Transcript ASO-IMT et al

ATHEROTHROMBOSE
Stratification du risque vasculaire
Marqueurs carotidiens. Emphase sur “IMT”
Application 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
A. Roussin MD
André Roussin MD
Disclosures
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
A. Roussin MD
HUMAN ATHEROGENESIS
From yellow streak to plaque and thrombosis
1
2
Libby P. Circulation. 2001;104:365-372
3
4
5
6
7
A. Roussin MD
Inflammation markers
Koenig W, Khuseyinova N. ATVB 2007; 27: 15-26
A. Roussin MD
ASO and Drug Interventions
Napoli C et al.
Circulation
2006; 114:
2517-27
A. Roussin MD
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 > 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; 97:1837-1847
A. Roussin MD
Risque de développer MCAS pendant la vie
0.5 Femme
0.5 Homme
0.2
0.2
1/10
65
40
50
1/10
55
60
70
Age (années)
Lloyd-Jones, Lancet 1999; 353: 89-92
80
90
40
50
60
70
Age (années)
A. Roussin MD
Notion « traditionnelle » de risque vasculaire
Consensus 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)
Risque
 Patients > 30 ans avec Diabète sucré
Élevé
 Dyslipidémie sévère
•
Hypercholestérolémie familiale (LDL)
•
Hypoalphalipoprotéinémie familiale (HDL)
 Tous les autres
• Préciser le risque avec les tables de Framingham du NCEP III
A. Roussin MD
Risque cardiovasculaire Framingham modifié NCEP III
Pour calculer le risque d’IM et de mortalité CV
Points 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
Points
Total
Cholesterol
Age
20-39
Age
40-49
Age
50-59
Age
60-69
Age
70-79
<4.14
0
0
0
0
0
4.15-5.19
4
3
2
1
0
5.2-6.19
7
5
3
1
0
11
6.2-7.2
9
6
4
2
1
70-74
12
>7.21
11
8
5
3
1
75-79
13
A. Roussin MD
Risque cardiovasculaire Framingham modifié NCEP III
Pour calculer le risque d’IM et de mortalité CV
Points pour un homme
3. Smoking according to age
Points
Age
20-39
Age
40-49
Age
50-59
Age
60-69
Age
70-79
Non-Smoker
0
0
0
0
0
Smoker
8
5
3
1
1
4. HDL-C
5. Blood Pressure according to treatment
Sys BP
Untreated
Treated
<120
0
0
120-129
0
1
130-139
1
2
HDL-C
Points
>1.55
-1
1.30-1.54
0
1.04-1.29
1
140-159
1
2
<1.04
2
>160
2
3
A. Roussin MD
Pour calculer le risque d’IM et de mortalité CV
Pour un homme
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
>17
>30
Low Risk: < 10%


Medium Risk: 10-20%
High Risk: > 20%
A. Roussin MD
INTERHEART
Risk of AMI associated with Risk Factors in the Overall Population
ODDS RATIO
Risk factor
% 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
Alcohol Intake
19.3
24.5
14.3
24.0
0.72 (0.65, 0.79)
0.79 (0.73, 0.86)
0.86 (0.76, 0.97)
0.91 (0.82, 1.02)
All combined
-
-
129.2 (90.2, 185.0)
129.2(90.2, 185.0)
333.7 (230.2, 483.9)
333.7 (230.2, 483.9)
All combined (extremes)
Yusuf S et al. Lancet 2004; 364: 937-52
A. Roussin MD
INTERHEART
Risk of AMI associated with Risk Factors in the Overall Population
POPULATION ATTRIBUTABLE RISK
Risk factor
% 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
A. Roussin MD
INTERHEART
Risk of AMI with Multiple Risk Factors
2.9
2.4
1.9
3.3
13.0
HTN
ApoB/A
42.3
68.5
182.9
333.7
512
256
OR (99% CI)
128
64
32
16
8
4
2
1
Smk
DM
Yusuf S et al. Lancet 2004; 364: 937-52
1+2+3
All 4
+Ob
+PS
All RFs
A. Roussin MD
Notion « élargie » risque vasculaire
Incluant 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
A. Roussin MD
Risk factors: markers and / or activators
Atherothrombosis
Stroke - MI - Death
Atherosclerosis
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
A. Roussin MD
New insights: What has been improved
1970-1980’
1990’
2000’
Weight
BMI
Waist circumference
HBP > 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
A. Roussin MD
New insights: What has been added
 Sub-clinical markers
 Serological markers
 hs-CRP
 Ankle-Brachial Index
 Lipoprotein(a)
 Micro-albuminuria
 Homocysteine
 Carotid intima-media thick.
