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Carotid Intima-Media Thickness InCarotid Intima-Media Thickness In
Clinical Practice: The UW VascularClinical Practice: Th...
Presenter Disclosure InformationPresenter Disclosure Information
• Research GrantsResearch Grants
– Siemens Medical Soluti...
• Started CIMT imaging in 2000 forStarted CIMT imaging in 2000 for
research studiesresearch studies
• DecisionsDecisions
–...
• Requested to perform CIMT studies forRequested to perform CIMT studies for
clinical use in 2001clinical use in 2001
• Mo...
• PatientsPatients
– 40-70 years old40-70 years old
– No established heart or vascular diseaseNo established heart or vasc...
• IncludesIncludes
– carotid IMTcarotid IMT
– blood sugarblood sugar
– complete lipid panelcomplete lipid panel
– blood pr...
CIMT MeasurementCIMT Measurement
UW Vascular HealthUW Vascular Health
Screening ProgramScreening Program
UW Vascular HealthUW Vascular Health
Screening ProgramScreening Program
UW Vascular HealthUW Vascular Health
Screening ProgramScreening Program
• ARIC-type scanningARIC-type scanning
protocolpro...
Multiple Risk Factor AssessmentMultiple Risk Factor Assessment
http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htmht...
Clinical Use of CIMTClinical Use of CIMT
“Vascular Age”“Vascular Age”
0.890.899595thth
0.800.809090thth
0.700.707575thth
0...
• N = 82N = 82 (45 males, 37 females)(45 males, 37 females)
• Mean chronological ageMean chronological age (CA)(CA)
= 55.8...
Vascular Age Alters CV RiskVascular Age Alters CV Risk
Change in Predicted 10-Year CHD RiskChange in Predicted 10-Year CHD...
0%
20%
40%
60%
80%
100%
ATP III Risk Modified By Vasc Age
<5% 5-10% 10-20% >20%
N =265N =265
N =75N =75
N =172N =172
N =21...
0%
20%
40%
60%
80%
100%
ATP III Risk Modified By Vasc Age
<5% 5-10% 10-20% >20%
N =75N =75
Vascular Age Alters CV RiskVasc...
0%
20%
40%
60%
80%
100%
ATP III Risk Modified By Vasc Age
<5% 5-10% 10-20% >20%
N =172N =172
Vascular Age Alters CV RiskVa...
0%
20%
40%
60%
80%
100%
ATP III Risk Modified By Vasc Age
<5% 5-10% 10-20% >20%
Vascular Age Alters CV RiskVascular Age Al...
CIMT ScreeningCIMT Screening
LimitationsLimitations
• Highly standardized protocols forHighly standardized protocols for
p...
CIMT Screening in Clinical PracticeCIMT Screening in Clinical Practice
Overcoming the LimitationsOvercoming the Limitation...
Proposed Algorithm for CV RiskProposed Algorithm for CV Risk
Assessment Using Carotid UltrasoundAssessment Using Carotid U...
UW Vascular HealthUW Vascular Health
Screening ProgramScreening Program
• Validation studyValidation study
• 40 subjects, ...
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Stein cimt for shape 11-05

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Stein cimt for shape 11-05

  1. 1. Carotid Intima-Media Thickness InCarotid Intima-Media Thickness In Clinical Practice: The UW VascularClinical Practice: The UW Vascular Health Screening Program ExperienceHealth Screening Program Experience James H. Stein, M.D.James H. Stein, M.D. Associate Professor, Division of Cardiovascular MedicineAssociate Professor, Division of Cardiovascular Medicine Co-Director, Preventive CardiologyCo-Director, Preventive Cardiology University of Wisconsin Medical SchoolUniversity of Wisconsin Medical School
  2. 2. Presenter Disclosure InformationPresenter Disclosure Information • Research GrantsResearch Grants – Siemens Medical SolutionsSiemens Medical Solutions – SonositeSonosite • Research EquipmentResearch Equipment – Camtronics Medical SystemsCamtronics Medical Systems – Siemens Medical SolutionsSiemens Medical Solutions – SonositeSonosite
  3. 3. • Started CIMT imaging in 2000 forStarted CIMT imaging in 2000 for research studiesresearch studies • DecisionsDecisions – Scanning protocol – segments, angles,Scanning protocol – segments, angles, near/far wallnear/far wall – Measurement protocol – manual vs. semi-Measurement protocol – manual vs. semi- automated, softwareautomated, software • Reproducibility – scanners, readersReproducibility – scanners, readers • Accuracy compared to core labAccuracy compared to core lab UW Atherosclerosis ImagingUW Atherosclerosis Imaging Research ProgramResearch Program
