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(Stroke. 2000;31:2958.)
© 2000 American Heart Association, Inc.
Original Contributions |
Potential of Carotid Enlargement as a Useful Indicator Affected by High Blood Pressure in a Large General Population of a Japanese City
The Suita Study
From the Department of Preventive Cardiology, National Cardiovascular Center, Suita, Japan.
Correspondence to Toshifumi Mannami, MD, Department of Preventive Cardiology, National Cardiovascular Center, Fujishirodai 5-7-1, Suita, Osaka 565-8565, Japan. E-mail mtoshi{at}hsp.ncvc.go.jp
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Abstract |
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Background and Purpose—Few studies have examined whether there is a relationship between carotid arterial diameter and cardiovascular risk factors in a large general population. The aim of this study was to investigate cross-sectionally whether, in a randomly selected general large population of a Japanese city, there is a relationship between common carotid artery (CCA) diameter and conventional cardiovascular risk factors.
Methods—The subjects of
the present study were randomly selected from the residents of the
city of Suita, located in the second largest urban area of Japan, and
consisted of 2284 men and 2568 women aged 30 to 89 years. The outer and
inner CCA diameters and intima-media thickness (IMT) of CCA were
detected and measured by a single physician with high-resolution
ultrasonography. We assessed cross-sectionally by age/sex group the
relationships between IMT or CCA diameters and
cardiovascular risk factors, especially blood pressure
levels divided into 3 groups: the normal group of subjects had a
diastolic blood pressure (DBP) <85 mm Hg and
systolic blood pressure (SBP) <130 mm Hg and were not
taking antihypertensive medication; the high group of subjects had DBP
90 mm Hg and/or SBP 140 mm Hg and/or were taking
antihypertensive medication; and the moderate group consisted of all
other subjects.
Results—The outer and inner CCA diameters for the high group were significantly (P<0.05) enlarged in comparison with those for the moderate and normal groups in all age/sex groups of both sexes after adjustment for body mass index, pack-years of smoking, alcohol consumption, and total serum cholesterol. Multiple regression analysis showed that age, body mass index, SBP, pack-years of smoking, alcohol consumption, and IMT were positively and significantly (P<0.005) related to both outer and inner CCA diameters in both sexes except for between alcohol consumption and outer CCA diameter in women and showed that only serum total cholesterol level was negatively and significantly (P<0.01) related to inner CCA diameter in both sexes.
Conclusions—Our present study showed that the outer and inner CCA diameters correlated with conventional cardiovascular risk factors, including high blood pressure and IMT. These findings suggest that the outer and inner CCA diameters may be a useful indicator of carotid atherosclerosis, particularly in relation to high blood pressure.
Key Words: blood pressure • carotid arteries • risk factors • ultrasonics
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Introduction |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Recent technological advances in high-resolution B-mode ultrasonography have enabled us to detect and evaluate minimal peripheral arterial wall or structure abnormalities directly and precisely at an early stage of atherosclerotic genesis and to visualize them clearly.1 Much attention has been paid to assessment of intima-media thickness (IMT) of the carotid arteries and to its association with cardiovascular risk factors2 3 4 5 6 7 8 9 10 11 12 and with both the prevalence13 14 and incidence15 of myocardial infarction and stroke. In fact, the IMT of the carotid arteries is practically considered the surrogate end point of cardiovascular disease,16 17 18 myocardial infarction, or stroke and also may be of useful predictive value for these diseases.19
Although most previous studies have mainly approached carotid atherosclerosis from the viewpoint of the relation of risk factors to arterial diseases, the relation of arterial disease to symptom development is not only a function of wall thickening but is additionally related to lumen compromise.20 21 22 It has been shown in clinical trials of animals that as the initial response to atherosclerosis, arteries enlarge or compensate, increasing the circumference described by the external elastic lamina and preserving the lumen diameter.23 Additionally, some autopsy studies in humans have shown a qualitative assessment of arterial compensation.24 25 Arterial enlargement may be involved in symptom development.
However, thus far few studies have focused on the relationship among common carotid artery (CCA) luminal enlargement, structural or morphological changes of the artery, and cardiovascular risk factors with the aid of B-mode ultrasonography,26 27 28 29 although it has been shown that arteries enlarge with increasing age, blood flow, and heart size30 and that the inner diameter of the aorta increases in the presence of hypertension.31 In particular, there have been no studies focusing on the relationships between CCA luminal enlargement and cardiovascular risk factors, such as body mass index (BMI), smoking, alcohol consumption, elevated blood lipids, fasting blood glucose (FBG), and high blood pressure, in a large general population with a wide age range.
