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

!