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177 link between coronary and carotid


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177 link between coronary and carotid

  1. 1. The Link Between Coronary and Carotid; How Strong Is It? Provided by: 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 Editorial Slides
  2. 2.  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 events. 2-5 Is Carotid IMT surrogate for CAD
  3. 3.  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 carotid segments. Is Carotid IMT surrogate for CAD
  4. 4. 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
  5. 5. 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
  6. 6.  HultheJ,WikstrandJ,Emanuelsson H,WiklundO, deFeyterPJ,WendelhagI. AtheroscleroticchangesinthecarotidarterybulbasmeasuredbyB-mode ultrasoundare associatedwiththeextentofcoronary atherosclerosis. Stroke 1997;28:1189–1194.  This was a small study.8 Segment specific alterations
  7. 7. • 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
  8. 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).
  9. 9. 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. Results
  10. 10.  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. Results
  11. 11. Number of risk factors and segments involved Urbina EM, Srinivasan SR, Tang R, Bond MG, Kieltyka L, Berenson GS. 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 1;90(9):953-8. 11
  12. 12. Conclusion:  Multiple risk factors for coronary artery disease cause different morphological changes in carotid arteries.
  13. 13. Limitations:  Carotid IMT observed in this study is less than 1.0 mm. Prior epidemiological data suggests that IMT > 1.0 mm has prognostic value.  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.
  14. 14. Questions: • 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 ?
  15. 15. Questions: • 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 ?
  16. 16. 1) Chambers BR, Norris JW. Outcome in patients with asymptomatic neck bruits. N Engl J Med. 1986; 315:860-865. 2) Bots ML, Hoes AW, Koudstaal PJ et al. Common carotid intima-media thickness and risk of stroke and myocardial infarction: the Rotterdam Study. Circulation. 1997; 96:1432-1437. 3) Sinha AK, Eigenbrodt M, Mehta JL. Does carotid intima media thickness indicate coronary atherosclerosis? Curr Opin Cardiol. 2002 Sep;17(5):526-530. 4) Salonen JT Salonen R Ultrasonographically assessed carotid morphology and the risk of coronary heart disease Arterioscler Thromb 1991; 11:1245-1249 5) Kuller L, Borhani N, Furberg C et al. Prevalence of sublcinical atherosclerosis and cardiovascular disease and association with risk factors in the Cardiovascular Health Study. Am J Epidemiol 1994;139:1164-1179. 6) Ku DN, Giddens DP, Zarins CK, Glagov S. Pulsatile flow and atherosclerosis in the human carotid bifurcation. Positive correlation between plaque location and low oscillating shear stress. Arteriosclerosis 1985;5:293–302. 7) Espeland MA, Tang R, Terry JG et al. Associations of risk factors with segment-specific intimal-medial thickness of the extracranial carotid artery. Stroke 1999; 30:1049-1055. 8) Hulthe J, Wikstrand J, Emanuelsson H, Wiklund O, de Feyter PJ, Wendelhag I. Atherosclerotic changes in the carotid artery bulb as measured by B-mode ultrasound are associated with the extent of coronary atherosclerosis. Stroke 1997;28:1189–1194. 9) Rosfors S, Hallerstam S, Jensen-Urstad K et al. Relationship between intima-media thickness in the common carotid artery and atherosclerosis in the carotid bifurcation. Stroke 1998; 29:1378-1382. 10) Zanchetti A, Bond MG, Hennig M, Neiss A, Mancia G, Dal Palu C, Hansson L, Magnani B, Rahn KH, Reid JL, Rodicio J, Safar M, Eckes L, Rizzini P. Calcium antagonist lacidipine slows down progression of asymptomatic carotid atherosclerosis: principal results of the European Lacidipine Study on Atherosclerosis (ELSA), a randomized, double- blind, long-term trial. Circulation. 2002 Nov 5;106(19):2422-7. 11) Urbina EM, Srinivasan SR, Tang R, Bond MG, Kieltyka L, Berenson GS. 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 1;90(9):953-8. References