  4. 4. • Requested to perform CIMT studies forRequested to perform CIMT studies for clinical use in 2001clinical use in 2001 • More decisionsMore decisions – Scanning and reading protocolsScanning and reading protocols – Reporting – normative data, percentiles,Reporting – normative data, percentiles, interpretationinterpretation – Program design – MD order/self-refer,Program design – MD order/self-refer, target audience, counselingtarget audience, counseling – Charges and billingCharges and billing UW Vascular HealthUW Vascular Health Screening ProgramScreening Program
  5. 5. • PatientsPatients – 40-70 years old40-70 years old – No established heart or vascular diseaseNo established heart or vascular disease – Target: “intermediate risk” patientsTarget: “intermediate risk” patients • Physician order requiredPhysician order required www.cvrc.wisc.edu/airpwww.cvrc.wisc.edu/airp UW Vascular HealthUW Vascular Health Screening ProgramScreening Program
  6. 6. • IncludesIncludes – carotid IMTcarotid IMT – blood sugarblood sugar – complete lipid panelcomplete lipid panel – blood pressure, waist circumference, andblood pressure, waist circumference, and body-mass indexbody-mass index – personalized counselingpersonalized counseling • Charge:Charge: – $295$295 – covered by 3 HMO’scovered by 3 HMO’s UW Vascular HealthUW Vascular Health Screening ProgramScreening Program
  7. 7. CIMT MeasurementCIMT Measurement
  8. 8. UW Vascular HealthUW Vascular Health Screening ProgramScreening Program
  9. 9. UW Vascular HealthUW Vascular Health Screening ProgramScreening Program
  10. 10. UW Vascular HealthUW Vascular Health Screening ProgramScreening Program • ARIC-type scanningARIC-type scanning protocolprotocol • Validation studyValidation study • 50 subjects, 650 subjects, 6 segments eachsegments each • Manually traced at UWManually traced at UW and AUTRECand AUTREC • Border detectionBorder detection program - Siemensprogram - Siemens Stein JH, et al. J Am Soc Echocardiogr 2005; 18:244Stein JH, et al. J Am Soc Echocardiogr 2005; 18:244
  11. 11. Multiple Risk Factor AssessmentMultiple Risk Factor Assessment http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htmhttp://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm ““Assigning the same number ofAssigning the same number of Framingham risk points to allFramingham risk points to all individuals of the same chronologicindividuals of the same chronologic age ignores great variation in plaqueage ignores great variation in plaque burden at a given age”burden at a given age” - Scott M. Grundy- Scott M. Grundy Am J Cardiol 2001;88:10EAm J Cardiol 2001;88:10E ““Assigning the same number ofAssigning the same number of Framingham risk points to allFramingham risk points to all individuals of the same chronologicindividuals of the same chronologic age ignores great variation in plaqueage ignores great variation in plaque burden at a given age”burden at a given age” - Scott M. Grundy- Scott M. Grundy Am J Cardiol 2001;88:10EAm J Cardiol 2001;88:10E
  12. 12. Clinical Use of CIMTClinical Use of CIMT “Vascular Age”“Vascular Age” 0.890.899595thth 0.800.809090thth 0.700.707575thth 0.600.605050thth 0.520.522525thth 0.460.461010thth 0.420.4255thth Mean CIMT (mm)Mean CIMT (mm)PercentilePercentile ARIC - 45 year old WM, RCCAARIC - 45 year old WM, RCCA
  13. 13. • N = 82N = 82 (45 males, 37 females)(45 males, 37 females) • Mean chronological ageMean chronological age (CA)(CA) = 55.8 ± 1.0 yrs= 55.8 ± 1.0 yrs (26 - 74 yrs)(26 - 74 yrs) • Mean Framingham 10-year total CHD riskMean Framingham 10-year total CHD risk = 9.4 ± 0.7%= 9.4 ± 0.7% • Duplicate scans:Duplicate scans: ∆∆CIMT = 0.004 ± 0.087CIMT = 0.004 ± 0.087 mmmm (r=0.983, p <0.001)(r=0.983, p <0.001) • Mean composite CIMT = 0.806 ± 0.022 mmMean composite CIMT = 0.806 ± 0.022 mm • Vascular ageVascular age ↑↑ 9.6 ± 1.8 yrs vs. CA9.6 ± 1.8 yrs vs. CA (p <0.001)(p <0.001) Clinical Use of CIMTClinical Use of CIMT UW Vascular Health Screening ProgramUW Vascular Health Screening Program Stein JH, et al. Clin Card 2004; 27:388Stein JH, et al. Clin Card 2004; 27:388
