screening for preclinical athero- and arterio-sclerosis
TRANSCRIPT
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Jong-Won Ha, MD, PhD.
Yonsei Univ College of Medicine
Screening for preclinical athero-
and arterio-sclerosis, clinical
relevance?
4th Annual Symposium of the Korean
Vascular Research Working Group
March 8, 2008
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Why Vascular
Evaluation is
Important ?
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Vascular Pathology
• Atherosclerosis: inflammatory
process that selectively affects
arteries
• Senescence of the arterial tree: a
biologic process that follows a
natural course that can be
accelerated by the combined injury
of multiple risk factors
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Atherosclerosis
• Aorta
– Abdominal
– Thoracic
• Coronary artery and carotid artery
• Lower extremity arteries
• Upper extremity arteries
Early
Late
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60 year-old man with abdominal
pain and claudication
• DM for 6 years
• HTN for 8 years
• Colon polyp and diverticulosis
• Blood sugar: 178 mg/dl
• BUN/Cr: 30.6/3.0
• T-Chol/HDL/LDL: 163/29/88
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ECG
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Patient Clinical Course
• We recommended the aortic
arch replacement surgery but
patient refused
• Anticoagulation was started
• 2 months later, patient had a
fatal massive cerebral infarction
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Lesson from this patient
Role of Vascular
Imaging in
Decision Making
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Morphology Function
?
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Normal vs Stiff aorta
Normal Stiff
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Comparison of Elastic Properties of DTA
Between Patients with Stroke and Non-stroke
0
0.4
0.8
1.2
1.6
2
Compliance Distensibility Stiffness
Stroke
Non-Stroke
P<0.05P<0.05
P<0.05
Kang SM et al. Echocardiography 2000
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• The regional elastic properties of DTA measured by TEE with AQ and M-mode method were abnormal in stroke
• TEE with AQ technique may have a possible clinical application for the detection of early atherosclerotic changes such as alteration of elastic properties in morphological normal DTA
Comparison of Elastic Properties of
DTA Between Patients with Stroke
and Non-stroke
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• Stroke patients without atheroma
of DTA (n = 21) also had
significantly lower C (1.1 +/- 0.4 vs
1.5 +/- 0.7 x 10(-3) cm2 mmHg(-1), P
= 0.038) and lower D (3.5 +/- 1.4 vs
4.8 +/- 2.4 x 10(-3) mmHg(-1), P =
0.021) than non-stroke patients
Comparison of Elastic Properties of
DTA Between Patients with Stroke
and Non-stroke
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• Structural (or functional)
alterations precedes
morphological changes
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•Aortic stiffening
was not inevitable
in older persons
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Carotid Artery Ultrasound
1982 James et al
First description of ultrasound
appearance of the carotid
arterial wall
“Thin inner – thick
outer lines”
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Intima + Media Thickness Measurement
IMT = distance between the bright lines
CCA IMT < 1.0 mm
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Carotid IMTEarly Studies
CCA IMT correlates with disease
in the coronary arteries
–Salonen et al, 1993: Each 0.1 mm
IMT increase = 11% in AMI risk
– IMT proposed as potential marker
for coronary artery disease
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Correlation between CV disease
and carotid artery wall thickness
8
9
10
11
12
13
14
15
1 2 3 4
Quartile of carotid artery wall thickness
Burke et al, 1995
(Thinnest) lThickest)
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Carotid Artery Imaging
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Feinstein SB. JACC July 18, 48:2360243, 2006
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Feinstein SB. JACC July 18, 48:2360243, 2006
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Two different TR signals
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Simplified Bernoulli Equation
∆ P = 4V2
CP971277-7
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Two different TR signals
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Two different LVOT signals
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20 year-old man
Rest 25W 50W 75W
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SBP/ DBP 103/ 75 mmHg
PP 28 mmHg
HR = 58 bpm
Aortic AIx 18 %
Aortic AIx (HR 75) 10 %
At Rest
Peak Exercise (100 W)
SBP/ DBP 115/ 71 mmHg
PP 44 mmHg
HR = 94 bpm
Aortic AIx -1 %
Aortic AIx (HR 75) 8 %
M/ 20
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74 year-old man
Rest 25 W 50 W
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SBP/ DBP 130/ 77 mmHg
PP 53 mmHg
HR = 51 bpm
Aortic AIx 45 %
Aortic AIx (HR 75) 33 %
At Rest
Peak Exercise (50 W)
SBP/ DBP 200/ 127 mmHg
PP 73 mmHg
HR = 57 bpm
Aortic AIx 37 %
Aortic AIx (HR 75) 28 %
M/ 74
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The Parameters of LVOT
Doppler
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Change of DT/ AT During Exercise
-0.3
-0.1
0.1
0.3
0.5
0.7
Rest to 25 Watt Rest to 50 Watt
* *
* p < 0.05
□ 20-29 30-39 ■ 40-49 50-59 ■ 60-69
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US for Vascular Imaging
• Excellent imaging tool for the evaluation of arteries
• Gives morphologic and functional information
• Detect preceding functional changes of arterial tree before overt atherosclerosis
• New techniques for analysis
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Yonsei Cardiovascular Hospital
Yonsei University College of Medicine