Increased Values Of Carotid Intima Media Thicknes

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02 Nov 2017

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1. Regional Hospital "Prim. Dr. Daut Mustafa" in the Prizren – Republic of Kosovo.

2. National Institute of Public Health of Kosovo – branch in Prizren.

Abstract

Background

Increased values of carotid intima-media thickness (CIMT) and high sensitivity C reactive protein (Hs-CRP) are predictors of acute coronary events. We analyzed the link between CIMT and the C reactive hypersensitive protein (Hs-CRP) in cases with coronary disease (CAD).

Methods

From 01 January 2012 till 30 June 2012, are evaluated 43 patients with acute coronary syndrome (group A), 50 patients with stable coronary artery disease (group B) and 50 healthy volunteers (group C). They all are analyzed for CIMT and Hs-CRP.

Results

CIMT values were higher in group A and B (0.94 mm ± 0.21 mm, 0.89 mm ± 0.19 mm), and they were lower in group C (0.64 mm ± 0.09 mm) and this seems to be statistically significant p<0.0001. But, values of Hs-CRP were higher in group A (1.87 mg/L ± 0.36 mg/L), and they were lower in group B and C (1.07 mg/L ± 0.28 mg/L, 0.97 mg/L ± 0.45 mg/L) and this was also with importance p<0.0001.

Conclusions

High CIMT and Hs-CRP values can predict the presence of unstable coronary disease.

Keywords: CIMT, Hs-CRP, atherosclerosis, stable coronary disease, unstable coronary disease.

Introduction

More than half of acute myocardial infarctions originate from blood vessels with stenosis less than 50% (Error: Reference source not found). Moreover, cholesterol is basically poor predictor of cardiovascular risk. This was documented by data from the Framingham heart study, where more than a third of patients with coronary artery disease (CAD) have values of total cholesterol ​​lower than 5.1 mmol / L (Error: Reference source not found). It is needed to improve prediction of cardiovascular risk. During the 1990s it became clear that many other factors, besides those conventional, as homeostatic and thrombotic mechanisms, markers of inflammation and genetic factors may have influence (Error: Reference source not found-Error: Reference source not found). For pathogenesis of coronary artery disease presence of atherosclerotic plaques is substantial (Error: Reference source not found). The structure of the coronary artery wall is not static, with enhancement of its external diameter; development of atherosclerotic plaques will be possible without significant narrowing the lumen of the artery (Error: Reference source not found). Several necropsy studies have reported very strong correlation between atherosclerosis in the carotid arteries with atherosclerosis in coronary arteries (Error: Reference source not found, Error: Reference source not foundError: Reference source not found). Increase of carotid artery intima-media thickness (CIMT) is considered as a marker for early atherosclerosis (Error: Reference source not found). Risk prediction for coronary artery disease can be improved adding information about the CIMT increase to traditional risk factors (Error: Reference source not found).

Recently, inflammation has emerged as an important factor in the process of atherosclerosis (Error: Reference source not found), so, high sensitivity C reactive protein (Hs-CRP) has drawn the attention of clinicians as new risk factors for CAD (Error: Reference source not found). In one recent study was concluded that Hs-CRP and conventional lipid parameters can be used to predict the risk of CAD (Error: Reference source not found).

Exercise stress testing provides useful information about the prognosis of patients with stable CAD and in stable patients after acute coronary syndrome (Error: Reference source not found). Subjects with stable CAD who achieve <5 MET (metabolic equivalent) in exercise stress test have four times higher mortality rate than subjects who have achieved > 10 MET (Error: Reference source not found).

Aim

The aim of this study was to analyze the association between changes in CIMT and Hs-CRP values ​​in cases with stable and unstable coronary artery disease.

Method

From 01 January 2012 till 30 June 2012 in prospective study are included 143 subjects which are classified into three groups. Group A (patients with acute coronary syndrome) included 43 patients with acute coronary artery syndrome: 25 (58.14%) patients with acute myocardial infarction and 18 (41.86%) patients with unstable angina pectoris. Group B has included 50 patients with stable coronary artery disease: 37 (74%) of them with stable angina pectoris and 13 (26%) patients with stable condition after myocardial infarction, all of them achieved ≥ 5 MET (metabolic equivalents) in exercise stress testing. Group C (control group) has included 50 healthy volunteers with negative exercise stress testing. From the study were excluded all subjects with chronic and acute inflammatory diseases, patients after recent myocardial infarction (< one month from the study onset), patients with recent trauma (surgery, burns), and with malignancies. Adjustment was made for age and sex. All individuals were interviewed about risk factors, regular therapy. Routine biochemical analyzes were performed with special emphasis on fasting glucose levels and lipid profile (total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides). In group A blood samples for Hs-CRP were obtained on admission, at a time interval shorter than six hours from the onset of symptoms and stored at -70°C; also are taking samples for cardiac (Troponin I, Myoglobin, CK-MB) enzymes.

Carotid ultrasound was done by a single operator using an Aloka-Prosound SSD-4000SV system equipped with a 7.5 MHz linear array probe. Measurements were carried out at the far wall on the right and left common carotid artery, and the mean value was taken into account in the study (Figure 1).

Figure 1. Measurement method of CIMT.

