CAROTID ATHEROSCLEROSIS AS AN ADDITIONAL PREDICTOR OF CARDIOVASCULAR RISK: ANALYSIS USING THE SCORE IN THE POPULATION AGED 40–64 YEARS

Highlights

• Total carotid plaque thickness ≥ 1.4 mm (TPT14) and the maximum stenosis percentage > 25% showed added prognostic information in assessing the 10-year risk of fatal cardiovascular events in the population of apparently healthy men aged 40–64 years.
• Integration of the TPT14 parameter into the SCORE significantly changed the risk structure and improves risk stratification, especially in clinically significant ranges where the transition between moderate, high and very high risk categories may influence medical decision-making.
• No effect of ultrasound parameters on cardiovascular risk was found in women, which is probably due to the peculiarities of the risk structure and the lower prevalence of carotid atherosclerosis in this population.

Absract

Aim. To research predictive value of ultrasound carotid plaque parameters in assessing 10-year cardiovascular risk (CVR) once added to SCORE in apparently healthy population and developing a risk recalculation table for actual parameters.

Methods. We analyzed data from 777 members of representative sample of unorganized population aged 40–64 years, formed as part of the ESSE-RF study (299 men, 478 women). Cardiac screening, carotid ultrasound, CVR assessment by SCORE, and 10-year prospective follow-up were performed. All participants signed a voluntary informed consent to participate in the study. Statistical analysis included Weibull regression, estimation of the added value of parameters (likelihood ratio, AIC, AUC), calibration, risk recalculation by relative risk and Bayesian methods, reclassification analysis (NRI).

Results. In men, total carotid plaque thickness ≥ 1.4 mm and maximum stenosis > 25% showed independent prognostic value once added to SCORE. When integrating the first parameter into SCORE, risk reclassification affected 54.9% of men (NRI = 0.41; p = 0.022), especially in intermediate categories (moderate, high risk). Specifically, the risk category increased in 22% and decreased in 32.9% of men. In women, there was no significant relationship between ultrasound parameters and CVR, assumed due to the risk distribution features and low overall risk level. The table of SCORE-specific CVR recalculation was developed based on total plaque thickness ≥ 1.4 mm parameter.

Conclusion. The study emphasizes importance of taking subclinical atherosclerosis into account when assessing CVR, especially in men with intermediate SCORE values. Adding specific ultrasound parameters improves risk stratification and can influence clinical decisions. The proposed risk recalculation system provides a practical tool that facilitates personification of therapeutic and preventive measures. Overall, the work demonstrates potential of ultrasound atherosclerosis parameters in improving existing risk assessment methods and may be of particular interest for development of personalized approaches to CVD prevention, however, additional studies are needed to confirm the properties of the model proposed.

1. Vos T., Lim S.S., Abbafati C., Abbas K.M., et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020; 396(10258): 1204–1222. doi: 10.1016/S0140–6736(20)30925–9.

2. Boytsov S.A., Pogosova N.V., Ansheles A.A., Badtieva V.A., et al. Cardiovascular prevention 2022. Russian national guidelines. Russian Journal of Cardiology. 2023; 28(5): 119–249. doi: 10.15829/1560–4071–2023–5452. (In Russ.)

3. Visseren F.L.J., Mach F., Smulders Y.M., Carballo D., et al. 2021 ESC Guidelines on cardiovascular disease prevention in clinical practice. Eur. Heart. J. 2021; 42(34): 3227–3337. doi: 10.1093/eurheartj/ehab484.

4. Boitsov S.A., Pogosova N.V., Bubnova M.G., Drapkina O.M. Cardiovascular prevention 2017. National guidelines. Russian Journal of Cardiology. 2018; 23(6): 7–122. doi: 10.15829/1560–4071–2018–6–7–122. (In Russ.)

5. Conroy R.M., Pyorala K., Fitzgerald A.P., Sans S., et al. Estimation of ten-year risk of fatal cardiovascular disease in Europe: the SCORE project. Eur. Heart. J. 2003; 24(11): 987–1003. doi: 10.1016/s0195–668x(03)00114–3.

6. Balakhonova T.V., Ershova A.I., Ezhov M.V., Barbarash O.L., et al. Focused vascular ultrasound. Consensus of Russian experts. Cardiovascular Therapy and Prevention. 2022; 21(7): 105–126. doi: 10.15829/1728–8800–2022–3333. (In Russ.)

7. Stork S., van den Beld A.W., von Schacky C., Angermann C.E., et al. Carotid artery plaque burden, stiffness, and mortality risk in elderly men: a prospective, population-based cohort study. Circulation. 2004; 110(3): 344–8. doi: 10.1161/01.CIR.0000134966.10793.C9.

8. Lamina C., Meisinger C., Heid I.M., Lowel H., et al. Association of ankle-brachial index and plaques in the carotid and femoral arteries with cardiovascular events and total mortality in a population-based study with 13 years of follow-up. Eur. Heart. J. 2006; 27(21): 2580–7. doi: 10.1093/eurheartj/ehl228.

9. Yang C.W., Guo Y.C., Li C.I., Liu C.S., et al. Subclinical Atherosclerosis Markers of Carotid Intima-Media Thickness, Carotid Plaques, Carotid Stenosis, and Mortality in Community-Dwelling Adults. Int. J. Environ. Res. Public. Health. 2020; 17(13): 4745. doi: 10.3390/ijerph17134745.

