2/19/2013 1 Carotid Plaque & IMT Carotid Plaque & IMT Imaging: Where Do We Imaging: Where Do We Stand? Stand? Roger S. Blumenthal, MD, FACC Roger S. Blumenthal, MD, FACC Professor of Medicine Professor of Medicine Director, Johns Hopkins Ciccarone Center Director, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease for the Prevention of Heart Disease Disclosures: None Disclosures: None Objectives Objectives Limits to FRS prediction Limits to FRS prediction Carotid ultrasound as tool to predict Carotid ultrasound as tool to predict cardiovascular disease risk cardiovascular disease risk Carotid plaque presence Carotid plaque presence Carotid intima Carotid intima-media thickness (CIMT) media thickness (CIMT) measurement measurement Consensus statement from ASE/SVM Consensus statement from ASE/SVM Limitations of Current CV Risk Limitations of Current CV Risk Prediction Models Prediction Models Heavily dependent on age Heavily dependent on age Do not account on changes in patient’s health Do not account on changes in patient’s health status over time status over time Focused on short Focused on short-term (10 term (10-year) risk year) risk Family history not incorporated into estimates Family history not incorporated into estimates Patients with high levels of a single risk factor Patients with high levels of a single risk factor may not be correctly classified solely on FRS may not be correctly classified solely on FRS Smoking considered as present or absent only Smoking considered as present or absent only
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2/19/2013
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Carotid Plaque & IMT Carotid Plaque & IMT
Imaging: Where Do We Imaging: Where Do We
Stand?Stand?
Roger S. Blumenthal, MD, FACCRoger S. Blumenthal, MD, FACC
Professor of MedicineProfessor of Medicine
Director, Johns Hopkins Ciccarone Center Director, Johns Hopkins Ciccarone Center for the Prevention of Heart Diseasefor the Prevention of Heart Disease
Disclosures: NoneDisclosures: None
ObjectivesObjectives
�� Limits to FRS predictionLimits to FRS prediction
�� Carotid ultrasound as tool to predict Carotid ultrasound as tool to predict
�� Carotid intimaCarotid intima--media thickness (CIMT) media thickness (CIMT)
measurementmeasurement
�� Consensus statement from ASE/SVMConsensus statement from ASE/SVM
Limitations of Current CV Risk Limitations of Current CV Risk
Prediction ModelsPrediction Models
�� Heavily dependent on ageHeavily dependent on age
�� Do not account on changes in patient’s health Do not account on changes in patient’s health status over timestatus over time
�� Focused on shortFocused on short--term (10term (10--year) riskyear) risk
�� Family history not incorporated into estimatesFamily history not incorporated into estimates
�� Patients with high levels of a single risk factor Patients with high levels of a single risk factor may not be correctly classified solely on FRSmay not be correctly classified solely on FRS
�� Smoking considered as present or absent onlySmoking considered as present or absent only
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Advantages of Carotid Ultrasound as Advantages of Carotid Ultrasound as
an Imaging Modalityan Imaging Modality
�� NonNon--invasive, safeinvasive, safe
�� InexpensiveInexpensive
�� Readily available, Readily available, portable, and quickportable, and quick
�� Plaque visualizationPlaque visualization
�� HemodynamicsHemodynamics
�� OfficeOffice--based assessmentbased assessment
Ultrasound Ultrasound Assessment of Assessment of
Carotid Carotid IMT and Plaque PresenceIMT and Plaque Presence
mediamedia
adventitia
intimaplaque
Advantages of Carotid Advantages of Carotid Study To Study To
Refine Refine Risk Prediction Risk Prediction �� Completely noninvasive Completely noninvasive –– no radiation, no harmful no radiation, no harmful
exposures, no known biological effectsexposures, no known biological effects
�� Identifies range of disease Identifies range of disease –– increased CIMT, nonincreased CIMT, non--occlusive occlusive
plaque, stenosisplaque, stenosis
�� Normal values are known Normal values are known –– 2525--85 years old, both sexes, most 85 years old, both sexes, most
races/ethnicitiesraces/ethnicities
�� Predicts future MI, CHD death, and stroke, with incremental Predicts future MI, CHD death, and stroke, with incremental
predictive powerpredictive power
�� Track serial changesTrack serial changes
�� Recommended by NCEP ATP III, AHA, ACC, ASE, SVM, Recommended by NCEP ATP III, AHA, ACC, ASE, SVM, SAIP, and ESC to assist with CVD risk stratificationSAIP, and ESC to assist with CVD risk stratification
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Carotid Duplex ProtocolCarotid Duplex Protocol
�� Presence or absence of plaquePresence or absence of plaque
�� Would the presence of carotid plaque on Would the presence of carotid plaque on ultrasound alter her management?ultrasound alter her management?
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How is Plaque Defined?How is Plaque Defined?
