COMPARISON OF ULTRASOUND-MEASURED
PROPERTIES
OF THE COMMON CAROTID ARTERY
TO TOBACCO SMOKE EXPOSURE
IN A COHORT OF INDONESIAN PATIENTS
Presentan : dr. Dedy Savradinata
Supervisor : dr. Farida, Sp.S(K)
INTRODUCTION
• Indonesia has one of the highest incidences of smoking in the
world, with 72% of the male population over 15 years of age
using tobacco products.
• Worldwide, smoking is known to be a significant lifestyle
factor that contributes to the development of stroke and
coronary artery disease.
• According to the CDC, smoking is the leading cause of death in
Indonesia, contributing to 8% of all deaths in the country.
The World Bank Group. Smoking prevalence, males (% of adults).http://databank.worldbank.org/data/reports.aspx?source=2&series=SH.PRV.SMOK.MA&country=.Published 2016. Accessed January 15, 2016.
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.
Wolf PA, D'Agostino RB, Kannel WB, Bonita R, Belanger A. Cigarette smoking as a risk factor for stroke. JAMA.1988;259(7):1025.
INTRODUCTION
• Smoking has been shown to cause inflammatory vascular changes that
can alter the structural and functional properties of blood vessels such as
carotid local stiffness and carotid intima-media thickness (CIMT), both of
which correlate directly with future cardiovascular events.
• Increased carotid arterial stiffness is a condition seen in
patients with cardiovascular risk factors such as hypertension,
diabetes, and atherosclerosis.
• Exposure to second-hand smoke (SHS) has also been
associated with development of cardiovascular risk factors.
The World Bank Group. Smoking prevalence, males (% of adults).http://databank.worldbank.org/data/reports.aspx?source=2&series=SH.PRV.SMOK.MA&country=.Published 2016. Accessed January 15, 2016.
Wolf PA, D'Agostino RB, Kannel WB, Bonita R, Belanger A. Cigarette smoking as a risk factor for stroke. JAMA.1988;259(7):1025
Kohn JC, Lampi MC, Reinhart-King CA. Age-related vascular stiffening: Causes and consequences. Front Genet.2015;6(MAR):1–17.
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.
AIM OF THE STUDY
• The purpose of this study was to use point-of-care
ultrasound (POCUS) to investigate the relationship
between tobacco smoke exposure and the physical
characteristics of the common carotid artery (CCA) which
include CIMT and carotid stiffness.
METHODS
Study design and population Data collection
• A prospective cross-sectional study • Following consent, participants
across 20 different primary care were given a questionnaire to
clinics affiliated with the public health obtain self-reported demographic
department of Bandung, West Java, and health information including
Indonesia between July 1, 2016 and age, BMI, current smoking status,
August 1, 2016. past medical history, and
• Data was collected from a medications.
convenience sample of Indonesian
patients presenting to clinic for any
chief complaint.
METHODS
Ultrasound measurements Statistical analysis
• We performed data analysis using
• Measured blood pressure and heart rate twice VassarStats website for statistical
from each arm of the participant via a manual computation.
sphygmomanometer. • Multiple regression was performed to
• The participants underwent a point of care compare the exposure of tobacco smoke to
ultrasound using a Nanomaxx Ultrasound System CIMT and values of arterial distensibility.
connected to a linear 7.5 MHz probe. • We also incorporated other factors
• The right CCA was visualized with B-mode in a associated with increased CIMT and carotid
longitudinal view. arterial stiffness, including age, BMI, gender,
• With minimal pressure to avoid compression of and presence of cardiovascular risk factors in
the participant's vasculature, a 1-cm long the analysis.
segment of the CCA just proximal to the carotid • Linear regression was performed to examine
bulb was captured and stored. associations of CIMT with each measure of
carotid arterial stiffness.
METHODS
Distensibility coefficient : Cross-sectional compliance :
DC = CSC =
Statistical analysis
Stiffness : Young's elastic modulus :
β= YEM =
SBP = systolic blood pressure (average of 3 values)
DBP = diastolic blood pressure (average of 3 values)
= systolic CCA diameter (average of 5 values)
= diastolic CCA diameter (average of 5 values)
= difference between average systolic - average diastolic CCA diameter
= pulse pressure; difference between systolic diastolic blood pressure
K is a constant that equals 133.3
RESULTS
We enrolled a total of
663 patients in the
study.
426 patients had a
history of smoking and
237 patients had a
history of second-hand
smoke exposure.
RESULTS
Compared to nonsmokers,
the smoking group was
older, had a higher
proportion of males,
exhibited increased CIMT,
and exhibited decreased
DC
RESULTS
There was a positive association between all vascular health variables (with the exception of
CSC), and the measured factors. With the exception of CSC, all of the adjusted R2 values were
statistically
RESULTS
• For all 4 statistically significant variables, age seemed to contribute the most out of all of the
lifestyle factors for the variation between individuals. In the individuals exposed to SHS, YEM and
CIMT was positively associated with measured lifestyle factors
RESULTS
RESULTS
RESULTS
DISCUSSION
• We found that our primary dependent variable, carotid distensibility,
exhibited a weakly positive association with the measures of
cardiovascular risk that we measured.
• Age seemed to be the greatest contributing factor to increased arterial
distensibility, which is consistent with previous studies.
• Associations between tobacco smoke exposure and CIMT were more
consistent across both smokers and individuals exposed to second-hand
smoke.
• The association was surprisingly much stronger for individuals exposed
to SHS than for smokers.
LIMITATIONS
• It is possible that patients from different geographic regions or
backgrounds may have different ultrasound findings.
• The convenience sampling of patients may have the potential for
selection bias although this was limited by the fact that every
patient present was approached for enrollment.
• Several aspects of data were self-reported from patients. This
included height, weight and past medical history.
• Carotid distensibility was calculated using peripheral blood
pressure measurements instead of central blood pressure.
• Did not quantify the length of smoking history.
CONCLUSION
• Our data yielded weak associations between carotid distensibility and
cardiovascular risk, as well as between CIMT and carotid arterial
stiffness.
• We were able to demonstrate an increase in thickness of the CIMT in
patients who have been exposed by tobacco through the use of
ultrasound.
• Patients who had been exposed to SHS had thicker CIMTs compared to
those who smoke directly.
• The promise of using ultrasound to confirm the relationship between a
lower DC and thicker CIMT with risk of cardiovascular disease and
stroke.
THANK YOU