10. Bérard E., Bongard V., Ruidavets J.B., Amar J. Pulse wave velocity, pulse pressure and number of carotid or femoral plaques improve prediction of cardiovascular death in a population at low risk. J. Hum. Hypertens. 2013; 27(9): 529–34. doi: 10.1038/jhh.2013.8.

11. Chazova I.E., Trubacheva I.A., Zhernakova Yu.V., Oshchepkova E.V., et al. The prevalence of arterial hypertension as a risk factor of cardiovascular diseases in one of the cities in siberian federal district. Systemic Hypertensions. 2013; 10(4): 30–37. (In Russ.)

12. Zhernakova Yu.V., Kaveshnikov V.S., Serebriakova V.N., Trubacheva I.A., et al. The prevalence of carotid atherosclerosis in spontaneous populations in Tomsk. Systemic Hypertensions. 2014; 11(4): 37–42. (In Russ.)

13. Kaveshnikov V.S., Serebryakova V.N., Trubacheva I.A., Shalnova S.A. Carotid atherosclerosis severity in unorganized adult population. Rational Pharmacotherapy in Cardiology. 2019; 15(1): 84–89. doi: 10.20996/1819–6446–2019–15–1–84–89. (In Russ.)

14. Boytsov S.A., Karpov Yu.A., Kukharchuk V.V., Rogoza A.N., et al. Identification of patients at high cardiovascular risk: problems and possible solutions. (part i). Journal of Atherosclerosis and Dyslipidemias. 2010; 1 (1): 8–14. (In Russ.)

15. Touboul P.J., Hennerici M.G., Meairs S., Adams H., et al. Mannheim carotid intima-media thickness and plaque consensus (2004–2006–2011). An update on behalf of the advisory board of the 3rd, 4th and 5th watching the risk symposia, at the 13th, 15th and 20th European Stroke Conferences, Mannheim, Germany, 2004, Brussels, Belgium, 2006, and Hamburg, Germany, 2011. Cerebrovasc. Dis. 2012; 34(4): 290–6. doi: 10.1159/000343145.

16. Johri A.M., Nambi V., Naqvi T.Z., Feinstein S.B., et al. Recommendations for the Assessment of Carotid Arterial Plaque by Ultrasound for the Characterization of Atherosclerosis and Evaluation of Cardiovascular Risk: From the American Society of Echocardiography. J. Am. Soc. Echocardiogr. 2020; 33(8): 917–933. doi: 10.1016/j.echo.2020.04.021.

17. Li W., Wang Y., Chen S., Zhao J., et al. Evaluation of Carotid Artery Atherosclerosis and Arterial Stiffness in Cardiovascular Disease Risk: An Ongoing Prospective Study From the Kailuan Cohort. Front. Cardiovasc. Med. 2022; 9: 812652. doi: 10.3389/fcvm.2022.812652.

18. Polak J.F., Szklo M., Kronmal R.A., Burke G.L., et al. The value of carotid artery plaque and intima-media thickness for incident cardiovascular disease: the multi-ethnic study of atherosclerosis. J. Am. Heart. Assoc. 2013; 2(2): e000087. doi: 10.1161/JAHA.113.000087.

19. Ershova A.I., Meshkov A.N., Deev A.D., Aleksandrova E.L., et al. Atherosclerotic plaque in carotid arteries as a risk marker for cardiovascular events risk in middle aged population. Cardiovascular Therapy and Prevention. 2018; 17(4): 34–39. doi: 10.15829/1728–8800–2018–4–34–39. (In Russ.)

20. Sillesen H., Sartori S., Sandholt B., Baber U., et al. Carotid plaque thickness and carotid plaque burden predict future cardiovascular events in asymptomatic adult Americans. Eur. Heart. J. Cardiovasc. Imaging. 2018; 19(9): 1042–1050. doi: 10.1093/ehjci/jex239.

21. Nambi V., Chambless L., Folsom A.R., He M., et al. Carotid intima-media thickness and presence or absence of plaque improves prediction of coronary heart disease risk: the ARIC (Atherosclerosis Risk In Communities) study. J. Am. Coll. Cardiol. 2010; 55(15): 1600–7. doi: 10.1016/j.jacc.2009.11.075.

22. Parkkila K., Kesäniemi Y.A., Ukkola O. Comparing ultrasonographically assessed carotid and abdominal aorta plaques in cardiovascular disease risk estimation. BMC. Cardiovasc. Disord. 2023; 23(1): 245. doi: 10.1186/s12872–023–03264–1.

23. Guaricci A.I., Lorenzoni V., Guglielmo M., Mushtaq S., et al. Prognostic relevance of subclinical coronary and carotid atherosclerosis in a diabetic and nondiabetic asymptomatic population. Clin. Cardiol. 2018; 41(6): 769–777. doi: 10.1002/clc.22952.

24. Romanens M., Adams A., Wenger M., Warmuth W. Prognostic impact of carotid plaque imaging using total plaque area added to SCORE2 in middle-aged subjects: the ARteris Cardiovascular Outcome (ARCO) cohort study. Swiss. Med. Wkly. 2024; 154: 3735. doi: 10.57187/s.3735.

25. Nicolaides A.N., Panayiotou A.G., Griffin M., Tyllis T., et al. Arterial Ultrasound Testing to Predict Atherosclerotic Cardiovascular Events. J. Am. Coll. Cardiol. 2022; 79(20): 1969–1982. doi: 10.1016/j.jacc.2022.03.352.