A. Roussin MD ATHEROTHROMBOSE Stratification du risque vasculaire Marqueurs carotidiens. Emphase sur IMT Application pratique et Consensus canadien 2006.

A. Roussin MDA. Roussin MD

ATHEROTHROMBOSEATHEROTHROMBOSEStratification du risque vasculaireStratification du risque vasculaire

Marqueurs carotidiens. Emphase sur “IMT”Marqueurs carotidiens. Emphase sur “IMT”Application pratique et Consensus canadien 2006Application pratique et Consensus canadien 2006

André Roussin MD, FRCP, Internal medicineAndré Roussin MD, FRCP, Internal medicineDirector, Vascular Lab, Notre-Dame Hospital (CHUM)Director, Vascular Lab, Notre-Dame Hospital (CHUM)

Associate Professor of medicine and ResearcherAssociate Professor of medicine and ResearcherUniversity of MontrealUniversity of Montreal

ChairChair PresidentPresident

TIGC.ORGTIGC.ORG SSVQ.ORGSSVQ.ORG


André Roussin MDAndré Roussin MDDisclosuresDisclosures

AstraZenecaAstraZeneca Bristol-Myers SquibbBristol-Myers Squibb Boeringher-IngelheimBoeringher-Ingelheim GlaxoSmithKlineGlaxoSmithKline Leo PharmaLeo Pharma

Merck FrosstMerck Frosst PfizerPfizer Roche Diagnostics Roche Diagnostics Schering CanadaSchering Canada sanofi aventissanofi aventis

I have been on advisory boards or received I have been on advisory boards or received honorarium as consultant or speaker or honorarium as consultant or speaker or received research funds from the following received research funds from the following companies:companies:


11

Libby P. Libby P. Circulation. Circulation. 2001;104:365-2001;104:365-372372

22 33 44 55 66 77

HUMAN ATHEROGENESISHUMAN ATHEROGENESISFrom yellow streak to plaque and thrombosisFrom yellow streak to plaque and thrombosis


Inflammation markersInflammation markers

Koenig W, Khuseyinova N. ATVB 2007; 27: 15-26


ASO and Drug InterventionsASO and Drug InterventionsNapoli C et Napoli C et

al. al. Circulation Circulation 2006; 114: 2006; 114:

2517-272517-27


Cardiovascular disease worldwideCardiovascular disease worldwide CVD (CAD, Stroke and PAD) is the leading cause of CVD (CAD, Stroke and PAD) is the leading cause of

death worldwidedeath worldwide11

CVD contributed in 2001 nearly one third of all global CVD contributed in 2001 nearly one third of all global deathsdeaths1-21-2

3 Risk factors are responsible for > 75% of all CVD 3 Risk factors are responsible for > 75% of all CVD worldwideworldwide11

Elevated cholesterolElevated cholesterolSmokingSmokingHigh blood pressureHigh blood pressure

Of the three, elevated cholesterol carries the greatest Of the three, elevated cholesterol carries the greatest attributable risk for CADattributable risk for CAD33

1.1. WHO. World Health report 2002WHO. World Health report 2002

2.2. American Heart Association: statistical fact sheet 2003American Heart Association: statistical fact sheet 2003

3.3. Wilson P et al. Circ 1998; 97:1837-1847Wilson P et al. Circ 1998; 97:1837-1847


Risque de développer MCAS pendant la vieRisque de développer MCAS pendant la vie

FemmeFemme HommeHomme0.0.55

0.0.55

0.0.22

0.0.22

Age (années)Age (années) Age (années)Age (années)4040 5050 6060 7070 80 90

6565 55551/101/10 1/101/10

Lloyd-Jones, Lancet 1999; 353: 89-92Lloyd-Jones, Lancet 1999; 353: 89-92


Notion « traditionnelle » de risque vasculaireNotion « traditionnelle » de risque vasculaireConsensus Canadien sur les DyslipidémiesConsensus Canadien sur les Dyslipidémies Calcul du risque de coronaropathie à 10 ansCalcul du risque de coronaropathie à 10 ans

ASO présenteASO présente• Coronaropathie (MCAS)Coronaropathie (MCAS)• Maladie artérielle périphériqueMaladie artérielle périphérique• ASO carotidienne (ICT, AVC isch. , plaque)ASO carotidienne (ICT, AVC isch. , plaque)

Patients > 30 ans avec Diabète sucréPatients > 30 ans avec Diabète sucré

Dyslipidémie sévèreDyslipidémie sévère• Hypercholestérolémie familiale (LDL)Hypercholestérolémie familiale (LDL)• Hypoalphalipoprotéinémie familiale (HDL)Hypoalphalipoprotéinémie familiale (HDL)

Tous les autresTous les autres

• Préciser le risque avec les tables de Framingham du NCEP IIIPréciser le risque avec les tables de Framingham du NCEP III

RisqueRisque

ÉlevéÉlevé


Risque cardiovasculaire Framingham modifié NCEP IIIRisque cardiovasculaire Framingham modifié NCEP IIIPour calculer le risque d’IM et dePour calculer le risque d’IM et de mortalité CVmortalité CV

Points pour un hommePoints pour un homme

AgeAge PointsPoints

20-3420-34 -9-9

35-3935-39 -4-4

40-4440-44 00

45-4945-49 33

50-5450-54 66

55-5955-59 88

60-6460-64 1010

65-6965-69 1111

70-7470-74 1212

75-7975-79 1313

PointsPoints

Total Total

CholesterolCholesterol

Age Age

20-3920-39

AgeAge

40-4940-49

AgeAge

50-5950-59

AgeAge

60-6960-69

AgeAge

70-7970-79

<4.14<4.14 00 00 00 00 00

4.15-5.194.15-5.19 44 33 22 11 00

5.2-6.195.2-6.19 77 55 33 11 00

6.2-7.26.2-7.2 99 66 44 22 11

>7.21>7.21 1111 88 55 33 11

1. Age1. Age2. Total Cholesterol (mmol/L) according to age2. Total Cholesterol (mmol/L) according to age


PointsPoints

Age Age

20-3920-39

AgeAge

40-4940-49

AgeAge

50-5950-59

AgeAge

60-6960-69

AgeAge

70-7970-79

Non-SmokerNon-Smoker 00 00 00 00 00

SmokerSmoker 88 55 33 11 11

3. Smoking according to age

HDL-CHDL-C PointsPoints

>1.55>1.55 -1-1

1.30-1.541.30-1.54 00

1.04-1.291.04-1.29 11

<1.04<1.04 22

4. HDL-CSys BPSys BP UntreatedUntreated TreatedTreated

<120<120 00 00

120-129120-129 00 11

130-139130-139 11 22

140-159140-159 11 22

>160>160 22 33

5. Blood Pressure according to treatment

Risque cardiovasculaire Framingham modifié NCEP IIIRisque cardiovasculaire Framingham modifié NCEP IIIPour calculer le risque d’IM et dePour calculer le risque d’IM et de mortalité CVmortalité CV