The present study sought to investigate cross-sectionally the association of CCA luminal enlargement with conventional cardiovascular risk factors in a randomly selected large general population of a Japanese city and also to explore whether the phenomenon of enlargement of the diameter occurs generally as a result of the influence of high blood pressure, ie, in men as well as in women and in young as well as in old persons.
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Subjects and Methods |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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Subjects
The population for the present study is based on a random sample selected from the residents of the city of Suita, located in the second largest urban area in Japan; the sample comprised 12 200 men and women aged 30 to 79 years, although 3000 men and women were added randomly in the same way in 1996 and 1997. The basic sampling of the population started in 1989 with a cohort study base.
The subjects have been visiting the National Cardiovascular Center between Tuesday and Thursday every 2 years for regular health checkups, and approximately 2500 subjects have been participating in the health checkups every year. In addition to performing a routine blood examination that included total serum cholesterol, HDL cholesterol, triglyceride, and glucose levels and blood pressure and anthropometric measurements, a physician or nurse administered questionnaires covering personal and family history of cardiovascular and other diseases, as well as smoking and drinking habits. The carotid ultrasonic examinations were begun in April 1994, but the examinations were not done on the all days when the regular health checkups were performed between Tuesday and Thursday because the examinations were performed by a single physician. The subjects in the present study included 2284 men and 2568 women, aged 30 to 89 years, who attended regular health checkups and consecutively underwent the ultrasonic examination only once between April 1994 and February 2000.
Study Variables
The definitions of hypertension, smoking, and
diabetes mellitus were as follows. The subjects were classified as
current smokers if they smoked at least 1 cigarette per day, nonsmokers
if they had never smoked, and past smokers if they had quit smoking for
>1 year. Subjects were defined as hypertensive if DBP was 90
mm Hg and/or SBP 140 mm Hg or if they were taking
antihypertensive medication. Those subjects whose FBG
levels were 7.00 mmol/L (126 mg/dL) based on the new criteria or
who were taking antidiabetic medication were defined as diabetic.
Subjects who had a history of coronary heart disease or
cerebrovascular disease were excluded from the present study (140
men and 70 women). The subjects’ blood was sampled after overnight
fasting, resulting in 111 men and 144 women being excluded because they
did not meet this condition. Altogether, 251 men and 214 women among
the total of 4852 subjects were excluded from this analysis.
Blood pressure was measured twice in the right arm with a mercury
sphygmomanometer, with the subject in a sitting position after taking a
short rest. The second measurement was used for the analysis.
BMI was calculated as weight (kilograms) divided by height (meters)
squared.
The details of the method of carotid ultrasonic examination
have already been
published.12 The
method used in the present study was the same. We used a
high-resolution B-mode ultrasonic machine with 7.5-MHz transducers,
yielding an axial resolution of 0.2 mm. The regions between
30 mm proximal from the beginning of the dilation of the
bifurcation bulb and 15 mm distal from the flow divider of both
CCAs were scanned. All measurements were made at the time of scanning
with the instrument’s electronic caliper and were recorded as
photocopies. The IMT was measured on a longitudinal scan of the CCA at
a point 10 mm proximal from the beginning of the dilation of the
bulb. IMT was defined as the mean of the IMT of the near and far walls
at the point of measurement. IMT-CMAX was defined as the maximum IMT in
the scanned CCA area. We used 2 other carotid atherosclerotic indexes:
We defined a plaque as an area where IMT was 1.10 mm and
calculated the plaque number by counting the number of plaques in the
bilateral carotid arteries in the scanning area. We also calculated the
plaque score by totaling the maximum thickness of all the plaques in
the same area.