�� Focal wall thickening Focal wall thickening that is at least 50% that is at least 50% greater than that of greater than that of surrounding vessel wallsurrounding vessel wall
OROR
�� Focal thickening of IMTFocal thickening of IMTgreater than 1.5 mmgreater than 1.5 mm
Stein JH, et al.. J Am Soc Echocardiogr 2008.Stein JH, et al.. J Am Soc Echocardiogr 2008.Mannheim Consensus Cerebrovasc Dis 2007.Mannheim Consensus Cerebrovasc Dis 2007.
Carotid Plaque and CADCarotid Plaque and CAD
�� Patients with occlusive carotid disease 7 times Patients with occlusive carotid disease 7 times
more likely to have positive exercise stress test more likely to have positive exercise stress test
than patients with normal carotid arteriesthan patients with normal carotid arteries
�� Presence of carotid plaques associated with Presence of carotid plaques associated with
angiographic CAD angiographic CAD
�� MultiMulti--vessel CAD associated with higher vessel CAD associated with higher
prevalence of carotid plaque than singleprevalence of carotid plaque than single--vessel vessel
diseasedisease Bruckert E et al. Atherosclerosis 1992
Nowak J et al. Stroke 1998
Skaguchi M et al. Ultrasound Med Biol 2003
Prospective Studies Relating Carotid Plaque Prospective Studies Relating Carotid Plaque Presence to Incident CVD in Asymptomatic Presence to Incident CVD in Asymptomatic
IndividualsIndividualsStudyStudy NN AgeAge YrsYrs EventEvent Adjusted HR Adjusted HR
Yao CityYao City 1,2891,289 6060--7474 55 StrokeStroke 3.2 (1.43.2 (1.4--7.1)7.1)
Modified from Johnson HM, et al. J Nuc Cardiol 201 1;18:153Modified from Johnson HM, et al. J Nuc Cardiol 201 1;18:153
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Case 1 Carotid Duplex: Screen for plaqueCase 1 Carotid Duplex: Screen for plaque
Does Plaque Presence (Increased CV Risk) Does Plaque Presence (Increased CV Risk)
Justify Initiation of Preventive Therapies?Justify Initiation of Preventive Therapies?
�� Smoking cessationSmoking cessation
�� Smokers shown images of carotid plaques were more likely to Smokers shown images of carotid plaques were more likely to stop smoking at 6 monthsstop smoking at 6 months
�� Quit Rates 22% versus 6%, p=0.003 in those who had plaqueQuit Rates 22% versus 6%, p=0.003 in those who had plaque
Bovet P, et al. Bovet P, et al. PrevPrev Med 2002.Med 2002.
�� Lifestyle modificationLifestyle modification
�� Patients more likely to adhere to diet and exercise Patients more likely to adhere to diet and exercise
recommendations after seeing pictures of plaquerecommendations after seeing pictures of plaque
�� Would you initiate treatment with a statin?Would you initiate treatment with a statin?
�� What should be her target LDLWhat should be her target LDL--C?C?
“Less is “Less is NotNot More”More”
“PPIs for persons with nonulcer dyspepsia, opioid “PPIs for persons with nonulcer dyspepsia, opioid
medications for persons with chronic medications for persons with chronic
nonmalignant pain, and STATIN medications nonmalignant pain, and STATIN medications
for persons without CAD are all examples of the for persons without CAD are all examples of the
widespread use of medications with known widespread use of medications with known adverse effects despite the ABSENCE of adverse effects despite the ABSENCE of
DATA FOR PATIENT BENEFIT for these DATA FOR PATIENT BENEFIT for these
indications.”indications.”
Redberg R et al. Arch Intern Med. Dec 13 2010.