Points pour un hommePoints pour un homme


PointsPoints 10-year Risk10-year Risk

00 11

11 11

22 11

33 11

44 11

55 22

66 22

77 33

88 44

99 55

1010 66

1111 88

1212 1010

1313 1212

1414 1616

1515 2020

1616 2525

>17>17 >30>30

High Risk: > 20%High Risk: > 20%

Medium Risk: 10-20%Medium Risk: 10-20%

Low Risk: < 10%Low Risk: < 10%

Pour calculer le risque d’IM et de mortalité CVPour calculer le risque d’IM et de mortalité CV

Pour un hommePour un homme


INTERHEARTINTERHEARTRisk of AMI associated with Risk Factors in the Overall PopulationRisk of AMI associated with Risk Factors in the Overall Population

ODDS RATIOODDS RATIO

Risk factorRisk factor % Cont % Cases% Cont % Cases OR (99% CI) adj for OR (99% CI) adj for age, sex, smok age, sex, smok

OR (99% CI) adj for OR (99% CI) adj for all all

ApoB/ApoA-1 (5 v 1)ApoB/ApoA-1 (5 v 1) 20.020.0 33.533.5 3.87 (3.39, 4.42)3.87 (3.39, 4.42) 3.25 (2.81, 3.76)3.25 (2.81, 3.76)

Curr smokingCurr smoking 26.826.8 45.245.2 2.95 (2.72, 3.20)2.95 (2.72, 3.20) 2.87 (2.58, 3.19)2.87 (2.58, 3.19)

DiabetesDiabetes 7.57.5 18.418.4 3.08 (2.77, 3.42)3.08 (2.77, 3.42) 2.37 (2.07, 2.71)2.37 (2.07, 2.71)

HypertensionHypertension 21.921.9 39.039.0 2.48 (2.30, 2.68)2.48 (2.30, 2.68) 1.91 (1.74, 2.10)1.91 (1.74, 2.10)

Abd Obesity (3 v 1)Abd Obesity (3 v 1) 33.333.3 46.346.3 2.22 (2.03, 2.42)2.22 (2.03, 2.42) 1.62 (1.45, 1.80)1.62 (1.45, 1.80)

PsychosocialPsychosocial -- -- 2.51 (2.15, 2.93)2.51 (2.15, 2.93) 2.67 (2.21, 3.22)2.67 (2.21, 3.22)

Veg & fruits dailyVeg & fruits daily 42.442.4 35.835.8 0.70 (0.64, 0.77)0.70 (0.64, 0.77) 0.70 (0.62, 0.79)0.70 (0.62, 0.79)

Exercise Exercise 19.319.3 14.314.3 0.72 (0.65, 0.79)0.72 (0.65, 0.79) 0.86 (0.76, 0.97)0.86 (0.76, 0.97)

Alcohol IntakeAlcohol Intake 24.524.5 24.024.0 0.79 (0.73, 0.86)0.79 (0.73, 0.86) 0.91 (0.82, 1.02)0.91 (0.82, 1.02)

All combinedAll combined -- -- 129.2 (90.2, 185.0)129.2 (90.2, 185.0) 129.2(90.2, 185.0)129.2(90.2, 185.0)

All combined (extremes)All combined (extremes) 333.7 (230.2, 483.9)333.7 (230.2, 483.9) 333.7 (230.2, 483.9)333.7 (230.2, 483.9)

Yusuf S et al. Lancet 2004; 364: 937-52


INTERHEARTINTERHEARTRisk of AMI associated with Risk Factors in the Overall PopulationRisk of AMI associated with Risk Factors in the Overall Population

POPULATION ATTRIBUTABLE RISKPOPULATION ATTRIBUTABLE RISK

Risk factorRisk factor % Cont % Cases% Cont % Cases PAR 1 (99% CI)PAR 1 (99% CI) PAR 2 (99% CI)PAR 2 (99% CI)

ApoB/ApoA-1(5 v 1)ApoB/ApoA-1(5 v 1) 20.020.0 33.533.5 54.1 (49.6, 58.6)54.1 (49.6, 58.6) 49.2 (43.8, 54.5)49.2 (43.8, 54.5)

Curr smokingCurr smoking 26.826.8 45.245.2 36.4(33.9,39.0)36.4(33.9,39.0) 35.7,(32.5,39.1)35.7,(32.5,39.1)

DiabetesDiabetes 7.57.5 18.518.5 12.3 (11.2, 13.5)12.3 (11.2, 13.5) 9.9 (8.5, 11.5)9.9 (8.5, 11.5)

HypertensionHypertension 21.921.9 39.039.0 23.4 (21.7, 25.1)23.4 (21.7, 25.1) 17.9 (15.7, 20.4)17.9 (15.7, 20.4)

Abd Obesity (3 v 1)Abd Obesity (3 v 1) 33.333.3 46.346.3 33.7 (30.2, 37.4)33.7 (30.2, 37.4) 20.1 (15.3, 26.0)20.1 (15.3, 26.0)

PsychosocialPsychosocial -- -- 28.8 (22.6, 35.8)28.8 (22.6, 35.8) 32.5 (25.1, 40.8)32.5 (25.1, 40.8)

Veg & fruits dailyVeg & fruits daily 42.442.4 35.835.8 12.9 (10.0, 16.6)12.9 (10.0, 16.6) 13.7 (9.9, 18.6)13.7 (9.9, 18.6)

ExerciseExercise 19.319.3 14.314.3 25.5 (20.1, 31.8)25.5 (20.1, 31.8) 12.2 (5.5, 25.1)12.2 (5.5, 25.1)

Alcohol Alcohol 24.524.5 24.024.0 13.9 (9.3, 20.2)13.9 (9.3, 20.2) 6.7 (2.0, 20.2)6.7 (2.0, 20.2)

CombinedCombined -- -- 90.4 (88.1, 92.4)90.4 (88.1, 92.4) 90.4 (88.1, 92.4)90.4 (88.1, 92.4)