The CCA diameter measurements were made in the portion of the CCA where the wall interfaces are parallel. The outer CCA diameter was the mean of the maximal distance between the adventitia-to-periadventitia interface and the periadventitia-to-adventitia interface on the far wall of the right and left CCAs at the point of the beginning of the dilation of the bifurcation bulb. The inner CCA diameter was the mean of the minimal distance between the near-wall intima-lumen interface and the far-wall lumen-intima interface of the right and left CCAs at the point of the beginning of the dilation of the bifurcation bulb. The intrareader reproducibility of the measurements was assessed for the outer and inner CCA diameters in 50 subjects just before the start of ultrasonic examination in April 1994. The outer and inner CCA diameters were examined twice at a 1-month interval in a blinded manner for the correlation coefficient between the first and second measurements of the outer and inner CCA diameters (r=0.92, r=0.91, respectively; P<0.001). In addition, the correlation coefficients of the outer and inner CCA diameters between right and left were assessed at the same time (r=0.82, r=0.85, respectively; P<0.001). The measurements of the outer and inner diameters and IMT in our study were made on frozen images during diastole because arterial wall motion during systole causes ultrasonographic images to blur.
Blood samples drawn from the subjects after a fast of 12
hours were collected in EDTA-containing tubes. Total
cholesterol and triglyceride levels were
assayed enzymatically with a Toshiba TBA-80M biochemical discrete
analyzer. Glucose was assayed enzymatically, and HDL
cholesterol was measured after precipitation with heparin
and calcium ions with a Toshiba TBA-20R biochemical discrete
analyzer. The measurements of total cholesterol,
HDL cholesterol, and triglyceride levels were
standardized in accordance with the protocol of the Centers for Disease
Control and Prevention.
Statistical Methods
The Statistical Package for the Social Sciences (SPSS
Inc) was used for the analysis. The distributions of the key
variables in the present analysis were all normal,
except for triglyceride. The mean levels of all numerical
values were tested by the Student’s t test after
triglyceride was converted into natural logarithms, and
mean levels of all categorical values were tested by the
2 square test. Univariate and
multiple linear regression analyses were used. In addition,
multiple regression analysis was performed with
cardiovascular risk factors (age, BMI, SBP, FBG,
pack-years of smoking, alcohol consumption per day, total serum
cholesterol, HDL cholesterol,
triglyceride, IMT) selected as independent variables.
We assessed mean levels of the outer and inner CCA diameters in each
age/sex group divided into 3 groups according to blood pressure levels:
the normal group of subjects had DBP <85 mm Hg and SBP
<130 mm Hg and were not taking antihypertensive medication; the
high group of subjects had DBP 90 mm Hg and/or SBP 140
mm Hg and/or were taking antihypertensive medication; and the moderate
group consisted of all other subjects. The difference between those 3
groups was obtained by 1-way ANOVA. Values of P<0.05
were considered significant.
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Results |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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BMI was significantly higher (P<0.05) in men than in women among the 3 younger age groups. SBP and DBP were significantly higher (P<0.05) in men than in women only in the youngest age group (aged 30 to 44 years). Women had significantly higher (P<0.05) levels of total serum cholesterol and HDL cholesterol than men, except in the youngest age group. Men had significantly higher (P<0.05) levels of triglyceride and FBG than women except in the oldest age group. The percentage of hypertension was significantly higher (P<0.05) in men than in women only in the youngest age group. The percentage of diabetes was significantly higher (P<0.05) in men than in women except in the oldest age group (aged 75 to 89 years). Men had a significantly higher (P<0.05) percentage of current smokers and drinkers than women in all age groups. The inner and outer CCA diameters, IMT, and IMT-CMAX increased as the class of age group became higher in both sexes. Furthermore, men had significantly larger (P<0.05) inner and outer CCA diameters, IMT, and IMT-CMAX than women except for IMT-CMAX in the oldest age group (Table 1
).
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In univariate analysis, the inner CCA
diameter was significantly (P<0.01) correlated with
age, BMI, pack-years of smoking, alcohol consumption, SBP, DBP,
triglyceride, FBG, IMT, and IMT-CMAX in both sexes, with
alcohol consumption only in men, and with HDL cholesterol
only in women. The outer CCA diameter was significantly
(P<0.01) correlated with age, BMI, pack-years of
smoking, SBP, DBP, triglyceride, FBG, IMT, and IMT-CMAX in
both sexes, with alcohol consumption only in men, and with total serum
cholesterol and HDL cholesterol only in women
(Table 2).
