+

IMT

Plaque

ARMV
8-11-Novembre 2014
RCV

Prvention
Primaire

P-J Touboul Neurologue

Dpartment de Neurologie , Centre de prvention de lattaque
crbrale
b l
Hopital Bichat and Medical School
INSERM U698

+ Athrosclrose:Maladiepernicieuse
Silencieusependant3040annes
Semanifestebrutalement(AVCIM)
Atteint300000sujets/anenFrance
DatedesvnementsImprvisible
d
i ibl
Evnementssurviennenttardivement

+ AVCetIM:Epidmiologie
g
IncidencedesAVCestde650000patients/anne(US)
I id
d AVC d 6
i
/
(US)
AVCetIMvontaugmenterdansles20ans:
Esprancevieaugmente(AVC++)
Poids(MI++)
Modedevie(AVCetIM)
Cardiopathies(Stroke)
Femme(AVCetIM)
LAVCestunemaladiecomplexe.(<>IM)

Athrognse
g

Dysfonction endotheliale & EIMT

Survenue Plaque

Thrombus

Glass , Cell 2001,104:503-516

+ HistoireNaturelledelathrosclrose
I
Macropha
ges

II

III

IV

Stries
Lsions
Plaque
Ath
Athrome
lipidiques Intermediaires
Fibreuse

Premire Dcennie

2me Dcennie

Stades Lipidiques

VI
Lsion
compliques

3me et Dcennie
Hyperplasie
yp p
MI Thrombose
Hmorragie
et collagne

Stary HC et al. Circulation. 1995;92:1355-1374.

Identification des sujets asymptomatiques

risque CV intermdiaire
EVENEMENTS CLINIQUES

Stnose
Athrosclerose

Plaque
EIM

Marqueur

HTA/Diabte
Cholestrol
/Tabac

Facteurs de risque

Nutrition-Gnes

+
Mthodes potentielles

Calcifications
coronaires

Index
Pression
Systolique

IRMIRM
ARM

Mesure EIM

PourquoiUltrasons?

Seulemthodemontrantlaparoiartrielle

NonTraumatique

PrdicteurdurisquedvnementCV
q

ArtreCarotideestunefentresurlerisqueCVcar

EIM/Plaqueintgredesfacteursgntiquesetenvironnementaux

Peuttremodifieparcertainsmdicaments

EpaisseurIntimaMedia

VALIDATION

EIMdelACC
Corrlationentre:

Spcimensanatomiquescarotidesetimageschographiques

Profilcaractristique":liserdlimitparunezonehypochogne

r = O.9
Capteur

P. Prox

P.Distale
I M A

L
Lumire

ACC P.Distale

+ MesureEIM
Artre Carotide Commune

Proximale

Distale

EIM

EpaisseurIntimaMdia

EIMACC Normale

EIMACC Augmente

CerebroVascularDisease2004

MannheimConsensus

DfinitionEIMetPlaque

Procduredacquisition

Populationcible

Mthodedemesure

Epaisseur intima
Media
(1) EIM est un liser
caractristique visualis
par chotomographie
sur les 2 parois des
ACC en CL

Plaque
(2) Structure localise
incidente dans la lumire
artrielledau - 0.5 mm ou
50% de la paroi adjacente
ou encore ralise un
i i
paississement
t > ou =
1.5 mm mesur de
linterface mdiaadventice ll interface
intima-lumire artrielle.

EIMetPlaque

EIM:MesureSemiAutomatique

MesurePlaque
Dtectionautomatique

EpaisseurIntimaMdia

EIM et Facteurs de risque CV

Athrosclrose prcoce et EIM

Facteurs de risque
q dEIM
NonModifiables

Age
Sexe
Gntique

Modifiables

Hypertension
p

Lipides

Diabte

Tabac

Hyperhomocystinnmie

Hritabilit

(Stroke. 2005;36:5-8.)

Hritabilit d
d EIM

565 sujets
j
de 154 familles ou un p
parent tait
atteint d
d athrosclrose carotide
EIM , plaque et stnose /ultrasons
EIMT h2 0.61
0 61 (P < 0
0.01)
01)

Zannad F and al.Hum Genet1998

EIM de llACC
ACC : Facteurs de risque
Pression artrielle
Lepluspuissant:PressionSystolique

EtudesCastmoins:0.06to0.25mm

Etudestransversales

DiffrentpourlaPDresults.

CHS5000sujets>65y

EIMdiminueavecchaqueQdePSquandPDaugmente

Effetpressionpulse?

+
IMTs

1.04
0.95
0.9

0.86
0.81
0.81
< 61

78-81

> 147

< 116

Quintiles DEof DBP (mmHg)Quintiles of SBP

(mmHg)

CHS Psaty ..

