This article has Open Peer Review reports available.
Appropriateness of carotid plaque and intima-media thickness assessment in routine clinical practice
© Baroncini et al; licensee BioMed Central Ltd. 2008
Received: 02 September 2008
Accepted: 16 October 2008
Published: 16 October 2008
To describe the findings and evaluate appropriateness of a carotid artery study including the measurement of IMT, the presence of atherosclerotic plaque, and their correlation with cardiovascular risk factors.
555 patients (220 men; 67.06 ± 12.44 years) were included in the study. 120 patients (21.62%) presented carotid plaque: 108 (19.45%) in patients with at least one risk factor and 12 (2.1%) in patients without risk factors. With respect to appropriateness of the present studies: 65% were appropriate, 22% were uncertain and 13% were inappropriate. The IMT medians were higher in males (0.0280; 95% CI, 00.82 to 0.478; p = 0.0057) and in hypertensive patients (0.391; 95% CI, 0.0190 to 0.0592; p = 0,001). There was a linear increase in mean IMT for each year increased in age (0.0059; 95% CI; 0.0050 to 0.0067). Carotid plaque was more frequent in patients with CAD (p = 0.0002), diabetes (p = 0.024) and hypertension (p = 0.036).
Assessment of carotid arteries identified increased incidence of plaque in patients with CAD, diabetes and hypertension. IMT was increased in older patients, hypertensive patients and males. Forty-five percent of the patients were studied based on uncertain and inappropriate reasons.
It has been proven that the atherosclerotic changes in the carotid artery mirror general atherosclerosis. Ultrasound measurements of IMT and plaque occurrence in the carotid arteries are important not only for the assessment of structural alterations but also because the extent of atherosclerosis in these vessels reflects the severity of arterial damage in other vascular territories . Epidemiological studies and clinical trials have shown that carotid artery intima-media thickness can identify prevalent and incident cardiovascular disease (CVD) events, and progression and regression of atherosclerosis . Intima-media thickness (IMT) of the carotid arteries is increasingly used in clinical trials as an important risk marker to investigate normal aging and preclinical atherosclerosis . Several studies demonstrated that carotid IMT is significantly associated with risk for myocardial infarction, stroke, death from coronary artery disease, or a combination of these events . Interestingly, in daily clinical practice, with the diffusion of knowledge and the education of public opinion, many physicians request carotid ultrasound studies even in patients without cardiovascular risk. We carried out this study to describe the findings and evaluate the appropriateness of carotid artery studies with ultrasound, including the measurement of ITM; the presence or not of atherosclerotic plaque; and their correlation with traditional cardiovascular risk factors in routine exams from our Doppler vascular laboratory.
Patient's baseline characteristics
Patients with risk factors (N/%)
Age (y ± SD)
67.6 ± 11.7
History of hypertension (N/%)
History of dyslipidemia (N/%)
History of diabetes mellitus (N/%)
Cardiovascular history (N/%)
Current smoking (N/%)
Patients without risk factors (N/%)
Age (y ± SD)
64.6 ± 15.1
Indications for carotid ultrasound study (N/%)
Patients with risk factors
Dizziness or vertigo
Transient amnesia or disorientation
Previous carotid artery disease
Patients without risk factors
Dizziness or vertigo
Transient amnesia or disorientation
Previous carotid artery disease
Measurements were made with a high-resolution B-mode ultrasonography (Philips Medical Systems' HD11 platform) with a broadband width linear array transducer L 3–12 MHz. Sonography and readings were carried out by trained and certified sonographers. Measurements of IMT were take on the distal 10 mm of both right and left common carotid artery in the far wall. Five determinations were conducted on each side and the average measurement was used for the IMT. An artery was classified as being affected by plaque if there was a localized thickening > 1.5 mm that did not uniformly involve the whole left or right carotid artery with or without flow disturbance. The vascular ultrasonographist identified plaques on common, internal and external carotids at the time of ultrasound measurement.
