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Carotid IMT and Prevention
TATJANA RUNDEK, MD PhDProfessor of Neurology, Epidemiology and Public Health Director, Clinical translational DivisionDepartment of Neurology, Miller School of Medicine,Miami Florida, USA
LECTURE
Jan 18, 2013, 11:30-11:45 am
Definition
Vascular Risk/Stroke Risk
Should we screen for IMT?
Carotid IMT & Prevention
What is Carotid cIMT?
US Measure of ATH ?
EndotheliumIntima
Media
Consensus documents
ASE CONSENSUS; Soc Vas Med. JASE. 2008
Carotid IMT protocols: Where to measure ?
Lorenz MW et al. Circulation 2007.
CIMT >75th percentile (>1mm) are considered high and indicative of increased CVD/Stroke risk
(2-5x)
Carotid IMT and risk of MI, StrokeLarge population based studies
Lorenz MW et al. Circulation 2007.
ASE CONSENSUS STATEMENT (Soc Vas Med)JESI 2008
IMT in Clinical Trials
Amarenco P at al. Stroke 2004
ENHANCE, IMPROVE-IT,
ILLUMINATE, RADIANCE 1,2
Nissen SE at al. NEJM 2007;356:1304-16
Should we screen for IMT?
Yes, No, Maybe…..
Screening for Nontraditional Markers
cIMT, CAC, ABI
hsCRP, Leu, Homocysteine, lipoprotein(a)
periodontal disease
Insufficient evidence to support
their routine use!
Ann Intern Med 2009;151:474-82.
No
US Preventive Services Task Force
Who should be screened forCarotid IMT/Plaque?
Intermediate risk:
10%-20% 10-year risk of CHD
*Maybe be miscalibrated among women and young men (6-20%)
ASE CONSENSUS STATEMENT (Soc Vas Med);NHANCE III
Prevalence in the US adult population over age 20
Low Risk <10% 35%
Intermediate 10-20%* 40%
High >20% 25%
Yes
Cao, JJ. at al. Circulation 2007;116:32-38; Nambi V. at al. ARIC. JACC 2010
Does IMT Adds to Traditional Risk Factors in Prediction of CHD in ROC Analysis?
ALL CHD
ALL
Cause
Mortality
RF=0.694 RF+CRP=0.70 RF+IMT=0.71
RF=0.75
RF+CRP=0.75
RF+IMT=0.77
IMT Meta-Analysis: IMT in Screening for CHD
Recent IMT Meta-AnalysiscIMT regression in clinical trials
Costanzo, P. et al. Does cIMT regression predict reduction of CVD events? A meta-analysis of 41 randomized trials. JACC 2010: 56, 2006–20. N=18,307
Conclusion:
Regression or slowed progression of cIMT, induced by
CVD meds do not reflect reduction in CV events.
Recently published on CIMT: USE-IMT
Recently published on CIMT: PROG-IMT
Lancet 2012; 379: 2053–62
InterpretationThe association between cIMT progression assessed from 2 US scans and CVD risk in the general population remains unproven. No conclusion can
be derived for cIMT progression as a surrogate in clinical trials.
2010 ACCF/AHA Guidelines for assessment of CV risk in asymptomatic adults
Circulation 2010;122: 2748-2764
cIMT/plaque Class IIa B
FRS Class Ib B
CAC Class IIa B
CRP Class IIa B
ECG Class IIa C
ABI Class IIa B
MRI plaque NO Benefit
Evidence
IMT: ICAL 2013 Standards
Each screening exam must include: Age, sex, race associated risk (standardized
IMT tables should be used) Plaque characteristics/size should be
reported separately IMT report must include SD (or predicted
ranges) based on age and sex Specific measures (mean, max, mean of
max, etc.) should be used on the basis of the risk prediction used for interpretation
IMT: ICAL 2013 Standards
The IAC does not advocate use of CIMT as a screening method for ath risk until further peer-
reviewed literature is available.
If providers choose to perform CIMT testing, rigorous methodological protocols should be
strictly followed
!