Comparison of ultrasound-measured properties of the common carotid artery to tobacco smoke exposure in a cohort of Indonesian patients

doi:10.5847/wjem.j.1920-8642.2017.03.003

Abstract

Abstract:

BACKGROUND: The purpose of this study was to use point-of-care ultrasound (POCUS) to investigate the relationship between tobacco smoke exposure and the characteristics of the common carotid artery (CCA). The effect of both primary and secondary smoking on CCA properties was evaluated.

METHODS: We performed a prospective cross-sectional study across 20 primary care clinics in Bandung, West Java, Indonesia in July 2016. Point of care ultrasound was performed on a convenience sample of Indonesian patients presenting to clinic. The CCA wall stiffness and carotid intima-media thickness (CIMT) were measured during diastole and systole. These measurements were correlated with smoke exposure and cardiovascular disease.

RESULTS: We enrolled 663 patients in the study, with 426 patients enrolled in the smoking category and 237 patients enrolled in the second-hand smoke category. There was an overall positive correlation with the measured lifestyle factors and the ultrasound-measured variables in the group of individuals who smoked. For all variables, age seemed to contribute the most out of all of the lifestyle factors for the positive changes in CIMT and CCA wall stiffness.

CONCLUSION: Our data yielded correlations between CCA properties and cardiovascular risk, as well as between CIMT and arterial stiffness. We were also able to demonstrate an increase in thickness of the CIMT in patients who have been exposed by tobacco through the use of ultrasound. Further large scale studies comparing patients with multiple cardiac risk factors need to be performed to confirm the utility of ultrasound findings of cardiovascular disease and stroke.

Key words: Carotid artery thickness, Point of care ultrasound, Indonesia, Intimal thickness

Allen R. Yu, Bima Hasjim, Luke E. Yu, Christopher Gabriel, Alexander Anshus, Jonathan B. Lee, Michael J. Louthan, Esther C. Kim, Katrina Lee, Christina Tse, Thomas Keown, Shadi Lahham, Maili Alvarado, Steven Bunch, Abdulatif Gari, J. Christian Fox. Comparison of ultrasound-measured properties of the common carotid artery to tobacco smoke exposure in a cohort of Indonesian patients[J]. World Journal of Emergency Medicine, 2017, 8(3): 177-183.

