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Increased Carotid Intima-Media Thickness As a Predictor for Abnormal Myocardial Perfusion by Dobutamine Stress Echocardiography

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Increased Carotid Intima-Media Thickness As a Predictor for Abnormal Myocardial Perfusion by Dobutamine Stress Echocardiography ISSN: 2536-9474 (Print) Original article / FYMJ ISSN: 2536-9482 (Online) Fayoum University Medical Journal Metwally et al., 2020,6(1), 1-17 Increased carotid intima-media thickness as a predictor for abnormal myocardial perfusion by dobutamine stress echocardiography in patients with diabetes mellitus type 2 Mohammed Othman Metwally(1), Eman Mahmoud Abdelfattah(2), Mohammed Gamal Mousa(3) , Khaled Ahmed Elkhashab(4) (1) Cardiology department, Faculty of Medicine, Fayoum University. (2) Lecturer of Cardiology, Faculty of Medicine, Fayoum University. (3) Lecturer of Cardiology, Faculty of Medicine, Fayoum University. (4) Professor of Cardiology, Faculty of Medicine, Fayoum University. Corresponding author: Dr. Mohammed Othman Metwally E-mail: [email protected] Tel: 01005063030 Abstract carotid intima-media thickness (CIMT) and Background: Coronary artery disease carotid plaques by carotid ultrasonography and (CAD) remains a leading cause of death among myocardial perfusion imaging by dobutamine patients with diabetes mellitus (DM). Hence, stress echocardiography (DSE) were performed screening tests for early diagnosis of CAD may for all subjects. lead to early treatment and therefore improved Results: The prevalence of abnormal outcomes. myocardial perfusion by DSE in asymptomatic Aim of the work: The aim of this study was diabetic patients was 8%. There was positive to correlate myocardial perfusion abnormality correlation between CIMT and duration of DM by dobutamine stress echocardiography to and age. In relation to wall motion score index carotid intima-media thickness in type 2 (WMSI), there was significant elevation in diabetic patients free from cardiac symptoms. CIMT (p=0.022) and carotid plaque (p=0.028) Subjects and methods: Fifty type 2 in the patients with positive stress study. diabetic patients with or without other risk Conclusion: The findings of this study show factors (case group) and twenty-five non- that increased CIMT and carotid plaque were diabetic patients (control group) were included significantly related to the presence and extent in this study. Full history taking, complete of abnormal myocardial perfusion, it is clinical examination, ECG, assessment of reasonable to recommend using CIMT to Page 1 ISSN: 2536-9474 (Print) Original article / FYMJ ISSN: 2536-9482 (Online) Fayoum University Medical Journal Metwally et al., 2020,6(1), 1-17 identify asymptomatic patients with type 2 be concluded from these studies which make an diabetes mellitus at higher risk for CAD and open field for more research [5]. indirect predictor for cardiovascular events. Several ways for screening SMI were tried to Keywords: Carotid intima media thickness, dobutamine predict abnormal myocardial perfusion such as stress echocardiography, asymptomatic diabetic exercise or pharmacological stress tests, carotid patients intima media thickness, coronary artery calcium, Radionuclide Imaging and CT Introduction coronary angiography [6]. Diabetes is a fast-growing health problem in Egypt with a significant impact on morbidity Carotid intima media thickness (CIMT) is one and mortality. Currently, the prevalence of type method of calculating plaque burden by 2 diabetes (T2DM) in Egypt is around 15.6% of assessing the level of arterial thickening all adults aged 20 to 79 [1]. Diabetes mellitus is present. CIMT used as a noninvasive marker of also a powerful risk factor for coronary artery atherosclerotic disease was also linked to an disease and carotid atherosclerosis [2]. increased risk of subsequent cardiovascular events [7]. Silent myocardial ischemia (SMI) is more common in diabetic patients with a prevalence Dobutamine stress echocardiography (DSE) is a about 15 % to 22 % [3]. Coronary artery well-established clinical tool, both for the disease (CAD) is usually a late diagnosis in diagnostic and prognostic assessment of diabetic patients and the disease is usually more patients with known or suspected coronary advanced at that time [4]. artery disease [8]. Screening tests for early diagnosis of CAD may The aim of this study was to correlate lead to early treatment and therefore improved myocardial perfusion abnormality by outcomes. So, many studies were conducted dobutamine stress echocardiography to carotid searching for a valid and reliable screening intima-media thickness in type 2 diabetic method. However, no sufficient evidence could patients free from cardiac symptoms. Page 2 ISSN: 2536-9474 (Print) Original article / FYMJ ISSN: 2536-9482 (Online) Fayoum University Medical Journal Metwally et al., 2020,6(1), 1-17 Subjects and Methods Patient with