|Year : 2014 | Volume
| Issue : 2 | Page : 84-87
Prevalence and predictors of carotid artery atherosclerosis and its association with coronary artery disease in north Indian population
Zafar Ali Wani1, Riyaz Ahmad Bhat1, Imran Khan1, Irfan Khan2, Tahir Saleem1, Zeeshan Wani3
1 Department of General Medicine, Sher-i-Kashmir Institute of Medical Sciences, Soura Srinagar, Kashmir, India
2 Department of Pathology, Government Medical College, Jammu, Jammu and Kashmir, India
3 Department of Gastroenterology, ILBS, New Delhi, India
|Date of Web Publication||3-Oct-2014|
Riyaz Ahmad Bhat
Flat F 18, Married Hostel, Sher i Kashmir Institute of Medical Sciences, Soura, Srinagar 190 011, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Background: The reported prevalence of concomitant coronary and carotid atherosclerotic disease has varied among studies due to differences in study populations and methodologies used.
Objectives: The purpose of the study was to know the prevalence of carotid atherosclerotic disease and to evaluate the relationship between coronary and carotid atherosclerotic disease.
Materials and Methods: We performed a prospective study from December 2010 to November 2012 to determine the association of carotid artery stenosis (CAS) with documented coronary artery disease on Angiography in Kashmiri population. Continuous variables were expressed as mean ± SD. Two-sided unpaired "t"- test was performed for continuous variables and x 2 test for discrete variables. Multivariate stepwise logistic regression analysis was performed to detect independent predictors of CAS using factors that had significant relation in univariate analysis. A value of P ≤ 0.05 was considered statistically significant.
Results: The study included 100 patients among whom 19.0% had significant carotid atherosclerotic stenosis (stenosis > 50%). The severity of carotid atherosclerotic stenosis and the carotid artery disease were significantly correlated (P = 0.001). The percentage of patients with three vessel involvements (42.1%) and significant carotid stenosis were more as compared with two vessels (31.6%) and one vessel involvement (21.1%). Independent predictors of significant CAS were the presence of left main descending carotid artery disease (31.3%), triple vessel carotid artery disease (17.8%), increasing age, a history of stroke or myocardial infarction (21.05%), smoking status (78.9%), diabetes mellitus (78.94%), and hypertension (78.94%). We did not find any significant correlation between carotid atherosclerotic stenosis and gender or degree of dyslipidemia.
Conclusions: The degree of carotid atherosclerotic disease is related to the extent of coronary artery disease and important risk factors.
Keywords: Carotid atherosclerotic disease, coronary artery disease, myocardial infarction
|How to cite this article:|
Wani ZA, Bhat RA, Khan I, Khan I, Saleem T, Wani Z. Prevalence and predictors of carotid artery atherosclerosis and its association with coronary artery disease in north Indian population. Nig J Cardiol 2014;11:84-7
|How to cite this URL:|
Wani ZA, Bhat RA, Khan I, Khan I, Saleem T, Wani Z. Prevalence and predictors of carotid artery atherosclerosis and its association with coronary artery disease in north Indian population. Nig J Cardiol [serial online] 2014 [cited 2020 Apr 5];11:84-7. Available from: http://www.nigjcardiol.org/text.asp?2014/11/2/84/142087
| Introduction|| |
Atherosclerosis is a systemic inflammatory vascular disorder, involving multiple arterial beds.  Although modern pharmacotherapy and revascularization have markedly enhanced the prognosis of patients with atherosclerotic vascular disease, myocardial infarction (MI) and stroke remain leading causes of mortality and morbidity due to this disease.  Concomitant atherosclerotic lesions of the extracranial internal carotid arteries (ICAs) and the coronary circulation portend an adverse prognosis in various clinical settings, including asymptomatic individuals, stroke patients, and patients undergoing coronary artery bypass surgery. ,, Previous postmortem , and clinical ,,, studies, often small in sample size, have reported a variable prevalence of concomitant carotid and coronary lesions in patients with or without clinically evident cardiovascular disease. Thus, the prevalence of clinically important, concomitant carotid artery stenosis (CAS) and coronary artery disease (CAD) requires further definition in larger populations.
We performed ICA duplex ultrasound studies in consecutive patients undergoing clinically driven nonemergent coronary artery angiography. The prevalence and predictors of severe internal CAS in patients with CAD were analyzed using current consensus guidelines for the definition of CAS. 
| Materials and methods|| |
One hundred hospitalized patients undergoing nonemergent coronary angiography between December 2010 and November 2012 were enrolled in the study. Ethical approval from the hospital ethical committee was sought beforehand. The patients who were included in the study were those who either had documented CAD or were admitted in the Hospital with suspicion of acute coronary syndrome having symptoms, Electrocardiography (ECG) changes or raised cardiac biomarkers and were found to have CAD on angiography. Patients who did not give consent or were clinically unstable were excluded from the study.
