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(Stroke. 1999;30:841-850.)
© 1999 American Heart Association, Inc.

Original Contributions

Carotid Plaque, Intima Media Thickness, Cardiovascular Risk Factors, and Prevalent Cardiovascular Disease in Men and Women

The British Regional Heart Study

Shah Ebrahim, DM; Olia Papacosta, MSc; Peter Whincup, MB, PhD; Goya Wannamethee, PhD; Mary Walker, MFPHM[Hon]; Andrew N. Nicolaides, FRCS; Surinder Dhanjil, MSc; Maura Griffin, MSc; Gianni Belcaro, MD; Ann Rumley, PhD Gordon D.O. Lowe, MD

From the Department of Social Medicine, University of Bristol (UK) (S.E.); Department of Primary Care and Population Sciences, Royal Free Hospital School of Medicine, London (UK) (O.P., P.W., G.W., M.W.); Irvine Laboratory for Cardiovascular Investigation and Research, Department of Vascular Surgery, Imperial College School of Medicine, St Mary's Hospital, London (UK) (A.N.N., S.D., M.G., G.B.); and University Department of Medicine, Royal Infirmary, Glasgow, Scotland (A.R., G.D.O.L.).

Correspondence to Professor Shah Ebrahim, Department of Social Medicine, University of Bristol, Canynge Hall, Whiteladies Road, Bristol BS8 2PR, UK.

Background and Purpose—B-mode ultrasound is a noninvasive method of examining the walls of peripheral arteries and provides measures of the intima-media thickness (IMT) at various sites (common carotid artery, bifurcation, internal carotid artery) and of plaques that may indicate early presymptomatic disease. The reported associations between cardiovascular risk factors, clinical disease, IMT, and plaques are inconsistent. We sought to clarify these relationships in a large, representative sample of men and women living in 2 British towns.

Methods—The study was performed during 1996 in 2 towns (Dewsbury and Maidstone) of the British Regional Heart Study that have an 2-fold difference in coronary heart disease risk. The male participants were drawn from the British Regional Heart Study and were recruited in 1978–1980 and form part of a national cohort study of 7735 men. A random sample of women of similar age to the men (55 to 77 years) was also selected from the age-sex register of the general practices used in the original survey. A wide range of data on social, lifestyle, and physiological factors, cardiovascular disease symptoms, and diagnoses was collected. Measures of right and left common carotid IMT (IMT_cca) and bifurcation IMT (IMT_bif) were made, and the arteries were examined for plaques 1.5 cm above and below the flow divider.

Results—Totals of 425 men and 375 women were surveyed (mean age, 66 years; range, 56 to 77 years). The mean (SD) IMT_cca observed were 0.84 (0.21) and 0.75 (0.16) mm for men and women, respectively. The mean (SD) IMT_bif were 1.69 (0.61) and 1.50 (0.77) mm for men and women, respectively. The correlation between IMT_cca and IMT_bif was similar in men (r=0.36) and women (r=0.38). There were no differences in mean IMT_cca or IMT_bif between the 2 towns. Carotid plaques were very common, affecting 57% (n=239) of men and 58% (n=211) of women. Severe carotid plaques with flow disturbance were rare, affecting 9 men (2%) and 6 women (1.6%). Plaques increased in prevalence with age, affecting 49% men and 39% of women aged <60 years and 65% and 75% of men and women, respectively, aged >70 years. Plaques were most common among men in Dewsbury (79% affected) and least common among men in Maidstone (34% affected). IMT_cca showed a different pattern of association with cardiovascular risk factors from IMT_bif and was associated with age, SBP, and FEV₁ but not with social, lifestyle, or other physiological risk factors. IMT_bif and carotid plaques were associated with smoking, manual social class, and plasma fibrinogen. IMT_bif and carotid plaques were associated with symptoms and diagnoses of cardiovascular diseases. IMT_bif associations with cardiovascular risk factors and prevalent cardiovascular disease appeared to be explained by the presence of plaques in regression models and in analyses stratified by plaque status.

Conclusions—IMT_cca, IMT_bif, and plaque are correlated with each other but show differing patterns of association with risk factors and prevalent disease. IMT_cca is strongly associated with risk factors for stroke and with prevalent stroke, whereas IMT_bif and plaque are more directly associated with ischemic heart disease risk factors and prevalent ischemic heart disease. Our analyses suggest that presence of plaque, rather than the thickness of IMT_bif, appears to be the major criterion of high risk of disease, but confirmation of these findings in other populations and in prospective studies is required. The association of fibrinogen with plaque appears to be similar to its association with incident cardiovascular disease. Further work elucidating the composition of plaques using ultrasound imaging would be helpful, and more data, analyzed to distinguish plaque from IMT_bif and IMT_cca, are required to understand the significance of thicker IMT in the absence of plaque.

Key Words: atherosclerosis • cardiovascular diseases • carotid arteries • risk factors • ultrasonography

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