*continuation of CRP::MPO::Vulnerable plaques::CIMT thread*
On Fri, 31 Oct 2003 18:48:10 -0500, Dr. Andrew B. Chung, MD/PhD
<
[email protected]> wrote:
> Dr Chaos wrote:
>
>> Dr. Andrew B. Chung, MD/PhD <[email protected]> wrote:
>> > Dr Chaos wrote:
>> >> Dr. Andrew B. Chung, MD/PhD <[email protected]> wrote:
>> >> > Imho, you are looking at the wrong part of the body with CIMT.
>> >> Dr. Chos
>> >> If the biochemical process is similar everywhere and there is
>> >> mechanistic correlation between states likely to cause carotid
>> disease
>> >> as coronary disease, it should be a good proxy for increased risk
>> >> probability.
Dr. Blanchard replys:
you are exactly right, Dr. Chaos, please read on...
>> > Dr. Chung replys
>> > Ime, the CIMT information contributes very little additively to the
>> CAD
>> > risk assessment ascertainable from a good history, physical exam, EKG,
>> and
>> > basic blood work including serum glucose and a lipid profile.
>>
>> Dr. Chaos ... I would be surprised if that were true.
Dr. Blanchard replys:
Dr. Chaos, your suspicion is very true, as I address below Dr. Chung's
reply to you...
> Dr. Chung replys to Dr. Chaos:
> It remains my experience. There are various stigmata detectable by an
> astute
> physician on physical exam that tells that physician that there is
> atherosclerosis.
Dr. Blanchard disagrees in reply:
Even the most experienced physician cannot identify atherosclerosis until
the late stages of this silent killer, which continues to this day to be
the number 1 killer and crippler in the united states; more than all
cancers and accidents combined!
> These include characteristic changes of retinal arteries,
Dr. Blanchard disagrees in reply:
Atherosclerosis, early and late, cannot be seen in the retinal arteries:
Illustrative reference (
www.pubmed.gov):
Arteriosclerosis, Thrombosis, and Vascular Biology. 2000;20:1644.
Are Retinal Arteriolar Abnormalities Related to Atherosclerosis? The
Atherosclerosis Risk in Communities Study Ronald Klein; A. Richey Sharrett;
Barbara E. K. Klein; Lloyd E. Chambless; Lawton S. Cooper; Larry D.
Hubbard; Greg Evans
an exerpt from the illustrative reference...
Arteriolar narrowing and nicking appear to be related to hypertension and
inflammatory factors. Nicking may also be related to endothelial
dysfunction. Results suggest that these arteriolar changes are
pathologically distinct from atherosclerosis. Including their measurement
in population studies may permit evaluation of the independent contribution
of arteriolar disease to various ischemic diseases of the heart, brain, and
other organs.
> cholesterol nodules in the skin (especially around the eyes),
Dr. Blanchard disagrees in reply:
ummm, you might be diagnosis asthma instead.
Illustrative reference (
www.pubmed.gov):
Trans Am Ophthalmol Soc. 1993;91:99-125; discussion 125-9. Periocular
xanthogranulomas associated with severe adult-onset asthma.
Jakobiec FA, Mills MD, Hidayat AA, Dallow RL, Townsend DJ, Brinker EA,
Charles NC.
Massachusetts Eye and Ear Infirmary, Boston.
> bruits,
Dr. Blanchard disagrees in reply:
A late manifestation of atherosclerosis. If you are screening your patients
for the vascular surgeon, then you missed the early atherosclerosis boat
anyway.
Illustrative reference (
www.pubmed.gov):
Obuchowski NA, Modic MT, Magdinec M, Masaryk TJ.
Assessment of the efficacy of noninvasive screening for patients with
asymptomatic neck bruits.
Stroke. 1997 Jul;28(7):1330-9.
> right/left arm pressure differences, ABIs less than 0.7,
Dr. Blanchard disagrees in reply:
you are looking for vascular obstruction caused by atherosclerosis (like
carotid bruits), and like I replied above, is a late finding in the disease
process.
Illustrative reference (
www.pubmed.gov):
Vasc Med. 2003 May;8(2):95-100. Early-onset peripheral arterial occlusive
disease: clinical features and determinants of disease severity and
location.
