Carotid IMT and stiffness provide additional p information to standard ultrasound examination

S. Carerj, MD, FESC, C.Zito MD PhD Cardiology, University of Messina, Italy

ATHEROSCLEROSIS

5% 19% 24% 14% 12% 5% 54% 18% 13% 6%

4% 000% 000%

52%

Atherotrombosis Infections Accidents

Cancer Pulmonary disease AIDS

Coronary heart disease Stroke Other Congestive heart failure High blood pressure Diseases of the arteries Rheumatic fever or rheumatic heart disease

*Cardiovascular disease, ischemic heart disease and cerebrovascular disease. Worldwide defined as Member States by WHO Region (African, Americas, Eastern Mediterranean, European, South-East Asia and Western Pacific)

Congenital cardiovascular defects

The World Health Report, 2000, WHO Geneva, 2000

Perc. breakdown of deaths from cardiovascular diseases AHA - Heart Disease and Stroke Statistical Update 2001

Pyramid of atherosclerosis

AMI Rest Echo WMA Stroke Inducibile Ischemia=WMA Echostress + CFR Obstructive arterial process: Plaque with artery flow conditioning Intrusive Arterial Process Stiffness

Endothelial dysfunction

Early Quantitative Evaluation of Atherosclerosis

Evaluation of endothelial function (FMD) Evaluation of Hardness of Blood Vessel Walls Pulse Wave velocity (PWV) : Stiffness of blood vessels is indirectly presumed from the velocity of pulse waves travelling a certain distance between the carotid artery and the femoral artery. This is useful to know the condition of the entire vascular system system. Pressure-strain Elasticity Modulus (Ep) and Stiffness Parameter (). PressureEp) These indices directly indicate stiffness of local arterial walls. y Arterial Compliance (AC). This index indicates extensibility of a blood vessel. Augmentation index Evaluation of Organic Change: IMT (Intima-Media Thickness) Evaluation (Intima Media measurement is useful in the judgment of the level of atherosclerosis

Why the carotid artery?

Accessible and meaningful Wall thickening and prevalence of atherosclerosis are associated with coronary and cerebrovascular events Increased stiffness reflects stiffening of proximal aorta aorta, causing (systolic) hypertension Which characteristics? Intima media Intima-media thickness (IMT): early atherosclerosis Stiffness: arteriosclerosis
Polak JF, Ultrasound Q 2009 Simon A, ATVB 2010 Brandts A, Radiology 2009

What is QIMT?
Quality Intima Media Thickness (RFQIMT)
Measure in micrometer the distance between Intima and Adventitia (IMT)

Healthy Vessel Diameter : 5.93 mm IMT : 324 m

Patient Vessel Diameter : 6.61 mm IMT : 976 m

Frame rate 30 frames/s

Why RF signal?
There is a strong interaction between RF signal and tissue intrinsically characteristics It contains 100% of the detected US signal information (the following signal processing will introduce minimal approximation which will alter micrometric information) Allows Real Time analysis under a constant accurate measurement monitoring

Quality FEEDBACK for RFQIMT

Homogeneity of the measure profile (green)

Standard deviation

Synchronism with ECG (Vessel pulsation)

Quality FEEDBACK for RFQIMT

: NEWS

ECG sync + Standard Deviation with value visualization Orange > 21 < Green

RF versus video IMT

RF
Operator dependence Reproducibility p y Processing speed no 21 m real-time

video
yes ~ 50 m off-line labor intensive

Droste et al. Cerebrovasc Dis 2010

ACC 34th Bethesda Conference Task Force 4: How do We Select Patients for Atherosclerosis Imaging? Patients at intermediate risk f total CVD for C p comprise about 40% of the adult population. They have at least 1 major risk CVD factor and have a 6-20% 10-year risk of a hard CVD events, possibly warranting f th t ibl ti further risk stratification by noninvasive tests to assess atherosclerotic burden.
Wilson, S ith Bl Wil Smith, Blumenthal, W th l Wong, 34th B th d C f Bethesda Conference T k Task Force 4, J Am Coll Cardiol 2003

