AORTIC STIFFNESS INDEXES AS A PREDICTOR FOR CHRONIC STABLE CORONARY ARTERY DISEASE IN TYPE 2 DIABETIC PATIENTS.

Document Type : Original Article

Authors

Cardiology Department, Faculty of Medicine, Al-Azhar University

Abstract

Background: Type 2 diabetic patients have increased arterial stiffness and are at particular risk for augmented cardiovascular morbidity and mortality. As diabetes is a systemic disease and it has a higher incidence of having a greater extent of atherosclerosis, it can affect the coronary arteries as well as the aorta.
Objective: Assessment of the effect of diabetes mellitus on the aorta by calculating aortic stiffness parameters using echocardiography measurements, and using these parameters as a predictor for coronary artery disease (CAD) presence and severity.
Patients and Methods: This study was conducted within one year from October 2018 until October 2019. Fifty diabetic patients were enrolled, suspected to have chronic stable coronary artery disease by symptoms and risk factors, divided into two groups after coronary angiography: Group I included patients with coronary artery disease, and group II with normal coronaries. All patients were subjected to full history taking, general and local examination, echocardiography including calculation of aortic stiffness parameters, laboratory investigations and coronary angiography.
Results: Thirty-six per cent of the patients had normal coronaries, and sixty-four per cent had coronary lesions. Aortic systolic and diastolic diameters were significantly higher in group I compared to group II. Aortic stiffness index and elastic modulus were significantly higher in group I and aortic distensibility was significantly lower in group I compared to group II. Stiffness index and elastic modulus had a positive correlation with the complexity of CAD based on SYNTAX score and aortic distensibility had a negative correlation with it. Aortic stiffness index had the highest sensitivity and a cutoff value of > 17.4 to detect CAD.
Conclusion: Aortic stiffness index has the highest predictive power for CAD presence and severity meaning that the patients with higher aortic stiffness index most probably will have a higher chance of having a complex CAD.

Keywords

Main Subjects


AORTIC STIFFNESS INDEXES AS A PREDICTOR FOR CHRONIC STABLE CORONARY ARTERY DISEASE IN TYPE 2 DIABETIC PATIENTS.

By

Muhammad Ahmad Fouad Kamel Badr, Ahmad Kamal Motaweih and Ahmad Abd El-Ra’oof Mahdy

Cardiology Department, Faculty of Medicine, Al-Azhar University

Corresponding author: Muhammad Ahmad Fouad Kamel Badr,

Mobile: +201118245391, E-mail: m.fouadbadr@gmail.com

ABSTRACT

Background: Type 2 diabetic patients have increased arterial stiffness and are at particular risk for augmented cardiovascular morbidity and mortality. As diabetes is a systemic disease and it has a higher incidence of having a greater extent of atherosclerosis, it can affect the coronary arteries as well as the aorta.

Objective: Assessment of the effect of diabetes mellitus on the aorta by calculating aortic stiffness parameters using echocardiography measurements, and using these parameters as a predictor for coronary artery disease (CAD) presence and severity.

Patients and Methods: This study was conducted within one year from October 2018 until October 2019. Fifty diabetic patients were enrolled, suspected to have chronic stable coronary artery disease by symptoms and risk factors, divided into two groups after coronary angiography: Group I included patients with coronary artery disease, and group II with normal coronaries. All patients were subjected to full history taking, general and local examination, echocardiography including calculation of aortic stiffness parameters, laboratory investigations and coronary angiography.

Results: Thirty-six per cent of the patients had normal coronaries, and sixty-four per cent had coronary lesions. Aortic systolic and diastolic diameters were significantly higher in group I compared to group II. Aortic stiffness index and elastic modulus were significantly higher in group I and aortic distensibility was significantly lower in group I compared to group II. Stiffness index and elastic modulus had a positive correlation with the complexity of CAD based on SYNTAX score and aortic distensibility had a negative correlation with it. Aortic stiffness index had the highest sensitivity and a cutoff value of > 17.4 to detect CAD.

Conclusion: Aortic stiffness index has the highest predictive power for CAD presence and severity meaning that the patients with higher aortic stiffness index most probably will have a higher chance of having a complex CAD.

Keywords: Aortic stiffness index, coronary artery disease, type2 diabetes mellitus.

 

 

INTRODUCTION

     Aortic stiffness is a complication of a long process of arteriosclerosis which is a result of diabetes, along with other causes, as an important contributing factor (Amraotkar et al., 2017).

     Type 2 diabetic patients have increased arterial stiffness and are at particular risk for augmented cardiovascular morbidity and mortality. This high cardiovascular risk is not completely explained by the clustering of traditional risk factors, and increased arterial stiffness may be one pathophysiological mechanism that links diabetes to increased cardiovascular morbidity and mortality (Cardoso et al., 2013).

     Aortic stiffness is an independent predictor of vascular morbidity and mortality as evidenced by studies performed in patients with diabetes as well as other risk factors  and Gale et al., 2019). And (Vlachopoulos et al., 2019

     The present study aimed to identify the power of aortic stiffness index, calculated using echocardiography measurements, to predict the presence of coronary artery disease in patients with type II DM, and its anticipation to have high-grade stenosis in the predicted group.