 Insulinemia
 Coronary calcification
 sLp-PLA2
A. Roussin MD
CCS position statement 2006
Treatment of dyslipidemia and prevention of CVD
Niveau
de risque
Risque
MCAS
en 10 ans
≥ 20 %
Élevé
Modéré
ou ASO
ou Diabète
10 - 19%
Recommendations
LDL-C
mmol/L
CT/HDL
Cible
primaire
Cible
secondaire
< 2.0
< 4.0
Traiter si
Traiter si
≥ 3.5
≥ 5.0
But du
traitement
Objectif
accessoire
Baisse
de LDL-C
Apo B
> 50%
< 0.85
< 1.05
> 40%
Bas
< 10%
Traiter si
Traiter si
≥ 5.0
≥ 6.0
Adapté de: Can J Cardiol 2006; 22 (11): 913-927
< 1.2
A. Roussin MD
Ultrasonographie carotidienne
Évaluation de l’ASO et stratification de risque CV
 Épaisseur Intima-Media
 Intima-media
thickness
• “IMT”
 Épaisseur de plaque
 Surface de plaque
 Volume de plaque
 Sténose
 Type de plaque:
 Échogénicité
 Homogénéité
 Faible coût
 Accessible
 Non-invasive
 Imagerie excellente
 Quantitative
 Reproductible
 Mesure l’ASO intimale
avant la sténose
angiographique
A. Roussin MD
Ultrasound Examination of the Carotid Artery
External carotid
Internal carotid
Skin
1.0 cm
Bifurcation
Common
carotid
B-mode
ultrasound
Near Wall
Periadventitia-adventitia
Adventitia-media
Intima-lumen
Smilde TJ et al. Lancet 2001; 357: 577-581
0.5-1.0 cm
1.0 cm
Far Wall
Adventitia-periadventitia
Media-adventitia
Lumen-intima
A. Roussin MD
Façons de déterminer la valeur d’un marqueur de risque
Vasan R S. Circ 2006; 113: 2335-2362
A. Roussin MD
Considérations avant l’adoption d’un marqueur de risque CV
Vasan R S. Circ 2006; 113: 2335-2362
A. Roussin MD
Marqueurs structurels et fonctionnels de risque CV
Vasan R S. Circ 2006; 113: 2335-2362
A. Roussin MD
Reproducibility of non-invasive ultrasonic measurement of carotid
atherosclerosis
The 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 < 0.2 mm
Result
 Highly reproducible measurement
 B-mode ultrasound can monitor small rates of lesion
progression
Stroke 1992, Aug 23 (8), 1062-8
A. Roussin MD
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
A. Roussin MD
IMT
Reproducibility 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
A. Roussin MD
IMT: quantitative vs caliper
A. Roussin MD
IMT and ≥ 70% Coronary Stenosis
Sensitivity vs Specificity
0
100
20
80
120
40
60
60
40
80
20
100
0
100
Sensitivity
IMT = 0.6
80
60
IMT = 0.8
40
20
0
100
I
IMT =1.0
80
60
40
20
0
Specificity
IMT of
0.6 mm
0.8 mm
1.0 mm
Sensitivity
95%
55%
20%
Aminbaklish A. et al. Clin. Invest. Med 1999; 22:265-274
Specificity
20%
60%
90%
A. Roussin MD
Evaluating Atherosclerosis by IMT measurement
Anatomy
0.02 mm
0.80 mm
Courtesy E. Braunwald
Buithieu JA.
/ Roussin MD
Evaluating Atherosclerosis by IMT measurement
Methodology
ECA ICA
10 mm
ICA
10 mm
Bulb
10 mm
CCA
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
Mean CIMT 1.174 mm
CCA
Buithieu J /
A. Roussin MD
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 Δ = 3 %
Buithieu JA.
/ Roussin MD
The Atherosclerosis Risk in Communities (ARIC) Study
Predictive Value of CIMT: Methodology
Prospective, multicenter study
ECA
N = 12841 aged 45 - 64 y (72.5 ± 5.5)
 7289 women, 5552 men
10 mm
No evidence of CV disease at enrollment
10 mm
Median follow-up 5.2 years
10 mm
Mean CIMT over 1 cm - far walls of
ICA
Bulb
CCA
Right & Left
CCA-Bulb-ICA
Chambless LE & al. Am J Epidemiol 1997. 146:483-494
Buithieu JA.
