Retrospective Cohort Study
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Cardiol. Jan 26, 2019; 11(1): 24-37
Published online Jan 26, 2019. doi: 10.4330/wjc.v11.i1.24
Subclinical carotid atherosclerosis predicts all-cause mortality and cardiovascular events in obese patients with negative exercise echocardiography
Rafael Vidal-Perez, Raúl Franco-Gutiérrez, Alberto J Pérez-Pérez, Virginia Franco-Gutiérrez, Alberto Gascón-Vázquez, Andrea López-López, Ana María Testa-Fernández, Carlos González-Juanatey
Rafael Vidal-Perez, Raúl Franco-Gutiérrez, Alberto J Pérez-Pérez, Alberto Gascón-Vázquez, Andrea López-López, Ana María Testa-Fernández, Carlos González-Juanatey, Department of Cardiology, Hospital Universitario Lucus Augusti, Lugo 27003, Spain
Virginia Franco-Gutiérrez, Department of Otolaryngology, Hospital Carmen y Severo Ochoa, Cangas del Narcea 33800, Spain
Alberto Gascón-Vázquez, Faculty of Medicine, University of Santiago de Compostela, Santiago de Compostela 15782, Spain
Author contributions: All authors helped to perform the research; Vidal-Perez R contributed to manuscript writing, performing procedures, and data analysis; Franco-Gutiérrez R contributed to manuscript writing, drafting of the document, conception and design of the study, and data analysis; Pérez-Pérez AJ, Franco-Gutierrez V, Gascón-Vázquez A and López-López A contributed to manuscript writing; Testa-Fernández AM and González-Juanatey C contributed to performing procedures, drafting of the document, and conception and design of the study.
Institutional review board statement: The study was reviewed and approved for publication by our Institutional Reviewer.
Informed consent statement: All study participants or their legal guardian provided informed written consent about personal and medical data collection prior to study enrolment.
Conflict-of-interest statement: All the Authors have no conflict of interest related to the manuscript.
STROBE statement: The authors declare that the STROBE statement was followed in the article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Raúl Franco-Gutiérrez, MD, Staff Physician, Department of Cardiology, Hospital Universitario Lucus Augusti, Av/Doctor Ulises Romero nº1, Lugo 27003, Spain. raul.franco.gutierrez@sergas.es
Telephone: +34-982296738 Fax: +34-982295390
Received: September 19, 2018
Peer-review started: September 19, 2018
First decision: October 26, 2018
Revised: December 16, 2018
Accepted: December 24, 2018
Article in press: December 24, 2018
Published online: January 26, 2019
Processing time: 129 Days and 8.6 Hours
Abstract
BACKGROUND

Obesity is a major health problem due to its high prevalence. The relationship between obesity and cardiovascular disease is unclear. Some studies agree that certain conditions associated with obesity, such as physical inactivity or cardiovascular risk factors, are responsible for cardiovascular risk excess among obese people. Carotid intima-media thickness and carotid plaques (CP) have been associated with cardiovascular adverse events in healthy populations, and recent data suggest a higher prevalence of subclinical carotid atherosclerosis in obese and metabolically unhealthy patients. However, there are no studies correlating subclinical atherosclerosis and adverse events (AE) in obese subjects.

AIM

To determine the association between carotid disease and AE in obese patients with negative exercise echocardiography (EE).

METHODS

From January 1, 2006 to December 31, 2010, 2000 consecutive patients with a suspicion of coronary artery disease were submitted for EE and carotid ultrasonography. Exclusion criteria included previous vascular disease, left ventricular ejection fraction < 50%, positive EE, significant valvular heart disease and inferior to submaximal EE. An AE was defined as all-cause mortality, myocardial infarction and cerebrovascular accident. Subclinical atherosclerosis was defined as CP presence according to Manheim and the American Society of Echocardiography Consensus.

RESULTS

Of the 652 patients who fulfilled the inclusion criteria, 226 (34.7%) had body mass indexes ≥ 30 kg/m2, and 76 of them (33.6%) had CP. During a mean follow-up time of 8.2 (2.1) years, 27 AE were found (11.9%). Mean event-free survival at 1, 5 and 10 years was 99.1% (0.6), 95.1% (1.4) and 86.5% (2.7), respectively. In univariate analysis, CP predicted AE [hazard ratio (HR) 2.52, 95% confidence interval (CI) 1.17-5.46; P = 0.019]. In multivariable analysis, the presence of CP remained a predictor of AE (HR 2.26, 95%CI 1.04-4.95, P = 0.041). Other predictors identified were glomerular filtration rate (HR 0.98, 95%CI 0.96-0.99; P = 0.023), peak metabolic equivalents (HR 0.83, 95%CI 0.70–0.99, P = 0.034) and moderate mitral regurgitation (HR 5.02, 95%CI 1.42–17.75, P = 0.012).

CONCLUSION

Subclinical atherosclerosis defined by CP predicts AE in obese patients with negative EE. These patients could benefit from aggressive prevention measures.

Keywords: Carotid intima media thickness; Carotid plaque; Carotid disease; Myocardial infarction; Mortality; Stroke; Exercise stress echocardiography

Core tip: There is a controversy about obesity and coronary artery disease prognosis. Several studies suggest a greater influence of physical inactivity than that of body mass index on mortality, but there are no data addressing the influence of subclinical atherosclerosis in patients with suspected coronary artery disease submitted to a non-invasive treadmill test. Our study shows that clinical atherosclerosis in other vascular beds, such as carotid plaque presence, is a greater predictor than functional capacity. These patients could benefit from aggressive prevention measures.