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References 46

1	The World Bank Group. Smoking prevalence, males. http://databank.worldbank.org/data/reports.aspx?source=2&series=SH.PRV.SMOK.MA&country=. Published 2016. Accessed January 15, 2016.
2	Wolf PA, D'Agostino RB, Kannel WB, Bonita R, Belanger A. Cigarette smoking as a risk factor for stroke. JAMA. 1988; 259(7):1025.
3	The Centers for Disease Control and Prevention (CDC).. CDC in Indonesia Factsheet. Centers Dis Control Prev. 2013(CDC):1-2. http://www.cdc.gov/globalhealth/countries/indonesia/pdf/indonesia.pdf\nwww.cdc.gov/globalhealth/countries/indonesia/pdf/indonesia.pdf.
4	Kohn JC, Lampi MC, Reinhart-King CA. Age-related vascular stiffening: Causes and consequences. Front Genet. 2015; 6(MAR):1-17.
5	van Popele NM, Grobbee DE, Bots ML, Asmar R, Topouchian J, Reneman RS, et al. Association between arterial stiffness and atherosclerosis: the Rotterdam Study. Stroke. 2001; 32(2):454-60.
6	Failla M, Effects of cigarette smoking on carotid and radial artery distensibility. J Hypertens. 1997; 15(12 Pt 2):1659-64. doi: 10.1097/00004872-199715120-00069 pmid: 9488219
7	Camplain R, Meyer ML, Tanaka H, Palta P, Agarwal SK, Aguilar D, et al. Smoking behaviors and arterial stiffness measured by pulse wave velocity in older adults: The Atherosclerosis Risk in Communities (ARIC) Study. Am J Hypertens. 2015 Dec 10. pii: hpv189.
8	Maloberti A. Structural and functional abnormalities of carotid artery and their relation with EVA phenomenon. High Blood Press Cardiovasc Prev. 2015; 22(4):373-9.
9	Gaibazzi N. Differential incremental value of ultrasound carotid intima-media thickness, carotid plaque, and cardiac calcium to predict angiographic coronary artery disease across Framingham risk score strata in the APRES multicentre study. Eur Heart J Cardiovasc Imaging. 2016; 17(9):991-1000. pmid: 26358694
10	O'Leary D, Polak J, Kronmal R, Manolio TA, Burke GL, Wolfson SK Jr. Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults. N Engl J Med. 1999; 340(1):14-22. doi: 10.1056/NEJM199901073400103 pmid: 9878640
11	McEvoy JW, Blaha MJ, DeFilippis AP, Lima JA, Bluemke DA, Hundley WG, et al. Cigarette smoking and cardiovascular events: role of inflammation and subclinical atherosclerosis from the MultiEthnic Study of Atherosclerosis. Arterioscler Thromb Vasc Biol. 2015; 35(3):700-9.
12	Lorenz MW, Polak JF, Kavousi M, Mathiesen EB, Völzke H, Tuomainen TP, et al. Carotid intima-media thickness progression to predict cardiovascular events in the general population (the PROG-IMT collaborative project): a meta-analysis of individual participant data. Lancet. 2012; 379(9831):2053-62.
13	Zhang L, Yin JK, Duan YY, Liu X, Xu L, Wang J, et al. Evaluation of carotid artery elasticity changes in patients with type 2 diabetes. Cardiovasc Diabetol. 2014; 13(10):39.
14	Weberruß H, Pirzer R, Böhm B, Elmenhorst J, Pozza RD, Netz H, et al. Increased intima-media thickness is not associated with stiffer arteries in children. Atherosclerosis. 2015; 242(1):48-55.
15	Doyon A, Kracht D, Bayazit AK, Deveci M, Duzova A, Krmar RT, et al. Carotid artery intima-media thickness and distensibility in children and adolescents: Reference values and role of body dimensions. Hypertension. 2013; 62(3):550-6.
16	Carmona R. The 2006 Report of the Surgeon General. The Health Consequences of Involuntary Exposure to Tobacco Smoke. Am J Prev Med. 2007; 32:542-543. pmid: 17533072
17	Chen W, Yun M, Fernandez C, Li S, Sun D, Lai CC, et al. Secondhand smoke exposure is associated with increased carotid artery intima-media thickness: The Bogalusa Heart Study. Atherosclerosis. 2015; 240(2):374-9.
18	Lane HA, Smith JC, Davies JS. Noninvasive assessment of preclinical atherosclerosis. Vasc Health Risk Manag. 2006; 2(1):19-30.
19	Gamble G, Zorn J, Sanders G, MacMahon S, Sharpe N. Estimation of arterial stiffness, compliance, and distensibility from M-mode ultrasound measurements of the common carotid artery. Stroke. 1994; 25(1):11-6.
20	Godia EC, Madhok R, Pittman J, Trocio S, Ramas R, Cabral D, et al. Carotid artery distensibility: a reliability study. J ultrasound Med. 2007; 26(9):1157-65.
21	Law Y, Chan YC, Cheng SW. Endovascular repair of giant traumatic pseudo-aneurysm of the common carotid artery. World J Emerg Med. 2015; 6(3):229-32. doi: 10.5847/wjem.j.1920-8642.2015.03.013 pmid: 26401187
22	Nambi V, Chambless L, He M, Folsom AR, Mosley T, Boerwinkle E, et al. Common carotid artery intimamedia thickness is as good as carotid intimamedia thickness of all carotid artery segments in improving prediction of coronary heart disease risk in the Atherosclerosis Risk in Communities (ARIC) study. Eur Heart J. 2012; 33(2):183-90.
23	Benetos A, Waeber B, Izzo J, Mitchell G, Resnick L, Asmar R, et al. Influence of age, risk factors, and cardiovascular and renal disease on arterial stiffness: clinical applications. Am J Hypertens. 2002; 15(12):1101-8. doi: 10.1016/s0895-7061(02)03029-7 pmid: 12460708
24	Kawasaki T, Sasayama S, Yagi S, Asakawa T, Hirai T. Non-invasive assessment of the age related changes in stiffness of major branches of the human arteries. Cardiovasc Res. 1987; 21(9):678-87.