Assessment of coronary angiography
The diameter stenosis was calculated by quantitative coronary angiography with an automated coronary analysis system. CAD was taken as a lumen diameter stenosis of >50% in one major coronary artery.
Assessment of carotid stenosis
CAS was analyzed by Carotid Doppler (SIEMENS). Imaging was performed in a supine position with the head turned away from the side being scanned and the neck extended. Transverse and longitudinal scans were obtained on the common carotid artery, the carotid bifurcation, and the internal and external carotid artery by B-mode and color Doppler ultrasound. Area stenosis (percent) was measured as: [1-(the area of residual lumen/the area of the normal vessels)] ×100. We defined echographic CAS as the carotid atherosclerosis with area stenosis of ≥50% on the common carotid artery, the carotid bifurcation, and the ICA.
Data analysis was performed using the Statistical Package for the Social Sciences Version 20. Continuous variables were expressed as mean ± SD. Two-sided unpaired "t"- test was performed for continuous variables and x 2 test for discrete variables. Multivariate stepwise logistic regression analysis was performed to detect independent predictors of CAS using factors that had significant relation in univariate analysis. A value of P ≤ 0.05 was considered statistically significant.
| Results|| |
The study population consisted of 100 patients of CAD who were subjected to conventional coronary angiography. The patients were then subjected to carotid Doppler study to look for carotid atherosclerotic disease. The demographic and clinical features are presented in [Table 1] and [Table 2]. The prevalence of the various categories of CAS and their severity are shown in [Table 3]. Also the extent and severity of CAD is presented in [Table 3]. The distribution of various known risk factors and carotid atherosclerosis is shown in [Table 4].
|Table 1: Prevalence of carotid artery stenosis along different age groups. Carotid artery stenosis is defined by ≥50 stenosis|
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|Table 2: Demographic and clinical characteristics of the study population and association with significant carotid arterial stenosis (≥50%) in the study sample|
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|Table 3: Correlation of carotid atherosclerotic disease severity with coronary artery disease severity|
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|Table 4: Distribution of carotid atherosclerosis with respect to various known risk factors|
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In the study population, significant carotid atherosclerotic disease was present in 19%. Whereas the prevalence of nonsignificant CAS was 6% and remaining 75% had normal patent carotids. The severity of CAS showed a significant correlation with CAD extent (P = 0.001). Clinically significant CAS (>50%) was found in 5.3%, 21.1%, 36.6%, and 42.1% among patients with normal or nonobstructive CAD, single vessel CAD, double vessel CAD, and triple vessel CAD, respectively. The multivariate stepwise logistic regression analysis showed that independent predictors of severe CAS or total internal carotid occlusion were the presence of left main descending CAD, triple vessel disease, increasing age, a history of stroke, smoking status, diabetes mellitus, and hypertension. However, no significant correlation between CAS and gender or degree of dyslipidemia was found.
| Discussion|| |
The present study shows overall prevalence of CAS of 19%. Out of these, 5.3% had angiographically normal coronaries, 21.1% had one coronary vessel involvement, 31.6% had two coronary vessel involvement and 42.1% had three coronary vessel involvement. Nonsignificant carotid stenosis (stenosis < 50%) was found in 6% of patients who also had single coronary vessel involvement.
Various authors have studied the concomitant relation between carotid artery disease and CAD. Racco et al. evaluated the real incidence of carotid vessel disease using an echo-duplex technique. They studied 193 patients who were hospitalized for diagnostic coronary angiography; 44.5% had CAD and among these, 12.2% had significant CAS.  Tanimoto et al. found significant correlation of CAS with CAD.  Steinvil et al. found similar results. 
Concurrent CAD and CAS is frequently detected in clinical practice. This association and presence of atherosclerotic risk factors increases the chances of MI, stroke, and death. The progression of CAS on sequential Doppler studies has been shown to be a stronger correlate of future MI events than of stroke.  The presence of CAS has been shown to increase the risk of perioperative stroke in patients undergoing coronary artery bypass grafting (CABG).  Similarly, the presence of CAD increases the risk of peripheral vascular surgery including carotid endarterectomy.  The role of screening for asymptomatic CAS in patients with CAD is not clear. ,
Our study indicates that some degree of atherosclerotic carotid disease is frequently detected among patients with extensive CAD. Furthermore, the traditional atherosclerotic risk factors greatly increase the risk of acquiring CAS and CAD. We found that among patients with significant CAS, diabetes was present in 78.94%, hypertension in 78.94%, smoking history in 78.94%, and past history of MI or stroke in 21.04%.