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In men, age, BMI, SBP, pack-years of smoking, alcohol
consumption per day, and IMT were significantly
(P<0.005) related to the inner and outer CCA
diameters, and total serum cholesterol was related to only
the inner CCA diameter in multiple regression analysis in which
age, BMI, SBP, pack-years of smoking, alcohol consumption per day,
total serum cholesterol, HDL cholesterol,
triglyceride, and IMT were entered as independent
variables
(Table 3). In women, age, BMI, SBP, pack-years of smoking,
and IMT were significantly (P<0.001) related to the
inner and outer CCA diameters, and alcohol consumption and total serum
cholesterol were related to only the inner CCA diameter in
the same multiple regression analysis
(Table 4). As also shown in
Tables 3 and 4, the strongest correlate of the outer CCA
diameter was IMT and that of the inner diameter was SBP.
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Figure 1 (for men) and
Figure 2 (for women) show mean values of the inner and outer
CCA diameters, adjusted for BMI, pack-years of smoking, alcohol
consumption, and total serum cholesterol by age/sex group
and blood pressure levels divided into 3 groups: the normal group of
subjects had DBP <85 mm Hg and SBP <130 mm Hg and were
not taking antihypertensive medication; the high group of subjects had
DBP 90 mm Hg and/or SBP 140 mm Hg and/or were taking
antihypertensive medication; and the moderate group consisted of all
other subjects. The mean values of the high group were higher than
those of the normal and moderate groups in all age/sex groups of both
sexes. Furthermore, the mean values of the high group were
significantly (P<0.05) higher than those of the
normal group in all age/sex groups of both sexes by 1-way ANOVA
(Figures 1 and 2).
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P<0.05 between the moderate group vs the normal
group in each age class by Scheffé’s test.
P<0.05 between the high group vs the moderate
group in each age class by Scheffé’s
test.
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Figure 3 shows the age-adjusted mean values of the outer and
inner diameters by sex and level of IMT divided into 5 classes. In both
sexes, the higher the level of IMT, the more the outer diameter was
dilated. However, the inner diameter did not dilate with increase in
the level of IMT. In addition, the inner diameter did not dilate as
much as the outer diameter in men as well as in
women.
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Discussion |
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TopAbstractIntroductionSubjects and MethodsResultsDiscussionReferences |
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To our knowledge, the present cross-sectional study has shown for the first time that strong relationships exist between carotid arterial enlargement and risk factors for cardiovascular disease, particularly blood pressure, in a large general population of men and women aged 30 to 89 years; a few large cross-sectional studies investigating factors related to increase in size of the CCA have been published, but these were restricted to a limited age range.26 27 28 29 Our present data also show that arterial diameter is correlated with many cardiovascular risk factors, such as SBP, BMI, pack-years of smoking, alcohol consumption, total serum cholesterol, and IMT. In addition, we show that SBP and IMT are strongly associated with enlargement of the carotid artery and that both outer and inner carotid arterial diameters enlarge with increasing blood pressure level from youth to old age (from 30 to 89 years) in men as well as in women. However, the interpretation of these findings is limited because our present study is cross-sectional.
Most previous studies have focused on the role of
arterial luminal enlargement in compensating for thickening
of the arterial
wall.24 25 26
In fact, without this compensatory mechanism, the arterial
wall would cause the lumen of the artery to narrow, thereby subjecting
the endothelium to an increase in shear stress caused
by flowing blood.32
The artery appears to compensate for the presence of thickened walls by
dilating, thereby stabilizing the shear stress caused at the interface
between blood and the
endothelium.33
As shown in
Figure 3
, our present data suggest that the carotid
outer diameter, which may be considered the interadventitial
diameter, may dilate to compensate for thickened walls of the
CCA, but the carotid inner diameter may not dilate as much as the outer
diameter, perhaps because it is confounded by the thickness of the IMT
layer. This finding also suggests that thickening of the IMT would
obscure the true diameter of the vessel, especially the inner diameter,
and that the outer diameter is more likely to be truly
representative of the vessel size.
On the other hand, some previous studies reported that several cardiovascular risk factors were independently related to increased carotid lumen diameter and that increased SBP appeared to be one of the most important and strongest correlates of increased lumen diameter.27 In addition, an association between hypertension or high blood pressure and carotid arterial enlargement was reported in several noninvasive studies with the aid of B-mode ultrasonography.27 34 This finding seems reasonable when we consider that human arteries are dynamic conduits that respond to different stimuli on the basis of physical principles, for example, elevated blood pressure and its long-term cyclic stress on elastic fibers, resulting in degenerative changes and stiffening of walls.35 It is also possible that arterial diameter is itself a measure of vascular regulatory function. The regulation of flow and blood pressure is complex, and how it affects arterial diameter is only partly understood. Many factors, including baroreceptor function, seem to reflect increasing vessel diameter.