25	Gepner AD, Korcarz CE, Colangelo LA, Hom EK, Tattersall MC, Astor BC, et al. Longitudinal effects of a decade of aging on carotid artery stiffness: The multiethnic study of atherosclerosis. Stroke. 2014; 45(1):48-53.
26	Johnson HM, Piper ME, Baker TB, Fiore MC, Stein JH. Effects of smoking and cessation on subclinical arterial disease: A substudy of a randomized controlled trial. PLoS One. 2012; 7(4):1-6.
27	Kweon S, Lee Y, Shin M, Choi JS, Rhee JA, Choi SW, et al. Effects of cumulative smoking exposure and duration of smoking cessation on carotid artery structure. Circ J. 2012; 76(8):2041-7.
28	Sharrett AR, Ding J, Criqui MH, Saad MF, Liu K, Polak JF, et al. Smoking, diabetes, and blood cholesterol differ in their associations with subclinical atherosclerosis: the Multiethnic Study of Atherosclerosis (MESA). Atherosclerosis. 2006; 186(2):441-7.
29	Meyer ML, Tanaka H, Palta P, Cheng S, Gouskova N, Aguilar D, et al. Correlates of segmental pulse wave velocity in older adults: The Atherosclerosis Risk in Communities (ARIC) Study. Am J Hypertens. 2016; 29(1):114-22.
30	Norman PE, Curci JA. Understanding the effects of tobacco smoke on the pathogenesis of aortic aneurysm. Arterioscler Thromb Vasc Biol. 2013; 33(7):1473-7.
31	Chang CM, Corey CG, Rostron BL, Apelberg BJ. Systematic review of cigar smoking and all cause and smoking related mortality. BMC Public Health. 2015; 15(1):390.
32	Kent KC, Zwolak RM, Egorova NN, Riles TS, Manganaro A, Moskowitz AJ, et al. Analysis of risk factors for abdominal aortic aneurysm in a cohort of more than 3 million individuals. J Vasc Surg. 2010; 52(3):539-48. doi: 10.1016/j.jvs.2010.05.091 pmid: 20630687
33	Kuivaniemi H, Ryer EJ, Elmore JR, Tromp G. Understanding the pathogenesis of abdominal aortic aneurysms. Expert Rev Cardiovasc Ther. 2015; 13(9):975-87.
34	Sutton-Tyrrell K, Najjar SS, Boudreau RM, Venkitachalam L, Kupelian V, Simonsick EM, et al. Elevated aortic pulse wave velocity, a marker of arterial stiffness, predicts cardiovascular events in well-functioning older adults. Circulation. 2005; 111(25):3384-90.
35	Goff DC, Lloyd-Jones DM, Bennett G, Coady S, D'Agostino RB, Gibbons et al, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: A report of the American college of cardiology/American heart association task force on practice guidelines. Circulation. 2014; 129(25 Suppl 2):S49-73.
36	Whelton SP, Blankstein R, Al-Mallah MH, Lima JA, Bluemke DA, Hundley WG, et al. Association of resting heart rate with carotid and aortic arterial stiffness: Multi-ethnic study of atherosclerosis. Hypertension. 2013; 62(3):477-84.
37	Lunder M, Janic M, Kejzar N, Sabovic M. Associations among different functional and structural arterial wall properties and their relations to traditional cardiovascular risk factors in healthy subjects: a cross-sectional study. BMC Cardiovasc Disord. 2012; 12:29.
38	Zoungas S, Cameron JD, Kerr PG, Wolfe R, Muske C, McNeil JJ, et al. Association of carotid intima-medial thickness and indices of arterial stiffness with cardiovascular disease outcomes in CKD. Am J Kidney Dis. 2007; 50(4):622-30. doi: 10.1053/j.ajkd.2007.07.012
39	Zureik M, Temmar M, Adamopoulos C, Bureau JM, Courbon D, Thomas F, et al. Carotid plaques, but not common carotid intima-media thickness, are independently associated with aortic stiffness. J Hypertens. 2002; 20(1):85-93. doi: 10.1097/00004872-200201000-00013 pmid: 11791030
40	Su TC, Hwang JJ, Shen YC, Chan CC. Carotid intima-media thickness and long-term exposure to traffic-related air pollution in middle-aged residents of Taiwan: A cross-sectional study. Environ Health Perspect. 2015; 123(8):773-8.
41	Brook RD, Rajagopalan S, Pope CA, Brook JR, Bhatnagar A, Diez-Roux AV, et al. Particulate matter air pollution and cardiovascular disease: An update to the scientific statement from the american heart association. Circulation. 2010; 121(21):2331-78.
42	Jones MR, Diez-Roux A V, O'Neill MS, Guallar E, Sharrett AR, Post W, et al. Ambient air pollution and racial/ethnic differences in carotid intima-media thickness in the Multi-Ethnic Study of Atherosclerosis (MESA). J Epidemiol Community Health. 2015; 69(12):1191-8.
43	Provost EB, Louwies T, Cox B, Op't Roodt J, Solmi F, Dons E, et al. Short-term fluctuations in personal black carbon exposure are associated with rapid changes in carotid arterial stiffening. Environ Int. 2016; 88:228-34.
44	O'Neill MS, Diez-Roux AV, Auchincloss AH, Shen M, Lima JA, Polak JF, et al. Long-term exposure to airborne particles and arterial stiffness: The multi-ethnic study of atherosclerosis (MESA). Environ Health Perspect. 2011; 119(6):844-51.
45	Lenters V, Uiterwaal CS, Beelen R, Bots ML, Fischer P, Brunekreef B, et al. Long-term exposure to air pollution and vascular damage in young adults. Epidemiology. 2010; 21(4):512-20.
46	Gan WQ, Allen RW, Brauer M, Davies HW, Mancini GBJ, Lear SA. Long-term exposure to traffic-related air pollution and progression of carotid artery atherosclerosis: a prospective cohort study. BMJ Open. 2014; 4(4):e004743.