The prevalence estimates of carotid stenosis in patients with CAD in our study are comparable with other studies conducted worldwide. It is suggested that screening of CAS is beneficial especially in older patients with multivessel CAD and presence of various traditional atherosclerotic risk factors.
| References|| |
|1.||Ross R. Atherosclerosis--an inflammatory disease. N Engl J Med 1999;340:115-26. |
|2.||Steg PG, Bhatt DL, Wilson PW, D′Agostino R Sr, Ohman EM, Röther J, et al. One year cardiovascular event rates in outpatients with atherothrombosis. JAMA 2007;297:1197-206. |
|3.||Aichner FT, Topakian R, Alberts MJ, Bhatt DL, Haring HP, Hill MD, et al. REACH Registry Investigators. High cardiovascular event rates in patients with asymptomatic carotid stenosis: The REACH Registry. Eur J Neurol 2009;16:902-8. |
|4.||Pickett CA, Jackson JL, Hemann BA, Atwood JE. Carotid bruits as a prognostic indicator of cardiovascular death and myocardial infarction: A meta-analysis. Lancet 2008;371:1587-94. |
|5.||Stamou SC, Hill PC, Dangas G, Pfister AJ, Boyce SW, Dullum MK, et al. Stroke after coronary artery bypass: Incidence, predictors, and clinical outcome. Stroke 2001;32:1508-13. |
|6.||Mazighi M, Labreuche J, Gongora-Rivera F, Duyckaerts C, Hauw JJ, Amarenco P. Autopsy prevalence of intracranial atherosclerosis in patients with fatal stroke. Stroke 2008;39:1142-7. |
|7.||Gongora-Rivera F, Labreuche J, Jaramillo A, Steg PG, Hauw JJ, Amarenco P. Autopsy prevalence of coronary atherosclerosis in patients with fatal stroke. Stroke 2007;38:1203-10. |
|8.||Tanimoto S, Ikari Y, Tanabe K, Yachi S, Nakajima H, Nakayama T, et al. Prevalence of carotid artery stenosis in patients with coronary artery disease in Japanese population. Stroke 2005;36:2094-8. |
|9.||Kallikazaros I, Tsioufis C, Sideris S, Stefanadis C, Toutouzas P. Carotid artery disease as a marker for the presence of severe coronary artery disease in patients evaluated for chest pain. Stroke 1999;30:1002-7. |
|10.||Hofmann R, Kypta A, Steinwender C, Kerschner K, Grund M, Leisch F. Coronary angiography in patients undergoing carotid artery stenting shows a high incidence of significant coronary artery disease. Heart 2005;91:1438-41. |
|11.||Hertzer NR, Young JR, Beven EG, Graor RA, O′Hara PJ, Ruschhaupt WF 3 rd , et al. Coronary angiography in 506 patients with extracranial cerebrovascular disease. Arch Intern Med 1985;145:849-52. |
|12.||Grant EG, Benson CB, Moneta GL, Alexandrov AV, Baker JD, Bluth EI, et al. Carotid artery stenosis: Gray-scale and Doppler Us diagnosis-society of radiologists in ultrasound consensus conference. Radiology 2003;229:340-6. |
|13.||Racco F, Sconocchini C, Reginelli R, Pratillo G, Alesi C, Rondanini C, et al. Importance of ischemic heart disease in patients with carotid arteriosclerosis and lower extremity arteriopathy. Results of a prospective study. Minerva Cardioangiol 1995;43:345-54. |
|14.||Steinvil A, Sadeh B, Arbel Y, Justo D, Belei A, Borenstein N, et al. Prevalence and predictors of concomitant carotid and coronary artery atherosclerotic disease. J Am Coll Cardiol 2011;57:779-83. |
|15.||Sabeti S, Schlager O, Exner M, Mlekusch W, Amighi J, Dick P, et al. Progression of carotid stenosis detected by duplex ultrasonography predicts adverse outcomes in cardiovascular high-risk patients. Stroke 2007;38:2887-94. |
|16.||Naylor AR, Mehta Z, Rothwell PM, Bell PR. Carotid artery disease and stroke during coronary artery bypass: A critical review of the literature. Eur J Vasc Endovasc Surg 2002;23:283-94. |
|17.||Sprung J, Abdelmalak B, Gottlieb A, Mayhew C, Hammel J, Levy PJ, et al. Analysis of risk factors for myocardial infarction and cardiac mortality after major vascular surgery. Anaesthesiology 2000;93:129-40. |
|18.||Qureshi AI, Alexandrov AV, Tegeler CH, Hobson RW 2 nd , Dennis Baker J, Hopkins LN. American Society of Neuroimaging, Society of Vascular and Interventional Neurology. Guidelines for screening of extracranial carotid artery disease: A statement for healthcare professionals from the multidisciplinary practice guidelines committee of the American Society of Neuroimaging; cosponsored by the Society of Vascular and Interventional Neurology. J Neuroimaging 2007;17:19-47. |
|19.||Wolff T, Guirguis-Blake J, Miller T, Gillespie M, Harris R. Screening for carotid artery stenosis: An update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2007;147:860-70 |
[Table 1], [Table 2], [Table 3], [Table 4]