/ Roussin MD
The Atherosclerosis Risk in Communities (ARIC) Study
Age and Gender adjusted
CHD incidence/1000 patient-year
Predictive Value of CIMT for Myocardial Infarct / Death
Mean F-up 5.2 y
Chambless LE & al. Am J Epidemiol 1997. 146:483-494
CIMT (mm)
Buithieu JA.
/ Roussin MD
The Atherosclerosis Risk in Communities (ARIC) Study
Age and Gender adjusted
Stroke incidence/1000 patient-year
Predictive Value of CIMT for Stroke
Mean F-up 7.2 y
Chambless LE & al. Am J Epidemiol 2000. 151:478-487
CIMT (mm)
Buithieu JA.
/ Roussin MD
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
0.19 mm
CHD
Stroke
Men
Women
1.17
1.38
0.18 mm
Chambless LE & al. Am J Epidemiol 1997. 146:483-494
Chambless LE & al. Am J Epidemiol 2000. 151:478-487
Men
Women
1.21
1.36
Buithieu JA.
/ Roussin MD
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 < 0.6 mm
CHD
Stroke
CIMT
Men
Women
Men
Women
> 1.0 mm (Yes/No)
1.20
2.62
1.78
2.02
> 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. 146:483-494
Chambless LE & al. Am J Epidemiol 2000. 151:478-487
Buithieu JA.
/ Roussin MD
The Atherosclerosis Risk in Communities (ARIC) Study
Predictive Value of CIMT: Conclusions


N = 15 792 patients
CIMT measurements
Reproducible
Independent predictor of adverse cardiovascular
events
after 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. 146:483-494
Chambless LE & al. Am J Epidemiol 2000. 151:478-487
A. Roussin MD
Predicting clinical coronary events: role of Carotid IMT
CLAS 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:
1) Progression of CAD
2) Increased coronary events

Absolute IMT thickness and progression of IMT more strongly
correlated with coronary events than
1) Changes in lipid levels
2) 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; 128:262-269
A. Roussin MD
Predicting clinical coronary events: role of Carotid IMT
CLAS Sub-Study
Non fatal MI, Coronary Death, Revascularization
CHD Risk
CIMT directly associated with
higher risk for future MI and CHD death
7.70
MI - CHD death
Any coronary event
N = 146 CABG
p < 0.001
6.16
4.62
3.08
1.54
0.00
< 0.566
0.566-0.635
0.636-0.732
> 0.733
Carotid Intima-Media Thickness (mm)
Hodis HN & al. Ann Intern Med 1998. 128:262-269
Buithieu JA.
/ Roussin MD
Predicting clinical coronary events: role of Carotid IMT progression
CLAS Sub-Study
Non fatal MI, Coronary Death, Revascularization
CHD Risk
CIMT progression directly associated with
higher risk for future MI and CHD death
5
MI - CHD death
4
Any coronary event
N = 146 CABG
p < 0.001
3
2
1
0
< 0.011
0.011-0.017
0.018-0.033
> 0.033
CIMT progression (mm/y)
Hodis HN & al. Ann Intern Med 1998. 128:262-269
Buithieu JA.
/ Roussin MD
Cardiovascular Health Study (NHLBI)
Predictive Value of CIMT: methodology





Prospective, multicenter study
N = 4476 aged > 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
O’Leary D & al N Eng J Med 1999;.340: 14-22
Buithieu JA.
/ Roussin MD
Cardiovascular Health Study (NHLBI)
Predictive Value of CIMT for Myocardial Infarction & Stroke
Cumulative Event-free Rate (%)
100
95
1st Quintile
5%
2nd Quintile
90
3rd Quintile
85
4th Quintile
80
75
5th Quintile
25 %
0
0
1
2
3
O’Leary D & al N Eng J Med 1999;.340: 14-22
4
5
6
7
Years
Buithieu JA.
/ Roussin MD
Cardiovascular Health Study (NHLBI)
(Rate per 1000 Person-Years)
Myocardial Infarction or Stroke
Predictive Value of CIMT for Myocardial Infarction & Stroke
O’Leary D & al N Eng J Med 1999;.340: 14-22
Quintiles
Buithieu JA.
/ Roussin MD
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
MI - CVA
MI
CVA
1
< 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
> 1.18
18.7
2.22
2.46
2.13
Adjusted Relative Risk *
* Relative Risk adjusted for age, sex, sBP, HTN, Atrial fibrillation, Diabetes
O’Leary D & al N Eng J Med 1999;.340: 14-22
Buithieu JA.
