Carotid Doppler Ultrasonography in Patients with Co-existing Type 2 Diabetes Mellitus and Hypertension in Nigeria

  • AO Adekoya
  • AA Olatunji
  • AR Akinola
  • O Odusan
  • AO Adekoya
  • OO Olawale
Keywords: Blood Flow Velocity, Carotid Intima Media Thickness, Carotid plaque, Hypertension, Subclinical atherosclerosis, Type 2 Diabetes mellitus

Abstract

Background: The co-existence of diabetes mellitus (DM) and hypertension (HTN) has been rising globally with subclinical atherosclerotic complications. These vascular changes can be detected using carotid ultrasonography.

Objectives: To determine and compare the carotid arterial structural wall changes and blood flow velocities of adults with co-existing DM and HTN with age- and sex-matched non-diabetic, non-hypertensive controls.

Methods: A cross-sectional comparative study of 300 participants comprising 200 adults with co-existing DM and HTN and 100 age- and sex-matched controls was done. Their carotid arteries were examined bilaterally for plaques, carotid intima media thickness (CIMT) and flow velocities – peak systolic velocity (PSV), end diastolic velocity (EDV), pulsatility index (PI) and resistive index (RI) using 4–12MHz linear array transducer. Visceral obesity and serum lipids were also assessed.

Results: The mean age of the subjects was 56.13 ± 6.93 years; they comprised 38% males and 62% females. The subjects’ CIMT was statistically significantly higher (p = 0.001) with a three-fold mean increase (45.5%) compared to the controls (13.7%). Lower flow velocities but higher indices were also observed in the subjects. Strong and significant correlations were observed between EDV and PI (r =-0.663, p =>0.001), EDV and RI (r = -0.661, p =>0.001) and PI and RI (r =0.988, p = >0.001) among the subjects.

Conclusion: Significant reduction in flow velocities with increased CIMT may be an early indication of subclinical atherosclerosis. Therefore, carotid ultrasonography should be mandatory in individuals at risk for early detection and possible prevention of atherosclerotic complications.

References

Mahmood SS, Levy D, Vasan RS, Wang TJ. The Framingham Heart Study and the epidemiology of cardiovascular disease: a historical perspective. Lancet 2014; 383: 999-1008. https://doi.org/10.1016/S0140-6736(13)61752-3

World Health Organization, World Health Statistics Report, Geneva: WHO, 2012. Available at: https://www.who.int/gho/publications/world_health_statistics/EN_WHS2012_Full.pdf. (Accessed 12 May 2020).

World Health Organization. Non-communicable diseases. Available at: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases. (Accessed 12 May 2020).

Okubadejo NU, Ozoh OB, Ojo OO, Akinkugbe AO, Odeniyi IA, Adegoke O, et al. Prevalence of hypertension and blood pressure profile amongst urban-dwelling adults in Nigeria: a comparative analysis based on recent guideline recommendations. Clin Hypertens. 2019; 15: 7. https://doi.org/10.1186/s40885-019-0112-1

Uloko AE, Musa BM, Ramalan MA, Gezawa ID, Puepet FH, Uloko AT, et al. Prevalence and risk factors for diabetes mellitus in Nigeria: a systematic review and meta-analysis. Diabetes Ther 2018; 9: 1307-1316. https://doi.org/10.1007/s13300-018-0441-1

Berraho M, El Achhab Y, Benslimane A, El Rhazi K, Chikri M, Nejjari C. Hypertension, and Type 2 diabetes: a cross-sectional study in Morocco (EPIDIAM Study). Pan Afr Med J 2012; 11: 52.

Kayode OO, Odukoya OO, Odeniyi IA, Olopade OB, Fasanmade OA. Pattern of complications and comorbidities among diabetic patients in a tertiary healthcare center in Nigeria. J Clin Sci 2015; 12: 29-35. https://doi.org/10.4103/1595-9587.160765

Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo JL Jr, et al. Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education Program Coordinating Committee. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003; 42: 1206-1252. https://doi.org/10.1161/01.HYP.0000107251.49515.c2

Stein JH, Korcarz CE, Hurst RT, Lonn E, Kendall CB, Mohler ER, et al. American Society of Echocardiography Carotid Intima-Media Thickness Task Force. Use of carotid ultrasound to identify subclinical vascular disease and evaluate cardiovascular disease risk: a consensus statement from the American Society of Echocardiography Carotid Intima-Media Thickness Task Force. Endorsed by the Society for Vascular Medicine. J Am Soc Echocardiogr 2008; 21: 93-111. https://doi.org/10.1016/j.echo.2007.11.011

Protocols for collecting height, weight, and waist measurements in New Zealand health monitor (NZHM) surveys. 2008. Available at: https://www.moh.govt.nz/notebook/nbbooks.nsf/0/e846bf606184f2cdcc257487007eb4e8/$FILE/protocols-for-collecting-height-weight-waist-measurements.pdf. (Accessed on 17 June 2021).