Carotid IMT and Incident CV Events

1288 Finnish men; age 40-60 years, follow-up period 2 years Relative Hazard of Coronary Events

8 7 6 5 4 3 2 1 0

6,71

4,15 2,17 1 Normal IMT Plaque Stenosis

Salonen JT et al. Arteriosclerosis and Thrombosis, 1991;11:1245

Combined intimal-medial thickness predicts total MI and stroke

Physiologic Porperties of The Aorta

Cavalcante JL, JACC 2011

Insulting Leading To Structural Changes in The Aorta and Its Functioning

Cavalcante JL, JACC 2011

The Reflected Flows

- Pumped Blood Flow - Reflected Blood Flow from each bifurcations Sum of All Reflected Blood Flows

Bifurcations Level

Aortic Flow Vessel walls Distension Systemic Pressure

Aortic V l Closure A ti Valve Cl

Distension

Reflected wave Slow

Elastic vessel

Stroke Volume
Stiff vessel

Aortic A ti Flow

Reflected wave Fast

Arterial-Ventricular Coupling: Role of the Stiffness

Vlacahopoulos C, Cardiology 2010

Intrinsic and Extrinsic Parameters that influence Systemic Circulation

Vessel properties and

Nathaniel Dittoe; Crit Care Med 2007

Device and methods for determing arterial Stiffness i l S iff

Laurent S. Eur Heart J 2006

Position Statement of European Network for Non-invasive Investigation of Large Arteries

S. Laurent , Eur J Cardiol 2006

Whats RFQAS?
Quality Arterial Stiffness (RFQAS)
Evaluation of the vessel walls E l ti f th l ll Distension due to Pressure Wave mechanical push of the Pressure Wave. This wave is generated by the blood flow through the Sistole/Diastole cardiac phases p
Frame rate 486 frames/s

Normal stiffness Diameter: 7 04 mm 7.04 Distension: 536 m Stiffness PWV: 5.7 m/s

RFQAS

: What it measures?

Diameter Change of Diameter Ch f Di

Distension

Stiffness
Brachial AP
Local AP

Blood Pressure

RFQAS

: Report
QAS WorkSheet an Report

Relationship Between Aorta and Carotid

Paini A, Hypertension 2006

Prediction of Cardiovascular Events With Stiffness Parameters

Vlachopoulos C, J Am Coll Cardiol. 2010; 55: 13181327.

A man is as old as his arteries

Thomas Sydenham (1624-1689 y (

Age:24 Age:45 A 45 PWV: 5.3 m/s PWV: 8.1 m/s

We gathered data from 16 867 subjects and patients from 13 different centres across eight European countries, in which PWV and basic clinical parameters were measured. Of these, 11 092 individuals were free from overt CV di f t disease, non-diabetic and untreated by di b ti d t t db either anti-hypertensive or lipid-lowering drugs and constituted the reference value population, of which the subset with optimal/normal blood pressures (BPs) (n =1455) is the normal value population.

Normalvaluesforpulsewavevelocity: averageaccordingtoage(1455subjects) average according to age (1455 subjects)

P.Boutouyrie,EurHeartJourn2010

Box and whiskers Plot for IMT and -index for controls, controls primary hypercholesterolemic (PHC) and familial hypercholesterolemics (FH)

Riggio S, Eur J Clin Invest 2010

Box and whiskers Plot for PWV and AIx for controls, primary hypercholesterolemic controls (PHC) and familial hypercholesterolemics (FH)

Eur J Clin Invest 2010

STIFFNESS PARAMETERS IN PATIENTS WITH DIFERENT CLUSTERS OF RISK FACTORS AND NORMAL IMT
No. 75 subjects p < 0.001 No. 75 subjects p < 0.01

Mohammed M, submitted

STIFFNESS PARAMETERS IN PATIENTS WITH DIFERENT CLUSTERS OF RISK FACTORS AND NORMAL IMT

(Stiffness
parameter) rho Absence of risk factors Presence of single risk factor Presence of two or more risk factors 0.353 0 353 0.319 0.423 p 0.00 0 00 0.03 0.00

PWV
rho 0.435 0 435 0.369 0.513 p 0.00 0 00 0.00 0.00

Mohammed M, submitted

STIFFNESS PARAMETERS IN PATIENTS WITH DIFERENT CLUSTERS OF RISK FACTORS AND NORMAL IMT

Male, 41 yrs hypertensive

Male, 64 yrs hypertensive and diabetic

Linear Regression between Beta, PVW and g Anti-Scl 70 Ab

Cusm Piccione M Angiology 2011 M.,

Case 1

Case 1

RCA

LCA

Case 2

Case 2

LAD

RCA

Thanks for your attention