/ Roussin MD
The Rotterdam Study
Comparative Predictive Value for Incident Myocardial Infarction
Population-based cohort
N = 6389 aged > 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. 109:1089-1094
A. Roussin MD
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, <1.0, 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. 109:1089-1094
A. Roussin MD
The Rotterdam Study
Comparative Predictive Value for Incident Myocardial Infarction
Incident MI : 258 / 6389 = 4.0 %
Severity of Atherosclerosis
Adjusted HR
None
Mild
Moderate
Severe
Carotid plaques
1.00
1.19
1.28
1.83
CIMT
1.00
1.56
1.63
1.95
Aortic Calcification
1.00
1.06
1.81
1.94
ABI
1.00
1.12
1.55
1.59
Composite Score
1.00
1.52
2.28
4.35
van der Meer IM & al. Circ 2004. 109:1089-1094
A. Roussin MD
Carotid Plaque
Predictive value




76 asymptomatic patients
Aged 35-65
TC > 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
A. Roussin MD
PLAQUE AREA
CAD rather than Stroke prediction
QuickTime™ and a
Microsof t Video 1 decompressor
are needed to see this picture.
Spence JD & al. Stroke 2002. 33(12):2910-2922
Buithieu JA.
/ Roussin MD
PLAQUE AREA
Stoke and MI risk
Plaque Area
(cm2)
Stroke alone
5 y Risk
RR
(%)
Stroke and MI
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 JA.
/ Roussin MD
PLAQUE AREA
Regression vs Progression
Spence JD & al. Stroke 2002. 33(12):2910-2922
Buithieu JA.
/ Roussin MD
PLAQUE AREA
Progression
Spence JD & al. Stroke 2002. 33(12):2910-2922
Buithieu JA.
/ Roussin MD
PLAQUE AREA
•
•
Predictor for MI and CVA
CIMT : mostly medial thickness
Medial hypertrophy
related to HTN
Correlation w LVH > CAD
predicts CVA > MI
Plaque area : intimal process
related to ASO
High associated with
coronary plaque
predicts MI more strongly
Spence JD & al. Stroke 2002. 33(12):2910-2922
A. Roussin MD
PLAQUE VOLUME
N = 21
Ainsworth CD & al. Stroke 2005. 36-1904-1909
N = 17
Buithieu JA.
/ Roussin MD
IMT vs Plaque area vs Plaque volume
Al-Shali & al. Atherosclerosis 2005-178:319-325
CIMT
 Hypertension
Total Plaque Area
 Smoking
 Plasma cholesterol
Total Plaque Volume
 Diabetes
Buithieu JA.
/ Roussin MD
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)
Young
AUC
healthy
Older
SE
healthy
pCAD
level
CIMT mean
0.66
0.55
0.77**
0.07
0.03
0.88
CIMT max
0.71
0.65
0.87**
0.07
0.01
1.01
0.035
0.80
laboratories
* pImaging
< 0.05 Research
** p < 0.01
Stroke Prevention and
Atherosclerosis Research Centre
0.040*
0.07
0.075**
0.00
Robarts Research Institute, London , Ontario, Canada
IMT roughness
Schmidt-Trucksass A & al. Atherosclerosis 2003. 166:57-65
Buithieu JA.
/ Roussin MD
Reference Values for CIMT (75th percentile)
1.2
CIMT (mm)
1.0
Men
Women
0.8
0.6
0.4
0.2
0.0
35 - 45
46 - 55
56 - 65
> 65
Age (years)
Redberg R & al. JACC Task Force #3. J Am Coll Cardiol 2003. 41:1886-1898
Buithieu JA.
/ Roussin MD
IMT selon l’âge
Age
Familial HC
Normal controls
10
20
30
40
50
60
70
80
IMT
(years) (mm)
0.53
0.55
0.58
0.60
0.64
0.73
0.78
0.80
From Weingert M, SSVQ 2006
De Groot Circ. 2004; 109 (suppl): 111:33-38
A. Roussin MD
IMT conclusion 1
Atherosclerosis 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. < 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
A. Roussin MD
IMT conclusion 2
Progression 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; 26:386-391
O’Leary, D.H. et al NEJM, 1999; 340:14-25
Mannami, T. et al Arch.-Int. Med 2000; 160: 2297-2303
Hodes, H.N. et al Ann Int Med 1998; 128: 262-269
A. Roussin MD
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
A. Roussin MD
IMT conclusion 4
Carotid 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
A. Roussin MD
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 > 40 with risk
factors
Genest JG & al. Can Med Assoc J 2003. 168(9):921-924
A. Roussin MD
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
A. Roussin MD
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
Class IIa, Level of evidence C
Class IIa, Level of evidence C
Class IIa, Level of evidence C
Class IIb, Level of evidence C
A. Roussin MD