! Richard William F.

Schmit English 1010

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Carotid intima-media thickness & Heart Disease

Thump-thump, Thump-thump, Thump-thump. That is the sound of your heart beating inside its chest cavity. Every heartbeat you here, is another second taken off your life. You may be 44 in calendar years, but are your arteries as young as you feel? CIMT tests analyzed with specialized software compares your CIMT results with others of your age or sex. At that point discussions between physicians and patients can influence the changes that are necessary to maintain healthy arteries. Today, the role of CIMT is controversial as a preventative screening tool in patients with zero to little symptoms of cardiovascular disease or atherosclerotic disease. I have selected the issue of Heart disease prevention because it is the leading cause of death in the United States in both men and women, accounting for nearly 25 percent of all deaths each year. I have selected the issue of Heart Disease prevention by examining the impact of Carotid intima-media thickness (CIMT), and how screening tools (such as ultrasound) can prevent patients from having a heart attack. I am interested in this topic because I have several members of my family in the health care, diagnostic and preventative field, but I also have several family members that have severe heart conditions. The Heart Disease and Stroke Statistics had this statement: "Coronary heart disease (CHD), the most common type of heart disease, places an unnecessary burden on the United States healthcare system. In 2010 alone, CHD was projected to have cost the United States almost $110 billion in increased health care services, medications, and lost productivity. In 2006, an estimated 7,095,000 inpatient cardiovascular operations and procedures were

! performed in the United States" (American Heart Association, 2009). I have learned about the CIMT subject based on my research, including from its beginning to present day and how it has had much power to affect change in medical diagnostics and prevention in common medicine. Today, the role of CIMT is controversial as a preventative screening tool in patients with zero to little symptoms of

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cardiovascular disease or atherosclerotic disease. I have learned that there is room for the accomplishment of more disease deterrence and prevention under this non-invasive, medical procedure if more physicians would promote its screening abilities. I was fascinated by watching studied patients receive their ultrasound exam and then watch when CIMT results are analyzed with specialized software to determine arterial age, they can be used for the purpose of educating asymptomatic patients to make lifestyles changes that will prevent complications from atherosclerosis before symptoms of CHD manifest. Based on different sources that I've found, I have learned that the role of Carotid intima-media thickness (CIMT), combined with FDA-approved software to determine arterial age, in its cognitive function to prevent asymptomatic patients from developing complications from atherosclerosis before symptoms of CHD manifest is controversial. The testing is controversial because it has not been proven that ultrasound and other imaging machines are not harmful to patients, especially pregnant mothers. However, I disagree that Ultrasound can prevent damage and harm to a patient. The amount of radiation admitted from the machine is less that a microwave and unless a patient uses the machine in access, I do not believe it can cause permanent harm. Based on different sources that I've found as well as an interview with an

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Ultrasound technician, I agree that increased thickness in the carotid artery walls can lead to coronary heart disease; a relationship between a patients arterial age and increases in Atherosclerosis is well known. I also agree that through measurements of plaque build-up in the carotid artery wall rather than the lumen, cardiovascular risk factors with carotid ultrasound can be identified earlier than with the standard Duplex carotid imaging exams. In my interview with an Ultrasound Diagnostic Technician, I learned the following: "Recently at the Redwood Medical facility, fifty subjects (ages 21-70 years old) underwent a CIMT evaluation scan of the carotid artery with a GE Logic Book Ultrasound machine. The results indicate that the majority of participants where in favor of using CIMT scanning to evaluate arterial age as a screening tool to identify those at risk for cardiovascular or coronary heart disease " (Brett Vig Ultrasound Diagnostic Technician interview, 2013). This is very interesting because many people have to pay for Ultrasound out of their own pocket and many people do not fully understand the benefits of Ultrasound as a preventative care measure. It was very interesting to learn that Atherosclerosis, (Latin for hardening of the arteries) is caused by fat, cholesterol and other substances that build-up in the arteries, known as plaque (image 1 - see below). If the plaque continually builds-up along the intima, the arterial lumen will start to narrow, obstructing blood flow, and if left untreated, can lead to cardiovascular disease. Carotid atherosclerosis measurements also replicate the degree of coronary and systemic arterial injury. Through measurements of the carotid artery wall rather than the lumen, cardiovascular risk factors with carotid ultrasound are identified earlier than standard Duplex carotid imaging With the use of a high-resolution B-mode ultrasound, the common carotid, and the carotid bifurcation can