Categorical variables were expressed as percentages and continuous variables were expressed as mean ± SD, with a 95% confidence interval (CI) and a significance level of 5%. Multiple linear regression analysis was used to assess the association between cardiovascular risk factors and IMT. Age and sex were used as control variables. Twenty-five IMT measurements identified as possible outliers or influential cases were eliminated using the DFFITS procedure. χ2 test with Yates correction was used to correlate each risk factor and the presence of plaque. The regression logistic model was used to assess all variables with respect to the presence of plaque. Statistical significance was indicated by a value of p < 0.05. Analyses were performed using Statistica/W version 5.1 (StatSoft, Tulsa, Okla.).
Ultrasound measurements (95% CI)
In a routine vascular laboratory the assessment of carotid arteries identified increased incidence of plaque in patients with CAD, diabetes and hypertension. In addition, carotid IMT was increased in hypertensive patients and males. Older patients presented higher values of carotid IMT. Forty-five percent of the studies were categorized as uncertain and inappropriate.
- Benedetto FA, Mallamaci F, Tripepi G, Zoccali C: Prognostic value of ultrasonographic measurement of carotid intima-media thickness in dialysis patients. J Am Soc Nephrol. 2001, 12: 2458-2464.PubMedGoogle Scholar
- Gepner AD, Keevil JG, Wyman RA, Korcarz CE, Aeschlimann SE, Busse KL, et al.: Use of carotid intima-media thickness and vascular age to modify cardiovascular risk prediction. J Am Soc Echocardiogr. 2006, 19: 1170-1174.View ArticlePubMedGoogle Scholar
- Touboul PJ, Hennerici MG, Meairs S, Adams H, Amarenco P, Desvarieux M, et al.: Mannheim intima-media thickness Consensus. Cerebrovasc Dis. 2004, 18: 346-349.View ArticlePubMedGoogle Scholar
- Stein JH, Korcarz CE, Hurst RT, Lonn E, Kendall CB, Mohler ER, et al.: ASE Consensus Statement. Use of carotid ultrasound to identify subclinical vascular disease and evaluate cardiovascular disease risk: a consensus statement from the American Society of Echocardiography. Carotid Intima Media-Thickness Task Force endorsed by the Society of Vascular Medicine. J Am Soc Echocardiogr. 2008, 21: 93-111.View ArticlePubMedGoogle Scholar
- Touboul PJ, Hennerici MG, Meairs S, Adams H, Amarenco P, Bornstein L, et al.: Mannheim carotid intima-media thickness consensus. Cerebrovasc Dis. 2007, 23: 75-80.View ArticlePubMedGoogle Scholar
- Hurst RT, NG DWC, Kendall C, Khandheria B: Clinical use of carotid intima-media thickness: review of the literature. Echocardiogra. 2007, 20: 907-914. 10.1016/j.echo.2007.02.028.View ArticleGoogle Scholar
- Potter K, Reed CJ, Green DJ, Hankey GJ, Arnolda LF: Ultrasound settings significantly alter arterial lumen and wall thickness measurements. Cardiovascular Ultrasound. 2008, 6: 6-View ArticlePubMedPubMed CentralGoogle Scholar
- Toikka JO, Laine H, Ahotupa M, Haapanen A, Viikari JSA, Hartiala JJ, et al.: Increased arterial intima-media thickness and in vivo LDL oxidation in young men with borderline hypertension. Hypertension. 2000, 36: 929-933.View ArticlePubMedGoogle Scholar