Barretto S, Ballman KV, Rooke TW, Kullo IJ.
Division of Cardiovascular Diseases and Internal Medicine, Mayo Clinic,
Rochester, Minnesota 55905, USA.
an exerpt from the illustrative reference...
Early-onset peripheral lower extremity arterial occlusive disease (PAD) is
an uncommon, poorly characterized manifestation of atherosclerotic vascular
disease.
> murmur of a sclerotic aortic valve,
Dr. Blanchard disagrees in reply:
Sclerosis of the aortic valve is a terminal stage of atherosclerosis, and a
majority of these patients have already had a stroke or heart attack.
Illustrative reference (
www.pubmed.gov):
Am J Cardiol. 2002 May 1;89(9):1030-4. Aortic valve sclerosis, mitral
annular calcium, and aortic root sclerosis as markers of atherosclerosis in
men.
Tolstrup K, Roldan CA, Qualls CR, Crawford MH.
Veterans Affairs Medical Center and University of New Mexico, Albuquerque,
New Mexico 87108, USA.
an exerpt from the illustrative reference...
We concluded that the prevalence of AVS, MAC, or ARS by transesophageal
echocardiography in men is common, and their presence is highly associated
with aortic atheromatous disease and coronary, carotid, or peripheral
artery disease.
> loss of hair growth on the lower legs
Dr. Blanchard disagrees in reply:
Atherosclerosis does not cause arteriosclerosis.
Illustrative reference (
www.pubmed.gov):
Relation of leg hair loss to arteriosclerosis.
JAMA. 1970 Jul 6;213(1):130. No abstract available.
> ... to name a few.
Dr. Blanchard disagrees in reply:
can you share more of them with me?
> Other clues
> include EKG evidence of old heart attacks, calcified coronaries or aorta
> seen on chest X-ray, or calcified mammary arteries on mammogram.
Dr. Blanchard disagrees in reply:
Calcification is a terminal stage of atherosclerosis
Illustrative reference (
www.pubmed.gov):
Arterioscler Thromb Vasc Biol. 1995 Sep;15(9):1512-31. A definition of
advanced types of atherosclerotic lesions and a histological classification
of atherosclerosis. A report from the Committee on Vascular Lesions of the
Council on Arteriosclerosis, American Heart Association.
Stary HC, Chandler AB, Dinsmore RE, Fuster V, Glagov S, Insull W Jr,
Rosenfeld ME, Schwartz CJ, Wagner WD, Wissler RW.
Office of Scientific Affairs, American Heart Association, Dallas, TX 75231-
4596, USA.
an exerpt from the illustrative reference...
Beginning around the fourth decade of life, lesions that usually have a
lipid core may also contain thick layers of fibrous connective tissue (type
V lesion) and/or fissure, hematoma, and thrombus (type VI lesion). Some
type V lesions are largely calcified (type Vb), and some consist mainly of
fibrous connective tissue and little or no accumulated lipid or calcium
(type Vc).
> Fasting serum glucose greater than 100 +/-
Dr. Blanchard disagrees in reply:
you are trying to diagnosis pre-diabetes, not atherosclerosis with serum
glucose.
> LDL greater than 160 and/or HDL less than 40 raises suspicion even if
> there were no stigmata.
Dr. Blanchard disagrees in reply:
Some experts believe LDL must be over 100 to be atherogenic
Illustrative reference (
www.pubmed.gov):
J Clin Invest. 2000 Dec;106(12):1501-10. Defining the atherogenicity of
large and small lipoproteins containing apolipoprotein B100.
Veniant MM, Sullivan MA, Kim SK, Ambroziak P, Chu A, Wilson MD, Hellerstein
MK, Rudel LL, Walzem RL, Young SG.
Gladstone Institute of Cardiovascular Disease, Cardiovascular Research
Institute, University of California, San Francisco, California, USA.
[email protected]
> A positive family history is also helpful.
yes, it is helpful, but not diagnostic of atherosclerosis.
> If you have any of the above, it remains my experience, that CIMT
> information is not going to change management.
