Subclinical carotid atherosclerosis predicts all-cause mortality and cardiovascular events in obese patients with negative exercise echocardiography

doi:10.4330/wjc.v11.i1.24

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World Journal of Cardiology

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Retrospective Cohort Study

World J Cardiol. Jan 26, 2019; 11(1): 24-37
Published online Jan 26, 2019. doi: 10.4330/wjc.v11.i1.24

Table 1 Baseline characteristics

	n = 226	No plaque, n = 150	Plaque, n = 76	P value
Age	63.2 (11.4)	60.6 (12.1)	68.2 (7.3)	< 0.001^a
Male sex	106 (46.9%)	64 (42.7%)	42 (55.3%)	0.099
Hypertension	166 (73.5%)	100 (66.7%)	66 (86.8%)	0.002^a
Diabetes mellitus	45 (19.9%)	24 (16.0%)	21 (27.6%)	0.058
Dyslipidaemia	124 (54.9%)	74 (49.3%)	50 (65.8%)	0.027^a
Current smoker	55 (24.3%)	36 (24.0%)	19 (25.0%)	0.999
Family history of premature CAD	17 (7.5%)	13 (8.7%)	4 (5.3%)	0.516
BMI, kg/m²	33.3 (4.1)	33.2 (4.5)	33.4 (3.0)	0.694
Obesity				0.033^a
Grade 1	179 (79.2%)	126 (84.0%)	53 (69.7%)
Grade 2	39 (17.3%)	19 (12.7%)	20 (26.3%)
Grade 3	8 (3.5%)	5 (3.3%)	3 (3.9%)
No cardiovascular risk factors	29 (12.8%)	28 (18.7%)	1 (1.3%)	< 0.001^a
SCORE				< 0.001^a
Low-risk, < 1%	29 (12.8%)	28 (18.7%)	1 (1.3%)
Moderate-risk, 1%-5%	113 (50.0%)	78 (52.0%)	35 (46.1%)
High risk, 5%-10%	33 (14.6%)	20 (13.3%)	13 (17.1%)
Very high-risk, ≥ 10%	49 (21.7%)	24 (16.0%)	25 (32.9%)
Not classifiable	2 (0.9%)	0	2 (2.6%)
CAD PTP				0.017^a
< 15%	10 (4.4%)	10 (6.7%)	0
15-65%	180 (79.6%)	121 (80.7%)	59 (77.6%)
65-85%	36 (15.9%)	19 (12.7%)	17 (22.4%)
> 85%	0 (0%)	0 (0%)	0 (0%)
Fasting plasma glucose, mg/dL	113.8 (32.2)	112.5 (33.4)	116.6 (29.5)	0.369
Glomerular filtration rate, mL/min/1.73 m²	87.6 (25.4)	91.4 (27.1)	79.7 (20.3)	< 0.001^a
Total cholesterol, mg/dL	199.6 (40.5)	196.9 (38.5)	205.0 (43.9)	0.159
HDL cholesterol, mg/dL	48.6 (12.3)	49.6 (13.4)	46.5 (9.1)	0.043^a
Triglycerides, mg/dL	143.6 (75.9)	133.0 (60.0)	164.8 (97.6)	0.011^a
LDL cholesterol, mg/dL	122.1 (34.6)	120.2 (34.1)	125.9 (35.8)	0.257
Atrial fibrillation	26 (11.5%)	14 (9.3%)	12 (15.8%)	0.224
Treatment after EE
Angiotensin-converting enzyme inhibitor	29 (12.8%)	16 (10.7%)	13 (17.1%)	0.247
Angiotensin II receptor blockers	99 (43.8%)	54 (36.0%)	45 (59.2%)	0.001^a
Beta-blockers	72 (31.9%)	44 (29.3%)	28 (36.8%)	0.32
Calcium channel blockers	53 (23.5%)	27 (18.0%)	26 (34.2%)	0.011^a
Nitrates	21 (9.3%)	13 (8.7%)	8 (10.5%)	0.832
Statins	111 (49.1%)	66 (44.0%)	45 (59.2%)	0.043^a
Ezetimibe	6 (2.7%)	3 (2.0%)	3 (3.9%)	0.673
Fibrates	10 (4.4%)	5 (3.3%)	5 (6.6%)	0.476
Omega−3 fatty acids	4 (1.8%)	3 (2.0%)	1 (1.3%)	1
Antiplatelet drugs	109 (48.2%)	67 (44.7%)	42 (55.3%)	0.172
Anticoagulants drugs	17 (7.5%)	8 (5.3%)	9 (11.8%)	0.137
Oral antidiabetic drugs	28 (12.4%)	13 (8.7%)	15 (19.7%)	0.030^a
Insulin treatment	5 (2.2%)	2 (1.3%)	3 (3.9%)	0.338

^aP < 0.05. BMI: Body mass index; CAD: Coronary artery disease; EE: Exercise echocardiography; HDL cholesterol: High density lipoprotein cholesterol; LDL cholesterol: Low density lipoprotein cholesterol; PTP: Pre-test probability; SCORE: Systematic COronary Risk Evaluation.