Variables	Results
Total patients enrolled	663
Current smokers	426
Second-hand smoke	237
Male	195
Female	468
BMI (kg/m²), mean	23.7
HTN history (%)	107±25.1
Type 2 diabetes (%)	12±2.82
Hypercholesterolemia (%)	68±16.0
Previous cardiac event (%)	14±3.29
Previous stroke (%)	7±1.64
SBP (mmHg)	134±17
DBP (mmHg)	72±12
CIMT (mm)	0.529±0.359
DC (mmHg^-1×10^-3)	0.0028±0.002
CSC (mmHg^-1×10^-3)	0.177±1.13
β	10.9±16.6
YEM (mmHg)	157 000±12 300

Variables	Nonsmokers	Smokers	P value
Number of subjects	243	183
Number of males, n (%)	26 (10.7)	144 (78.7)	<0.001^*
Age, mean	40.8	47.9	<0.001^*
BMI, mean	23.9	23.5	0.418
HTN history, n (%)	61 (25.1)	46 (25.1)	0.460
Type 2 diabetes, n (%)	7 (2.88)	5 (2.73)	0.908
Hypercholesterolemia, n (%)	41 (16.9)	27 (14.8)	0.512
Previous heart attack, n (%)	6 (2.47)	8 (4.37)	0.306
Previous stroke, n (%)	5 (2.06)	2 (1.09)	0.410
SBP (mmHg)	133	135	0.484
CIMT (mm)	0.478	0.598	0.002^*
DC (mmHg^-1×10^-3)	0.0030	0.0025	0.007^*
CSC (mmHg^-1×10^-3)	0.150	0.213	0.610
β	10.1	11.8	0.303
YEM (mmHg)	150 000	166 000	0.493

Variables	Distensibility (mmHg^-1×10^-3)	Cross-sectional compliance (mmHg^-1×10^-3)	Stiffness	Young's elastic modulus (mmHg)	CIMT (mm)
Adjusted R²	0.114	0	0.0288	0.0439	0.0557
Variable contribution	0.002	0	-0.0019	-0.0023	0.0022
Contribution of age	0.1093	-0.0007	0.0315	0.0462	0.0453
P value	<0.0001^*	0.4234	0.0036^*	0.0002^*	0.0002^*

Variables	Distensibility (mmHg^-1×10^-3)	Cross-sectional compliance (mmHg^-1×10^-3)	Stiffness	Young's elastic modulus (mmHg)	CIMT (mm)
Adjusted R²	0.0163	0	0.0215	0.0335	0.2741
Variable contribution	0.0185	0.0172	0.0109	0.0115	0.0078
Contribution of age	0.0194	0.0004	0.0103	0.0114	0.1818
Highest contributing variable (if not age)	N/A	N/A	0.0167 (BMI)	0.0257 (BMI)	N/A
P value	0.4185	0.4687	0.0726^*	0.0232^*	<0.0001^*

Variables	Distensibility (mmHg^-1×10^-3)	Cross-sectional compliance (mmHg^-1×10^-3)	Stiffness	Young's elastic modulus (mmHg)
r²	0.033	0.0002	0.0023	0.0035
P value	0.0002^*	0.7873	0.3131	0.2231