PATIENTS AND METHODS

     This was a cohort study including a total of 50 diabetic patients admitted to the Cardiology Department, Al-Azhar University Hospitals within a year starting from October 2018 till October 2019. Patients were enrolled in the study after obtaining their written informed consents, and approval of the local ethics committee of the hospital. The patients included in the study were suspected to have chronic stable coronary artery disease by symptoms and risk factors. They were divided into two groups based on coronary angiography: Group I with coronary artery lesions and group II with normal coronaries. Group 1 was then divided into two subgroups according to the severity and complexity of CAD measured by SYNTAX score into low SYNTAX and intermediate to high SYNTAX where low syntax was lower than 22 and intermediate to high was higher than 22.

Exclusion Criteria: Patients with hypertension, previous CABG, structural heart disease and abnormal heart rhythm other than sinus rhythm.

     All patients were subjected to a detailed history, including age, sex, history of CAD, medications and risk factors including smoking and dyslipidemia and physical examination including local and general examination. Random blood sugar was measured using a test strip. Echocardiographic images were obtained in the parasternal long-axis and short-axis and apical two-chamber and four-chamber views using standard transducer positions. Phillips IE33, General Electric Healthcare (GE Vingmed, Norway) equipped with a harmonic M5S variable-frequency (1.7-4 MHz) phased-array transducer was used to detect left ventricular end-diastolic diameter (LVEDD), left ventricular end-systolic diameter (LVESD), ejection fraction (EF), mitral inflow velocities and aortic stiffness index were measured and the results were done blindly by two echo experts for all subjects according to ASE recommendations.

Aortic stiffness was assessed by calculating the following equations:

•   Aortic distensibility (D): D = 2 (As - Ad)/ [Ad (Ps - Pd)]

Expressed as (10^-3 cm2/Dyn)

•   Stiffness index (SI): SI = ln (Ps/Pd)/ [(As – Ad)/Ad]

•   Pressure strain elastic modulus (Ep): Ep = (Ps – Pd)/ [(As – Ad)/Ad] expressed as (10^-2 kPa)

Where: As was the aortic diameter at end-systole, Ad is the aortic diameter at end-diastole, Ps is the systolic BP, Pd was the diastolic BP, and ln was the natural logarithm.

Tissue Doppler imaging: Aortic upper-wall velocities were measured by TDI at the same point as in the M-mode measurements. The TDI of expansion peak velocity during systole (Sao) and early (Eao) and late (Aao) contraction peak velocities during diastole were obtained with a 1-mm sample volume size.

     Patients underwent coronary angiography (Performing on Philips Cath lab) (Retrograde coronary angiography using the Judkin’s technique) to assess the ischemic profile of the patient which was performed and analyzed by an expert operator who was blinded to the clinical state of the patients. Local anaesthesia was administered, and femoral artery puncture was performed. Arterial sheath was inserted, then guidewire and needle were removed. A catheter was cannulated, then multiple standard views of coronary arteries were recorded.

Statistical analysis: Statistical presentation and analysis of the present study were conducted, using the range, median, IQR, frequency and percentage, correlation, Roc curve, Chi-square, and Mann-Whitney test by SPSS V20 for windows. (SPSS Inc., Chicago, Illinois, USA).

P-value ≤ 0.05 was considered significant. Correlation analysis assessed the strength of association between two variables.


 

RESULTS

 

 

     Male percentages were higher in both groups. However, the Female percentage was higher in group I compared to group I with no statistically significant difference between the 2 groups. Also, there was no significant statistical difference between the two groups regarding smoking and family history of CAD (Table 1).


 

Table (1):  Demographic data and risk factors among the studied groups

Groups

Patients

Group I (N=32)

Group II (N=18)

Total

P-value

N

%

N

%

N

%

 

Males

18

56.25

11

61.11

29

58

0.738

Females

14

43.75

7

38.89

21

42

Total

32

100

18

100

50

100

Smoking

Yes

11

34.38

7

38.89

18

36

0.75

No

21

65.63

11

61.11

32

64

Family history

of CAD

Yes

18

56.25

9

50

27

54

0.67

No

14

43.75

9

50

23

46

               Chi²

 

 

 

 

 

     There were statistically significant differences between the two groups regarding LVESD aortic systolic diameter and aortic diastolic diameter. Apart from those, there was no statistically significant difference between the two groups regarding other echocardiography findings. LVESD, aortic systolic and diastolic diameters were higher in group I compared to group II (Table 2).