! be cross-examined to identify the presence of non-occlusive plaques and to measure CIMT. CIMT is an independent predictor of future CVD actions.

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IMAGE 1. The above illustration was taken from the site titled "Vascular Age" (Nersi
Nikakhtar, November

4, 2010).

The above graph shows the longitudinal image of the right internal carotid artery. "Color Doppler shows blood flowing from the upper right to the lower left. The area shown in black is plaque build-up causing a stenosis. Distal to the stenosis, turbulent blood flow is seen" (Robert L. Blum and Tim Russert, June 2008). It was fascinating to

learn that CIMT in the common carotid artery is strongly associated with risk factors for stroke and with prevalent stroke, also CIMT in the carotid bifurcation and associated plaque are more directly associated with ischemic heart disease risk factors and prevalent ischemic heart disease (American Heart Association, 2009). The Atherosclerosis Risk in Communities (ARIC) Study identified the following: "The prevalence of cardiovascular disease (CVD) was consistently greater in participants with progressively thicker IMT. The carotid IMT in participants with CVD caused the risk of myocardial infarction to increase by 10%, angina increased by 6%, cerebrovascular disease increased 6%, peripheral vascular disease increased 19%, and 8% increase in those with any form of CVD. The observed differences in intima-media thickness across disease groups are

! constant with the relationships between ubiquitous CVD and carotid atherosclerosis seen in previous clinical autopsy and ultrasound studies" (American Heart Association, 2009). The above quote demonstrates that the prevalence for CVD is ever increasing

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therefore there is clearly a need to develop and implement new methods to screen for the presence of atherosclerosis. Ultrasound detection of carotid plaque can by accomplished with high-resolution gray-scale (B-mode) imaging and can identify patients at risk for atherosclerotic changes. Carotid intima-media thickness is defined as the distance between the lumen-intima interface and the media-adventitia interface. If monitored consistently, carotid intimamedia thickness can be used as an indicator of progression or regression of atherosclerotic disease. "Increased thickness in the carotid artery walls can lead to coronary heart disease (CHD). If individuals are aware of their risk of CHD before symptoms occur, they may be able to take preventive medications and make lifestyle changes to prevent the onset of CHD" (American Heart Association, 2009). CIMT scanning is an effective screening tool when analyzed with specialized software, for determining arterial age in asymptomatic patients in an effort to prevent complications from atherosclerosis. The study that was performed and that is outlined in the following pages, is a retrospective data collection of patient surveys; whose CIMT scan data was entered in to a specialized software program to determine arterial age. The intended research results will help primary care physicians, and radiologists to recommend a diagnostic CIMT scan. When CIMT results are analyzed, they can be used for the purpose of educating asymptomatic patients to make lifestyles changes that will prevent complications from atherosclerosis before symptoms of CHD manifest.

! I was surprised to learn that Sonography being used for medical diagnosing and prevention is fairly new, but since the 1980's and the acquisition of 3-D imaging, the subject of ultrasound has evolved into an emerging field of study. Thus the objectives of this study were as follows: to promote the use of CIMT in conjunction with FDAapproved specialized software, to endorse CIMT as a screening tool in asymptomatic

