Stein cimt for shape 11-05

Carotid Intima-Media Thickness In Carotid Intima-Media Thickness In Clinical Practice: The UW Vascular Clinical 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 CardiologyUniversity of Wisconsin Medical SchoolUniversity of Wisconsin Medical School

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

• Started CIMT imaging in 2000 for Started 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 Imaging UW Atherosclerosis Imaging Research ProgramResearch Program

• Requested to perform CIMT studies for Requested 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 Health UW Vascular Health Screening ProgramScreening Program

• 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 required Physician order required

www.cvrc.wisc.edu/airpwww.cvrc.wisc.edu/airp


• IncludesIncludes– carotid IMTcarotid IMT– blood sugarblood sugar– complete lipid panelcomplete lipid panel– blood pressure, waist circumference, and blood 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


CIMT MeasurementCIMT Measurement




• ARIC-type scanning ARIC-type scanning protocolprotocol

• Validation studyValidation study• 50 subjects, 6 50 subjects, 6

segments eachsegments each• Manually traced at UW Manually traced at UW

and AUTRECand AUTREC• Border detection Border detection

program - Siemensprogram - SiemensStein JH, et al. J Am Soc Echocardiogr 2005; 18:244Stein JH, et al. J Am Soc Echocardiogr 2005; 18:244

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 of Assigning the same number of Framingham risk points to all Framingham risk points to all individuals of the same chronologic individuals of the same chronologic age ignores great variation in plaque age ignores great variation in plaque burden at a given age”burden at a given age”- Scott M. Grundy- Scott M. GrundyAm J Cardiol 2001;88:10EAm J Cardiol 2001;88:10E

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)PercentilePercentileARIC - 45 year old WM, RCCAARIC - 45 year old WM, RCCA

• N = 82 N = 82 (45 males, 37 females)(45 males, 37 females)• Mean chronological age Mean 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 risk Mean Framingham 10-year total CHD risk

= 9.4 ± 0.7%= 9.4 ± 0.7%• Duplicate scans: Duplicate scans: CIMT = 0.004 ± 0.087 mm CIMT = 0.004 ± 0.087 mm

(r=0.983, p <0.001)(r=0.983, p <0.001)• Mean composite CIMT = 0.806 ± 0.022 mm Mean composite CIMT = 0.806 ± 0.022 mm • Vascular age Vascular age 9.6 ± 1.8 yrs vs. CA 9.6 ± 1.8 yrs vs. CA (p <0.001)(p <0.001)

Clinical Use of CIMT Clinical 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

Vascular Age Alters CV Risk Vascular Age Alters CV Risk Change in Predicted 10-Year CHD RiskChange in Predicted 10-Year CHD Risk

• Substituting VA Substituting 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

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Stein JH, et al. Clin Card 2004; 27:388Stein JH, et al. Clin Card 2004; 27:388

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

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N = 515N = 515

Gepner AG, et al. (submitted)Gepner AG, et al. (submitted)

0%

20%

40%

60%

80%

100%


<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 = 4N = 4

N = 15N = 15

N = 3N = 3

30%30%

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N = 515N = 515


0%

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40%

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<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 = 38N = 38

N = 5N = 5

N = 28N = 28

42%42%

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N = 515N = 515


0%

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40%

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80%

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<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 = 12N = 12

N = 5N = 5

N = 58N = 58

N =265N =265 28%28%

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CIMT ScreeningCIMT ScreeningLimitationsLimitations

• Highly standardized protocols for Highly standardized protocols for performing and interpreting studiesperforming and interpreting studies– timetime to perform, measure and interpret to perform, measure and interpret– trainingtraining – scanning, reading – scanning, reading

• High-end instrumentation - expensiveHigh-end instrumentation - expensive• ReimbursementReimbursement• Surrogate for Surrogate for coronarycoronary atherosclerosis atherosclerosis

CIMT Screening in Clinical PracticeCIMT Screening in Clinical PracticeOvercoming the LimitationsOvercoming the Limitations

• TimeTime– Abbreviated protocolAbbreviated protocol• common carotid arterycommon carotid artery• plaqueplaque screening screening

– 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

Proposed Algorithm for CV Risk Proposed Algorithm for CV Risk Assessment Using Carotid UltrasoundAssessment Using Carotid Ultrasound

““Intermediate” Intermediate” RiskRisk

Plaque Plaque ScreenScreen

Plaque Plaque AbsentAbsent

Plaque Plaque PresentPresent

CCA CIMT CCA CIMT MeasurementMeasurement

• Intensify Intensify treatmenttreatment

• CCA CIMT CCA CIMT optionaloptional

Traditional Traditional Risk Risk

AssessmentAssessment

Wyman R, et al. 2005. Submitted.Wyman R, et al. 2005. Submitted.


• Validation studyValidation study• 40 subjects, 3 40 subjects, 3

views of CCA views of CCA segmentsegment

• Border detection Border detection program – program – SonoCalcSonoCalcTMTM

• AUTRECAUTREC

Gepner AG, et al. J Am Soc Echocardiogr Gepner AG, et al. J Am Soc Echocardiogr 2005; in press.2005; in press.

Health & Medicine

Stein cimt for shape 11-05