Artery Wall Disease Assessment with IMT for Everyone, but Especially for South Asians plus CCTA FFR with QCPA when needed.

More people die of heart attack and stroke, than from any other cause.

More people die of heart attack and stroke than any other cause.  South Asians have 60% of the world’s heart attacks, nearly 25% of those under age 40.  Non-South Asians only have 1% of their heart attacks under age 45, so the risk factor calculators based on non-South Asian data are misleading.

We provide the most accurate detection and treatment of all stages of the artery disease that causes heart attacks and strokes using a range of testing and monitoring from blood tests for advanced cholesterol parameters, non-cholesterol causes and rare causes when necessary, an earliest-stage pre-plaque detection using the radiation-free inexpensive and convenient in-office IMT ultrasound through cutting-edge FDA-approved coronary artery flow limitation and un-calcified plaque visualization with CCTA-FFR-QCPA when a higher expense and small radiation exposure are acceptable to the patient.

Treatment ranges from lifestyle change through blood test-based supplement choices and several statin and non-statin cholesterol-reducing medications when necessary. The result for nearly all patients is proof that you have stopped your artery disease from progressing towards a higher risk of heart attack, which standard cholesterol blood tests and treadmill testing does not do.

The first step is to use your 10 year heart attack risk calculator. If your calculated 10 year risk of heart attack is below ASCVD 5% or PREVENT 2.5% and you do not have one of several risk enhancing factors such as South Asian ancestry or a strong family history of heart attack, then no further testing or treatment beyond a heart-healthy diet and exercise is needed.

The next step for those with calculated heart attack risk above these levels, is to measure the earliest visible stage of artery inflammation, which is the thickening of the IMT (in media thickness) layer in the carotid artery in the neck that precedes the plaque seen by other tests.  If you are going to have a heart attack in the next 10 years, you have a 95% chance that the carotid IMT ultrasound will detect your disease little inflammation.  A normal result indicates a less than 1 in 200 chance of heart attack over the next 10 years, only requiring rechecking every 5 years. The carotid IMT ultrasound is the most sensitive and accurate test for measuring the IMT and also detects all types of plaque, including the earliest and most dangerous subsequent stage of disease called un-calcified or “soft” plaque. Un-calcified plaque creates a 40% chance of heart attack over the next 10 years and must be treated immediately. Treatment usually stops and sometimes reverses the general population progression of increased thickness of the IMT towards a higher risk of heart attack! He carotid IMT ultrasound is the most accurate, convenient (in-office), inexpensive, and radiation-free test to prove that you have stopped this artery disease progression and greatly reduce your chance of heart attack and stroke.

The second step for those who need or desire to have a complete and direct measurement of their heart artery disease, regardless of cost or radiation use (which is low, similar to a mammogram) we use the FDA approved and first line-recommended test to diagnose chest pain, but instead use it as a preventive tool, called the CCTA-FFR-QC Plaque Analysis (full name: Coronary Computed Tomography Angiogram-Fractional Flow Reserve-Quantitative Coronary Plaque Analysis). This test identifies exactly the location and degree of heart artery blockages and un-calcified plaque. Currently $2,620 out of pocket.

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IMT Video

The Cause of Artery Disease

The cause of heart attack and stroke is bad cholesterol that becomes trapped in the wall of the artery. It becomes so inflamed by the body’s clean-up process, that toxic side effects of inflammation kill the smooth cells that line the artery, causing a rough spot. Blood cells stick to the rough spot causing a clot, that fills the artery within seconds. Both the cholesterol and inflammation that make up artery disease, thicken a layer in the artery wall called the intima-media. Uncontrolled inflammation continues to thicken the IMT, often leading to plaque, which is a localized mound of inflammation which is the immediate cause of artery blockage when it ruptures.

FIGURE 1: IMT/Plaque Ultrasound images showing intima-media layer of arterial wall (left image) and carotid artery plaque build-up (right image).

Assessing Artery Disease

It follows that one of the first structural changes that can be detected non-invasively in artery disease is an increase in IMT, which can be very accurately measured using harmless sound waves, by a special high frequency ultrasound, called an IMT/Plaque ultrasound. This is an FDA approved test that measures the thickness of the two innermost layers (intima and media) of the walls of the carotid artery (located in the neck). Our ultrasound provider’s proven reproducibility also allows for comparisons within 1 to 3 years enabling treatment decisions based on IMT changes¹⁰. 

Why Consider IMT/Plaque Ultrasound?

The European Society of Cardiology recommends the IMT plaque score to reclassify those at intermediate risk of heart attack. A meta-analysis proved that the change in the mean IMT indicates whether the risk of heart attack has been reduced or is still progressing towards higher risk.