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patients, to establish the general consensus of the convenience sample patient population through the use of survey, to evaluate the relationship between ultrasound carotid artery scanning versus other carotid artery imaging modalities, and to identify the association between early markers of plaque build-up and the risk of atherosclerotic disease in individuals. Today, when CIMT results are analyzed with specialized software, they can be used for the purpose of educating asymptomatic patients to make lifestyles changes that will prevent complications from atherosclerosis. CIMT scanning should be used more in the medical field as a precautionary tool to help eliminate future cardiovascular health care problems. According to The Gurnick Academy of Medical Arts: "ultrasound has improved ways to detect impaired blood flow from clots or atherosclerosis" (American Heart Association Position Statement on State Efforts to Mandate Coronary Arterial Calcification and Carotid Intima Media Thickness Screenings Among Asymptomatic Adults, 2012). There are a few different perspectives about the use of Ultrasound as a preventative medicine. Overtime, Ultrasound has been slowly used and accepted in the medical community as a form of diagnosis; however, over the last five decades ultrasound technology has been continually improved. View one of Ultrasound as a

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preventative medicine for heart disease is that the medical community believes that yes, it should be used. Today, when CIMT results are analyzed with specialized software, this information can be used for the purpose of educating asymptomatic patients to make lifestyles changes that will prevent complications from atherosclerosis before symptoms of CHD manifest. CIMT scanning should be used more in the medical field as a precautionary tool to help eliminate future cardiovascular health care problems. Diagnostic ultrasound is acknowledged as safe, effective, and highly reproducible imaging modality capable of providing clinically relevant information about carotid arteries in an efficient and in-expensive fashion" (YSENMED Yueshen Import & Export
CO., Ltd. Medical Ultrasonography, January 2011).

View two as Ultrasound as a preventative medicine is that ultrasound can be dangerous and there is not enough research done to prove that it is a good source for preventative medicine. View three is that Ultrasound as a preventative medicine is inconclusive and needs to further be researched before insurances and doctors use Ultrasound everyday as a preventative tool for heart disease. CIMT testing is an approximately 15-20 minute outpatient procedure. There is no needles, no pills, or radiation. The test uses state-of-the-art ultrasound equipment and FDA-approved software applications to analyze the data. This is relevant because it highlights the ease of which this scan can by done in multiple clinical settings from hospitals to family clinics and everything in between. Dr. Sanford Carimi, a physician in Janesville, Wisconsin stated, "If I tell you your cholesterol is 130, that won't bother you," he said. "If I show you that you have a plaque in the blood vessel leading to your brain, you're more likely to make some changes" (Marilynn Marchione, 2007). Cardiovascular disease can be life threatening. Certain

! factors can contribute to developing cardiovascular disease: smoking, obesity, alcohol,

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consuming foods high in saturated or poly-saturated fat, high cholesterol, not eating many fruits or vegetables, or lack of physical activity. "There is growing evidence that patients can improve lipid levels and decrease the rate of cardiovascular events by adding specific foods to their diets and switching from saturated and polyunsaturated to monounsaturated fats and n-3 fatty acids. Appropriate dietary changes decrease arteriosclerotic plaque formation. Brief discussions between physicians and patients can influence patients' food choices. Changes in diet can reduce the premature mortality and morbidity associated with coronary artery disease" (Steven C. Masley, 1998). The above quote shows the importance of adapting our dietary habits to prevent complications that may arise from CVD. Other lifestyle changes may include medications to reduce CVD. "For one-third of heart disease sufferers, the first symptom is dropping dead of a heart attack. Finding these people early and treating them could save lives" (Marilynn
Marchione, 2007). Why is this fact important? Cardiovascular disease doesn't only affect

adults in their 'golden years,' but adults of all ages. This is proven by the following statistic: "In 2008, 33% of deaths due to CVD occurred before the age of 75 years, which is well before the average life expectancy of 77.9 years" (American Heart Association,
AHA Statistical Update, 2012).