Furthermore, our present data show that carotid arterial diameter, adjusted for BMI, pack-years of smoking, alcohol consumption, and total serum cholesterol level, increased with elevation of blood pressure in both young and elderly people and in both men and women, although there was a slight difference between men and women in the manner of enlargement of the diameter with age by hypertensive status. In other words, for men there was relatively little difference in outer lumen diameter by hypertensive status in the youngest age group, and the difference became progressively larger with age. In contrast, among women there was a relatively large difference by hypertensive status even in the youngest age group, and the difference remained constant with increasing age. These data strongly suggest that chronic high blood pressure causes enlargement of arterial diameter and that the outer and inner carotid arterial diameters might be a useful indicator of high blood pressure. However, a longitudinal study is needed to confirm these findings because our present study was cross-sectional.
In addition, the present study provides reasonable evidence that BMI was strongly correlated with CCA diameter and that the CCA diameters of men were generally larger than those of women. These findings are consistent with previous studies27 28 29 and seem to be physically and morphologically natural phenomena. In other words, the larger the size of body, the larger is the CCA diameter in general.
Our present data also show that alcohol consumption was associated with enlargement of arterial diameter in both sexes. Thus far, few cross-sectional studies have reported a relationship between alcohol consumption and arterial wall characteristics.28 In fact, in our previous report we did not find any association between IMT and alcohol consumption,12 and no association was found with IMT in certain previous ultrasonographic studies.11 12 36 Taking into consideration the fact that alcohol intake has been positively related to the internal dimension of the left ventricle, independent of blood pressure, in a nonalcoholic general population,37 we may infer that some common mechanisms might act between alcohol consumption and increased vascular and ventricular internal dimensions.
In conclusion, the present study shows that there were significant relationships between carotid arterial enlargement and many cardiovascular risk factors in a large general population with a wide age range in both sexes and also suggests that alcohol intake may cause enlargement of the arterial diameter in both men and women. In addition, our present data strongly suggest that arterial enlargement may be a useful indicator of carotid atherosclerosis, particularly in relation to high blood pressure. Therefore, in addition to the use of IMT as an indicator, we believe that attention should be focused on this morphological index, which may lead to better pathophysiological understanding of vessel diseases.
Received June 13, 2000; revision received August 30, 2000; accepted August 30, 2000.
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  R. Labrum, S. Bevan, M. Sitzer, M. Lorenz, and H. S. Markus Toll Receptor Polymorphisms and Carotid Artery Intima-Media Thickness Stroke, April 1, 2007; 38(4): 1179 - 1184. [Abstract] [Full Text] [PDF]
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J. Krejza, M. Arkuszewski, S. E. Kasner, J. Weigele, A. Ustymowicz, R. W. Hurst, B. L. Cucchiara, and S. R. Messe Carotid Artery Diameter in Men and Women and the Relation to Body and Neck Size Stroke, April 1, 2006; 37(4): 1103 - 1105. [Abstract] [Full Text] [PDF]
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 R. Kimura, S. Honda, T. Kawasaki, H. Tsuji, S. Madoiwa, Y. Sakata, T. Kojima, M. Murata, K. Nishigami, M. Chiku, et al. Protein S-K196E mutation as a genetic risk factor for deep vein thrombosis in Japanese patients Blood, February 15, 2006; 107(4): 1737 - 1738. [Full Text] [PDF]
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M. Zureik, J. Gariepy, D. Courbon, J.-F. Dartigues, K. Ritchie, C. Tzourio, A. Alperovitch, A. Simon, and P. Ducimetiere Alcohol Consumption and Carotid Artery Structure in Older French Adults: The Three-City Study Stroke, December 1, 2004; 35(12): 2770 - 2775. [Abstract] [Full Text] [PDF]
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U. G.R. Schulz and P. M. Rothwell Major Variation in Carotid Bifurcation Anatomy: A Possible Risk Factor for Plaque Development? Stroke, November 1, 2001; 32(11): 2522 - 2529. [Abstract] [Full Text] [PDF]
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