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Case 2Case 2
�� 43 year old female43 year old female
�� Family history of premature CHDFamily history of premature CHD
�� Father CABG at age 49, brother MI at age 47Father CABG at age 49, brother MI at age 47
Distribution of CIMT in the General Distribution of CIMT in the General
Population: ARIC StudyPopulation: ARIC Study
0.64 0.650.74
0.80.75 0.78
0.930.98
0.85 0.85
1.091.14
0
0.2
0.4
0.6
0.8
1
1.2
1.4
LCCA RCCA L Bulb R Bulb
0.72 0.71
0.84 0.850.83 0.84
1.03 1.040.99 1.01
1.311.21
0
0.2
0.4
0.6
0.8
1
1.2
1.4
LCCA RCCA L Bulb R Bulb
0.61 0.61
0.73 0.750.71 0.71
0.88 0.910.81
0.93
1.091.16
0
0.2
0.4
0.6
0.8
1
1.2
1.4
LCCA RCCA L Bulb R Bulb
0.70.66
0.82
0.66
0.8 0.77
1.06
0.77
0.93 0.9
1.23
0.9
0
0.2
0.4
0.6
0.8
1
1.2
1.4
LCCA RCCA L Bulb R Bulb
Black Women
White Women
Black Men
White Men
Howard G, et al Stroke 1993; 24:1297-1304
45 yrs
55 yrs65 yrs
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Distribution of CIMT in General Population: AXA Stu dyDistribution of CIMT in General Population: AXA Stu dy
Gariepy J et al Arterioscler Thromb Vasc Biol 1998
Modified from Johnson HM, et al. J Nuc Cardiol 201 1;18:153Modified from Johnson HM, et al. J Nuc Cardiol 201 1;18:153
Prospective Studies Relating CCA CIMT to Prospective Studies Relating CCA CIMT to Incident CVD Events in Asymptomatic IndividualsIncident CVD Events in Asymptomatic Individuals
2010 ACCF/AHA Guideline for Assessment 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic of Cardiovascular Risk in Asymptomatic
AdultsAdultsRecommendation for Measurement of Carotid Recommendation for Measurement of Carotid IntimaIntima--Media ThicknessMedia Thickness
CLASS IIa (Level of Evidence: B)CLASS IIa (Level of Evidence: B)
“Measurement of carotid artery intima“Measurement of carotid artery intima--media media thickness is reasonable for cardiovascular risk thickness is reasonable for cardiovascular risk assessment in asymptomatic adults at intermediate assessment in asymptomatic adults at intermediate risk (43,44). Published recommendations on risk (43,44). Published recommendations on required equipment, technical approach, and required equipment, technical approach, and operator training and experience for performance of operator training and experience for performance of the test must be carefully followed to achieve highthe test must be carefully followed to achieve high --quality results (44).quality results (44).
Greenland P, et al. J Am Coll Cardiol 2011 (in pres s)Greenland P, et al. J Am Coll Cardiol 2011 (in pres s)
–– Training and certificationTraining and certificationStein JH, et al. J Am Soc Echocardiogr 2008;21:93Stein JH, et al. J Am Soc Echocardiogr 2008;21:93
•• “Intermediate” risk“Intermediate” risk–– 1010--year Framingham risk of 6year Framingham risk of 6--20% 20% –– Not already at high risk Not already at high risk
•• Family history of premature CV disease in a Family history of premature CV disease in a firstfirst--degree relative (men <55, women <65 yo)degree relative (men <55, women <65 yo)
•• Younger people with severe abnormalities in a Younger people with severe abnormalities in a single risk factor who are not being treated single risk factor who are not being treated with medications (with medications ( e.g.,e.g., genetic dyslipidemia, genetic dyslipidemia, heavy smoker) heavy smoker)
•• Women <60 years old with Women <60 years old with ≥≥2 CV risk factors2 CV risk factorsStein JH, et al. J Am Soc Echocardiogr 2008;21:93Stein JH, et al. J Am Soc Echocardiogr 2008;21:93
Greenland P, et al. J Am Coll Cardiol 2011 (in pres s)Greenland P, et al. J Am Coll Cardiol 2011 (in pres s)
2010 ACCF/AHA Guideline for Assessment 2010 ACCF/AHA Guideline for Assessment of Cardiovascular Risk in Asymptomatic of Cardiovascular Risk in Asymptomatic
AdultsAdults
Objective: To determine whether CIMT has added value
in the 10-year risk prediction (FRS) of first-time MI
or stroke.
Methods: Meta-analysis of 14 population based cohorts,
45,828 individuals median follow-up 11 years:
4,007 MI or strokes observed.
Only 5/14 studies
significant
association
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“… the added value of common CIMT measurements to the Framingham
risk score in the general population was small”: Of 45,828 individuals
from 14 cohort studies worldwide, 0.8% were correctly reclassified.
“In individuals at intermediate risk, the added value was 3.2% in men
and 3.9% in women. Our results suggest, that common CIMT measurements
should not be routinely performed in the general population because
the overall added value is small and unlikely to be of clinical importance”
Objective: to compare improvement in prediction of incident CHD
of 6 risk markers: 1) coronary artery calcium
2) IMT
3) ABI
4) brachial flow-mediated dilatation
5) hsCRP
6) FHx
Methods: 6814 MESA participants from 6 US field centers (1330
intermediate risk participants).
7.6 years follow-up: 94 CHD and 123 CVD events.
AUC and NRI were calculated.
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“Coronary artery calcium, ABI, hsCRP and family history were independent
predictors of incident CHF in intermediate-risk individuals. CAC provided
superior discrimination and risk reclassification compared with other risk
markers.”
“CIMT […] was not associated with incident CHD in multivariable analyses.”
Prospective cohort study, n=6698, age 45-84.
IMT and CAC measured at baseline in 6 field centers
Main outcome: risk of incident CVD (CAD, stroke, CVD death) over 5.3 yrs. of f/u.