Table 2 Baseline echocardiography, treadmill exercise stress echocardiography and carotid ultrasonography characteristics

	n = 226	No plaque, n = 150	Plaque, n = 76	P value
Baseline echocardiography
Baseline ejection fraction, %	64.6 (5.2)	64.5 (5.2)	64.7 (5.3)	0.823
Mitral regurgitation	82 (36.3%)	43 (28.7%)	39 (51.3%)	0.001^a
Aortic regurgitation	57 (25.2%)	33 (22.0%)	24 (31.6%)	0.16
Tricuspid regurgitation	116 (51.3%)	73 (48.7%)	43 (56.6%)	0.325
Pulmonary regurgitation	3 (1.3%)	3 (2.0%)	0 (0%)	0.553
Pulmonary artery systolic pressure, mmHg	32.6 (7.3)	30.5 (5.8)	35.1 (6.2)	0.013^a
Treadmill exercise stress echocardiography
Stress protocol				0.778
Naughton	14 (6.2%)	10 (6.7%)	4 (5.3%)
Bruce	212 (93.8%)	140 (93.3%)	72 (94.7%)
Systolic blood pressure
Baseline	141.8 (18.8)	140.7 (18.7)	143.9 (18.9)	0.222
Peak	197.6 (23.8)	196.6 (23.0)	199.7 (25.4)	0.361
Heart rate
Baseline	73.6 (12.4)	74.0 (11.9)	72.8 (13.5)	0.409
Peak	146.0 (13.1)	148.2 (13.4)	141.7 (11.5)	< 0.001^a
Percentage	93.1 (5.6)	93.0 (5.5)	93.3 (5.8)	0.718
Maximal stress test	26 (11.5%)	17 (11.3%)	9 (11.8%)	1
Rate-pressure, × 103 mmHg beats/min
Basal	10.5 (2.4)	10.4 (2.3)	10.5 (2.6)	0.831
Peak	28.9 (4.4)	29.1 (4.4)	28.3 (4.3)	0.174
Exercise time, min	8.6 (2.9)	8.1 (2.9)	7.1 (2.4)	0.011^a
METs	8.5 (2.9)	8.8 (3.1)	7.9 (2.3)	0.015^a
Carotid ultrasonography
CIMT, mm	0.80 (0.20)	0.74 (0.18)	0.91 (0.18)	< 0.001^a
CIMT > 0.9 mm	62 (27.4%)	27 (18.0%)	35 (46.1%)	< 0.001^a

^aP < 0.05. CIMT: Carotid intima media thickness; METs: Metabolic equivalents.

Table 3 Univariate analysis of adverse events (all-cause mortality, myocardial infarction and cerebrovascular accident)

	Hazard ratio	95% Confidence interval	P value
Age	1.1	1.05-1.15	< 0.001^a
Male sex	0.68	0.31-1.50	0.338
Hypertension	2.52	0.75-8.44	0.134
Diabetes mellitus	1.42	0.60-3.38	0.427
Dyslipidaemia	1.89	0.82-4.36	0.134
Current smoker	1.23	0.52-2.95	0.635
Family history of premature CAD	2.17	0.65-7.26	0.21
No cardiovascular risk factors	0.3	0.04-2.24	0.242
High/very high SCORE	2.15	0.98-4.71	0.055
Atrial fibrillation	2.45	0.98-6.10	0.055
CAD PTP ≥ 65%	1.44	0.57-3.60	0.441
BMI, kg/m²	0.93	0.80-1.09	0.381
Fasting plasma glucose	1	0.99-1.01	0.863
Glomerular filtration rate, mL/min/1.73 m²	0.98	0.96-0.99	0.002^a
Total cholesterol, mg/dL	1	0.99-1.00	0.333
HDL cholesterol, mg/dL	1	0.95-1.02	0.409
Triglycerides, mg/dL	1	0.99-1.01	0.189
LDL cholesterol, mg/dL	0.99	0.98-1.01	0.294
Left ventricular ejection fraction, %	0.98	0.91-1.06	0.563
Moderate mitral regurgitation	5.29	1.57-17.84	0.007^a
Moderate aortic regurgitation	4.24	0.57-31.55	0.158
Moderate tricuspid regurgitation	2.03	0.27-15.19	0.492
METs	0.77	0.66-0.90	0.001^a
CIMT	0.91	0.14-6.19	0.926
CIMT > 0.9 mm	0.79	0.33-1.91	0.603
CP presence	2.52	1.17-5.46	0.019^a

^aP < 0.05. BMI: Body mass index; CAD: Coronary artery disease; CIMT: Carotid intima media thickness; CP: Carotid plaque; HDL cholesterol: High density lipoprotein cholesterol; LDL cholesterol: Low density lipoprotein cholesterol; METs: Metabolic equivalents; PTP: Pre-test probability; SCORE: Systematic Coronary Risk Evaluation.

Table 4 Multivariate adverse event analysis (all-cause mortality, myocardial infarction and cerebrovascular accident)

	Hazard ratio	95% Confidence interval	P value
Glomerular filtration rate	0.98	0.96-0.99	0.023^a
Moderate mitral regurgitation	5.02	1.42-17.75	0.012^a
METs	0.83	0.70-0.99	0.034^a
CP presence	2.26	1.04-4.95	0.041^a

^aP < 0.05. CP: Carotid plaque; METs: Metabolic equivalents.

Citation: Vidal-Perez R, Franco-Gutiérrez R, Pérez-Pérez AJ, Franco-Gutiérrez V, Gascón-Vázquez A, López-López A, Testa-Fernández AM, González-Juanatey C. Subclinical carotid atherosclerosis predicts all-cause mortality and cardiovascular events in obese patients with negative exercise echocardiography. World J Cardiol 2019; 11(1): 24-37
URL: https://www.wjgnet.com/1949-8462/full/v11/i1/24.htm
DOI: https://dx.doi.org/10.4330/wjc.v11.i1.24