- Barenbrock M, Hausberg M, Kosch M, Golubev SA, Kisters K, Rahn KH: Flow-mediated vasodilatation and distensibility in relation to intima-media thickness of large arteries in mild essential hypertension. Am J Hypertens. 1999, 12: 973-979.View ArticlePubMedGoogle Scholar
- Cromheeke KM, Kockx MM, De Meyer GRY, Bosmans JM, Bult H, Beelaerts WJF, et al.: Inducible nitric oxide synthase colocalizes with signs of lipid oxidation/perioxidation in human atherosclerotic plaques. Cardiovascular Research. 1999, 43: 744-754.View ArticlePubMedGoogle Scholar
- Thakory AH, Guo CY, Larson MG, Corey D, Wang TJ, Vasan RS, D'Agostino RB, Lipinska I, Keaney JF, Benjamin EJ, O'Donnell CJ: Association of multiple inflammatory markers with carotid intimal medial thickness and stenosis (from the Framingham Heart Study). Am J Cardiol. 2007, 99: 1598-1602.View ArticleGoogle Scholar
- Mustafa A, Walls J: End-stage renal disease, atherosclerosis, and cardiovascular mortality: Is C-reactive protein the missing link?. Kidney International. 2001, 59: 407-414.View ArticleGoogle Scholar
- Damas JK, Waehre T, Yndestad A, Gullestad L, Aukrust P: Atherosclerotic plaque stabilization – potential role of immunomodulatory therapy. Vascular Disease Prevention. 2004, 1: 17-31. 10.2174/1567270043480832.View ArticleGoogle Scholar
- Fujisawa M, Haramaki R, Miyasaki H, Imaizumi T, Okusa S: Role of lipoprotein (a) and TGF-β1 in atherosclerosis of haemodialysis patients. J Am Soc Nephrol. 2000, 11: 1889-1895.PubMedGoogle Scholar
- Shishehbor M, Bhatt DL: Inflammation and atherosclerosis. Current Atherosclerosis Reports. 2004, 6: 131-139.View ArticlePubMedGoogle Scholar
- Gosling J, Slaymaker S, Gu L, Tseng S, Zlot CH, Young SG, Rollins BJ, Charo IF: MCP-1 deficiency reduces susceptibility to atherosclerosis in mice that overexpress human apolipoprotein B. J Clin Invest. 1990, 103: 773-778. 10.1172/JCI5624.View ArticleGoogle Scholar
- Lombardo A, Biasucci LM, Lanza AG, Coli S, Silvestri P, Cianflone D, Liuzzo G, Burzotta F, Crea F, Maseri A: Inflammation as a possible link between coronary and carotid plaque instability. Circulation. 2004, 109: 3158-3163.View ArticlePubMedGoogle Scholar
- Lee WY, Allison MA, Kim DJ, Song CH, Barret-Connor E: Association of interleukin-6 and C-reactive protein with subclinical carotid atherosclerosis (the Rancho Bernardo Study). Am J Cardiol. 2007, 99: 99-102.View ArticlePubMedGoogle Scholar
- Crouse JR, Raichlen JS, Riley WA, Evans GW, Palmer MK, O'Leary DH, Grobbee DE, Bots ML: Effect of rosuvastatin on progression of carotid intima-media thickness in low-risk individuals with subclinical atherosclerosis. JAMA. 2007, 297: 1344-1353.View ArticlePubMedGoogle Scholar
- Langenfeld MR, Forst T, Hohberg C, Kann P, Lübben G, Konrad T, Füllert SD, Sachara C, Pfützner A: Pioglitazone decreases carotid intima-media thickness independently of glycemic control in patients with type 2 diabetes mellitus: result from a controlled randomized study. Circulation. 2005, 111: 2525-2531.View ArticlePubMedGoogle Scholar
- Nissen SE, Nicholls SJ, Sipahi I, Libby P, Raichlen JS, Ballantyne CM, Davignon J, Erbel R, Fruchart JC, Tardif JC, Schoenhagen P, Crowe T, Cain V, Wolski K, Goormastic M, Tuzcu EM: Effect of very high-intensity statin therapy on regression of coronary atherosclerosis. The Asteroid Trial. JAMA. 2006, 295: 1556-1565.View ArticlePubMedGoogle Scholar
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.