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
A. Roussin MDA. Roussin MD
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:
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
Inflammation markersInflammation markers
Koenig W, Khuseyinova N. ATVB 2007; 27: 15-26
A. Roussin MDA. Roussin MD
ASO and Drug InterventionsASO and Drug InterventionsNapoli C et Napoli C et
al. al. Circulation Circulation 2006; 114: 2006; 114:
2517-272517-27
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
AgeAge40-4940-49
AgeAge50-5950-59
AgeAge60-6960-69
AgeAge70-7970-79
<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. Age 2. Total Cholesterol (mmol/L) according to age2. Total Cholesterol (mmol/L) according to age
A. Roussin MDA. Roussin MD
PointsPoints
Age Age 20-3920-39
AgeAge40-4940-49
AgeAge50-5950-59
AgeAge60-6960-69
AgeAge70-7970-79
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
A. Roussin MDA. Roussin MD
PointsPoints 10-year Risk10-year Risk00 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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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%
CI)
OR
(99%
CI)
Yusuf S et al. Lancet 2004; 364: Yusuf S et al. Lancet 2004; 364: 937-52937-52
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
Serological markersSerological markers
hs-CRPhs-CRP
Lipoprotein(a)Lipoprotein(a)
HomocysteineHomocysteine
InsulinemiaInsulinemia
sLp-PLAsLp-PLA22
A. Roussin MDA. Roussin MD
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
NiveauNiveaude risquede risque
Risque Risque MCASMCAS
en 10 ansen 10 ansRecommendationsRecommendations But duBut du
traitementtraitementObjectifObjectif
accessoireaccessoire
LDL-CLDL-Cmmol/Lmmol/L CT/HDLCT/HDL BaisseBaisse
de LDL-Cde LDL-C Apo 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
A. Roussin MDA. Roussin MD
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
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
A. Roussin MDA. Roussin MD
Ultrasound Examination of the Carotid ArteryUltrasound Examination of the Carotid Artery
B-modeB-modeultrasoundultrasound
SkinSkinExternal 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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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.
Adapted from Weingert M SSVQ 2006Adapted from Weingert M SSVQ 2006
A. Roussin MDA. Roussin MD
IMT: quantitative vs caliperIMT: quantitative vs caliper
A. Roussin MDA. Roussin MD
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 100100 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
A. Roussin MDA. Roussin MD
Evaluating Atherosclerosis by IMT measurementEvaluating Atherosclerosis by IMT measurementAnatomyAnatomy
0.80 mm
0.02 mm
Courtesy E. Braunwald
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
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
CCA
ICAECA
Bulb
CCA
ICA
10 mm
10 mm
10 mm
Mean CIMT 1.174 mm
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
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
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
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
CCA
ICA
ECA
10 mm
10 mm
10 mm
Bulb
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
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
Chambless LE & al. Am J Epidemiol 1997. 146:483-494Chambless LE & al. Am J Epidemiol 1997. 146:483-494
Age
and
Gen
der a
djus
ted
CH
D in
cide
nce/
1000
pat
ient
-yea
r
CIMT (mm)
Mean F-up 5.2 y
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
The Atherosclerosis Risk in Communities (ARIC) StudyThe Atherosclerosis Risk in Communities (ARIC) Study Predictive Value of CIMT for Predictive Value of CIMT for StrokeStroke
Chambless LE & al. Am J Epidemiol 2000. 151:478-487Chambless LE & al. Am J Epidemiol 2000. 151:478-487
Age
and
Gen
der a
djus
ted
Stro
ke in
cide
nce/
1000
pat
ient
-yea
r
CIMT (mm)
Mean F-up 7.2 y
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
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
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
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
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
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
2.12.1DiabetesDiabetes2.52.5Current smoking
Current smoking1.31.3
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
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
ReproducibleReproducibleIndependent 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
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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
CH
D R
isk
Non
fata
l MI,
Cor
onar
y D
eath
, Rev
ascu
lariz
atio
n
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
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
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