Dr. Blanchard disagrees in reply:
CIMT takes out the guesswork in atherosclerosis management, even in the
most advanced cases. How do you individualize your atherosclerosis
management? With the criteria you have given me? How do you know when you
have reached maximum medical therapy?
Illustrative reference (
www.pubmed.gov):
there are many, many references about the changing criteria for the risk
factor management; lipid, hypertension...
> Moreover, if you have none of
> the above, it would be very unclear what one would do with high CIMT
> numbers without actual clear visualization of a "plaque."
Dr. Blanchard disagrees in reply:
CIMT has been shown to increase with progressive atherosclerosis and
decrease with proper treatment of atherosclerosis.
Illustrative reference (
www.pubmed.gov):
Stroke. 2003 Oct;34(10):2374-9. Epub 2003 Aug 28.
Risk factors for progression of atherosclerosis measured at multiple sites
in the arterial tree: the Rotterdam Study.
van der Meer IM, Iglesias del Sol A, Hak AE, Bots ML, Hofman A, Witteman
JC.
Department of Epidemiology and Biostatistics, Erasmus University Medical
Center, Rotterdam, The Netherlands.
and for regression of atherosclerosis with proper treatment...
Arch Intern Med. 2003 Aug 11-25;163(15):1837-41. Regression of carotid and
femoral artery intima-media thickness in familial hypercholesterolemia:
treatment with simvastatin.
Nolting PR, de Groot E, Zwinderman AH, Buirma RJ, Trip MD, Kastelein JJ.
Departments of Vascular Medicine, Academic Medical Center, Amsterdam, the
Netherlands.
[email protected]
an exerpt from the illustrative reference...
CONCLUSIONS: High-dose simvastatin therapy reduces arterial wall IMT in
more than two thirds of the patients, with its largest effect on the
femoral artery. Furthermore, patients with FH who were treated with both
statin and antihypertensive medication experienced a significantly greater
benefit in terms of IMT reduction.
>> Dr. Chaos ... I'm not a researcher
>> in this area of course, but I would see the carotid system as an
>> actual experiment regarding the patient's biochemistry (some of whose
>> factors are measurable) mixed with the specific genetic response.
>>
> Dr. Chung replys:
> That experiment can be found elsewhere as described above.
Dr. Chaos, CIMT is well validated as a measure of atherosclerosis, which as
you have anticipated correctly, is a global process.
>
>> Dr. Chaos
>> I'd imagine it would be provide more specific information.
>>
> Dr. Chung replys:
> Only if there is actual visualization of "plaque."
Dr. Blanchard disagrees in reply:
oh my goodness.. you should really get out of the office more often Dr.
Chung.
>
>> Dr. Chaos
>> Naturally this is a scientific hypothesis which ought to be tested
>> empirically, but my "prior" says that it could be better.
>>
> Dr. Chung replys:
> See above.
Dr. Blanchard disagrees in reply:
360,000 patients studied over 9 years proves that CIMT is extremely useful
for understanding atherosclerosis. Don't forget either, that CIMT is
endorsed by the American Heart Association.
Illustrative reference (
www.pubmed.gov):
Int J Epidemiol. 2001 Oct;30 Suppl 1:S17-22. Coronary heart disease trends
in four United States communities. The Atherosclerosis Risk in Communities
(ARIC) study 1987-1996.
Rosamond WD, Folsom AR, Chambless LE, **** CH; ARIC Investigators.
Atherosclerosis Risk in Communities.
Department of Epidemiology, School of Public Health, University of North
Carolina, Chapel Hill, NC 27514, USA.
[email protected]
an exerpt from the illustrative reference...
METHOD: The ARIC study used retrospective community surveillance to monitor
admissions to acute care hospitals and deaths due to CHD (both in-and out-
of-hospital) among all residents 35-74 years of age. The surveillance areas
included over 360 000 men and women in four communities: Forsyth County,
North Carolina; the city of Jackson, Mississippi; eight northern suburbs of
Minneapolis, Minnesota; and Washington County, Maryland.
I welcome any comments and questions regarding the clinical validity or
usefullness of Carotid Intima Media Thickness, or CIMT.
~~~
Patrick Blanchard, M.D., A.B.F.P.
Board Certified in Family Practice
.