Yusuf S et al. Lancet 2004; 364: 937-52


INTERHEARTINTERHEARTRisk of AMI with Multiple Risk FactorsRisk of AMI with Multiple Risk Factors

SmkSmk DMDM HTNHTN ApoB/AApoB/A 1+2+31+2+3 All 4All 4 +Ob+Ob +PS+PS All RFsAll RFs

2.9 2.4 1.9 3.3 13.0 42.3 68.5 182.9 333.72.9 2.4 1.9 3.3 13.0 42.3 68.5 182.9 333.7

11

22

44

88

1616

3232

6464

128128

256256

512512

OR

(99

% C

I)O

R (

99%

CI)

Yusuf S et al. Lancet 2004; 364: Yusuf S et al. Lancet 2004; 364: 937-52937-52


Notion « élargie » risque vasculaireNotion « élargie » risque vasculaireIncluant Incluant le Consensus Canadien sur les Dyslipidémiesle Consensus Canadien sur les Dyslipidémies

AjoutantAjoutant les facteurs de risque « émergents » les facteurs de risque « émergents »

• MCAS familiale précoceMCAS familiale précoce: RR = 1.7 à 2: RR = 1.7 à 2

• ApoBApoB, Lp(a), LDL dense, ApoA1, Lp(a), LDL dense, ApoA1

• Syndrome métaboliqueSyndrome métabolique

• Marqueurs sub-cliniques d'ASO: Marqueurs sub-cliniques d'ASO: • ITHITH, , ECG effort, PlaquesECG effort, Plaques et Intima-media et Intima-media

• Facteurs de risque émergentsFacteurs de risque émergents• hsCRPhsCRP, homocystéine, homocystéine


Risk factors: Risk factors: markers and / or activatorsmarkers and / or activators

AtherosAtherosclerosisclerosis AtheroAtherothrombosisthrombosisStroke - MI - DeathStroke - MI - Death

IM IM Plaque Plaque Stenosis Stenosis ThrombosisThrombosis

Triggering FactorsTriggering Factors

Inflammation FactorsInflammation Factors

Procoagulant FactorsProcoagulant Factors

Endothelial FactorsEndothelial Factors

Cells, Intercellular + intracellular signaling, proteins-enz. actionsCells, Intercellular + intracellular signaling, proteins-enz. actions

Smoking, Diabetes, LDL/oxLDL, HBP, AgII/AT1, Shear stressSmoking, Diabetes, LDL/oxLDL, HBP, AgII/AT1, Shear stress

TF, PAI-1 / tPA and TxATF, PAI-1 / tPA and TxA22 / Prostacycline imbalances / Prostacycline imbalances


New insights: What has been improvedNew insights: What has been improved

1970-1980’1970-1980’ 1990’1990’ 2000’2000’

WeightWeight BMIBMI Waist circumferenceWaist circumference

HBP > 160HBP > 160 HBP goal: 140HBP goal: 140 Ideal BP: 120Ideal BP: 120

Chol + TGChol + TG LDL + HDL + TGLDL + HDL + TG LDL + TC/HDL + ApoBLDL + TC/HDL + ApoB

DiabetesDiabetes DiabetesDiabetes Diabetes + Met. SyndromeDiabetes + Met. Syndrome

SmokingSmoking SmokingSmoking SmokingSmoking

SedentarismSedentarism SedentarismSedentarism FitnessFitness

CADCAD CAD + StrokeCAD + Stroke CAD + Stroke CAD + Stroke + PAD+ PAD


New insights: What has been addedNew insights: What has been added

Sub-clinical markersSub-clinical markers

Ankle-Brachial IndexAnkle-Brachial Index

Micro-albuminuriaMicro-albuminuria

Carotid intima-media thick.Carotid intima-media thick.

Coronary calcificationCoronary calcification

Sub-clinical markersSub-clinical markers

Ankle-Brachial IndexAnkle-Brachial Index

Micro-albuminuriaMicro-albuminuria

Carotid intima-media thick.Carotid intima-media thick.

Coronary calcificationCoronary calcification

Serological markersSerological markers

hs-CRPhs-CRP

Lipoprotein(a)Lipoprotein(a)

HomocysteineHomocysteine

InsulinemiaInsulinemia

sLp-PLAsLp-PLA22

Serological markersSerological markers

hs-CRPhs-CRP

Lipoprotein(a)Lipoprotein(a)

HomocysteineHomocysteine

InsulinemiaInsulinemia

sLp-PLAsLp-PLA22


CCS position statement 2006CCS position statement 2006Treatment of dyslipidemia and prevention of CVDTreatment of dyslipidemia and prevention of CVD

Adapté de: Can J Cardiol 2006; 22 (11): Adapté de: Can J Cardiol 2006; 22 (11): 913-927913-927

NiveauNiveau

de risquede risque

Risque Risque MCASMCAS

en 10 ansen 10 ansRecommendationsRecommendations

But duBut du

traitementtraitement

ObjectifObjectif

accessoireaccessoire

LDL-CLDL-C

mmol/Lmmol/LCT/HDLCT/HDL

BaisseBaisse

de LDL-Cde LDL-CApo BApo B

ÉlevéÉlevé≥ ≥ 20 %20 %ou ASOou ASO

ou Diabèteou Diabète

Cible Cible primaireprimaire

< 2.0< 2.0

Cible Cible secondairesecondaire

< 4.0< 4.0> 50%> 50% < 0.85< 0.85

ModéréModéré 10 - 19%10 - 19%Traiter siTraiter si

≥ ≥ 3.53.5Traiter siTraiter si

≥ ≥ 5.05.0> 40%> 40%

< 1.05< 1.05

BasBas < 10%< 10%Traiter siTraiter si

≥ ≥ 5.05.0Traiter siTraiter si

≥ ≥ 6.06.0 < 1.2< 1.2


Ultrasonographie carotidienneUltrasonographie carotidienneÉvaluation de l’ASO et stratification de risque CVÉvaluation de l’ASO et stratification de risque CV

Ultrasonographie carotidienneUltrasonographie carotidienneÉvaluation de l’ASO et stratification de risque CVÉvaluation de l’ASO et stratification de risque CV

Faible coFaible coûtût

AccessibleAccessible Non-invasiveNon-invasive

Imagerie excellenteImagerie excellente

QuantitativeQuantitative

ReproductibleReproductible

Mesure l’ASO intimale Mesure l’ASO intimale avant la sténose avant la sténose angiographiqueangiographique

