The Link Between Coronary and Carotid; How Strong Is It?
Jawahar L Mehta, M.D.,PhD
Anjan K Sinha, M.D.
Division of Cardiovascular Medicine
University of Arkansas for Medical Sciences, Little Rock, AR
VP Watch – November 20, 2002 - Volume 2, Issue 47
Asymptomatic patients with cervical bruits
when followed prospectively by clinical and
Doppler examination had strikingly high
number of cardiac deaths. 1
Ultrasonographically assessed carotid
arteriosclerosis is being used as a surrogate
measure for coronary arteriosclerosis. The
presence of any structural changes in the
common carotid arteries or carotid bulbs is
associated with higher risk of cardiovascular
Is Carotid IMT surrogate for CAD
Technically easier to measure common
carotid and carotid bifurcation.
Most of the trials have used mean values
of Intima media thickness (IMT) measured
at common carotid, bifurcation and internal
Is Carotid IMT surrogate for CAD
Arteriosclerosis in non uniform
• It is well known that plaques both in
coronary and extracoronary circulation are
non uniformly distributed.
• Under steady flow conditions plaques tend
to form in areas of low, rather than high,
shear stress, but indicate in addition that
marked oscillations in the direction of wall
shear may enhance atherogenesis. 6
Segment specific alterations
• Few clinical trials have selectively evaluated the
individual carotid segments.
The patterns of differences in mean IMTamong
segments vary, depending on age, hypertension,BMI in
women, and coronary (case-control) status.
Sex,postmenopausal status, LDL cholesterol, systolic
blood pressure,and history of myocardial infarction all
had statistically significant relationshipswith IMT that
were fairly homogeneous amongarterial sites. 7
HultheJ,WikstrandJ,Emanuelsson H,WiklundO, deFeyterPJ,WendelhagI.
ultrasoundare associatedwiththeextentofcoronary atherosclerosis. Stroke
This was a small study.8
Segment specific alterations
• This study clearly demonstrate that Carotid
bifurcation stenosis is associated with
adverse cardiac outcome however it is small
study and includes older subjects.
• Study is not powered to evaluate the relative
significance of individual risk factors.8
As reported in VP Watch of this week,
Urbina EM et al. show for the first time the
different morphological patterns observed in
carotid arteries with different risk factor profile.
Large population study including both blacks
and whites.Young adults are studied (all the
prior studies included middle aged to elderly).
Systolic blood pressure was the major
contributor to the explained variance of common
carotid IMT followed by race (black more than
white), age, LDL cholesterol, and HDL
cholesterol (inverse association), in that order.
Age was the major contributor for carotid bulb
IMT followed by systolic blood pressure, HDL
cholesterol (inverse association), LDL
cholesterol, race (black more than white), and
insulin level (inverse association).
Gender (men more than women) and BMI
were the only contributors to the variance of
internal carotid IMT.
Number of risk factors and segments involved
Urbina EM, Srinivasan
SR, Tang R, Bond MG, Kieltyka L,
Impact of multiple coronary risk
factors on the intima-media
thickness of different segments of
carotid artery in healthy young
adults (The Bogalusa Heart Study).
Am J Cardiol. 2002 Nov
Multiple risk factors for coronary artery
disease cause different morphological
changes in carotid arteries.
Carotid IMT observed in this study is less
than 1.0 mm. Prior epidemiological data
suggests that IMT > 1.0 mm has prognostic
Hypertension is prominent risk factor for both
carotid bifurcation as well as well as common
carotid changes. Hypertension is known to
cause medial hypertrophy and differences
may be due to different hemodynamic profiles
of the segments.
• Would individual segment of carotid
artery involvement have different
prognostic value ?
• Should we only measure carotid
bifurcation IMT (has highest sensitivity
for combined risk factors) ?
• How will we define what is normal and
what is abnormal ?
• Is one risk factor more important in a
particular individual than other since he or
she has demonstrated morphological
changes in their segmental carotid
arteries suggestive of specific risk factor ?
• Do therapeutic interventions selectively
change the morphology ?
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