1

2

1

2

Legend: Lumen-Intima interface (1); Media-Adventicia interface (2).

Bicycle Exercise testing (Cardiax – Stress ECG, Germany) was performed to assess exercise functional capacity (expressed in MET’s) using a protocol of Bruce. Exercise was continued until the heart rate reached 85% of the estimated maximum age predicted target heart rate for each patient, or was symptom limited. For the study are taken in consideration only patients which achieved ≥ 5 MET’s.

Diagnosis of acute coronary syndrome was established by the recommendations of the ESC (European Society of Cardiology) 2011th (Error: Reference source not found) and 2012th (Error: Reference source not found).

Statistics

All data are presented as the means ± SD or frequency (%), unless otherwise stated. The baseline clinical characteristics of the groups were compared using the two-tailed Student's t-test for continuous variables and the chi-square or Fisher's exact test for non-continuous variables, as appropriate. Statistical significance was set at the P < 0.05 level.

Results

Baseline clinical characteristics of the study population are summarized in Table 1.

Table 1. Baseline clinical characteristics of study populations.

Group A

Group B

Group C

P Value

Age (Years)

59.3±4.5

57.3±9.7

56.1±7.3

0.129 NS

Male n (%)

29 (67.44)

32 (64)

23 (46)

0.072 NS

Hypertension n (%)

18 (41.86)

17 (34)

9 (18)

0.038 S

Diabetes n (%)

22 (51.16)

22 (44)

11 (22)

0.022 S

BMI kg/m2

29.37±2.7

28.12±2.3

24.6±3.1

0.0001 S

Fasting Glucose mmol/L

7.3±2.15

6.94±1.81

5.733±2.29

0.001 S

Cholesterol total mmol/L

6.45±2.31

6.13±2.10

5.13±1.48

0.004 S

LDL-C mmol/L

4.53±1.27

4.1±1.01

2.97±1.11

0.0001 S

HDL-C mmol/L

0.95±0.32

1.05±0.29

1.41±0.34

0.0001 S

Triglycerides mmol/L

3.27±0.53

3.19±1.01

2.014±0.85

0.0001 S

Smoker’s n (%)

30 (69.77)

31 (62)

23 (46)

0.057 NS

CIMT values ​​were higher in group A and B, and the lower values of CIMT ​​were in group C (0.94 mm ± 0.21 mm, 0.89 mm ± 0.19 mm, 0.64 mm ± 0.09 mm), statistical analysis showed significant difference between group A and C (p <0.0001), and also between group B and C (p <0.0001). But, a significant difference was not found between group A and B (p> 0.05) (Figure 1).

Figure 1. Mean CIMT±SD for study groups.

Values of Hs-CRP ​​were significantly higher in group A (1.87 mg /L ± 0:36 mg /L), then the values of Hs-CRP in group B (1:07 mg /L ± 0:28 mg /L) and in group C (0.97 mg /L ± 0:45 mg /L) (p<0.0001). But, wasn't found significant difference between groups B and C (p>0.1) (Figure 2).

Figure 2. Mean Hs-CRP ±SD in studied groups.

Discussion

One of the most important results of this study is that CIMT can predict the presence of coronary artery disease, but it cannot be predicted coronary events. These data are consistent with the findings of other authors (Error: Reference source not found, Error: Reference source not found). However, the results of this study do not support the authors which suggest that CIMT is a good predictor of coronary events (Error: Reference source not found, Error: Reference source not found).

Another important fact in this study is that elevated levels of Hs-CRP seems to more coincide with plaque destabilization in cases of acute coronary syndrome, because the values of Hs-CRP does not differ significantly in cases with stable CAD than they are in healthy individuals. These data are not consistent with the data by many authors (Error: Reference source not found, Error: Reference source not found). Our results confirm data from previous studies by other authors (Error: Reference source not found, Error: Reference source not found) that elevated levels of Hs-CRP are manifestations of atherosclerotic plaque instability and a sign of increased risk of acute coronary events.

According to Ridker et al., (2003) Hs-CRP has established as independent risk factor for future cardiovascular events, and adds prognostic information at Framingham Risk Score (FRS), and at all levels of the metabolic syndrome (Error: Reference source not found). The findings of this study support this opinion.

Result from this study have shown that measurement of CIMT should be used as a tool to identify individuals with the presence of coronary atherosclerosis, but when these changes are associated with increased value ​​of Hs-CRP (in the absence of other causes for the growth of Hs-CRP) then destabilization of stable CAD should suspected.

Small sample size is a major limitation of this study; larger studies are needed to clarify the diagnostic value of CIMT to identify CAD, and usefulness of HS-CRP for prediction acute coronary syndrome in cases with increased CIMT.

Conclusion

CIMT is a non invasive predictor of coronary artery disease, but it has little prognostic value in predicting CAD events. While Hs-CRP is a good predictor of acute coronary events, but normal values ​​of Hs-CRP does not exclude the presence of stable coronary disease. Hs-CRP and CIMT analyzed together will help each other in the diagnosis of coronary disease, and for predicting coronary events. We support consensual statements for assessment of CIMT and Hs-CRP in individuals who are traditionally considered at moderate cardiovascular risk.



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