Today, the role of CIMT is controversial as a preventative screening tool in patients with zero to little symptoms of cardiovascular disease or atherosclerotic disease. There is room for the accomplishment of more disease deterrence and prevention under this medical procedure if more physicians would promote its screening abilities. The completed survey demonstrates the progress of ultrasound towards being used towards diagnostic and preventive medicine because ultrasound is: 1. Noninvasive, no needles, no pills, painless

! 2. Harmless, no radiation or, at present, no definitive proof that ultrasound at diagnostic levels is harmful. 3. Reproducible, images can be acquired repeatedly. 4. Cost effective, less expensive then CT or MRI

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5. Excellent imaging acquisition to identify abnormalities that aid in the diagnosis of disease or prevention of other diseases. In my opinion, CIMT results can and should be used for the purpose of educating asymptomatic patients to make lifestyles changes that will prevent complications from atherosclerosis before symptoms of CHD manifest.

Citations American Heart Association Heart Association. "American Heart Association. Heart Disease and Stroke Statistics 2009 Update." American Heart Association. N.p.,

! 2009. Web. 24 June 2013. <http://www.nanocorthx.com/Articles/HeartDiseaseStrokeStatistics.pdf>. Blum, Robert. "Tim Russert: Dead at 58 The Case for Coronary Artery Calcium CT Scan." Robert Blum Website. N.p., June 2008. Web. 13 July 2013. <http://www.bobblum.com/ESSAYS/BIOMED/Coronary-CT.html>. Diffen Health. "CT Scan vs Ultrasound." CT Scan vs Ultrasound Comparisons. N.p., 2012. Web. 14 July 2013. <http://www.diffen.com/difference/CT_Scan_vs_Ultrasound>. Journal of the American Society of Echocardiography. "Use of Carotid Ultrasound to

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Identify Subclinical Vascular Disease and Evaluate Cardiovascular Disease Risk: A Consensus Statement from the American Society of Echocardiography Carotid Intima-Media Thickness Task Force Endorsed by the Society for Vascular Medicine." ASE CONSENSUS STATEMENT. N.p., Feb. 2008. Web. 27 June 2013. <http://www.cvrc.wisc.edu/airp/vascularage/ASEcarotidUSconsensusstmt.pdf>. Marchione, Marilynn. "Small Scanners Find Hidden Heart Disease." The Associated Press: Small Scanners Find Hidden Heart Disease. AP Associated Press, 8 Oct. 2007. Web. 3 July 2013. <http://www.cvrc.wisc.edu/airp/vaschealth/APmedia/AP-small_scanners.pdf>. Masley, Steven C. "Dietary Therapy for Preventing and Treating Coronary Artery Disease." American Family Physician. N.p., Mar. 1998. Web. 11 July 2013. <http://www.aafp.org/afp/1998/0315/p1299.html>.

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Nikakhtar, Nersi. "Vascular Age." Vascular Age. N.p., 14 Nov. 2010. Web. 12 July 2013. <http://www.cvrc.wisc.edu/airp/vascularage/vascularage.htm>. Stein, James H. "Carotid Intima-media Thickness And Vascular Age: You Are Only as Old as Your Arteries Look." Carotid Intima-media Thickness And Vascular Age. Atherosclerosis Imaging Research Program, Cardiovascular Medicine Section, Department of Medicine University of Wisconsin Medical School, 21 Feb. 2004. Web. 7 July 2013. <http://www.scifun.org/conversations/Conversations4Teachers/Ref.1.pdf>. Vig, Brett. Interview by Richard William F. Schmit. Interview type: Interview of Ultrasound Technician. July 14, 2013. Winslow, Ron. " Your Risk of Heart Disease." Ultrasonography,medical Ultrasonography, Ultrasound ,diagnostic Sonography. The Wall Street Journal, 1 June 2010. Web. 15 July 2013. <http://www.medical-xray.com/news/Info_center/431.html>. Woods, Lauren. "Cholesterol-lowering Medication Accelerates Depletion of Plaque in Arteries." Cholesterol-lowering Medication Accelerates Depletion of Plaque in Arteries. NYU Langone Medical Center / New York University School of Medicine, 13 Dec. 2011. Web. 10 July 2013. <http://www.eurekalert.org/pub_releases/2011-12/nlmc-cma121311.php>.

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