 

Table (2):  Comparative analysis between Group I and Group II regarding echocardiography findings

Groups

Parameters

Group I(N=32)

Group II(N=18)

P-value

Left ventricular diastolic diameter (LVDD) (mm)

Range

37.8

-

64

38.7

-

53.4

0.051

Median (IQR)

50.15(8.55)

46.70(7.33)

Left ventricular systolic diameter (LVSD) (mm)

Range

22.1

-

45.5

23.4

-

38.1

0.014

Median (IQR)

34.05(7.18)

30.15(5.98)

Ejection fraction (EF)

Range

47

-

71

56

-

72

0.073

Median (IQR)

62.50(16.75)

65.50(9.25)

E wave (cm/s)

Range

49.4

-

116.1

48.3

-

100.9

0.538

Median (IQR)

84.40(26.05)

85.85(20.90)

A wave (cm/s)

Range

33.1

-

94.4

24.9

-

80.5

0.442

Median (IQR)

61.80(19.08)

60.65(20.15)

Deceleration time

(DT) (ms)

Range

147.3

-

265.4

126.1

-

245.9

0.968

Median (IQR)

182.45(35.13)

185.10(49.38)

Expansion peak velocity during
 systole (AO. S)

Range

6.8

-

14.5

6.5

-

15.5

0.517

Median (IQR)

9.50(2.13)

9.05(1.90)

Early contraction peak velocities during diastole (AO. E)

Range

4.4

-

19.6

7.1

-

20.8

0.122

Median (IQR)

13.00(4.45)

14.00(3.88)

Late contraction peak velocities during diastole (AO. A)

Range

3.6

-

14.6

4.1

-

12.4

0.701

Median (IQR)

8.70(3.23)

8.85(3.23)

Aortic Systolic Diameter

Range

24.8

-

37.6

25

-

34

0.004

Median (IQR)

30.10(2.63)

27.95(2.78)

Aortic diastolic Diameter

Range

22.2

-

34.4

23.2

-

30.1

0.014

Median (IQR)

28.05(3.70)

26.00(3.63)

Mann-Whitney Test

 

 

     By comparing the aortic stiffness parameters between group I and group II, there was a statistically significant difference between the two groups in aortic stiffness index, aortic distensibility and elastic modulus. Both aortic stiffness index and elastic modulus were directly proportional to the presence of CAD while aortic distensibility was inversely proportional to the same event (Table 3).

 

Table (3):  Aortic stiffness parameters in the studied groups

Groups

Parameters

Group I

Group II

P-value

Stiffness index

Range

17.3

-

23.2

14.3

-

23.2

0.001

Median (IQR)

19.80(2.18)

16.25(5.08)

Aortic Distensibility

Range

1

-

5.3

1

-

6.6

0.009

Median (IQR)

3.00(1.15)

4.55(3.18)

Ep

Range

68

-

76.2

65.4

-

76.2

0.001

Median (IQR)

70.90(5.85)

67.50(6.03)

Mann-Whitney Test

 

     Males were higher than females in patients diagnosed with CAD. Nevertheless, a higher number of females were diagnosed with intermediate and high SYNTAX score. However, the difference between groups was statistically insignificant. Also, there is no statistically significant difference between the patients’ smoking, and family history of CAD & the degree of SYNTAX score (Table 4).

 

 

Table (4):  Relation between the complexity of CAD & demographic data and risk factors

SYNTAX

Patients

Low

Intermediate and High

Total

P-value

N

%

N

%

N

%

Males

9

69.23

9

47.37

18

56.25

0.221

Females

4

30.77

10

52.63

14

43.75

Total

13

100

19

100

32

100

Smoking

Yes

5

38.46

6

31.58

11

34.38

0.687

No

8

61.54

13

68.42

21

65.63

Family history

of CAD

Yes

8

61.54

10

52.63

18

56.25

0.618

No

5

38.46

9

47.37

14

43.75

               Chi²

 

     Apart from deceleration time (DT) which shows a statistical significance to the degree of SYNTAX score, it was found that all echocardiography findings were of no statistical significance to the SYNTAX score. DT is inversely proportionate to the degree of coronary artery disease complexity as it decreases by the increase of the SYNTAX (Table 5).

 

 

Table (5): Relation between the complexity of CAD and Echocardiography findings

SYNTAX

Parameters

Low

Intermediate and High

P-value

LVDD (mm)

Range

38.2

-

60

37.8

-

64

0.443

Median (IQR)

48.10(8.60)

51.20(8.30)

LVSD (mm)

Range

28

-

45.5

22.1

-

41.9

0.328

Median (IQR)

31.50(6.90)

34.10(4.90)

EF

Range

47

-

70

47

-

71

0.513

Median (IQR)

65.00(16.50)

62.00(16.00)

E wave (cm/s)

Range

49.4

-

111.1

65.8

-

116.1

0.111

Median (IQR)

81.50(16.20)

93.00(27.40)

A wave (cm/s)

Range

33.1

-

85.1

35.3

-

94.4

0.908

Median (IQR)

60.80(15.15)

63.60(20.40)

DT (ms)

Range

167.1

-

265.4

147.3

-

211.7

0.004

Median (IQR)

202.50(58.00)

176.60(25.00)

Ao. S wave (cm/s)

Range

6.8

-

14.5

7.3

-

12.2

0.219

Median (IQR)

9.90(3.40)

9.20(1.20)

Ao. E wave (cm/s)

Range

4.9

-

19.6

4.4

-

17.7

0.309

Median (IQR)

13.80(6.35)

