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ORIGINAL ARTICLE
Year : 2017  |  Volume : 16  |  Issue : 4  |  Page : 192-195  

Study of carotid intimal medial thickness in essential hypertension with or without left ventricular hypertrophy


1 Department of Medicine, GGS Medical College and Hospital, Faridkot, Punjab, India
2 Department of Radiodaignosis, GGS Medical College and Hospital, Faridkot, Punjab, India

Date of Web Publication16-Oct-2017

Correspondence Address:
Himanshu Khutan
Department of Medicine, GGS Medical College and Hospital, Faridkot, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/aam.aam_9_17

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   Abstract 


Introduction: Hypertension and atherosclerosis though separate entities, are interrelated as hypertension plays an important role in the pathogenesis of atherosclerosis. This study was undertaken to study the association of carotid intimal medial thickness with left ventricular hypertrophy (LVH) in hypertensive patients. Materials and Methods: Hundred hypertensives (JNC-7, Stage 1 and 2) between 30 and 55 years were enrolled in this prospective observational study conducted at a tertiary care teaching institute of Punjab, India. Electrocardiogram, Carotid Doppler, and Echocardiography were carried out in addition to routine biochemical investigations. Results: Increased carotid intimal medial thickness (CIMT) had statistically significant association with age, duration of hypertension, high systolic and diastolic blood pressure (BP), left ventricular hypertrophy and left ventricular mass index but was not associated with body mass index, low-density lipoproteins, and total cholesterol. Conclusions: LVH and arterial wall changes occur concurrently, and therefore, management of hypertension should not be limited just to control of BP but should also include therapy for carotid plaques and increased CIMT.

   Abstract in French 

Résumé
Introduction: L'hypertension et l'athérosclérose par des entités distinctes sont interdépendantes car l'hypertension joue un rôle important dans la pathogenèse de l'athérosclérose. Cette étude a été entreprise pour étudier l'association de l'épaisseur médiale de l'intimité carotidienne avec le ventricule gauche hypertrophie (HVI) chez les patients hypertendus. Matériaux et méthodes: cent hypertensives (JNC-7, étape 1 et 2) entre 30 et 55 ans ont été inscrits à cette étude d'observation prospective menée dans un institut d'enseignement tertiaire de Punjab, en Inde. Electrocardiogramme, Carotide Le Doppler et l'échocardiographie ont été réalisés en plus des études biochimiques de routine. Résultats: augmentation de la médiale de l'intimité carotidienne l'épaisseur (CIMT) a eu une association statistiquement significative avec l'âge, la durée de l'hypertension, la pression artérielle systolique et diastolique (PA) l'hypertrophie ventriculaire gauche et l'indice de masse ventriculaire gauche, mais n'a pas été associé à l'indice de masse corporelle, aux lipoprotéines de faible densité et au total cholestérol. Conclusions: les modifications de la LHH et de la paroi artérielle se produisent simultanément et, par conséquent, la prise en charge de l'hypertension ne doit pas être limitée juste pour contrôler la BP, mais devrait également inclure une thérapie pour les plaques carotidiennes et une CIMT accrue.
Mots-clés: épaisseur médiale de l'intimité carotidienne, hypertension, hypertrophie ventriculaire gauche

Keywords: Carotid intimal medial thickness, hypertension, left ventricular hypertrophy


How to cite this article:
Khutan H, Aggarwal S, Kajal K S, Garg R, Kaur R, Kaur A. Study of carotid intimal medial thickness in essential hypertension with or without left ventricular hypertrophy. Ann Afr Med 2017;16:192-5

How to cite this URL:
Khutan H, Aggarwal S, Kajal K S, Garg R, Kaur R, Kaur A. Study of carotid intimal medial thickness in essential hypertension with or without left ventricular hypertrophy. Ann Afr Med [serial online] 2017 [cited 2019 Nov 20];16:192-5. Available from: http://www.annalsafrmed.org/text.asp?2017/16/4/192/216717