Faible coFaible coûtût

AccessibleAccessible Non-invasiveNon-invasive

Imagerie excellenteImagerie excellente

QuantitativeQuantitative

ReproductibleReproductible

Mesure l’ASO intimale Mesure l’ASO intimale avant la sténose avant la sténose angiographiqueangiographique

Épaisseur Intima-MediaÉpaisseur Intima-Media Intima-media Intima-media

thicknessthickness• ““IMT”IMT”

Épaisseur de plaqueÉpaisseur de plaque Surface de plaqueSurface de plaque Volume de plaqueVolume de plaque

SténoseSténose

Type de plaque:Type de plaque:ÉchogénicitéÉchogénicitéHomogénéitéHomogénéité

Épaisseur Intima-MediaÉpaisseur Intima-Media Intima-media Intima-media

thicknessthickness• ““IMT”IMT”

Épaisseur de plaqueÉpaisseur de plaque Surface de plaqueSurface de plaque Volume de plaqueVolume de plaque

SténoseSténose

Type de plaque:Type de plaque:ÉchogénicitéÉchogénicitéHomogénéitéHomogénéité


Ultrasound Examination of the Carotid ArteryUltrasound Examination of the Carotid Artery

B-modeB-modeultrasoundultrasound

SkinSkin

External carotidExternal carotid Internal carotidInternal carotid

1.0 cm1.0 cm

0.5-1.0 cm0.5-1.0 cm

1.0 cm1.0 cm

BifurcationBifurcation

CommonCommoncarotidcarotid

Near WallNear Wall

Periadventitia-adventitiaPeriadventitia-adventitiaAdventitia-mediaAdventitia-media

Intima-lumenIntima-lumen

Far WallFar Wall

Adventitia-periadventitiaAdventitia-periadventitiaMedia-adventitiaMedia-adventitiaLumen-intimaLumen-intima

Smilde TJ et al. Lancet 2001; 357: 577-581Smilde TJ et al. Lancet 2001; 357: 577-581


Façons de déterminer la valeur d’un marqueur de risqueFaçons de déterminer la valeur d’un marqueur de risqueVasan R S. Circ 2006; 113: 2335-2362Vasan R S. Circ 2006; 113: 2335-2362


Considérations avant l’adoption d’un marqueur de risque CVConsidérations avant l’adoption d’un marqueur de risque CVVasan R S. Circ 2006; 113: 2335-2362Vasan R S. Circ 2006; 113: 2335-2362


Marqueurs structurels et fonctionnels de risque CVMarqueurs structurels et fonctionnels de risque CV

Vasan R S. Circ 2006; 113: 2335-2362Vasan R S. Circ 2006; 113: 2335-2362


Reproducibility of non-invasive ultrasonic measurement of carotid Reproducibility of non-invasive ultrasonic measurement of carotid atherosclerosisatherosclerosis

The Asymptomatic Carotid Artery Plaque Study (ACAPS)The Asymptomatic Carotid Artery Plaque Study (ACAPS)

858 patients858 patients 12 measurements in each patient12 measurements in each patient Repeated at 1 monthRepeated at 1 month Within and between sonographer variationWithin and between sonographer variation

858 patients858 patients 12 measurements in each patient12 measurements in each patient Repeated at 1 monthRepeated at 1 month Within and between sonographer variationWithin and between sonographer variation

Stroke 1992, Aug 23 (8), 1062-8Stroke 1992, Aug 23 (8), 1062-8

Mean IMT difference (exam 2-exam 1) 0.13 mmMean IMT difference (exam 2-exam 1) 0.13 mm 90% of patients – mean difference 90% of patients – mean difference < 0.2 mm< 0.2 mm

ResultResult Highly reproducible measurementHighly reproducible measurement B-mode ultrasound can monitor small rates of lesion B-mode ultrasound can monitor small rates of lesion

progressionprogression

Mean IMT difference (exam 2-exam 1) 0.13 mmMean IMT difference (exam 2-exam 1) 0.13 mm 90% of patients – mean difference 90% of patients – mean difference < 0.2 mm< 0.2 mm

ResultResult Highly reproducible measurementHighly reproducible measurement B-mode ultrasound can monitor small rates of lesion B-mode ultrasound can monitor small rates of lesion

progressionprogression


Protocoles pour Épaisseur Intima-Media (IMT)Protocoles pour Épaisseur Intima-Media (IMT)

12 point manual measurement12 point manual measurement Near and far wall of CCA, ICA, BulbNear and far wall of CCA, ICA, Bulb Near and far wall of CCA, ICANear and far wall of CCA, ICA Far wall of CCAFar wall of CCA Mean of maximal IMT measurementMean of maximal IMT measurement Mean of mean IMT measurementMean of mean IMT measurement Manual VS automated edge detectionManual VS automated edge detection

Plaque thickness summedPlaque thickness summed Plaque area summedPlaque area summed Plaque volume summedPlaque volume summed

Adapted from Weingert M SSVQ 2006Adapted from Weingert M SSVQ 2006


IMTIMTReproducibility of MeasurementReproducibility of Measurement

Intra observer variability lower in studies limited to Intra observer variability lower in studies limited to common carotid artery far wallcommon carotid artery far wall ( (± 0.02 mm) VS multiple ± 0.02 mm) VS multiple measurements at different carotid sites (± 0.06 mm)measurements at different carotid sites (± 0.06 mm)

Studies using automated computerized IMT Studies using automated computerized IMT measurement rather than manual cursor placement have measurement rather than manual cursor placement have best reproducibility. best reproducibility.