12.20(4.50)

Ao. A wave(cm/s)

Range

4.9

-

10.5

3.6

-

14.6

0.145

Median (IQR)

7.60(3.40)

8.90(4.00)

Aortic Systolic Diameter

Range

24.8

-

37.6

26.8

-

32.3

0.171

Median (IQR)

29.50(3.40)

30.20(2.30)

Aortic diastolic Diameter

Range

22.2

-

34.4

22.2

-

31.1

0.526

Median (IQR)

28.30(6.40)

28.00(2.80)

Mann-Whitney Test

 

     By comparing the patients of different degree of CAD, it has been shown that aortic stiffness parameters have a statistically significant difference with the degree of complexity of CAD measured by the SYNTAX score. While aortic stiffness index and Ep were directly proportionate to the higher CAD complexity, aortic distensibility was inversely proportionate to the same finding (Table 6).

 

 

Table (6):  Relation between the complexity of CAD and Aortic stiffness parameters

SYNTAX

Parameters

Low

Intermediate and High

P-value

Stiffness index

Range

17.7

-

22.4

17.3

-

23.2

0.002

Median (IQR)

18.70(1.45)

20.50(1.70)

Aortic distensibility

Range

2.7

-

4.3

1

-

5.3

0.012

Median (IQR)

3.40(1.20)

2.80(0.80)

Ep

Range

68.8

-

76.1

68

-

76.2

0.060

Median (IQR)

70.00(3.25)

74.30(5.70)

Mann-Whitney Test

 

 

     By studying the correlation between all the previous findings and the SYNTAX score, it was found that the degree of the SYNTAX score was directly correlated to the aortic stiffness index and EP, and inversely correlated to the aortic distensibility. There was also a direct correlation between aortic stiffness index and EP while it was inversely correlated to aortic distensibility. Finally, there was an inverse correlation between the aortic distensibility and EP. There was a statistically significant difference between SYNTAX score and aortic stiffness index and between SYNTAX score and aortic distensibility and SYNTAX score and EP. Also, there was a statistical significance between stiffness index and aortic distensibility and between stiffness index and EP. Finally, there was a statistical significance between aortic distensibility and EP (Table 7).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Table (7):  Correlation between SYNTAX score, aortic stiffness parameters, risk factors, clinical examinations and echocardiography findings

Correlations

Parameters

SYNTAX score

Stiffness index

Aortic distensibility

Ep

r

P-value

r

P-value

r

P-value

r

P-value

Stiffness index

0.603

<0.001

 

 

 

 

 

 

Aortic

distensibility

-0.552

0.001

-0.820

<0.001

 

 

 

 

Ep

0.420

0.017

0.694

<0.001

-0.680

<0.001

 

 

Age

0.104

0.572

-0.127

0.488

0.119

0.518

-0.008

0.966

FBS

0.164

0.368

-0.028

0.879

0.047

0.800

-0.052

0.779

SBP

0.285

0.114

0.097

0.599

-0.066

0.722

0.207

0.255

DBP

-0.277

0.125

-0.218

0.230

0.276

0.127

0.041

0.825

LVDD (mm)

0.022

0.904

0.142

0.439

-0.129

0.481

0.087

0.636

LVSD (mm)

-0.114

0.534

0.051

0.782

-0.260

0.150

0.098

0.592

EF

-0.060

0.746

-0.017

0.925

0.149

0.417

0.085

0.645

E wave (cm/s)

0.285

0.114

0.110

0.549

0.022

0.903

-0.128

0.484

A wave (cm/s)

0.009

0.961

0.094

0.609

-0.139

0.449

-0.027

0.884

DT (ms)

-0.196

0.283

-0.278

0.124

0.155

0.396

-0.233

0.200

Ao. S wave (cm/s)

-0.023

0.902

-0.087

0.636

-0.102

0.579

-0.032

0.863

Ao. E wave (cm/s)

-0.180

0.325

-0.211

0.246

0.206

0.258

-0.189

0.299

Ao. A wave(cm/s)

0.109

0.552

-0.010

0.958

-0.115

0.530

0.055

0.764

Aortic Systolic

Diameter

0.120

0.512

0.140

0.444

-0.077

0.676

0.145

0.429

Aortic diastolic

Diameter

0.044

0.812

-0.045

0.807

0.069

0.708

-0.129

0.480

 

 

     All of the aortic stiffness parameters were sensitive to detect CAD in the studied population with the aortic stiffness index has the highest sensitivity with a cutoff value of > 17.4. Aortic distensibility and EP also have slightly lower sensitivity with a cutoff value of ≤4.2 and >68.6 (Table 8 and Figure 1).

 

 

Table (8):  Roc curve between Group I and II regarding aortic stiffness parameters

ROC curve between Group I and Group II

 

Cutoff

Sens.

Spec.