Ogunlade O, Adalumo OA, Asafa MA. Challenges of body mass index classification: New criteria for young adult Nigerians. Niger J Health Sci 2015; 15: 71-74. https://doi.org/10.4103/1596-4078.182319

World Health Organization. Waist circumference and waist-hip ratio: report of a WHO expert consultation. Geneva: WHO, 2008; 5–7. Available at: https://www.who.int/nutrition/publications/obesity/WHO_report_waistcircumference_and_waisthip_ratio/en/. (Accessed on 18 June 2021).

Okafor CI, Raimi TH, Gezawa ID, Sabir AA, Enang O, Puepet F, et al. Performance of waist circumference and proposed cut-off levels for defining overweight and obesity in Nigerians. Ann Afr Med 2016; 15: 185-193. https://doi.org/10.4103/1596-3519.194275

Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concentration of low-density lipoprotein cholesterol in plasma, without use of the preparative ultracentrifuge. Clin Chem. 1972; 18: 499-502.

Dansinger M. Hemoglobin A1c (HbA1c) Test for Diabetes. Available at: https://www.webmd.com/diabetes/guide/glycated-hemoglobin-test-hba1c. (Accessed on 08 June 2021).

Goldman R. The recommended cholesterol levels by age. Available at: https://www.healthline.com/health/high-cholesterol/levels-by-age. (Accessed on 08 June 2021).

Pignoli P, Tremoli E, Poli A, Oreste P, Paoletti R. Intimal plus medial thickness of the arterial wall: a direct measurement with ultrasound imaging. Circulation. 1986; 74: 1399-1406. https://doi.org/10.1161/01.cir.74.6.1399

Touboul PJ, Hennerici MG, Meairs S, Adams H, Amarenco P, Bornstein N, et al. Mannheim carotid intima-media thickness and plaque consensus (2004-2006-2011). An update on behalf of the advisory board of the 3rd, 4th and 5th watching the risk symposia, at the 13th, 15th and 20th European Stroke Conferences, Mannheim, Germany, 2004, Brussels, Belgium, 2006, and Hamburg, Germany, 2011. Cerebrovasc Dis. 2012; 34: 290-296. https://doi.org/10.1159/000343145

Tahmasebpour HR, Buckley AR, Cooperberg PL, Fix CH. Sonographic examination of the carotid arteries. Radiographics 2005; 25: 1561-1575. https://doi.org/10.1148/rg.256045013

Pourcelot L. Clinical applications of transcutaneous Doppler examination. In: Peronneau P (Editor). Doppler ultrasound velocimetry, Paris, France. INSERM 1975: 213–240.

Gosling RG, King DH. Arterial assessment by Doppler-shift ultrasound. Proc R Soc Med. 1974; 67: 447-449.

Umeh EO, Agunloye AM, Adekanmi AJ, Adeyinka AO. Ultrasound evaluation of intima-media thickness of carotid arteries in adults with primary hypertension at Ibadan, Nigeria. West Afr J Med. 2013; 32: 62-67.

Okafor EA, Adekanmi AJ, Atalabi OM. Relationship between carotid intima-media thickness and diabetes clinical risk factors among normotensive Type 2 diabetes mellitus among native black African population. Int J Clin Med 2018; 9: 203–219. https://doi.org/10.4236/ijcm.2018.93018

Ibinaiye PO, Kolade-Yunusa HO, Abdulkadir A, Yunusa T. Relationship of carotid artery intima media thickness to blood pressure, age and body mass index of hypertensive adult patients. Arch Int Surg 2015; 5: 63-68. https://doi.org/10.4103/2278-9596.158816

Mirza W, Arain M, Ali A, Bari V, Kazim M, Fatima K, et al. Carotid intima media thickness evaluation by ultrasound comparison amongst healthy, diabetic, and hypertensive Pakistani patients. J Pak Med Assoc 2016; 66: 1396-1400.

Serdar O, Mehmet S, Ali Haydar B, Meral C. The relationship between HbA1c and carotid intima-media thickness in Type 2 diabetic patients. Pan Afr Med J 2016; 23: 224. https://doi.org/10.11604/pamj.2016.23.224.8970

Olubunmi OA. Recent advances in the management of cerebrovascular accidents. Benin J Postgrad Med 2007; 9: 28–40. https://doi.org/10.4314/bjpm.v9i1.47370

Unamba NN, Unamba BC, Akpa MR. Serum lipid profile and its relationship with carotid intima-media thickness in hypertensive adults attending a tertiary hospital in southern Nigeria. Am J Med Med Sci 2017; 7: 202–209. https://doi.org/10.5923/j.ajmms.20170704.08

Soneye MA, Adekanmi AJ, Obajimi MO, Aje A. Intima media thickness of femoral arteries and carotids among an adult hypertensive Nigerian population: a case-control study to assess their use as surrogate markers of atherosclerosis. Ann Afr Med 2019; 18: 158–166. https://doi.org/10.4103/aam.aam_57_18