   Introduction Top


Hypertension is one of the leading causes of global burden of disease.[1] It is an important public health challenge in both economically developing and developed countries.[2] Hypertension doubles the risk of cardiovascular diseases, including coronary heart disease, congestive heart failure, ischemic and hemorrhagic stroke, renal failure, and peripheral arterial disease.[3] Complications of hypertension are either due to sustained elevation of blood pressure (BP) (with consequent changes in the vasculature and heart) or due to atherosclerosis that accompanies it.[3] Hypertension and atherosclerosis are two distinguished entities, but hypertension plays an important role in the pathogenesis of atherosclerosis.[4],[5] It has been demonstrated that wall shear stress; frictional force produced by circulating blood column plays an important role in the progression of atherosclerosis.[6] In patients with hypertension, concentric hypertrophy is most commonly observed. Reversal of the left ventricular hypertrophy (LVH) appears to improve the prognosis, and reduction in BP is an important component in the regression of LVH. Thus, early identification and initiation of treatment prove beneficial in cases of hypertension.[7] The aim of this study was to evaluate the association between carotid intimal medial thickness and LVH in hypertensive patients.


   Materials and Methods Top


Hundred hypertensive patients as per JNC7 criteria Stage 1 and 2 were enrolled in this study. This prospective observational study was conducted in a tertiary care teaching hospital of Punjab. After the informed consent, detailed history and clinical examination were carried out on all patients. Patients with primary hypertension between 30 and 55 years of age were included in the study and those with secondary hypertension, smokers, diabetes, coronary artery disease, stroke, peripheral vascular disease, and collagen vascular disorders were excluded from the study. BP was recorded using sphygmomanometer. In all the patients, two readings were taken at the same visit, in sitting position in the right arm with 10–15 min interval by the same investigator. Blood urea, fasting blood sugar and postprandial blood sugar, serum creatinine, and lipid profile were done using standard laboratory techniques. Height (in m) and weight (in kilograms) were measured, and body mass index (BMI) was calculated using the formula weight (kg)/height (m2).

Electrocardiogram

Twelve lead electrocardiogram (ECG) was done to exclude any major coronary artery disease and to evaluate for LVH as per the Romhilt and Estes point score system.[8] A score of 5 or more indicated LVH and correlated with increased ventricular mass.

Carotid ultrasonography

The intimal medial thickness of common carotid artery was determined by high-resolution B mode ultrasonography with a high frequency (7.5MHz) linear transducer on Philips Envisor. The common carotid was visualized at 1 cm proximal to its bifurcation, and common carotid intimal medial thickness was measured in the far wall. Three values were averaged to give mean common carotid intimal medial thickness value for each patient.

Echocardiography

Echocardiography was performed by harmonic imaging mode on Alpha Prosound 6-Aloka Doppler machine according to the standard protocol. M-mode tracings were quantified according to the recommendation of the American Society of Echocardiography. Left ventricular diastolic indices were assessed by echo-pulsed Doppler analysis. Left ventricular mass index (LVMI) >51 g/m2 was taken as the criteria for LVH.[9]

The data collected was analyzed statistically using Chi-square test and student t-test. P < 0.05 was considered as statistically significant.


   Results Top


Of the hundred patients, 52 were males and 48 were females. The mean age of the patients was 49.7 years. Out of hundred patients, sixty-one patients were in Stage 1 and thirty-nine patients were in Stage 2. Thirty-four patients had hypertension of ≤5 years duration, thirty-eight patients of 6–10 years, and twenty-eight patients of more than 10 years. Low-density lipoprotein (LDL) was found to be more than 130 mg/dl in twenty-eight patients and the remaining seventy-two, the levels were normal. Total cholesterol (TC) was found to be elevated in thirty-nine patients out of hundred. BMI of more than 25 kg/m2 was found in fifty-four patients, and the remaining forty-six were found to have BMI of <25 kg/m2. ECG score of more than or equal to 5 suggestive of LVH was observed in thirty-one patients out of hundred and similarly LVMI of more than 51 g/m2.7 was present in thirty patients. Carotid intimal medial thickness of more than 0.8 mm was present in sixty-one patients and the remaining thirty-nine; it was <0.8 mm. Twenty-one patients were found to have plaques in the carotid arteries [Table 1].
Table 1: Baseline characteristics

