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Effect of Carotid Atherosclerosis Screening on Risk
Stratification During Primary Cardiovascular
Disease Prevention
Robert L. Bard, MA, Henna Kalsi, MD, Melvyn Rubenfire, MD, Thomas Wakefield, MD, Beverly Fex, RVT, Sanjay Rajagopalan, MD, and Robert D. Brook, MD We investigated the effect that carotid plaque area
risk, and 35% (IMT) and 27% (CPA) were identified
(CPA) and intima media thickness (IMT) measure-
as high risk. These tests adjust the risk strata of
ments have on risk stratification in 95 patients with
>63% of patients deemed as having intermediate
intermediate Framingham scores (6% to 19%). The
risk by Framingham scores. 2004 by Excerpta
risk status of each patient was adjusted to be low,
Medica, Inc.
intermediate, or high based on the results of carotid
(Am J Cardiol 2004;93:1030 –1032)
ultrasound. After carotid testing, 44% (IMT) and
45% (CPA) of the intermediate-risk patients were
stratified as low risk, and 22% (IMT) and 40%
(CPA) were stratified as high risk. Using the thresh-

Measurement of carotid intima media thickness
(IMT) improves cardiovascular risk assessment, old values derived from our laboratory, 28% (IMT)
particularly in patients with intermediate Framingham and 45% (CPA) of patients were stratified as low
An abnormal IMT is an independent predic-tor of increased cardiovascular and it has From the Division of Cardiovascular Medicine and Section of Vas- been suggested that patients with values Ͼ1.0 mm cular Surgery, Department of Surgery, University of Michigan, Ann should be treated more aggressively than similar pa- Arbor, Michigan. Dr. Brook’s address is: 3918 Taubman Center, tients with a normal It is unknown how many 1500 East Medical Center Drive, Ann Arbor, Michigan 48109.
intermediate-risk patients’ therapies would change E-mail: Manuscript received September 29, based on carotid ultrasound results. Therefore, we 2003; revised manuscript received and accepted December 24,2003.
investigated the effect of carotid IMT and carotid 2004 by Excerpta Medica, Inc. All rights reserved.
The American Journal of Cardiology Vol. 93 April 15, 2004 TABLE 1 Clinical Characteristics of the Intermediate-risk
This project was approved by the institutional re- view board of the University of Michigan Medical School. We performed a retrospective analysis of the first 200 consecutive patients who had carotid IMT and CPA tests performed clinically. Data were ob- tained from each patient to calculate a Framingham Patients were risk stratifias low (Յ5%), inter- Framingham risk scores. Only intermediate-risk pa- tients (n ϭ 95) without established cardiovascular disease or risk equivalents (peripheral vascular dis- *Positive family history is equal to first-degree relative with documented ease, diabetes mellitus, symptomatic carotid disease, cardiovascular disease or event at Ͻ55 (male relative) or Ͻ65 (female and aortic disease) were considered for this study because this population’s medical management is the †Hypertension denotes previous diagnosis of elevated blood pressure most likely to be affected by the results of ultra- and/or currently on antihypertensive medication.
‡Hyperlipidemia history denotes previous diagnosis of elevated serum li- poproteins and/or currently on lipid-lowering medications.
Risk stratification was adjusted using established and CPA9 values from the literature (IMT riskstrata: low Ͻ0.80 mm, intermediate 0.80 to 0.99 mm,high Ն1.0 mm; CPA risk strata: low 0 mm2, interme- TABLE 2 Risk Assessment Results from the 95 Intermediate-
diate 0.01 to 12 mm2, high Ͼ12.0 mm2) and the 25th and 75th percentile values from our laboratory. The population of 200 patients included 62 low-, 95 inter- mediate-, and 43 high-risk patients as defined by the The carotid ultrasound tests were performed in an *Framingham risk score is equal to the absolute risk of “hard” cardiovascu- Intersocietal Commission for the Accreditation of lar disease events (myocardial infarction, cardiovascular death, or new-onset Vascular Laboratories-approved diagnostic vascular unstable angina) within a 10-year period.
unit using a 7.5-MHz linear array transducer con- nected to a Powervision ultrasounddevice (Toshiba, Inc., Tustin, Cali-fornia). On-screen measurements ofand were determined aspreviously described in the literature.
risk assessment results of the 95 in-termediate-risk played in and respec-tively. The median Framingham riskscore was 9, the range was 6 to 18,and the 25th and 75th percentileswere 7 and 13, respectively.
rived from IMT and CPA assess-ments (using either threshold crite-rion) differed substantially from theresults of the clinical Framinghamrisk scores and respec-tively).
changed in most patients (Ն63% ofcases). IMT and CPA changed the FIGURE 1. Effect of carotid IMT and CPA on subsequent risk stratification based on
criteria from the research literature. Risk category criteria are listed above each bub-
ble. Mean values for each category are listed below the bubbles in the flowchart.
Absolute number and percentage of patients stratified by risk to each category are