FIGURE 2: Survival free of heart attack, stroke or death, in high risk patients with asymptomatic carotid stenosis, was higher (upper line) with medical therapy to reduce plaque progression, than with medical therapy to reduce cholesterol blood tests and blood pressure to guidelines (lower line)⁶.

Who should have the IMT/Plaque Ultrasound?

This screening test can be performed between the ages of 25 and 80. It generally should be considered in South Asian men and women over age 25, because according to a recently published Lifetime Risk model for South Asians, two in three men, and one in two women had high lifetime predicted risks for cardiovascular disease, often beginning at age 20¹¹. In non-South Asian groups, the IMT/plaque ultrasound should be performed for men over 45 and women over 50. Risk factors include:

• Family history of heart attack and/or stroke
• Abnormal cholesterol levels (high LDL or “bad” cholesterol, low HDL or “good” cholesterol, or elevated triglycerides)
• High blood pressure (hypertension)
• Smoking (former or current)
• Diabetes or metabolic syndrome
• Overweight or physically inactive or unhealthy lifestyle
• Sleep apnea
• Chronic inflammatory disease or disorder (such as rheumatoid arthritis, lupus, psoriasis, HIV, inflammatory bowel disease)
• Prior abnormal CIMT test to help follow the effectiveness of risk-factor modification

The above risk factors as well as aging are contributing factors to an increased carotid intima-media thickness as well as risk for heart attack and stroke.

A More Complete Artery Disease Analysis and Treatment

At Cogent Family Healthcare, if, following an IMT ultrasound, artery disease is found, your condition is further assessed using blood tests that measure factors that contribute to artery wall inflammation. Each factor responds more favorably to different treatment interventions, so the blood test enables us to determine the optimal treatment plan for you. Our treatment of abnormal inflammatory components frequently results in resolution to normal in 6 to 12 weeks.

Inflammation Analysis: Inflammation analysis covers a variety of inflammatory markers, the most notable being myeloperoxidase (MPO), an enzyme that has been found to be to play a role in the inflammation in the artery wall. Multiple studies show that the plaque in the artery walls contains large amounts of MPO. This is especially true in places that are prone to rupture and can lead to heart attacks. Higher inflammation means that you are at a higher risk of having a heart attack. Studies show that, among patients with chest pain, an increased MPO level can predict their risk of heart attack over the next 30 days to six months. In other, longer studies involving middle-aged patients who were assumed to be healthy, an elevated MPO level predicted the risk of heart attack over two to 10 years.

Cardio Metabolic Analysis: A cardio metabolic analysis covers the three main areas of keeping a healthy metabolic profile: Glycemic Control, Lipid Profile, and Vascular Inflammation. While cholesterol testing has historically been used as the standard indicator for cardiovascular disease, up to 71% of people who have suffered heart attacks had “normal” cholesterol levels. This discrepancy is because it is the lipoprotein particles that carry the cholesterol particles throughout the body, not necessarily the cholesterol within them, that are responsible for key steps in plaque production and the resulting development of cardiovascular disease. At Cogent Family Healthcare, we provide advanced cholesterol testing technology that accurately measures both the density and number of lipoprotein particles. More than 30 percent of the population has a condition in which a patient’s cholesterol may be “normal” but their lipoprotein particle number, and hence, their actual risk, could be much higher than expected. Measuring the lipoprotein subgroups and other inflammatory factors, is the only way to evaluate such risk factors, which is crucial for an accurate assessment of cardiovascular risk, and the establishment of an effective treatment program.

We use the results of your IMT/Plaque ultrasound, your blood tests and genetic panel in combination with your cardiac risk factors, to create an effective treatment plan that may include lifestyle changes, supplements and/or medications, with the aim of:

• Reducing your risk for heart attack and stroke
• Reversing existing artery disease
• Maintaining your heart health

Furthermore, it allows us to monitor your progress as we aggressively treat your cardiovascular disease. We can document improvements or progression and make appropriate adjustments to help you reduce your risk of a heart attack or stroke.

How Does IMT/Plaque Ultrasound Compare to Other Tests?