dyssynchronization of cardiac muscle with echocardiography. This study was conducted on fifty type 2 diabetic patients with or without other risk Full history taking and complete physical factors (case group) and twenty-five sex and examination were done with special emphasis age matched non-diabetic patients (control on disease duration and treatment, smoking and group). They were recruited from outpatient hypertension. clinic of Internal Medicine Department, A 12 lead surface ECG was performed to Fayoum University Hospitals. identify and exclude old myocardial infarction The study was approved by the Faculty of (pathological Q waves), classic ischemic ST-T Medicine Research Ethical Committee and wave changes, left ventricular hypertrophy, written informed consent was obtained from all conduction defects and non-specific changes. study participants. Ultrasonographic evaluation of the carotid Inclusion criteria: arteries: Age (between 40 and 70 years). Long standing duration of type 2 Carotid intima-media thickness (CIMT) and diabetes (at least more than 5 years). carotid plaques were assessed by Absence of clinical or electrocardiogram (ECG) findings of ultrasonography of both the right and left ischemia. common carotid arteries using high–resolution Exclusion criteria: B-mode ultrasonography (Logic P5): Patients known to have ischemic heart disease (IHD). 1- Carotid intima-media thickness Patients with previous neck irradiation. Patients with history of carotid surgery (CIMT) measurement: or cerebrovascular accident. Any neck deformity interfering with Subjects were scanned in the supine position carotid ultrasonography. with the shoulder placed on a pillow and neck Patient with echocardiographic poor 0 window. extended, the head was turned about 45 away Patient with regional wall motion from the side being scanned. On longitudinal abnormalities at resting echocardiography. 2D ultrasound image of the carotid artery, the Page 3 ISSN: 2536-9474 (Print) Original article / FYMJ ISSN: 2536-9482 (Online) Fayoum University Medical Journal Metwally et al., 2020,6(1), 1-17 near wall and the far wall are displayed as 2 age-predicted maximum heart rate were echogenic lines (the adventitia and intima) that acheived . Atropine (up to a maximum of 1-2 are separated by the hypoechoic media. The mg) was used to achieve the target heart rate if distance between the leading edge of the first not achieved with dobutamine. Vital signs, bright line of the far wall (lumen-intima symptoms and ECG were monitored with each interface) and the leading edge of the second infusion stage and throughout the test. bright line (media-adventitia interface) is Echocardiographic digital images were defined as the CIMT. Values of more than 0.9 acquired continuously during the dobutamine mm or over the 75th percentile are considered infusion in the long parasternal-long and apical- abnormal. short 4- and 2-chamber views using Philips 2- Carotid plaques assessment: Epic 7C echocardiography machine. Regional wall motion was analyzed by determining the Plaque was defined as a localized protrusion of wall motion score index (WMSI) with a model the vessel wall, which extended into the lumen that divides the left ventricular myocardium (≥ 1.5 mm) or had a thickness exceeding the into 16 segments and assigns a wall motion intima-media thickness (IMT) of the adjacent score of 1 to 4 to each segment (1 = normal or portion of the vessel wall by >50%. This was hyperkanetic, 2 = hypokensia , 3 = akensia , 4 = measured bilaterally by using linear array dyskinetic). transducer scanning of common and internal carotid arteries. Abnormal wall motion of the anterior septal, medial septal, apical, and anterior segments Dobutamine stress echocardiography (DSE): indicates disease of the left anterior descending DSE was performed according to standard coronary artery, whereas abnormal motion of protocol. Dobutamine was injected initially the lateral and posterior segments indicates intravenously (using infusion pump) at a dose diseased circumflex artery and abnormal of 10 μ g/kg/min then increased by 10 μ motion of the inferior and basal septal segments g/kg/min every 3-5 minutes until a peak dose of indicates right coronary artery lesions. 40 μ g/kg/min and a target heart rate of 85% of Page 4 ISSN: 2536-9474 (Print) Original article / FYMJ ISSN: 2536-9482 (Online) Fayoum University Medical Journal Metwally et al., 2020,6(1), 1-17 End points for stopping the test were Inc, USA). For quantitative data, the mean, achievement of 85% of age-predicted standard deviation (SD), and range were maximum heart rate, development of sustained calculated. Independent t-test or Mann- ventricular tachycardia, decrease in absolute or Whitney-U test, as appropriate, was used in relative SBP by more than 30 mm Hg and comparing between two groups. Qualitative development of a new wall motion abnormality data were presented as number
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