IMT: quantitative vs caliperIMT: quantitative vs caliper


IMT and ≥ 70% Coronary StenosisIMT and ≥ 70% Coronary StenosisSensitivity vs SpecificitySensitivity vs Specificity

IMT ofIMT of SensitivitySensitivity SpecificitySpecificity0.6 mm0.6 mm 95% 95% 20%20%0.8 mm0.8 mm 55% 55% 60%60%1.0 mm1.0 mm 20% 20% 90% 90%

0 20 40 60 80 100

100 80 60 40 20 0

IMT = 0.6

IMT = 0.8

IMT =1.0

0

20

40

60

80

100

120

020406080100

Specificity

Sensitivity I

Aminbaklish A. et al. Clin. Invest. Med 1999; 22:265-274Aminbaklish A. et al. Clin. Invest. Med 1999; 22:265-274


Evaluating Atherosclerosis by IMT measurementEvaluating Atherosclerosis by IMT measurementAnatomyAnatomy

0.80 mm

0.02 mm

Courtesy E. Braunwald

Buithieu Buithieu J /J /


12 point manual measurement12 point manual measurementFar wall of Common Carotid ArteryFar wall of Common Carotid ArteryNear and far wall of CCA, ICANear and far wall of CCA, ICANear and far wall of CCA, ICA, BulbNear and far wall of CCA, ICA, BulbMean of maximal IMT measurementMean of maximal IMT measurementMean of mean IMT measurementMean of mean IMT measurementManual / automated edge detectionManual / automated edge detectionSummation of plaque thicknessSummation of plaque thicknessSummation of plaque areaSummation of plaque areaSummation of plaque volumeSummation of plaque volume

Evaluating Atherosclerosis by IMT measurementEvaluating Atherosclerosis by IMT measurementMethodologyMethodology

CCACCA

ICAICAECAECA

BulbBulb

CCACCA

ICAICA

10 mm

10 mm

10 mm

Mean CIMT 1.174 mm



ECG gatingECG gating DiastoleDiastole distal CCAdistal CCA Mean IMT over Mean IMT over

100 pts along at least 1 cm100 pts along at least 1 cm Avoids pulsatile deformation of wall thicknessAvoids pulsatile deformation of wall thickness Observer independentObserver independent Better precision/reproducibility : Intermeasurement Δ = 3 %Better precision/reproducibility : Intermeasurement Δ = 3 %

Evaluating Atherosclerosis by Evaluating Atherosclerosis by computerizedcomputerized IMT measurement IMT measurement

AutomatedAutomatedComputerizedComputerized

methodmethod



The Atherosclerosis Risk in Communities (ARIC) StudyThe Atherosclerosis Risk in Communities (ARIC) Study Predictive Value of CIMT: MethodologyPredictive Value of CIMT: Methodology

Chambless LE & al. Am J Epidemiol 1997. 146:483-494Chambless LE & al. Am J Epidemiol 1997. 146:483-494

Prospective, multicenter studyProspective, multicenter study

N = 12841 aged 45 - 64 y (72.5 ± 5.5)N = 12841 aged 45 - 64 y (72.5 ± 5.5) 7289 women, 5552 men7289 women, 5552 men

No evidence of CV disease at enrollmentNo evidence of CV disease at enrollment

Median follow-up 5.2 yearsMedian follow-up 5.2 years

Mean CIMT over 1 cm - far walls of Right & Left Mean CIMT over 1 cm - far walls of Right & Left CCA-Bulb-ICA CCA-Bulb-ICA

CCACCA

ICAICA

ECAECA

10 mm

10 mm

10 mm

BulbBulb



The Atherosclerosis Risk in Communities (ARIC) StudyThe Atherosclerosis Risk in Communities (ARIC) Study Predictive Value of CIMT for Predictive Value of CIMT for Myocardial Infarct / DeathMyocardial Infarct / Death


Ag

e an

d G

end

er a

dju

sted

C

HD

in

cid

ence

/100

0 p

atie

nt-

year

CIMT (mm)

Mean F-up 5.2 y



The Atherosclerosis Risk in Communities (ARIC) StudyThe Atherosclerosis Risk in Communities (ARIC) Study Predictive Value of CIMT for Predictive Value of CIMT for StrokeStroke


Ag

e an

d G

end

er a

dju

sted

S

tro

ke i

nci

den

ce/1

000

pat

ien

t-ye

ar

CIMT (mm)

Mean F-up 7.2 y



The Atherosclerosis Risk in Communities (ARIC) StudyThe Atherosclerosis Risk in Communities (ARIC) Study Predictive Value of CIMT by incremental valuePredictive Value of CIMT by incremental value

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

Chambless LE & al. Am J Epidemiol 1997. 146:483-494Chambless LE & al. Am J Epidemiol 1997. 146:483-494Chambless LE & al. Am J Epidemiol 2000. 151:478-487Chambless LE & al. Am J Epidemiol 2000. 151:478-487

IncrementIncrementCHDCHD StrokeStroke

MenMen WomenWomen MenMen WomenWomen

0.19 mm0.19 mm 1.171.17 1.381.38

0.18 mm0.18 mm 1.211.21 1.361.36



The Atherosclerosis Risk in Communities (ARIC) StudyThe Atherosclerosis Risk in Communities (ARIC) Study Predictive Value of CIMT by strataPredictive Value of CIMT by strata

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


CIMTCIMTCHDCHD StrokeStroke

MenMen WomenWomen MenMen WomenWomen

> 1.0 mm (Yes/No)> 1.0 mm (Yes/No) 1.201.20 2.622.62 1.781.78 2.022.02

> 1.0 mm> 1.0 mm 2.152.15 7.407.40 2.592.59 4.324.32

0.80 - 0.99 mm0.80 - 0.99 mm 2.442.44 3.353.35 2.082.08 3.143.14

0.70 - 0.79 mm0.70 - 0.79 mm 1.561.56 3.563.56 1.261.26 1.731.73

0.60 - 0.69 mm0.60 - 0.69 mm 1.211.21 2.532.53 0.790.79 2.072.07

HypertensionHypertension

2.12.1DiabetesDiabetes

2.52.5Current smokingCurrent smoking

1.31.3



The Atherosclerosis Risk in Communities (ARIC) StudyThe Atherosclerosis Risk in Communities (ARIC) Study Predictive Value of CIMT: ConclusionsPredictive Value of CIMT: Conclusions

N = 15 792 patientsN = 15 792 patients

CIMT measurementsCIMT measurements

ReproducibleReproducible

Independent predictor of adverse cardiovascular Independent predictor of adverse cardiovascular eventseventsafter adjustment for:after adjustment for:

•Age, sex, race, center, BMI, waist-hip ratio, Age, sex, race, center, BMI, waist-hip ratio, sporting activitysporting activity

•Diabetes, LDL, HDL, hypertension, smokingDiabetes, LDL, HDL, hypertension, smoking

•Fibrinogen, WBC, LVHFibrinogen, WBC, LVH



Predicting clinical coronary eventsPredicting clinical coronary events: r: role of Carotid IMTole of Carotid IMTCLAS Sub-StudyCLAS Sub-Study

133 patients: 8.8 year follow-up133 patients: 8.8 year follow-up Close correlation between far wall CCA-IMT and changes in Close correlation between far wall CCA-IMT and changes in

catheterization catheterization Progression of IMT correlated with:Progression of IMT correlated with:

1)1) Progression of CADProgression of CAD2)2) Increased coronary eventsIncreased coronary events

Absolute IMT thickness and progression of IMT more strongly Absolute IMT thickness and progression of IMT more strongly correlated with coronary events thancorrelated with coronary events than

1)1) Changes in lipid levelsChanges in lipid levels2)2) Lesion changes on coronary catheterizationLesion changes on coronary catheterization

Result: every 0.03 mm increase in IMT increases risk of Result: every 0.03 mm increase in IMT increases risk of coronary event 3.1 %coronary event 3.1 %

Hodis H.N. et al Ann Int Med 1998; 128:262-269Hodis H.N. et al Ann Int Med 1998; 128:262-269


Predicting clinical coronary eventsPredicting clinical coronary events: r: role of Carotid IMTole of Carotid IMTCLAS Sub-StudyCLAS Sub-Study

CIMT directly associated withCIMT directly associated withhigher risk for future MI and CHD deathhigher risk for future MI and CHD death

0.00

1.54

3.08

4.62

6.16

7.70

< 0.566 0.566-0.635 0.636-0.732 > 0.733

MI - CHD death Any coronary event

0.00

1.54

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4.62

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Carotid Intima-Media Thickness (mm)Carotid Intima-Media Thickness (mm)Hodis HN & al. Ann Intern Med 1998. 128:262-269Hodis HN & al. Ann Intern Med 1998. 128:262-269

N = 146 CABGp < 0.001



Predicting clinical coronary eventsPredicting clinical coronary events: r: role of Carotid IMTole of Carotid IMT progression progressionCLAS Sub-StudyCLAS Sub-Study

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

0

1

2

3

4

5

< 0.011 0.011-0.017 0.018-0.033 > 0.033


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CIMT progression (mm/y)CIMT progression (mm/y)Hodis HN & al. Ann Intern Med 1998. 128:262-269Hodis HN & al. Ann Intern Med 1998. 128:262-269

N = 146 CABGN = 146 CABGp < 0.001p < 0.001



Cardiovascular Health Study (NHLBI)Cardiovascular Health Study (NHLBI) Predictive Value of CIMT: methodologyPredictive Value of CIMT: methodology

Prospective, multicenter studyProspective, multicenter study

N = 4476 aged > 65 y (72.5 ± 5.5)N = 4476 aged > 65 y (72.5 ± 5.5)

Male 38.8 %, Caucasian 84.8 %Male 38.8 %, Caucasian 84.8 %

No evidence of CV disease at enrollmentNo evidence of CV disease at enrollment

Median follow-up 6.2 yearsMedian 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 CCA

Maximal CIMT mean of near & far walls of R + L ICAMaximal CIMT mean of near & far walls of R + L ICA

O’Leary D & al N Eng J Med 1999;.340: 14-22O’Leary D & al N Eng J Med 1999;.340: 14-22Buithieu Buithieu

J /J /


Cardiovascular Health Study (NHLBI)Cardiovascular Health Study (NHLBI) Predictive Value of CIMT for Myocardial Infarction & StrokePredictive Value of CIMT for Myocardial Infarction & Stroke

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CIMT - CCACIMT - CCAQuintileQuintile

CIMT - CCACIMT - CCAThickness (mm)Thickness (mm)

MI-CVA Rate MI-CVA Rate (%)(%)

at 7 yat 7 y

Adjusted Relative Risk *Adjusted Relative Risk *

MI - CVAMI - CVA MIMI CVACVA

11 < 0.87< 0.87 5.25.2 1.001.00 1.001.00 1.001.00

22 0.87 - 0.960.87 - 0.96 9.39.3 1.491.49 1.791.79 1.331.33

33 0.97 - 1.050.97 - 1.05 9.09.0 1.291.29 1.401.40 1.211.21

44 1.06 - 1.171.06 - 1.17 13.213.2 1.761.76 2.072.07 1.391.39

55 >> 1.18 1.18 18.718.7 2.222.22 2.462.46 2.132.13

* Relative Risk adjusted for age, sex, sBP, HTN, Atrial fibrillation, Diabetes* Relative Risk adjusted for age, sex, sBP, HTN, Atrial fibrillation, DiabetesO’Leary D & al N Eng J Med 1999;.340: 14-22O’Leary D & al N Eng J Med 1999;.340: 14-22



The Rotterdam StudyThe Rotterdam Study Comparative Predictive Value for Incident Myocardial InfarctionComparative Predictive Value for Incident Myocardial Infarction

Population-based cohortPopulation-based cohort

N = 6389 aged N = 6389 aged >> 55 (69.3 ± 9.2) 55 (69.3 ± 9.2)

Male 38.1 %, Caucasian 100 %Male 38.1 %, Caucasian 100 %

No prior MI or revascularizationNo prior MI or revascularization

Mean Follow-up 4.2 yearsMean Follow-up 4.2 years

van der Meer IM & al. Circ 2004. 109:1089-1094van der Meer IM & al. Circ 2004. 109:1089-1094



Carotid - UltrasonographyCarotid - Ultrasonography

Maximal CIMT mean of near and far wall of left & Maximal CIMT mean of near and far wall of left & right CCAright CCA

Carotid plaque - weighted scoreCarotid plaque - weighted score

Aorta - Lateral abdominal X-rayAorta - Lateral abdominal X-ray

Calcifications - length of affected areaCalcifications - length of affected area

0cm, <1.0, 1.0-2.5, 2.5-4.9, 5.0-9.9, ≥10.0cm0cm, <1.0, 1.0-2.5, 2.5-4.9, 5.0-9.9, ≥10.0cm

Lower extremities - Ankle-Brachial Index (ABI)Lower extremities - Ankle-Brachial Index (ABI)

1.50-1.21, 1.21-1.10, 1.10-0.97, 0.97-0.00 1.50-1.21, 1.21-1.10, 1.10-0.97, 0.97-0.00

Composite atherosclerosis scoreComposite atherosclerosis score


?