Okeahialam BN, Muoneme SA, Kolade-Yunusa HO. Carotid intima media thickness in non-diabetic hypertensive Nigerians: role of fasting and postprandial blood glucose. Int J Vasc Med. 2016; 2016: 1429451. https://doi.org/10.1155/2016/1429451

Ma X, Shen Y, Hu X, Hao Y, Luo Y, Tang J, et al. Associations of glycated hemoglobin A1c and glycated albumin with subclinical atherosclerosis in middle-aged and elderly Chinese population with impaired glucose regulation. Clin Exp Pharmacol Physiol 2015; 42: 582-587. https://doi.org/10.1111/1440-1681.12394

Mukai N, Ninomiya T, Hata J, Hirakawa Y, Ikeda F, Fukuhara M, et al. Association of hemoglobin A1c and glycated albumin with carotid atherosclerosis in community-dwelling Japanese subjects: the Hisayama Study. Cardiovasc Diabetol 2015; 14: 84. https://doi.org/10.1186/s12933-015-0247-7

Butt MU, Zakaria M. Association of common carotid intimal medial thickness (CCA-IMT) with risk factors of atherosclerosis in patients with Type 2 diabetes mellitus. J Pak Med Assoc 2009; 59: 590-593.

Yoo HJ, Choi KM. Adipokines as a novel link between obesity and atherosclerosis. World J Diabetes. 2014; 5: 357-363. https://doi.org/10.4239/wjd.v5.i3.357

Cooper-DeHoff RM, Pepine CJ. Metabolic syndrome and cardiovascular disease: challenges and opportunities. Clin Cardiol 2007; 30: 593–597. https://doi.org/10.1002/clc

Johnsen SH, Mathiesen EB, Joakimsen O, Stensland E, Wilsgaard T, Løchen ML, et al. Carotid atherosclerosis is a stronger predictor of myocardial infarction in women than in men: a 6-year follow-up study of 6226 persons: the Tromsø Study. Stroke 2007; 38: 2873-2880. https://doi.org/10.1161/STROKEAHA.107.487264

Mughal MM, Khan MK, DeMarco JK, Majid A, Shamoun F, Abela GS. Symptomatic and asymptomatic carotid artery plaque. Expert Rev Cardiovasc Ther 2011; 9: 1315-1330. https://doi.org/10.1586/erc.11.120

Phan TG, Beare RJ, Jolley D, Das G, Ren M, Wong K, et al. Carotid artery anatomy and geometry as risk factors for carotid atherosclerotic disease. Stroke 2012; 43: 1596-1601. https://doi.org/10.1161/STROKEAHA.111.645499

Ionescu A, Carciumaru N, Chirila S. Carotid Artery Disease - Left vs Right. ARS Medica Tomitana. 2017; 22: 169-173. https://doi.org/10.1515/arsm-2016-0028

Filardi V. Carotid artery stenosis near a bifurcation investigated by fluid dynamic analyses. Neuroradiol J 2013; 26: 439–453. https://doi.org/10.1177/197140091302600409

Chung H, Jung YH, Kim KH, Kim JY, Min PK, Yoon YW, et al. Carotid Artery End-Diastolic Velocity and Future Cerebro-Cardiovascular Events in Asymptomatic High-Risk Patients. Korean Circ J 2016; 46: 72-78. https://doi.org/10.4070/kcj.2016.46.1.72

Gupta A, Kesavabhotla K, Baradaran H, Kamel H, Pandya A, Giambrone AE, et al. Plaque echolucency and stroke risk in asymptomatic carotid stenosis. A systemic review and meta-analysis. Stroke 2015; 46: 91–97. https://doi.org/10.1161/STROKEAHA.114.006091

Rimmele DL, Borof K, Wenzel J, Jensen M, Behrendt CA, Waldeyer C, et al. Differential association of flow velocities in the carotid artery with plaques, intima media thickness and cardiac function. Atherosclerosis Plus 2021: 43; 18–23. https://doi.org/10.1016/j.athplu.2021.07.020

Solini A, Giannini L, Seghieri M, Vitolo E, Taddei S, Ghiadoni L, et al. Dapagliflozin acutely improves endothelial dysfunction, reduces aortic stiffness and renal resistive index in type 2 diabetic patients: a pilot study. Cardiovasc Diabetol 2017:23; 16: 138. https://doi.org/10.1186/s12933-017-0621-8

Yang JW, Cho KI, Kim JH, Kim SY, Kim CU, You GI, et al. Wall shear stress in hypertensive patients is associated with carotid vascular deformation assessed by speckle tracking strain imaging. Clin Hypertens 2014: 20: 10 https://doi.org/10.1186/2056-5909-20-10

Published
2022-03-25
Section
Original Research