PPV

NPV

Accuracy

Stiffness index

>17.4

96.87

72.22

86.1

92.9

77.4%

Aortic distensibility

≤4.2

93.75

61.11

81.1

84.6

72.4%

Ep

>68.6

94.77

70.14

84.2

90.7

75.4%

 

 

 

 

 

 

 

 

 

 

 

 

 


Figure (1): Roc curve between group I and II regarding aortic stiffness parameters

 

     All of the aortic stiffness parameters were sensitive to anticipate the severity of CAD. The aortic stiffness index was the highest sensitive with a cutoff value of>19.2. Aortic distensibility and EP were less sensitive to detect the severity of CAD with a cutoff value of ≤ 3.1 and > 73.2 respectively (Table 9 and Figure 2).

 

 

Table (9):  Roc curve between Low and intermediate to high SYNTAX score and aortic stiffness parameters

ROC curve between Low and Intermediate and High SYNTAX score

 

Cutoff

Sens.

Spec.

PPV

NPV

Accuracy

Stiffness index

>19.2

89.47

76.92

85.0

83.3

82.6%

Aortic distensibility

≤3.1

78.95

69.23

78.9

69.2

76.3%

Ep

>73.2

57.89

92.31

91.7

60.0

69.8%

 
   

Figure (2): Roc curve between low and intermediate to high SYNTAX score and aortic stiffness parameters

 

DISCUSSION

     Noninvasive echocardiographic measurement of aortic stiffness entails the measurement of parameters that are intrinsically associated with stiffness. This involves three main parameters: aortic stiffness index, aortic distensibility, and pressure-strain elastic modulus (Güngör et al., 2014).

     A previous study demonstrated that the noninvasively evaluated aortic stiffness index is comparable with invasive methods with a high degree of accuracy. Also, it was proven that increased aortic stiffness has recently been recognized as a predictor of cardiovascular events (Güngör et al., 2014).

     Therefore, the study was designed to assess the aortic stiffness parameter as a predictor and prognostic factor for the presence and complexity of CAD. The study included 50 diabetic patients who presented with Stable CAD at the diabetes clinic of Al-Azhar University Hospitals and was divided into two groups according to the presence of CAD, 32 patients with CAD detected by CA (group I), and 18 patients with normal coronaries (group II). The presence of CAD was correlated directly to LVSD, aortic systolic diameter, and aortic diastolic diameter.

     This agreed with another study which stated that when systolic aortic diameter was compared in control and CAD patients, cases with CAD had significantly larger systolic aortic diameter. Also, the same was true for the aortic diastolic diameters measured 3 cm above the aortic valve with a significantly bigger aortic diameter for the CAD patients compared to patients without CAD (Ozturk and Durmus, 2019).

     A previous study by  Sen et al.  (2013) showed similar results. Aortic systolic and aortic diastolic diameters were significantly different between the groups. That was also supported by another study that proved that LV systolic diameter was significantly higher (Güngör et al., 2014).

     Regarding the TDI of the upper aortic wall in parasternal long-axis and TDI of the mitral annulus, our study showed that there was no significant relationship between those variables and CAD. This was unlike the study by Cavalcante et al. (2011) who showed that Ao.S and Ao.E velocities of ascending aorta were significantly low in individuals with CAD and diabetes mellitus by using pulsed wave velocity to measure the aortic stiffness.

     Our study showed that by comparing the aortic stiffness parameters between group I and group II, there was a statistically significant difference between the two groups in aortic stiffness index, aortic distensibility, and elastic modulus. Both aortic stiffness index and elastic modulus directly proportional to the presence of CAD, while aortic distensibility is inversely proportional to the same event.

     The study of Sen et al. (2013) showed that aortic stiffness index and aortic distensibility were significantly different between the groups. This was in line with El-Naggar et al. (2020) who showed that patients with CAD had significantly higher aortic stiffness and elastic modulus and significantly lower aortic distensibility.

     SYNTAX score was calculated for the group of patients with CAD. This divided the patients with CAD into 2 groups according to the SYNTAX score into low and intermediate to high SYNTAX score.

     Based on our study, deceleration time (DT) showed a statistically significant difference with the degree of SYNTAX score being lower in patients with high SYNTAX score. This was seconded by a study by Elshafey et al. (2020) who stated that DT was found to be significantly lower in the obstructive CAD group.

     As regards the correlation between aortic stiffness parameters and CAD severity based on SYNTAX score, our study stated that there was a direct correlation between aortic stiffness index and elastic modulus and SYNTAX score and there was an inverse correlation between aortic distensibility and SYNTAX score.

     This was unlike the result found by Gaszner et al. (2012) who stated that there was no significant correlation between the SYNTAX score and regional arterial stiffness parameters using a different technique to measure aortic stiffness called regional velocity of the aortic pulse wave.

     Kilic et al. (2013) used Gensini score as a scoring system for CAD and found out that both aortic distensibility and aortic stiffness were independently correlated with Gensini score in the CAD group.

     As regards aortic strain elastic modulus, Karakurt et al. (2016) stated that the aortic strain elastic modulus in the intermediate and high-SYNTAX score group was significantly higher than in Low- SYNTAX score group.

     El-Naggar et al. (2020) studied aortic stiffness and stated that univariate and multivariate logistic regression analysis showed that decreased aortic distensibility and increased elastic modulus and aortic stiffness index were predictors for the severity and complexity of CAD.