• Risk factor calculator ACC/AHA. Artery wall plaque, which we measure as part of the IMT/plaque test, was found to be more than 3.4 times as powerful as the Framingham Risk Score in identifying heart attack risk⁷, and in another study, a very high IMT/plaque ultrasound score indicated seven times more risk than is predicted by all other risk factors combined (cholesterol, blood pressure, diabetes, smoking weight, exercise and alcohol) for women, and twice the risk for men⁵.
• The cardiac calcium score detects artery disease at a later stage than IMT, because inflammation and plaque are not calcified for many years, and frequently cause heart attack before calcification occurs. One study found that 47% of patients with a normal cardiac calcium score of zero, had plaque found on the IMT/Plaque Ultrasound⁸. An editorial in Mayo Clinic Proceedings⁹ stated “CIMT measurements might indeed be best used in younger patients in an office-based outpatient care environment (as opposed to the cardiac calcium score, which has a low prevalence in younger patients) with easily portable devices and without exposure to ionizing radiation.” The FDA and NIH also accept IMT/Plaque Ultrasound (but not coronary calcium scanning) to follow patients for atherosclerotic disease progression. The IMT/plaque ultrasound also does not expose the patient to ionizing radiation, as the cardiac calcium score does.
• A treadmill stress test only detects narrow points in an artery, which form after many years of severe artery inflammation. Similarly, chest pain during exercise only occurs when such narrow points are present in an artery, a much later stage of artery disease.

What to Expect During the IMT/Plaque Ultrasound Test

• No preparation is required for the IMT test. Patients may resume normal activities immediately following the test unless otherwise instructed.
• A diagnostic medical sonographer will perform the test in our office.
• A thick gel, the same consistency as hairstyling gel, is applied to the skin of the neck. With the use of a transducer (a small microphone-like device), the gel helps the sound waves to get from the machine into the body.
• Sound waves bounce off the carotid arteries. This creates "echoes" that are reflected back to the transducer, which converts them to electronic signals. A computer then processes the signals into pictures and shows them on a computer monitor.

References

1. http://www.cadiresearch.org/
2. Health, United States, 2016. http://www.cdc.gov/nchs/hus.htm. Mortality rate from heart disease and stroke corresponding to dates studies were done that created the composite curve for lifetime IMT progression used on Cardiorisk patient reports (See references on these reports).
3. Gianni Belcaro, et al. Carotid and femoral ultrasound morphology screening and cardiovascular events in low risk subjects: a 10-year follow-up study (the CAFES-CAVE study). Atherosclerosis 156 (2001) 379–387.
4. Amit Sachdeva, MD, et al. Lipid levels in patients hospitalized with coronary artery disease: An analysis of 136,905 hospitalizations in Get With The Guidelines. Am Heart J 2009;157:111-7.e2.
5. Association of coronary heart disease incidence with carotid arterial wall thickness and major risk factors: The Atherosclerosis Risk in Communities (ARIC) Study, 1987-1993. Chambless LE, et al. Am J Epidemiol.1997 Sept 15;146(6):483-94.
6. J. David Spence, MD et al. Effects of Intensive Medical Therapy on Microemboli and Cardiovascular Risk in Asymptomatic Carotid Stenosis. Arch Neurol. 2010;67(2):180-186.
7. J. David Spence, MD et al. Carotid Plaque Area: A Tool for Targeting and Evaluating Vascular Preventive Therapy. Stroke 2002, 33:2916-2922.
8. Steven J. Lester MD, FRCPCa, et al. Carotid Intima-Media Thickness and Coronary Artery Calcium Score as Indications of Subclinical Atherosclerosis. Mayo Clinic Proceedings. Volume 84, Issue 3, March 2009, Pages 229-233.
9. Thomas Gerber MD PhD, Allen Taylor MD. Editorial: Carotid Intima-Media Thickness: Can It Close the “Detection Gap” for Cardiovascular Risk? Mayo Clinic Proceedings. Volume 84, Issue 3, March 2009, Pages 229-233.
10. Naomi O. Riches, Stephen Alder, George L. White, Regina Druding, M. Gene Bond and Mario De Michele. Standardized ultrasound protocol, trained sonographers and digital system for carotid atherosclerosis screening. Journal of Cardiovascular Medicine 2010, 11:000–000.
11. Jeemon P, Prabhakaran D, Huffman MD, et al. Distribution of 10-year and lifetime predicted risk for cardiovascular disease in the Indian Sentinel Surveillance Study population (cross-sectional survey results). BMJ Open. Jan 1 2011;1(1):e000068.

Figures:

1. Actual intima-media layer and soft plaque image.
2. Effects of Intensive Medical Therapy on Microemboli and Cardiovascular Risk in Asymptomatic Carotid Stenosis. J. David Spence, MD et al. Arch Neurol. 2010;67(2):180-186.

If you’re at risk for cardiovascular disease, contact Dr. Sims today to schedule your artery wall evaluation. This quick, painless, FDA-approved test could save your life! Call Cogent Family Healthcare in Mountain View, California at (650) 386-0386.