ACTA FAC. MED. NAISS. 2003; 20 (4): 219-222

Original article

RELATIONSHIP BETWEEN CAROTID DISEASE AND THREE-VESSEL CORONARY DISEASE
 

Milan Đorić, Branko Lović, Ivan Tasić
Institute for prevention, treatment and rehabilitation of rheumatic and cardiovascular diseases Niška Banja
 

INTRODUCTION
During many years of clinical praxis a certain need for detailed examination of etiology, pathogenesis and clinical concequences of carotid disease was established, especially after proven facts that respectable percentage of cerebrovascular insults is caused by ruptured and unstable plaques in carotid arteries. Mortality of cerebrovascular disease is on the third place, just after cardiovascular disease and malignant neoplasms; morbidity per year is 160:100000 and it is growing exponentialy. Males are a fifth times higher risk group (5:1) in comparison to females (1,2).
Coronary disease with its clinical variates is practically leading among the group of cardiovascular diseases which are responsible for over 50 % of total mortality and certainly, its influence in medical as well as socio-economical aspect is more than well-known.
Knowing that risk factors for both entities are the same, deeply and frequently connected, and, according to experimental and clinical facts, practically, it can be treated like vitium artis if we fail to make detailed clinical examination of one in the presence of strong and clear clinical presentation of the other.
In a spectrum of diagnostic procedures for evaluation of changes on carotid arteries color Doppler echo sonography is a golden standard for non-invasive assessments which significantly reduce the need for invasive angiographical examination (3).

THE AIM OF THE STUDY
In order to improve diagnostic algorithm for coronary patients as well as patients with carotid disease, the aim of the study was to estimate the presence and severances of changes in carotid arteries in patients with proven three-vessel coronary disease

MATHERIAL AND METHODS
We have examined 45 patients, the average age 58+ - 6 years; among them there were 25 males and 20 females. All patients had coronary angiograms which proved three-vessel coronary disease. Moreover, we have done echo sonography with Color Doppler of carotid arteries, on Acuson-Sequoia C 256, using linear 7 MHz transducer, achieving 50 mm deep tissue penetration.
Intraluminal atherosclerotic changes were determined by B-mode like enlarging inthimo-medial complex over 0,05cm and plaque was determined at 2 and more mm. Carotid arteries were examined from, on the right side, truncus brachiocephalicus and, on the left side from the beginning of a carotis communis, up to their penetration to scull. The size and importance of the plaques were measured by the percentage of stenosis.
 

RESULTS
Out of 45 examined patients, 43 (95, 6%) had changes on carotid arteries (Figure 1). There were 11 (24, 44%) patients with stenosis up to 30%, 23 (51, 11%) stenosis up to 50% and 9 (20%) with stenosis over 50% (Figure 2). A very interesting and significant fact is that 4 (8,88%) patients had stenosis over 70%. Furthermore, only 2 patients (4,4%) were without any changes on carotid arteries.
Unilateral changes were detected in 18(40%) patients whereas bilateral ones in 25 (55, 55%). A very significant fact is that 7 patients (15, 55%) had stenosis over 50% and were with bilateral changes as well. Maximal percentage of stenosis was 92%. The correlation between three-vessel disease and stenosis over 50% as well as bilateral changes are high positive.
 

DISCUSSION
Carotid disease and its significance in every day clinical work of an internist as well as some other specialist like neurologist, neurosurgery became very important in the last few years, especially after big improvement and development of modern non-invasive imaging methods which bring us to new angle of diagnostic and treatment of this disease. Those methods give us information about structure, complexity and character of changes on one hand, and functional repercussion on the other. The problem of carotid disease is very important, not just like an isolated entity, but, like a condition in other severe diseases which demand medicament or surgical treatment (4, 5).Concerning that risk factors for coronary and carotid disease are common and that respectable percentage of patients with carotid disease is asympthomatic, bring us to knowledge that our special attention deserve proven coronary patient with multiple risk factors.
In our study, only 2 (4, 4%) patients had no changes on carotid arteries which reassure us that detailed examination of carotid arteries must be done in every coronary patient. Furthermore, 9 (20%) patients were with hemodynamically significant stenosis, over 50%, which is of essential value for their treatment and prognosis. Such a high percentage of big, significant stenosis may be both an answer and explanation for the frequent symptomatology like dizziness, vertigo, headache, instability and confusion in coronary patients which certainly can't be explained by basic coronary disease (6,7,8). Exulceratio of plaque is followed with transitory ischemic attack (TIA) or full cerebrovascular insult. In addition, if so called "silent zones" of the brain are affected, they can be presented by abortive clinical presentation or pass without being clinically detected (9,10).
Generally, 43 (95, 56%) patients had changes on carotid arteries. Out of 45 patients, 11 (24, 44%) had stenosis up to 30%, which is statistically significant. It's important to say that such a stenosis, under 50%, are as important as those which are over 50% since those are plaques full of lipids, foamy, with a gracile and thin fibrotic cover, and they often got ruptured and bring patients to severe neurological accident. The fact that there is high correlation between bilateral changes and three-vessel coronary disease is of an essential and crucial importance as, according to authors, size, severity and complication of lesions are in direct positive correlation with neurological accidents.(11,12). Furthermore, the fact that such a high percentage 7 patients (15,55%) had bilateral changes and stenosis over 50 % brings us to the conclusion and a new way of evaluating patients in reverse direction: we should "search" for coronary disease in asymptomatic patients with such changes on carotid arteries.
According to our study and literature data, especially when we know percentage of asymptomatic coronary and carotid patients, particularly in the presence of multiple risk factors, detection of one must be followed by detailed evaluation of the other.

CONCLUSION
1. Our results showed that prevalence and severity of carotid artery disease was high in coronary patients with three-vessel disease which emphasized the need of carotid artery examination in coronary patients and patients with multiple risk factors.
2. Color Doppler echo sonography is reliable, elegant and noninvasive method, which is very useful for clinical physician in diagnostic and therapeutic aspect.
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