     By studying Roc curve between group I and II regarding aortic stiffness parameters, aortic stiffness index was the only independent predictor of CAD presence with a cutoff value of aortic stiffness was >17.4, followed by aortic distensibility and elastic modulus.

     Kilic et al. (2013), who used Gensini score as a scoring system for CAD, have shown that aortic stiffness index along with aortic distensibility were good predictors for CAD. The aortic distensibility values of ≥1.24 predict the presence of a low Gensini score (≤26 for the study) with a sensitivity of 88.2% and specificity of 84.6% with an area under the curve of 0.94; whereas the aortic stiffness values of ≥3.36 predict the presence of low Gensini score with a sensitivity of 82.4% and specificity of 87.2% with area under the curve of 0.873 unlike our study, aortic stiffness index cutoff was >17.4 and aortic distensibility cut off ≤4.2 to predict high SYNTAX score in CA.

     As regards the aortic stiffness parameters to predict the complexity of CAD, it was found that all of the aortic stiffness parameters were sensitive to anticipate the severity of CAD. The aortic stiffness index was the highest sensitive (98.47) with a cutoff value of >19.2 and accuracy of 82.6%. Aortic distensibility and EP were less sensitive to detect the severity of CAD as they record sensitivity of 78.95 and 57.89 with a cutoff value of ≤ 3.1 and > 73.2 respectively.

     This was in agreement with El-Naggar et al. (2020), who showed that aortic stiffness parameters are predictors for the severity and complexity of CAD. However, along with diabetes, increased aortic stiffness index (> 17.7) was the only independent predictor of CAD severity, carrying twice the odds of having moderate-high SYNTAX score.

Limitations: The small size of the study population may have biased the statistical results. Other studies with a larger population are needed to confirm our results.

CONCLUSION

     Aortic stiffness parameters have a good predictive power concerning coronary artery disease in patients suspected of having ischemic heart disease or more severe coronary involvement. Aortic stiffness index (ASI) in particular has the highest predictive power for the presence and severity of CAD.

REFERENCES

  1. Amraotkar, R.A. Ghafghazi, S. Trainor, PJ. Hargis, C.W. Irfan, B. Rai, S. Bhatnagar, N.A and Defilippis, A.P. (2017): Presence of Multiple Coronary Angiographic Characteristics for the Diagnosis of Acute Coronary Thrombus. HHS Public Access, 24 (1): 25–34.
  2. Cardoso, C.R.L. Ferreira, M.T., Leite, N.C. and Salles, G.F. (2013): Prognostic Impact of Aortic Stiffness in High-Risk Type 2 Diabetic Patients: The Rio de Janeiro Type 2 Diabetes Cohort Study. Diabetes Care 36 (11): 3772–37\78.
  3. Cavalcante, J.L. João, A.C. Lima, A.R. and Mouaz, H.A. (2011): Aortic Stiffness: Current Understanding and Future Directions. Journal of the American College of Cardiology, 5 (14): 71511-71522.
  4. El-Naggar, H M. Anwar, H S. Helmy, H A. and Demitry, S R. (2020): Aortic Root Distensibility and Stiffness Assessed by Echocardiography as Predictors of Coronary Artery Lesion Severity in Patients Undergoing Coronary Angiography.European Heart Journal - Cardiovascular Imaging, 21 (1): 1503-1505.
  5. Elshafey, W.E. Abdelaziz, W.F. Mohamed, M.S. Omar, O. M (2020): Severity of Coronary Artery Disease by Coronary CT Angiography in Relation to Left Ventricular Diastolic Function. World Journal of Cardiovascular Diseases, 10 (04): 235–245.
  6. Gale, N.S. Albarrati, A.M. Munnery, M.M. McDonnell, B.J. Benson, V.S. Singer, R.M. Cockcroft, J.R. Shale, D.J. (2019): Aortic Pulse Wave Velocity as a Measure of Cardiovascular Risk in Chronic Obstructive Pulmonary Disease: Two-Year Follow-up Data from the ARCADE Study. Medicina (Lithuania), 55 (4): 89-95
  7. Gaszner, B. Lenkey, Z. Illyés, M. Sárszegi, Z. Horváth, I.G. Magyari, B. Molnár, F. Kõnyi, A. Cziráki, A. (2012): Comparison of Aortic and Carotid Arterial Stiffness Parameters in Patients with Verified Coronary Artery Disease. Clinical Cardiology, 35 (1): 26–31.
  8. Güngör, B. Yilmaz, H. Ekmekçi, A. Özcan, K.S. Tijani, M. Osmonov, D. Karataş, B. Taha, A. Mutluer, F.O. Gürkan, U. Bolca, O. (2014): Aortic Stiffness Is Increased in Patients with Premature Coronary Artery Disease: A Tissue Doppler Imaging Study. Journal of Cardiology, 63 (3): 223–229.
  9. Karakurt, A. Yildiz, C. Yildiz, A. Başbuğ, H. S. (2016): Assessment of Relation between Aortic Elastic Properties and the Complexity of Coronary Artery Disease. Acta Cardiologica, 71 (3): 267–273.
  10. Kilic, H. Salih, O. Akdemir, R. Karakurt, O. Cagirci, G. Yeter, E. Acikel, S. Dogan, M. Arslantas, U. Baha, R.M (2013): An Invasive but Simple and Accurate Method for Ascending Aorta-Femoral Artery Pulse Wave Velocity Measurement. Blood Pressure, 22 (1): 45–50.
  11. Ozturk, S. Durmus, G. (2019): Aortic Knob Width and Calcification Is Associated with the Extensivity of Lower Extremity Arterial Disease. Annals of Medical Research, 26 (9): 2026.-2030
  12. Sen, T. Tufekcioglu, O. Ozdemir, M. Tuncez, A. Uygur, B. Golbasi, Z. Kisacik, H. (2013): A New Echocardiographic Parameter of Aortic Stiffness and Atherosclerosis in Patients with Coronary Artery Disease: Aortic Propagation Velocity. Journal of Cardiology, 62 (4): 236–240.
  13. Vlachopoulos, C. Terentes-Printzios, D. Laurent, S. Nilsson, P. M. Protogerou, A. D. Aznaouridis, K. Xaplanteris, P. Koutagiar, I. Tomiyama, H. Yamashina, A. Sfikakis, P. Tousoulis, D. (2019): Association of Estimated Pulse Wave Velocity With Survival: A Secondary Analysis of SPRINT. JAMA Network Open, 2 (10): 158-163.

