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ICEBERG, poor management of dyslipidemia in the elderly. Is carotid ultrasound an alternative to conventional risk scores?

EuroPRevent 2014  

Doctor Murray Matangi (EUD ID : 32405)
Kingston Heart Clinic
Cardiology Dept.
460 Princess Street
K7L 1C2 - Kingston Canada
Phone : +1 6135443242 - Fax : +1 6135464487
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.

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Title : ICEBERG, poor management of dyslipidemia in the elderly. Is carotid ultrasound an alternative to conventional risk scores?
Topic : 01.08 - Atherosclerosis/CAD (Prevention & Epidemiology)
Acronym : Initial Carotid Evaluation Before Echocardiography Reveals Global risk
Category : Not Member of EACPR
Option : No Options

M. Matangi1, DW. Armstrong1, D. Brouillard1, U. Jurt1, AM. Johri2 - (1) Kingston Heart Clinic, Kingston, Canada (2) Queen's University, Kingston, Canada

Purpose. Age is the most important variable when calculating the Framingham risk score (FRS) to determine eligibility for lipid lowering therapy. Canadian lipid guidelines recognize that any evidence of atherosclerosis is a high-risk equivalent. The purpose of this analysis was to determine the prevalence of high-risk carotid disease in patients >70 years of age referred for a routine ECHO for non-vascular reasons, including, murmur, arrhythmia, hypertension and dyspnea.
Methods. All patients >70yrs, who are Statin naive undergoing ECHO have their carotids screened. Diabetics and those with a previous history of any vascular event are excluded. All patients give signed informed consent. Our carotid screening includes 2 or 3 images on each side to include the CCA, carotid bulb and ICA. A recent lipid profile is obtained from the referring MD and if not available a lipid profile is obtained. FRS is then calculated. A high-risk carotid was defined as the presence of carotid plaque using the ARIC definition or a maximal CCA IMT ≥1.20mm, the highest O'Leary quintile. CCA IMT is measured in the far wall offline using an automated edge detection program. 
Results. There were 54 males, of which 48 had carotid plaque (88.9%) and 52 had either carotid plaque or maximal CCA IMT ≥1.20mm (96.3%). There were 93 females, of which 81 had carotid plaque (87.1%) and 82 had either carotid plaque or maximal CCA IMT ≥1.20mm (88.2%). Overall 91.2% had evidence of high-risk carotid disease. Once the lipid profile was available 92 of 147 patients were calculated as high risk (62.6%) using the FRS. Of the remaining 55, 3 were low FRS and none had plaque. Of the 52 intermediate FRS 46 had carotid plaque (88.5%). Of those with a high risk carotid 93.2% had an LDL-cholesterol >2.00mmol/l, (mean 3.17±0.75mmol/l).
Conclusions. Our data indicate that cardiovascular risk is either not assessed or underestimated and therefore undertreated in the elderly, >70yrs. The high prevalence of high-risk carotid disease makes carotid screening for atherosclerosis seem unnecessary, and such patients can be assumed to be high-risk and treated with a Statin once their lipid profile is available. We anticipate such a conclusion may be seen as somewhat controversial. As our institution is a referral centre for cardiac disease, our data may not reflect and should not be extended to the general population >70 years.
Ninety-two patients were high-risk once their FRS was calculated. Eighty-six of these 92 patients had an LDL-Cholesterol >2.00mmol/l, yet none were being treated with a Stain suggesting that their FRS had never been calculated.