Incident MI : 258 / 6389 = 4.0 %

Adjusted HRAdjusted HRAdjusted HRAdjusted HRSeverity of AtherosclerosisSeverity of AtherosclerosisSeverity of AtherosclerosisSeverity of Atherosclerosis

NoneNoneNoneNone MildMildMildMild ModerateModerateModerateModerate SevereSevereSevereSevere

Carotid plaquesCarotid plaquesCarotid plaquesCarotid plaques 1.001.001.001.00 1.191.191.191.19 1.281.281.281.28 1.831.831.831.83

CIMTCIMTCIMTCIMT 1.001.001.001.00 1.561.561.561.56 1.631.631.631.63 1.951.951.951.95

Aortic CalcificationAortic CalcificationAortic CalcificationAortic Calcification 1.001.001.001.00 1.061.061.061.06 1.811.811.811.81 1.941.941.941.94

ABIABIABIABI 1.001.001.001.00 1.121.121.121.12 1.551.551.551.55 1.591.591.591.59

Composite ScoreComposite ScoreComposite ScoreComposite Score 1.001.001.001.00 1.521.521.521.52 2.282.282.282.28 4.354.354.354.35



Carotid PCarotid PlaquelaquePredictive valuePredictive value

76 asymptomatic patients76 asymptomatic patients Aged 35-65Aged 35-65 TC > 6.5TC > 6.5 Stress test, cath, carotid ultrasoundStress test, cath, carotid ultrasound

≥ ≥ 1 Plaque: 64%1 Plaque: 64%

57% had critical CAD57% had critical CAD Positive predictive value for coronary atherosclerosis: 76%Positive predictive value for coronary atherosclerosis: 76%

No PlaqueNo Plaque

Women: none had CADWomen: none had CAD Men: - with positive stress test – 21% significant CAD Men: - with positive stress test – 21% significant CAD

Giral P. et al. Am J Card 1999; 84: 14-17Giral P. et al. Am J Card 1999; 84: 14-17


PLAQUE AREAPLAQUE AREACAD rather than Stroke predictionCAD rather than Stroke prediction

Spence JD & al. Stroke 2002. 33(12):2910-2922Spence JD & al. Stroke 2002. 33(12):2910-2922

QuickTime™ and aMicrosoft Video 1 decompressorare needed to see this picture.



PLAQUE AREAPLAQUE AREAStoke and MI riskStoke and MI risk

Plaque Area Plaque Area (cm2)(cm2)

Stroke aloneStroke alone Stroke and MIStroke and MI

5 y Risk 5 y Risk (%)(%) RRRR 5 y Risk 5 y Risk

(%)(%) RRRR

0.00 - 0.110.00 - 0.11 1.61.6 1.01.0 4.84.8 1.01.0

0.12 - 0.450.12 - 0.45 2.32.3 1.41.4 9.39.3 1.91.9

0.46 - 1.180.46 - 1.18 3.93.9 2.42.4 12.312.3 2.52.5

1.19 - 6.731.19 - 6.73 4.04.0 2.42.4 14.014.0 2.92.9

Spence JD & al. Stroke 2002. 33(12):2910-2922Spence JD & al. Stroke 2002. 33(12):2910-2922Buithieu Buithieu

J /J /


PLAQUE AREAPLAQUE AREARegression vs ProgressionRegression vs Progression


J /J /


PLAQUE AREAPLAQUE AREAProgressionProgression


J /J /


PLAQUE AREAPLAQUE AREA Predictor for MI and CVAPredictor for MI and CVA

• CIMTCIMT : mostly medial thickness : mostly medial thicknessMedial hypertrophyMedial hypertrophyrelated to HTNrelated to HTNCorrelation w LVH > CADCorrelation w LVH > CADpredicts CVA > MIpredicts CVA > MI

• Plaque areaPlaque area : intimal process : intimal processrelated to ASOrelated to ASOHigh associated with High associated with coronary plaquecoronary plaquepredicts MI more stronglypredicts MI more strongly

• CIMTCIMT : mostly medial thickness : mostly medial thicknessMedial hypertrophyMedial hypertrophyrelated to HTNrelated to HTNCorrelation w LVH > CADCorrelation w LVH > CADpredicts CVA > MIpredicts CVA > MI

• Plaque areaPlaque area : intimal process : intimal processrelated to ASOrelated to ASOHigh associated with High associated with coronary plaquecoronary plaquepredicts MI more stronglypredicts MI more strongly

Spence JD & al. Stroke 2002. 33(12):2910-2922Spence JD & al. Stroke 2002. 33(12):2910-2922


PLAQUE VOLUMEPLAQUE VOLUME

N = 21 N = 17

Ainsworth CD & al. Stroke 2005. 36-1904-1909Ainsworth CD & al. Stroke 2005. 36-1904-1909Buithieu Buithieu

J /J /


IMT vs Plaque area vs Plaque volumeIMT vs Plaque area vs Plaque volume

CIMTCIMT

HypertensionHypertension

Total Plaque AreaTotal Plaque Area

SmokingSmoking

Plasma cholesterolPlasma cholesterol

Total Plaque VolumeTotal Plaque Volume

DiabetesDiabetes

Al-Shali & al. Atherosclerosis 2005-178:319-325Al-Shali & al. Atherosclerosis 2005-178:319-325Buithieu Buithieu

J /J /


Plaque roughnessPlaque roughness

IMT roughnessIMT roughness

N = 15 healthy (24.9 ± 2.3)N = 15 healthy (24.9 ± 2.3)N = 22 healthy (62.9 ± 3.5)N = 22 healthy (62.9 ± 3.5)N = 46 CAD (62.0 ± 9.2)N = 46 CAD (62.0 ± 9.2)

Schmidt-Trucksass A & al. Atherosclerosis 2003. 166:57-65Schmidt-Trucksass A & al. Atherosclerosis 2003. 166:57-65

* p < 0.05 ** p < 0.01

AUCAUC SESE pp level level

CIMT meanCIMT mean 0.660.66 0.070.07 0.030.03

CIMT maxCIMT max 0.710.71 0.070.07 0.010.01

IMT roughnessIMT roughness 0.800.80 0.070.07 0.000.00

YoungYounghealthyhealthy

OlderOlderhealthyhealthy CADCAD

CIMT meanCIMT mean 0.550.55 0.77**0.77** 0.880.88

CIMT maxCIMT max 0.650.65 0.87**0.87** 1.011.01

IMT roughnessIMT roughness 0.0350.035 0.040*0.040* 0.075**0.075**Imaging Research laboratories

Stroke Prevention and Atherosclerosis Research Centre

Robarts Research Institute, London , Ontario, Canada Buithieu Buithieu

J /J /


Reference Values for CIMT (75th percentile)Reference Values for CIMT (75th percentile)

35 - 45 46 - 55 56 - 65 > 65

MenWomen

0.0

0.2

0.4

0.6

0.8

1.0

1.2

CIM

T (

mm

)C

IMT

(m

m)