  14. 14. Vascular Age Alters CV RiskVascular Age Alters CV Risk Change in Predicted 10-Year CHD RiskChange in Predicted 10-Year CHD Risk • Substituting VASubstituting VA ↑↑ CHD risk in 37 (46%);CHD risk in 37 (46%); ↓↓ in 17 (20%)in 17 (20%) • Intermediate risk: 36% re-classified higher, 14% lower riskIntermediate risk: 36% re-classified higher, 14% lower risk -10 -5 0 5 10 15 20 25 AbsolutechangeAbsolutechange in10-yrRisk(%)in10-yrRisk(%) Unique subjectUnique subject Stein JH, et al. Clin Card 2004; 27:388Stein JH, et al. Clin Card 2004; 27:388
  15. 15. 0% 20% 40% 60% 80% 100% ATP III Risk Modified By Vasc Age <5% 5-10% 10-20% >20% N =265N =265 N =75N =75 N =172N =172 N =219N =219 N =87N =87 N =182N =182 N =26N =26N =2N =2 Vascular Age Alters CV RiskVascular Age Alters CV Risk UW Vascular Health Screening ProgramUW Vascular Health Screening Program ChangeinPredictedChangeinPredicted 10-YearCHDRisk10-YearCHDRisk N = 515N = 515 Gepner AG, et al. (submitted)Gepner AG, et al. (submitted)
  16. 16. 0% 20% 40% 60% 80% 100% ATP III Risk Modified By Vasc Age <5% 5-10% 10-20% >20% N =75N =75 Vascular Age Alters CV RiskVascular Age Alters CV Risk Change in “Intermediate” RiskChange in “Intermediate” Risk N = 4 N = 4 N = 15N = 15 N = 3 N = 3 ∆∆ 30%30% ChangeinPredictedChangeinPredicted 10-YearCHDRisk10-YearCHDRisk N = 515N = 515 Gepner AG, et al. (submitted)Gepner AG, et al. (submitted)
  17. 17. 0% 20% 40% 60% 80% 100% ATP III Risk Modified By Vasc Age <5% 5-10% 10-20% >20% N =172N =172 Vascular Age Alters CV RiskVascular Age Alters CV Risk Change in Predicted 10-Year CHD RiskChange in Predicted 10-Year CHD Risk N = 38 N = 38 N = 5 N = 5 N = 28 N = 28 ∆∆ 42%42% ChangeinPredictedChangeinPredicted 10-YearCHDRisk10-YearCHDRisk N = 515N = 515 Gepner AG, et al. (submitted)Gepner AG, et al. (submitted)
  18. 18. 0% 20% 40% 60% 80% 100% ATP III Risk Modified By Vasc Age <5% 5-10% 10-20% >20% Vascular Age Alters CV RiskVascular Age Alters CV Risk Change in Predicted 10-Year CHD RiskChange in Predicted 10-Year CHD Risk N = 12 N = 12 N = 5 N = 5 N = 58 N = 58 N =265N =265 ∆∆ 28%28% ChangeinPredictedChangeinPredicted 10-YearCHDRisk10-YearCHDRisk N = 515N = 515 Gepner AG, et al. (submitted)Gepner AG, et al. (submitted)
  19. 19. CIMT ScreeningCIMT Screening LimitationsLimitations • Highly standardized protocols forHighly standardized protocols for performing and interpreting studiesperforming and interpreting studies – timetime to perform, measure and interpretto perform, measure and interpret – trainingtraining – scanning, reading– scanning, reading • High-end instrumentation - expensiveHigh-end instrumentation - expensive • ReimbursementReimbursement • Surrogate forSurrogate for coronarycoronary atherosclerosisatherosclerosis
  20. 20. CIMT Screening in Clinical PracticeCIMT Screening in Clinical Practice Overcoming the LimitationsOvercoming the Limitations • TimeTime – Abbreviated protocolAbbreviated protocol • common carotid arterycommon carotid artery • plaqueplaque screeningscreening – Border detectionBorder detection • many excellent choicesmany excellent choices • limit to far walllimit to far wall • Expense – handheld or newer,Expense – handheld or newer, small ultrasound systemssmall ultrasound systems
  21. 21. Proposed Algorithm for CV RiskProposed Algorithm for CV Risk Assessment Using Carotid UltrasoundAssessment Using Carotid Ultrasound ““Intermediate”Intermediate” RiskRisk PlaquePlaque ScreenScreen PlaquePlaque AbsentAbsent PlaquePlaque PresentPresent CCA CIMTCCA CIMT MeasurementMeasurement • IntensifyIntensify treatmenttreatment • CCA CIMTCCA CIMT optionaloptional TraditionalTraditional RiskRisk AssessmentAssessment Wyman R, et al. 2005. Submitted.Wyman R, et al. 2005. Submitted.
  22. 22. UW Vascular HealthUW Vascular Health Screening ProgramScreening Program • Validation studyValidation study • 40 subjects, 340 subjects, 3 views of CCAviews of CCA segmentsegment • Border detectionBorder detection program –program – SonoCalcSonoCalcTMTM • AUTRECAUTREC Gepner AG, et al. J Am Soc EchocardiogrGepner AG, et al. J Am Soc Echocardiogr 2005; in press.2005; in press.

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