 

دور معامل تصلب الشريان الأورطي في توقع قصور الشريان التاجي المزمن المستقر في مرضي السکري من النوع الثاني

محمد أحمد فؤاد کامل بدر, أحمد کمال مطاوع و أحمد عبد الرؤوف مهدي

قسم القلب و الاوعية الدموية، کلية الطب، جامعة الازهر

محمد أحمد فؤاد کامل بدر

بريد الکتروني: m.fouadbadr@gmail.com، تليفون: 01118245391

خلفية البحث: ان مرضي السکري النوع الثاني لديهم معدل اصابة اعلي بالتصالب الشرياني و عرضة اکثر للاصابة بامراض القلب والأوعية الدموية او الوفاة بسببها. و بما ان المرض السکري مرض جهازي و الذي يسبب بنسبة اکبر في حدوث التصالب الشرياني, فانه يؤثر علي الشرايين التاجية کمايؤثر علي الشريان الاورطي.

الهدف من البحث: تقييم اثر المرض السکري النوع الثاني علي الشريان الأورطي  باستخدام الموجات فوق الصوتية علي القلب لقياس نسبة معاملات تصالب الشريان الاورطي و استخدام ذلک کمؤشر لتوقع حدوث امراض الشرايين التاجية و مقدار الخطورة کذلک.

المرضي و طرق البحث: تم اجراء الدراسة علي مدار سنة ابتداءا من اکتوبر 2018 الي اکتوبر 2019 تم دراسة 50 حالة من مرضي السکري النوع الثاني المتوقع وجود ذبحات صدريه مستقرة بالشکاوي المرضية و تواجد مععاملات الخطورة لديهم. تم تقسيم الحالات الي مجموعتين تبعا لنتيجة القسطرة التشخيصيه للشراين التاجية .المجموعة الأولي تم اکتشاف وجود تضيقات بالشرايين التاجية اما المجوعة الثانية کان لديهم شرايين تاجية سليمة. تم اخذ تاريخ مرضي لجميع الحالات و عمل الفحص السريري. کما تم عمل موجات فوق صوتية علي القلب وتم حساب معاملات تصالب الشريان الاورطي و عمل تحاليل و اخيرا تم عمل قسطرة تشخيصية لتصوير الشرايين التاجية.

نتائج البحث: ست ثلاثون بالمائة من الحالات کانت لديهم شرايين تاجية طبيعية بينما اربع و ستون بالمائة من الحالات کان لديهم تضيقات بالشرايين التاجية وتم استخدام معامل سنتاکس لتحديد شدة التضيقات . قياسات الشريان الاورطي في الانقباض والانبساط کانت اعلي بشکل ملحوظ في المجموعة الاولي بالمقارنه بالمجموعة الثانية. معامل تصالب الشريان الاورطي و معامل المرونة کانت اعلي بشکل ملحوظ في المجموعة الاولي ايضا و لکن کان معامل تمدد الشريان الاورطي اعلي في المجموعة الثانية بالمقارنه بالمجموعة الاولى. معامل تصالب الشريان الاورطي و معامل مرونة الشريان الاورطي لديهم علاقة ايجابيه بوجود تضيقات بالشرايين التاجية و بمقدار حدة الاصابة کذلک بينما معامل تمدد الشريان الاورطي لديه علاقة عکسية مع نفس المعايير. و من بين الثلاث معاملات کان مؤشر تصالب الشريان الاورطي صاحب اعلي حساسية تجاه تحديد وجود تضيقات بالشريان الاورطي و کذلک تحديد مقدار حدة الاصابة.