Age (years)Age (years)Redberg R & al. JACC Task Force #3. J Am Coll Cardiol 2003. 41:1886-1898Redberg R & al. JACC Task Force #3. J Am Coll Cardiol 2003. 41:1886-1898



IMT selon l’IMT selon l’âgeâge

De Groot Circ. 2004; 109 (suppl): 111:33-38De Groot Circ. 2004; 109 (suppl): 111:33-38

AgeAge IMT IMT (years)(years) (mm)(mm)

1010 0.530.532020 0.550.553030 0.580.584040 0.600.605050 0.640.646060 0.730.737070 0.780.788080 0.800.80

AgeAge IMT IMT (years)(years) (mm)(mm)

1010 0.530.532020 0.550.553030 0.580.584040 0.600.605050 0.640.646060 0.730.737070 0.780.788080 0.800.80

Familial HCFamilial HC

Normal controlsNormal controls

From Weingert M, SSVQ 2006From Weingert M, SSVQ 2006


IMT conclusion 1IMT conclusion 1Atherosclerosis is a diffuse diseaseAtherosclerosis is a diffuse disease

Detection in one vascular bed highly associated with Detection in one vascular bed highly associated with atherosclerosis in other bedsatherosclerosis in other beds

Carotid atheroma associated with increased risk of vascular Carotid atheroma associated with increased risk of vascular events in direct relationship to extent of atherosclerosisevents in direct relationship to extent of atherosclerosis

IMT IMT ≥ 1 mm vs. <≥ 1 mm vs. < 1 mm, associated with 5-fold increased risk 1 mm, associated with 5-fold increased risk of CADof CAD

Risk for CVA and MI correlate with carotid IMT independent of Risk for CVA and MI correlate with carotid IMT independent of standard risk factors (ARIC)standard risk factors (ARIC)



IMT conclusion 2IMT conclusion 2Progression and relationsProgression and relations

Normal progression is 0.02-0.05 mm/yearNormal progression is 0.02-0.05 mm/year

Direct relationship between number of risk factors and Direct relationship between number of risk factors and IMTIMT

Direct relationship between IMT and CAD and cardiac Direct relationship between IMT and CAD and cardiac events as well as strokeevents as well as stroke

Burk, G.I. et al Stroke 1995; 26:386-391Burk, G.I. et al Stroke 1995; 26:386-391O’Leary, D.H. et al NEJM, 1999; 340:14-25O’Leary, D.H. et al NEJM, 1999; 340:14-25Mannami, T. et al Arch.-Int. Med 2000; 160: 2297-2303Mannami, T. et al Arch.-Int. Med 2000; 160: 2297-2303Hodes, H.N. et al Ann Int Med 1998; 128: 262-269Hodes, H.N. et al Ann Int Med 1998; 128: 262-269


IMT conclusion 3IMT conclusion 3

↑ ↑ Carotid IMT: AssociationsCarotid IMT: Associations

IMT augmentation is associated with:IMT augmentation is associated with:

White matter lesions on MRIWhite matter lesions on MRI Coronary disease on catheterizationCoronary disease on catheterization EBCT coronary artery calcificationEBCT coronary artery calcification LVH on echocardiogramLVH on echocardiogram Microalbuminuria in diabeticsMicroalbuminuria in diabetics Peripheral Vascular DiseasePeripheral Vascular Disease



IMT conclusion 4IMT conclusion 4Carotid IMT: UsefulnessCarotid IMT: Usefulness

Reflects impact of multiple risk factorsReflects impact of multiple risk factors

Mirrors atherosclerotic burdenMirrors atherosclerotic burden

Predictor of cardiovascular and neurological eventsPredictor of cardiovascular and neurological events

Can reclassify patient to higher risk category, worthy Can reclassify patient to higher risk category, worthy of more aggressive treatmentof more aggressive treatment


RecommendedRecommended Physical examinationPhysical examination Ankle-brachial indexAnkle-brachial index

Possibly useful in subjects at moderate riskPossibly useful in subjects at moderate risk Carotid ultrasonographyCarotid ultrasonography ElectrocardiographyElectrocardiography Graded exercise testing in Men > 40 with risk Graded exercise testing in Men > 40 with risk

factorsfactors

Recommendations for the Management of Dyslipidemia and the Recommendations for the Management of Dyslipidemia and the Prevention of Cardiovascular Disease: 2003 UpdatePrevention of Cardiovascular Disease: 2003 UpdateDiagnosis of Asymptomatic AtherosclerosisDiagnosis of Asymptomatic Atherosclerosis

Genest JG & al. Can Med Assoc J 2003. 168(9):921-924Genest JG & al. Can Med Assoc J 2003. 168(9):921-924


Not currentlyNot currently recommended based on available recommended based on available evidenceevidence Flow-mediated vasodilatationFlow-mediated vasodilatation PlethysmographyPlethysmography Arterial complianceArterial compliance Electron beam CT scanningElectron beam CT scanning MRI scanningMRI scanning Intravascular ultrasonographyIntravascular ultrasonography

Recommendations for the Management of Dyslipidemia and the Recommendations for the Management of Dyslipidemia and the Prevention of Cardiovascular Disease: 2003 UpdatePrevention of Cardiovascular Disease: 2003 UpdateDiagnosis of Asymptomatic AtherosclerosisDiagnosis of Asymptomatic Atherosclerosis

Genest JG & al. Can Med Assoc J 2003. 168(9):921-924Genest JG & al. Can Med Assoc J 2003. 168(9):921-924


2006 Position Statement2006 Position Statement Recommendations for the Diagnosis and Treatment of Recommendations for the Diagnosis and Treatment of

Dyslipidemia and Prevention of Cardiovascular Dyslipidemia and Prevention of Cardiovascular DiseaseDisease

Useful non-invasive investigations in the Useful non-invasive investigations in the intermediate intermediate risk categoryrisk category to detect subclinical atherosclerosis to detect subclinical atherosclerosis and/or to further define future CAD riskand/or to further define future CAD risk

Ankle-Brachial Index (ABI)Ankle-Brachial Index (ABI) Carotid ultrasoundCarotid ultrasound Graded exercise testing (GXT)Graded exercise testing (GXT) Electrocardiogram (ECG)Electrocardiogram (ECG)

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

Class IIa, Level of evidence C



Class IIb, Level of evidence C

A. Roussin MD ATHEROTHROMBOSE Stratification du risque vasculaire Marqueurs carotidiens. Emphase sur IMT Application pratique et Consensus canadien 2006.

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