to detect subclinical
  atherosclerosis and/or to further define future
  CAD risk
• Ankle-Brachial Index (ABI)
• Carotid ultrasound
• Graded exercise testing (GXT)
• Electrocardiogram (ECG)

MacPherson R al. Can J Cardiol October 2006. In
Press