الاستنتاج: مؤشر تصالب الشريان الاورطي لديه اعلي مقدار توقع لوجود تضيقات بالشرايين التاجية و کذلک تحديد حدة الاصابه حيث ان المريض صاحب مؤشر اعلي لتصالب الشريان الاورطي لديه احتمال اعلي بوجود تضيقات بالشراين الاورطي و غالبا ما تکون اکثر حده بازدياد رقم المؤشر.

الکلمات الدالة: معامل تصالب الشريان الاورطي, مرض الشرايين التاجية, المرض السکري النوع الثاني.

  1. REFERENCES

    1. Amraotkar, R.A. Ghafghazi, S. Trainor, PJ. Hargis, C.W. Irfan, B. Rai, S. Bhatnagar, N.A and Defilippis, A.P. (2017): Presence of Multiple Coronary Angiographic Characteristics for the Diagnosis of Acute Coronary Thrombus. HHS Public Access, 24 (1): 25–34.
    2. Cardoso, C.R.L. Ferreira, M.T., Leite, N.C. and Salles, G.F. (2013): Prognostic Impact of Aortic Stiffness in High-Risk Type 2 Diabetic Patients: The Rio de Janeiro Type 2 Diabetes Cohort Study. Diabetes Care 36 (11): 3772–3778.
    3. Cavalcante, J.L. João, A.C. Lima, A.R. and Mouaz, H.A. (2011): Aortic Stiffness: Current Understanding and Future Directions. Journal of the American College of Cardiology, 5 (14): 71511-71522.
    4. El-Naggar, H M. Anwar, H S. Helmy, H A. and Demitry, S R. (2020): Aortic Root Distensibility and Stiffness Assessed by Echocardiography as Predictors of Coronary Artery Lesion Severity in Patients Undergoing Coronary Angiography.European Heart Journal - Cardiovascular Imaging, 21 (1): 1503-1505.
    5. Elshafey, W.E. Abdelaziz, W.F. Mohamed, M.S. Omar, O. M (2020): Severity of Coronary Artery Disease by Coronary CT Angiography in Relation to Left Ventricular Diastolic Function. World Journal of Cardiovascular Diseases, 10 (04): 235–245.
    6. Gale, N.S. Albarrati, A.M. Munnery, M.M. McDonnell, B.J. Benson, V.S. Singer, R.M. Cockcroft, J.R. Shale, D.J. (2019): Aortic Pulse Wave Velocity as a Measure of Cardiovascular Risk in Chronic Obstructive Pulmonary Disease: Two-Year Follow-up Data from the ARCADE Study. Medicina (Lithuania), 55 (4): 89-95
    7. Gaszner, B. Lenkey, Z. Illyés, M. Sárszegi, Z. Horváth, I.G. Magyari, B. Molnár, F. Kõnyi, A. Cziráki, A. (2012): Comparison of Aortic and Carotid Arterial Stiffness Parameters in Patients with Verified Coronary Artery Disease. Clinical Cardiology, 35 (1): 26–31.
    8. Güngör, B. Yilmaz, H. Ekmekçi, A. Özcan, K.S. Tijani, M. Osmonov, D. Karataş, B. Taha, A. Mutluer, F.O. Gürkan, U. Bolca, O. (2014): Aortic Stiffness Is Increased in Patients with Premature Coronary Artery Disease: A Tissue Doppler Imaging Study. Journal of Cardiology, 63 (3): 223–229.
    9. Karakurt, A. Yildiz, C. Yildiz, A. Başbuğ, H. S. (2016): Assessment of Relation between Aortic Elastic Properties and the Complexity of Coronary Artery Disease. Acta Cardiologica, 71 (3): 267–273.
    10. Kilic, H. Salih, O. Akdemir, R. Karakurt, O. Cagirci, G. Yeter, E. Acikel, S. Dogan, M. Arslantas, U. Baha, R.M (2013): An Invasive but Simple and Accurate Method for Ascending Aorta-Femoral Artery Pulse Wave Velocity Measurement. Blood Pressure, 22 (1): 45–50.
    11. Ozturk, S. Durmus, G. (2019): Aortic Knob Width and Calcification Is Associated with the Extensivity of Lower Extremity Arterial Disease. Annals of Medical Research, 26 (9): 2026.-2030
    12. Sen, T. Tufekcioglu, O. Ozdemir, M. Tuncez, A. Uygur, B. Golbasi, Z. Kisacik, H. (2013): A New Echocardiographic Parameter of Aortic Stiffness and Atherosclerosis in Patients with Coronary Artery Disease: Aortic Propagation Velocity. Journal of Cardiology, 62 (4): 236–240.
    13. Vlachopoulos, C. Terentes-Printzios, D. Laurent, S. Nilsson, P. M. Protogerou, A. D. Aznaouridis, K. Xaplanteris, P. Koutagiar, I. Tomiyama, H. Yamashina, A. Sfikakis, P. Tousoulis, D. (2019): Association of Estimated Pulse Wave Velocity With Survival: A Secondary Analysis of SPRINT. JAMA Network Open, 2 (10): 158-163.