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The increased CIMT had statistically significant association with age (mean age 49.7 ± 4.7 years), duration of hypertension (mean 9.5 ± 3.9 years), high systolic BP (mean 157 ± 8.7 mmHg), high diastolic BP (mean 94 ± 6 mmHg), and LVMI (mean 50.9 ± 20 g/2.7). Increased CIMT was not found to have any statistically significant relation with BMI (mean 25.6 ± 2.5 kg/m2), LDL (mean 119.8 ± 37.9 mg/dl), and TC (mean 192.7 ± 41.4 mg/dl). Furthermore, it was found that LVH had statistically significant association with higher age (mean age 50.8 ± 4.2 years), increasing the duration of hypertension (mean 10.8 ± 3.8 years), high systolic BP (mean 160.2 ± 7.9 mmHg), and high diastolic BP (mean 96 ± 6.9 mmHg), and increased CIMT (mean 1.07 ± 0.24 mm). LVH was not found to have any statistically significant relation with BMI (mean 25.8 ± 2 kg/m2), LDL (mean 113 ± 31 mg/dl), and TC (mean 186.2 ± 42.7 mg/dl) [Table 2] and [Table 3].
Table 2: Mean parameters in subjects with and without left ventricular hypertrophy

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Table 3: Mean parameters in subjects with and without increased carotid intimal medial thickness (>0.8 mm)

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   Discussion Top


The present study showed slightly male preponderance consisting of 52% males and 48% females. The prevalence of hypertension increased with age as maximum number of patients belonged to age group of 41–55 years. It was also found that 54% of the patients were obese with BMI more than 25 kg/m2. Similar findings were reported by Das et al.[10] and Kokiwar et al.[11]

The present study showed a statistically significant association between increased carotid intimal medial thickness with increasing age, being 87.5% cases in the age group of 51–55 years as compared to 26.3% in the age group of 31–40 years. Gender had no significant effect of CIMT, and these observations were consistent with the previous studies.[12],[13],[14],[15],[16]

The present study showed that increased CIMT was associated with increased duration of hypertension (P < 0.001) and stage of hypertension (P < 0.002). Similar results were observed in the studies conducted by Nand et al.,[12] Heiss et al.,[13] and Zanchetti et al.[17]

In this study, there was a positive association of CIMT and high diastolic BP (P < 0.001), however, the work done by Zanchetti et al.[17] and Nand et al.[12] concluded a significant association of CIMT with systolic BP but no significant association with diastolic BP.

The present study revealed a positive association of LVH with increasing age (P < 0.003), stage of hypertension (P < 0.005), and duration of hypertension (P < 0.001). The results were consistent with a study conducted by Conrady et al.[18] Plaques were present in 27.9% of the cases with increased CIMT with statistically significant P = 0.035. This observation was in agreement with a study conducted by Bonithon-Kopp et al.[19] which also observed that plaques developed more frequently in women with increased CIMT rather than in women with normal CIMT. Previous observational studies conducted by Zanchetti et al.,[17] Heiss et al.[13] and Bonithon-Kopp et al.[19] revealed a positive association between increased CIMT and increased LDL, TC and increased BMI but in our study, it was seen that increased CIMT was neither associated with LDL and TC levels nor with increased BMI. This is probably because the absolute and mean values of both LDL and TC were in the normal range. The present study showed that 43.3% of the cases with LVH had plaques while 11.4% of the cases without LVH had plaques, which is similar to the study results of Roman et al.[20] that showed LVH was twice as likely to have carotid atheromas (35% vs. 18%, P < 0.01).

It was found in the studies conducted by Zanchetti et al.,[17] Heiss et al.[13] and Bonithon-Kopp et al.[19] that there is a positive association between increased CIMT and increased LDL and TC and increased BMI (≥25 kg/m2) but in our study, it was seen that increased CIMT (>0.8 mm) was not associated with LDL and TC levels and increased BMI (≥25 kg/m2). Cuspidi et al.[21] also found that TC has the greatest impact on IM thickening.

A positive association between the carotid intimal thickness and LVH was obtained by echocardiography. Out of sixty-one patients with increased carotid intimal thickness, LVH was present in twenty-eight patients (45.9%) with P < 0.001, and in patients with a normal carotid intimal thickness, only two (5.1%) patients had LVH. The mean CIMT in patients with LVH was 1.07 ± 0.24 mm and in those without LVH was 0.8 ± 0.11 mm. This showed that there was a significant increase in the mean carotid intimal thickness in patients with LVH. The P value for the same was <0.001 which is highly significant. Previous studies conducted by Cuspidi et al.,[21] Di Bello et al.,[22] Vaudo et al.[23] also observed a positive association between LVMI and increased CIMT.


   Conclusions Top


Increased CIMT and LVH had a significant association with increased age, stage, and duration of hypertension, and presence of plaques. CIMT shows a significant increase in patients with LVH with P < 0.001. There is no significant correlation between BMI, LDL, and TC levels in patients with increased CIMT.