+
EIM ACC
ACC: F
Facteurs d
de Ri
Risques
Cholesterol total
HDL (diminu)
LDL (augment)
Diabte
Tabac

EIMetPlaque:Nouveauxfacteurs
derisqueCV
q

IMTPlaqueandemergentCV
Risks
711patients

DentalHistoryandOralExamination

Plaqueassessment

AtherosclerosisandemergentCV
Risks

29

Nombre de FR and EIM

Touboul et al, PARC Study 2003

EIM
et
ATHEROSCLEROSE

EIM:RemodelageouAthrosclrose

Filipovic Nenad

EIMetPlaque:EVAStudy

EIMACC
prdit la
survenue
dune
plaque
carotide

C Bonithon Kopp P-J Touboul ATVB 1996

IMTandPlaque:EVAStudy
d
que
S udy

Zureik, Ducimetiere, Touboul, et al. ATVB 2000;20:16221629

EpaisseurIntimaMediaThickness

EIM et vnements CV

IMAVC&IMT/Plaque

Study

Author

Year

Design

End.P

Age

F U(m)

Segments

KIHD

Salonen

93

Longitudinal

MI

42-60

1-36

CCA

ARIC

Chambless

97

Longitudinal

MI

45-64

Chambless

2000

Longitudinal

Stroke

Rotterdam

Bots

97

Nested K/C

MI,Stroke

64
127
86
128
32

CCA Bif ICA &

Combined
CCA Bif ICA&
Combined
CCA

Iglesias
g

2002

Nest K/Coht

MI

55

CCA Bif ICA &

Combined

Holander

2003

Longitudinal

Stroke

73

CCA

CHS

O Leary

1999

Longitudinal

MI,Stroke

74

CCA ICA & Combined

NA

Kitamura

2004

Longitudinal

Stroke

54

CCA ICA & Combined

MDCS

Rosvall

2005

Longitudinal

V Death

84

CCA

Rosvall

2005

Longitudinal

Stroke

84

CCA

LILAC

Murakami

2005

Longitudinal

V Death

>75

38

CCA

CAPS

Lorenz

2006

Longitudinal

MI Stroke

19-90
19
90

50

CCA Bif ICA

Death

>55

>65
No CVD
60-74
No CVD
46-68
No CV
CVD

Lorenz M and al Circulation 2007;115:459-467

HRIMpour1variationd1DSdEIMACCA(/ageetsexe)

ARIC

1,22

CHS

1,33

Rotterdam 1,44
,
MDCS

1,36

CAPS

1 18
1,18

Total

1,26
1

1,1

1,2

1,3

1,4

1,5

Lorenz et al Circulation 2007

+ HRStrokepour1variationd1DSd EIMACC(/ageetsexe)

CHS

1,37

ARIC

1,35

Rotterdam 1,29
MDCS

1,31

CAPS

1,16

Tota
l

1,32
1

1,1
,

1,2
,

,
1,3

1,4

1,5

1,6

Lorenz et al Circulation 2007

IMTMIandStroke
CardioVascularHealthStudy
CCA,ICAandCombinedmeasurementsoncarotid

artery
t
4476asymptomatichealthysubjects
447
y p
y
j
Atleast65yearsold
Meanfollowup6.2years
IMTclassifiedaccordingtoQuintiles

DH O Leary et coll NEJM Jan99

IMTMIandStroke

DH O Leary et coll NEJM Jan99

+
CCAIMT and PAD

IMTandintermittentclaudication
2Studies:ARICandRotterdamStudy
Subjectswithintermittentclaudicationhavea
significantincreaseofIMTcomparedtonormals(15
to20%)

IMTandAnklearmindex
RotterdamStudy
SignificantincreaseinIMTforanAaIndex<0.90
i ifi
i
i
f
d
Adjustedageandgenderdifference:0.107mm
j
g
g
7

IntimamediaThickness

IMT and CV Risk

IMMEDIATSTUDY
300centers
Frenchcardiologists
4000asymptomatichypertensives(GP)
Clinicalandbiologicfactorsatbaseline
ClassificationinL,M,H,VHCVRisk(WHO

ISH

IMMEDIATSTUDY

Scanningofcarotidarteriesandbifurcations

PrevalenceofcarotidplaqueandIMTmeasured/Math

SecondevaluationofCVRtakingintoaccount
Plaque
IMT>0,7mm

IMMEDIATSTUDY

Plaquein27%ofthepopulation

IMT>0,7mmin56%ofthepopulation

IMMEDIATSTUDY
CAROTID
ULTRASOUND
EVALUATION

Low Risk Medium Risk High Risk Very High Risk

Before CUE

6%

79%

13%

2%

After
te

10%
0%

37%

51%

2%
%

CU
CUE

Target organ damage more sensitive for individuals

classification into the different risks
X Girerd ISH 2001

IMTandPlaque:BRHS

BritishRegionalHeartStudy(Nationalcohortof7735men)
h
l
d (
l h
f
)

2TownsDewsburyandMaidstone(2folddifferenceinCHD)

425menand375women

S Ebrahim O Papacosta P Whincup and al Stroke 1999;30:

IMTandPlaque:BRHS

BritishRegionalHeartStudy
h
l
d

MeanCCAIMT:0.84and0.75mm(M/F)

MeanBifurcationIMT:1.69and1.50mm(M/F)

S Ebrahim O Papacosta P Whincup and al Stroke 1999;30:841-

IMTandPlaque:BRHS

CCAandBifIMTwerecorrelated
d f
l d

Prevalenceofplaquewas79%inDewsburyand34%inMaidstone

IMTwas0.1mmgreateramongthosewithplaques(average)

A
Amongthosewithoutplaque1of4(M)and1of16(F)hadIMTg.
gth ith t l
1 f (M) d1 f16(F)h dIMTg

S Ebrahim O Papacosta P Whincup and al Stroke 1999;30:841-

IMTandPlaque:BRHS

DifferentpatternsofassociationwithRF

CCAIMT :StronglyassociatedwithRFfor

stroke&itsprevalence
BIFIMTandplaque
BIFIMT d l
:StronglyassociatedwithMI
St
l
i t d ithMI
RFactors&itsprevalence.