inside each bubble.
assessments differed in most patientsand respectively). IMTand CPA stratified patients identi- plaque area (CPA) measurements on the risk stratifi- cally in only 42% (literature review) and 38% (inter- cation of patients with intermediate Framingham risk nal laboratory data) of cases. However, risk stratifica- tion differed by Ͼ1 level (e.g., low risk by IMT vs high risk by CPA) in very few situ-ations (14% to 17% of cases).
IMT and CPA changed the risk stra-tum in most patients deemed as in-termediate risk by clinical criteriaalone. This result suggests that IMTand CPA may be useful modalities toenhance risk assessment beyond theFramingham risk score. Many pa-tients without known atheroscleroticdisease were found to have an abnor-mal IMT (22% to 35%) or CPA(27% to 40%), thus placing them inthe highest-risk category (equivalentto the risk of coronary heart disease).
values for IMT or CPA do not cur-rently exist. Different threshold cri- FIGURE 2. Effect of carotid IMT and CPA on subsequent risk stratification based on
threshold values from our vascular laboratory. Risk category criteria are listed above

each bubble. Mean values for each category are listed below the bubbles in the flow-
chart. Absolute number and percentage of patients stratified by risk to each category
are inside each bubble.
very similar findings in our study.
Additional research is necessary tobetter define clinically useful CPA and IMT threshold values (e.g., age and risk factor TABLE 3 Agreement Between Carotid IMT and CPA in the
adjusted risk categories) and to determine the long- Cardiovascular Risk Stratification of Intermediate-risk Patients term clinical outcome of tailoring medical therapy According to Threshold Values Derived from the MedicalLiterature* based upon risk assessment modalities.
1. Greenland P, Smith SC, Grundy SM. Improving coronary heart disease risk
assessment in asymptomatic people. Role of traditional risk factors and nonin-
vasive cardiovascular tests. Circulation 2001;104:1863–1867.
2. Smith SC, Greenland P, Grundy SM. Prevention Conference V. Beyond
secondary prevention: identifying the high-risk patient for primary prevention.
Executive summary. Circulation 2000;101:111–1116.
*Each value represents the number of patients (n ϭ 95).
3. Aminbakhsh A, Mancini GBJ. Carotid intima-media thickness measurements:
what defines an abnormality? A systemic review. Clin Invest Med 1999;22:149 –
4. Simon A, Gariepy J, Chironi G, Megnien JL, Levenson J. Intima-media
thickness: a new tool for diagnosis and treatment of cardiovascular risk. J Hy-
2002;20:159 –169.
TABLE 4 Agreement Between Carotid IMT and CPA in the
5. Mukherjee D, Yadav JS. Carotid artery intimal-medial thickness: indicator of
Cardiovascular Risk Stratification of Intermediate-risk Patients atherosclerotic burden and response to risk factor modification. Am Heart J According to Threshold Values Derived from Our Vascular 6. O’Leary DH, Polak JF, Kronmal RA, Manolio TA, Burke GL, Wolfson SK.
Carotid-artery intima and media thickness as a risk factor for myocardial infarc-
tion and stroke in older adults. N Engl J Med 1999;340:14 –22.
7. Hodis HN, Mack WJ, LaBree L, Selzer RH, Liu CR, Liu CL, Azen SP. The
role of carotid arterial intima-media thickness in predicting clinical coronary events. Ann Intern Med 1998;128:262–269.
8. del Sol AI, Moons KGM, Hollander M, Hofman A, Koudstaal PJ, Grobbee DE,
Breteler MMB, Witteman JCM, Bots ML. Is carotid intima-media thickness useful in cardiovascular disease risk assessment? The Rotterdam Study. Stroke 2001;32:1532–1538.
9. Spence JD. Ultrasound measurement of carotid plaque as a surrogate outcome
*Each value represents the number of patients (n ϭ 95).
for coronary artery disease. Am J Cardiol 2002;89(suppl):10B–16B.



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