CASHMERE: No IMT effect with atorvastatin over 12 months

 Now I start to wonder of the benefit of IMT screening, or are expectations of less than 2 years regression too much to ask for?

July 9, 2008 | Michael O'Riordan

 This study, just like ENAHANCE, simply showed that if IMT is normal to start with, you won't see much regression with a statin.  

There is no reason why you can't use IMT to screen for cardiovascular risk,  but we have much better measures to follow treatment with, such as LDL-P, ApoB, the sphigmomanometer, the office scale, the tape measure, and perhaps Lp-PLA2. 

Rogerven:

 Now I start to wonder of the benefit of IMT screening

What are you doubting ... the usefulness of IMT as a CAD marker in studies ?

donspinelakemed:

 

There is no reason why you can't use IMT to screen for cardiovascular risk

I've never screened for CV risk with IMT.  How would I use it in daily general practice ?

Isn't Coronary Artery Calcium (CAC) possibly a better tool in this regard ? 

Are MDs in the US frequently ordering IMT to risk stratify CAD risk ?

Rogerven:

CASHMERE: No IMT effect with atorvastatin over 12 months

So I guess Pomegranate Juice beats Atorvastatin since it reduces IMT by 30% over 12 months.

Pomegranate juice consumption for 3 years by patients with carotid artery stenosis reduces common carotid intima-media thickness, blood pressure and LDL oxidation.

Aviram M, Rosenblat M, Gaitini D, Nitecki S, Hoffman A, Dornfeld L, Volkova N, Presser D, Attias J, Liker H, Hayek T.

The Lipid Research Laboratory, Rappaport Family Institute for Research in the Medical Sciences, Rambam Medical Center, Haifa 31096, Israel. aviram@tx.technion.ac.il

Dietary supplementation with polyphenolic antioxidants to animals was shown to be associated with inhibition of LDL oxidation and macrophage foam cell formation, and attenuation of atherosclerosis development. We investigated the effects of pomegranate juice (PJ, which contains potent tannins and anthocyanins) consumption by atherosclerotic patients with carotid artery stenosis (CAS) on the progression of carotid lesions and changes in oxidative stress and blood pressure. Ten patients were supplemented with PJ for 1 year and five of them continued for up to 3 years. Blood samples were collected before treatment and during PJ consumption. In the control group that did not consume PJ, common carotid intima-media thickness (IMT) increased by 9% during 1 year, whereas, PJ consumption resulted in a significant IMT reduction, by up to 30%, after 1 year. The patients' serum paraoxonase 1 (PON 1) activity was increased by 83%, whereas serum LDL basal oxidative state and LDL susceptibility to copper ion-induced oxidation were both significantly reduced, by 90% and 59%, respectively, after 12 months of PJ consumption, compared to values obtained before PJ consumption. Furthermore, serum levels of antibodies against oxidized LDL were decreased by 19%, and in parallel serum total antioxidant status (TAS) was increased by 130% after 1 year of PJ consumption. Systolic blood pressure was reduced after 1 year of PJ consumption by 21% and was not further reduced along 3 years of PJ consumption. For all studied parameters, the maximal effects were observed after 1 year of PJ consumption. Further consumption of PJ, for up to 3 years, had no additional beneficial effects on IMT and serum PON1 activity, whereas serum lipid peroxidation was further reduced by up to 16% after 3 years of PJ consumption. The results of the present study thus suggest that PJ consumption by patients with CAS decreases carotid IMT and systolic blood pressure and these effects could be related to the potent antioxidant characteristics of PJ

DrMurdoch:

donspinelakemed:

 There is no reason why you can't use IMT to screen for cardiovascular risk

I've never screened for CV risk with IMT.  How would I use it in daily general practice ?

Isn't Coronary Artery Calcium (CAC) possibly a better tool in this regard ? 

 Are MDs in the US frequently ordering IMT to risk stratify CAD risk ?

 

There are lots of issues to consider.   The Coronary Calcium Score is most useful for screening patients with advanced enough disease that that they have stable, calcified plaque.  The younger a patient is, the less likely it is that he or she will have calcifications, though there may be lots of unstable, not yet calcified plaque present.   So, there is much more potential for early detection with IMT.

There is individual variability as to what people present with first.  Some get peripheral atherosclerosis, first, some get carotid disease first, and some get coronary disease first. 

Then there is the cost.  Locally, one can get an IMT for about half the price of an EBT. 

It is possible locally to get calcium scores done by more traditional CT technique than EBT at a lower price, but with many more times the radiation exposure.

I personally don't get many EBTs or many IMTs, but they are often useful in convincing high-risk patients that they do have disease, and should be treated.  By the nature of my practice, most of my patients know this already. 

Well discussed Don. The technology of IVUS, CIMT and EBT Calcium score are indeed relevant. One certainly have to consider the technique and technician dependence of Ultrasound. Location of lesions - carotid vs coronary using CIMT and EBT technology have to be considered. Just like DXA scan, we use 3 regions of interest, the Spine, hip and forearm to improve detection, quantification and monitoring osteopenia/osteoporosis treatment or progression of disease.

In the field of Primary care, we simply rely on biological markers, which is indeed not enough or not capable of detecting progression or regression of endothelial disease. It is about time to consider all the aforementioned modalities and apply such technology understanding that we still do not understand why endothelial pathology do not have a uniform predilection of a certain vascular region - carotid, aorta, periphery, coronary, intracranial etc.

I would reserve caution interpreting different studies without understanding completely the technology - IMT and to consider the extent of IMT, as if indeed there is regression significant enough in one trial it is possible that the baseline may be more significant from one trial vs another to be able to demonstrate such change. At the same token, minimal thickness at baseline done at a short interval - maybe less than 2 or 3 years, may not show a change. 

Some interesting discussions: http://www.theheart.org/article/877457.do 

 http://dme.cybersessions.com/conference/855695/?userId=312232 - I hope you can open this, as you may need a pass - free nevertheless.

Jason my lovely neighbor keeps convincing me to use Pomegranite, I have a sample bottle in my cupboard for 2 years now. I will drink it IMMEDIATELY

I'd love to see some RCTs using IMT / EBT Calcium score to triage aggressiveness of CAD risk management in CAD asymptomatic patients.  I take it they dont exsit.   I wonder if this would prevent that 1 55 year old patient that is doing well and then dies of a sudden CAD event.