S Ebrahim O Papacosta P Whincup and al Stroke 1999;30:841-

Indications dtection

PARC
Paroi Artrielle et Risque
Cardiovasculaire

PARC:Protocole

EtudeEpidmiologiquefranaisevisantvaluerlarelation
entreEIMACCetlerisqueCV.
entreEIMACCetlerisqueCV
250centres

Mthodologieharmonise

In5300

H:Fagsde30to79

1/3 normaux (FR=0)

2/3 risque (FR=1ouplus).

Whole POPULATION
0,85
0,8

M e a n IM T

0 75
0,75
0,7

0,65
06
0,6
No RF

0,55

With RF
0,5
30-40

40-50

50-60
Age

60-70

70-80

FraminghamScore&EIM

Mean of FCS, points

15
13
11
9
7
5
IMT, mm
30-49

50-59

60-69

70-79

Age

+
MEN
Age y
Age,

30 39
30-39
(n=69)

40 49
40-49
(n=102)

50 59
50-59
(n=135)

60 69
60-69
(n=93)

70 79
70-79
(n=82)

P05

0.464

0.528

0.549

0.569

0.627

P10

0.519

0.560

0.585

0.618

0.647

P25

0.574

0.586

0.637

0.663

0.743

P50

0.616

0.653

0.701

0.738

0.798

P75

0.672

0.705

0.787

0.842

0.907

P90

0.749

0.756

0.836

0.909

0.955

P95

0.772

0.802

0.914

1.030

0.984

TABLE 2. Percentiles of Mean CCA-IMT Measurements by Decades

and Gender in Subjects Without Modifiable Cardiovascular Risk Factors
P05, P10, P25, P50, P75, P90, P95 : 5th,10th, 25th, 50th, 75th, 90th and 95th percentiles

Femme
Age,
y

30-39
(n=78)

40-49
(n=139)

50-59
(n=153)

60-69
(n=120)

70-79
(n=79)

P05

0.467

0.514

0.553

0.575

0.608

P10

0.492

0.539

0.586

0.612

0.658

P25

0.537

0.576

0.619

0.665

0.710

P50

0.588

0.640

0.669

0.752

0.758

P75

0.635

0.691

0.737

0.817

0.841

P90

0.670

0.726

0.789

0.865

0.882

P95

0 687
0.687

0 745
0.745

0 828
0.828

0 906
0.906

0 950
0.950

TABLE 2. Percentiles of Mean CCA-IMT Measurements by Decades

and Gender in Subjects Without Modifiable Cardiovascular Risk Factors
P05, P10, P25, P50, P75, P90, P95 : 5th,10th, 25th, 50th, 75th, 90th and 95th percentiles

y
PARCStudy:NormalValues

1050 subjects without Risk factors

EIMACCetprvalencedeplaque

IntimamediaThickness

IMT and Clinical Trials

IMTinRCTrials

Effectofaggressiveversusconventionallipid
gg
p
loweringonatherosclerosclerosisprogression
inFH:ASAPStudyy

325 FH
Atorvastatin
Atorvastatin 80 Simvastatin 40
Change of IMT over 2 years

Stalenhoef &al.The Lancet 02.01

IMTandLDLreduction

IMT Change
e in % ( From B
Baseline))

LDL reduction in % from Baseline

P Amarenco & al Stroke 2006

IMTandAntiHpertensiveDrugs
Someclassesofantihypertensivedrugsseemto

haveanantiatheroscleroticeffect
TheeffectsofthesetherapyonCIMThavebeen

modest
d
Thechangesobservedremainpartlyunconvincing

IMTandRCtrials
Moststudieshavebeenancillary
Smallsamplesize(lowpower)
USmethodologyandCIMTmeasurementnot
USmethodolog andC IMTmeasurementnot

alwayswelladressed.

IMTinClinicalPractice

EIMenpratiqueclinique:Lesbesoins

Mthodologiestandardise:Mannheimconsensus

Valeursderfrence:US,France,Italie,Core,AmriqueLatine

Populationrisqueintermdiare
p
q

ReferenceValues

CARMELAValeursnormalesValues

70

Intimamedia.comImage
Upload

11/12/2014

71

IMT Measurement

11/12/2014

CONCLUSION

EIM/ Plaque sont deux phnotypes identifiables du RCV

le diagnostic EIM/Plaque est le test non traumatique
l plus
le
l sensible
ibl ett lle moins
i couteux
t
pour lla dt
dtection
ti
de lathrosclrose carotide infra clinique

+
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