Petar Nikic, MD MS,1 Milan Savic, MD,2 Vladimir Jakovljevic, MD PhD,3 and Dragan Djuric, MD PhD41 Department of Neurology, General Hospital, Kruševac
2 Special Hospital for Prevention and Treatment of Cerebrovascular Diseases “St Sava”, Belgrade
3 Department of Physiology, Faculty of Medicine, University of Kragujevac, Kragujevac
4 Institute of Medical Physiology, Belgrade University School of Medicine, Belgrade, Serbia and Montenegro
Correspondence: Dr Dragan Djuric, Institute of Medical Physiology, Belgrade University School of Medicine, Višegradska 26\II, PO Box 783, Belgrade 11000, Serbia and Montenegro. Telephone 381-11-36-11-754, fax 381-11-684-558, e-mail drdjuric@EUnet.yu
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Abstract
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OBJECTIVES
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The present study examined the association between carotid atherosclerosis, coronary atherosclerosis and common carotid artery intima-media thickness (CCA-IMT) in patients with incident ischemic stroke and its subtypes (75 cases and 21 controls).
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METHODS
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Cases with ischemic brain infarctions (IBIs) were consecutively recruited and classified into subtypes by computed tomography and Bamford’s classification (the size and site of the infarct) as one of the following: total anterior circulation infarcts (TACIs); partial anterior circulation infarcts (PACIs); posterior circulation infarcts (POCIs); and lacunar infarcts. Controls were recruited among individuals hospitalized for a reason other than cerebrovascular disease at the same institutions and matched for age and sex. Patients and controls underwent B-mode ultrasonographic measurements of CCA-IMT, and were evaluated by a qualified internist and neurologist for the presence of ischemic coronary disease and a history of previous stroke or transient ischemic attack.
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RESULTS
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Of the 75 patients with an acute ischemic stroke, 10 (14%) were classified as TACIs, 34 (45%) as PACIs, 12 (16%) as POCIs and 19 (25%) as lacunar infarcts. Mean CCA-IMT was higher in patients (1.03±0.18 mm) than in controls (0.85±0.18 mm; P<0.0001).>CONCLUSIONS
An increased CCA-IMT as a marker of general atherosclerosis was associated with IBI and reflects cardiovascular risk. Carotid and coronary atherosclerosis were positively correlated with IBIs, with significant differences across the subtypes.
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DISCUSSION
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Atherosclerosis is consistently the cause of coronary artery disease and IBI. Stroke and myocardial infarction share common risk factors and pathological mechanisms, and are an important cause of death in older patients. Results of many studies suggest a significant positive relationship between the IMT of the CCA and vascular disease risk factors (11,12,14). This is very important in the primary prevention of cardiovascular complications (eg, sudden death, stroke and myocardial infarction), because an increased IMT can be used as an early marker of atherosclerosis (17–19,21). The present study was based on groups of patients and controls who had a large number of atherosclerosis risk factors. There was no difference in age, anthropometric data, diastolic blood pressure and total cholesterol between the two groups. All other main risk factors were identified more often in the study group. In agreement with previous reports, we found a highly significant correlation between far wall IMT of the CCA and IBI (12,16,26). Although this is a clinical study, our results are in line with observations from several previous large-scale population studies on the mean maximum far wall IMT of the CCA. However, it is important not to confuse the objectives of clinical versus epidemiological studies when reviewing our results. Epidemiological studies focus on samples or populations and not individuals. In addition, the following aspects should be carefully taken into account. First, there is no standardized method to measure the index of general atherosclerosis (CCA-IMT) by ultrasound. Moreover, there is no agreement on the carotid segments that should be investigated. Finally, many of these studies used an ultrasound scanning protocol that included carotid plaques in the measurement of the maximum IMT. The strongest data relating IMT measurement to cardiovascular events derive from the Atherosclerosis Risk in Communities (ARIC) study (15). In this prospective study, the relationship between carotid IMT and prevalent cardiovascular disease was studied over four to seven years of follow-up in 13,870 subjects aged 45 to 64 years. The results show increased IMT in participants with prevalent coronary artery disease, cerebrovascular disease and peripheral vascular disease. The carotid IMT in participants with cardiovascular disease was 10% greater in those with myocardial infarction, 6% greater in those with angina pectoris, 6% greater in those with cerebrovascular disease, 19% greater in those with peripheral vascular disease and 8% greater in those with any form of cardiovascular disease. The differences that were observed in IMT across disease groups are consistent with the associations between prevalent cardiovascular disease and carotid atherosclerosis found in previous clinical and epidemiological studies (15). In the Cardiovascular Health Study (CHS) (18), associations between the CCA-IMT and the incidence of new myocardial infarction or stroke in persons without clinical cardiovascular disease were studied in 5858 subjects older than 65 years of age. The relative risk of myocardial infarction or stroke increased linearly with IMT, and the relationship between cardiovascular events and IMT remained significant after adjustment for traditional risk factors. The study found a stronger association between IMT and stroke, possibly because IMT is a better predictor of complications on small vessels due to hypertension or due to some other aspects of physiological aging. However, some doubt still exists about the predictive power of IMT measurement as a screening tool for cardiovascular and cerebrovascular diseases, besides the well-established and easily detectable atherosclerosis risk factors (27).There are few studies that have explored the possible association between carotid artery IMT and cerebrovascular disease, and even fewer researchers have taken into account the different IBI subtypes (17,18,21,22). There is a highly significant relationship between IMT and IBI, both overall and in its four main subtypes (P<0.001).>
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