Limitation of the study

A relatively small sample size has limited the evaluation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Romhilt DW, Estes EH Jr. A point-score system for the ECG diagnosis of left ventricular hypertrophy. Am Heart J 1968;75:752-8.  Back to cited text no. 8
    
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Feigenbaum H. Evaluation of Systolic and Diastolic function of the Left Ventricle. In: Feigenbaum H, Armstrong WF, Ryan T, editors. Feigenbaum's Echocardiograph. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2005. p. 141-8.  Back to cited text no. 9
    
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Das SK, Sanyal K, Basu A. Study of urban community survey in India: Growing trend of high prevalence of hypertension in a developing country. Int J Med Sci 2005;2:70-8.  Back to cited text no. 10
    
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Kokiwar PR, Gupta SS, Durge PM. Prevalence of hypertension in a rural community of central India. J Assoc Physicians India 2012;60:26-9.  Back to cited text no. 11
    
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Nand N, Jain R, Seth S, Sen J, Sharma M. A new marker of carotid atherosclerosis in middle aged adults: Cystatin C or microalbuminuria. Indian Heart J 2010;62:320-3.  Back to cited text no. 12
    
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Heiss G, Sharrett AR, Barnes R, Chambless LE, Szklo M, Alzola C, et al. Carotid atherosclerosis measured by B-mode ultrasound in populations: Associations with cardiovascular risk factors in the ARIC study. Am J Epidemiol 1991;134:250-6.  Back to cited text no. 13
    
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Lim TK, Lim E, Dwivedi G, Kooner J, Senior R. Normal value of carotid intima-media thickness – A surrogate marker of atherosclerosis: Quantitative assessment by B-mode carotid ultrasound. J Am Soc Echocardiogr 2008;21:112-6.  Back to cited text no. 14
    
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Tice FD, Peterson JW, Orsinelli DA, Binkley PF, Cody RJ, Guthrie R, et al. Vascular hypertrophy is an early finding in essential hypertension and is related to arterial pressure waveform contour. Am Heart J 1996;132:621-7.  Back to cited text no. 15
    
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Puato M, Palatini P, Zanardo M, Dorigatti F, Tirrito C, Rattazzi M, et al. Increase in carotid intima-media thickness in grade I hypertensive subjects: White-coat versus sustained hypertension. Hypertension 2008;51:1300-5.  Back to cited text no. 16
    
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Zanchetti A, Crepaldi G, Bond MG, Gallus GV, Veglia F, Ventura A, et al. Systolic and pulse blood pressures (but not diastolic blood pressure and serum cholesterol) are associated with alterations in carotid intima-media thickness in the moderately hypercholesterolaemic hypertensive patients of the Plaque Hypertension Lipid Lowering Italian Study. PHYLLIS study group. J Hypertens 2001;19:79-88.  Back to cited text no. 17
    
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Bonithon-Kopp C, Jouven X, Taquet A, Touboul PJ, Guize L, Scarabin PY, et al. Early carotid atherosclerosis in healthy middle-aged women. A follow-up study. Stroke 1993;24:1837-43.  Back to cited text no. 19
    
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Roman MJ, Pickering TG, Schwartz JE, Pini R, Devereux RB. Association of carotid atherosclerosis and left ventricular hypertrophy. J Am Coll Cardiol 1995;25:83-90.  Back to cited text no. 20
    
21.
Cuspidi C, Mancia G, Ambrosioni E, Pessina A, Trimarco B, Zanchetti A, et al. Left ventricular and carotid structure in untreated, uncomplicated essential hypertension: Results from the Assessment Prognostic Risk Observational Survey (APROS). J Hum Hypertens 2004;18:891-6.  Back to cited text no. 21
    
22.
Di Bello V, Carerj S, Perticone F, Benedetto F, Palombo C, Talini E, et al. Carotid intima-media thickness in asymptomatic patients with arterial hypertension without clinical cardiovascular disease: Relation with left ventricular geometry and mass and coexisting risk factors. Angiology 2009;60:705-13.  Back to cited text no. 22
    
23.
Vaudo G, Schillaci G, Evangelista F, Pasqualini L, Verdecchia P, Mannarino E, et al. Arterial wall thickening at different sites and its association with left ventricular hypertrophy in newly diagnosed essential hypertension. Am J Hypertens 2000;13:324-31.  Back to cited text no. 23
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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