MI - CHD death Any coronary event
CH
D R
isk
CH
D R
isk
Non
fata
l MI,
Cor
onar
y D
eath
, Rev
ascu
lariz
atio
nN
on fa
tal M
I, C
oron
ary
Dea
th, R
evas
cula
rizat
ion
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
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
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 /
A. Roussin MDA. Roussin MD
Cardiovascular Health Study (NHLBI)Cardiovascular Health Study (NHLBI) Predictive Value of CIMT for Myocardial Infarction & StrokePredictive Value of CIMT for Myocardial Infarction & Stroke
Cum
ulat
ive
Eve
nt-fr
ee R
ate
(%)
100
95
90
0
85
80
75
0 21 3 7654
Years
1st Quintile
2nd Quintile
3rd Quintile
4th Quintile
5th Quintile
5 %
25 %
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 /
A. Roussin MDA. Roussin MD
Cardiovascular Health Study (NHLBI)Cardiovascular Health Study (NHLBI) Predictive Value of CIMT for Myocardial Infarction & StrokePredictive Value of CIMT for Myocardial Infarction & Stroke
QuintilesMyo
card
ial I
nfar
ctio
n or
Str
oke
(Rat
e pe
r 100
0 Pe
rson
-Yea
rs)
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 /
A. Roussin MDA. Roussin MD
Cardiovascular Health Study (NHLBI)Cardiovascular Health Study (NHLBI) Predictive Value of CIMT for Myocardial Infarction & StrokePredictive Value of CIMT for Myocardial Infarction & Stroke
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
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
The Rotterdam StudyThe Rotterdam Study Comparative Predictive Value for Incident Myocardial InfarctionComparative Predictive Value for Incident Myocardial Infarction
Carotid - UltrasonographyCarotid - UltrasonographyMaximal 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 area0cm, <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
van der Meer IM & al. Circ 2004. 109:1089-1094van der Meer IM & al. Circ 2004. 109:1089-1094
?
A. Roussin MDA. Roussin MD
The Rotterdam StudyThe Rotterdam Study Comparative Predictive Value for Incident Myocardial InfarctionComparative Predictive Value for Incident Myocardial Infarction
Incident MI : 258 / 6389 = 4.0 %
Adjusted HRAdjusted HRSeverity of AtherosclerosisSeverity of Atherosclerosis
NoneNone MildMild ModerateModerate SevereSevere
Carotid plaquesCarotid plaques 1.001.00 1.191.19 1.281.28 1.831.83
CIMTCIMT 1.001.00 1.561.56 1.631.63 1.951.95
Aortic CalcificationAortic Calcification 1.001.00 1.061.06 1.811.81 1.941.94
ABIABI 1.001.00 1.121.12 1.551.55 1.591.59
Composite ScoreComposite Score 1.001.00 1.521.52 2.282.28 4.354.35
van der Meer IM & al. Circ 2004. 109:1089-1094van der Meer IM & al. Circ 2004. 109:1089-1094
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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.
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
PLAQUE AREAPLAQUE AREAStoke and MI riskStoke and MI risk
Plaque Area Plaque Area (cm2)(cm2)
Stroke aloneStroke alone Stroke and MIStroke and MI5 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 /
A. Roussin MDA. Roussin MD
PLAQUE AREAPLAQUE AREARegression vs ProgressionRegression vs Progression
Spence JD & al. Stroke 2002. 33(12):2910-2922Spence JD & al. Stroke 2002. 33(12):2910-2922Buithieu Buithieu
J /J /
A. Roussin MDA. Roussin MD
PLAQUE AREAPLAQUE AREAProgressionProgression
Spence JD & al. Stroke 2002. 33(12):2910-2922Spence JD & al. Stroke 2002. 33(12):2910-2922Buithieu Buithieu
J /J /
A. Roussin MDA. Roussin MD
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
Spence JD & al. Stroke 2002. 33(12):2910-2922Spence JD & al. Stroke 2002. 33(12):2910-2922
A. Roussin MDA. Roussin MD
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 /
A. Roussin MDA. Roussin MD
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 /
A. Roussin MDA. Roussin MD
Plaque roughnessPlaque roughness
IMT roughnessIMT roughnessN = 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 /
A. Roussin MDA. Roussin MD
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 (m
m)
CIM
T (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
Buithieu Buithieu J /J /
A. Roussin MDA. Roussin MD
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
Familial HCFamilial HC
Normal controlsNormal controls
From Weingert M, SSVQ 2006From Weingert M, SSVQ 2006
A. Roussin MDA. Roussin MD
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)
Adapted from Weingert M SSVQ 2006Adapted from Weingert M SSVQ 2006
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
Adapted from Weingert M SSVQ 2006Adapted from Weingert M SSVQ 2006
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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
A. Roussin MDA. Roussin MD
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 IIa, Level of evidence C
Class IIa, Level of evidence C
Class IIb, Level of evidence C