RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,
PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION
1 NAME OF THE CANDIDATE DR MAYANK SARAWAG
AND ADDRESS DEPARTMENT OF GENERAL
K.S.HEGDE MEDICAL ACADEMY
2 NAME OF THE INSTITUTION K.S.HEGDE MEDICAL ACADEMY
3 COURSE OF STUDY AND M.D. (GENERAL MEDICINE)
4 YEAR OF JOINING THE 13th MAY 2008
5 TITLE OF THE TOPIC STUDY OF CAROTID INTIMA MEDIA
THICKNESS IN PATIENTS WITH
CORONARY ARTERY DISEASE AND
6 BRIEF RESUME OF INTENDED WORK
6.1 NEED FOR THE STUDY
Patients with established coronary artery disease (CAD) and stroke have
relatively thick carotid intima media compared to normal population. There are
several studies stating the role of intima media thickness of common carotid and
internal carotid arteries as an independent risk factor for CAD and stroke. It
shows diffuse ongoing atherosclerosis process affecting coronary and carotid as
well as other arteries of the body.
There have been only few research reports from India. GUPTA H. AND
COLLEAGUES1 results indicate that raised values of average and maximum
carotid intima media thickness are significantly associated with the presence of
CAD and this association is independent of the presence of other conventional
cardiovascular risk factors.
6.2 REVIEW OF LITERATURE
Role of carotid artery intima media thickness as a risk factor for CAD and stroke
have been studied by many researchers. BOTS M.L. AND COLLEAGUES2
study shows that an increased common carotid intima media thickness relates to
future cardiovascular and cerebrovascular events. Their study provides
supportive evidence for the use of intima media thickness measurements as an
intermediate or proxy end point in observational studies and trials.
O'LEARY D.H. AND COLLEAGUES3 study concluded that common carotid
artery (CCA) intima media thickness is associated with major risk factors for
atherosclerosis and existing CAD and atherosclerotic disease in older adults.
This association is not as strong as that for internal carotid artery intima media
thickness. The combination of these measures relates more strongly to existing
coronary heart disease and atherosclerotic disease and cerebrovascular disease
risk factors than either taken alone.
GRANER M. AND COLLEAGUES4 study concluded association of carotid
intima media thickness (IMT) with severity and extent of CAD as assessed by
quantitative coronary angiography. Carotid IMT seems to be a stronger predictor
of coronary atherosclerosis in the mid and distal parts of the coronary tree than
in the proximal part.
TSIVGOULIS G. AND COLLEAGUES5 study concluded that increased CCA-
IMT values are associated with a higher risk of long term stroke recurrence.
KABLAK-ZIEMBICKA A. AND COLLEAGUES6 study shows that IMT
increases with advancing CAD. Patient with mean IMT over 1.15mm have a
94% likelihood of having CAD. Coexistence of CAD with severe stenosis of
aortic arch arteries (like CCA and ICA) is relatively high and found in 16.6% of
patients with three vessel CAD.
OBJECTIVES OF THE STUDY
1.Carotid artery IMT thickness(by B-mode USG scan) - Its association with
6.3 CAD and stroke.
2.Quantitative correlation of carotid artery IMT with severity of occlusive
coronary artery disease as evidenced by coronary angiography.
3.Comparison of carotid artery IMT with conventional risk factors for
7 SUBJECTS AND METHODS
7.1 SOURCE OF DATA
CASES - Patients admitted in Medical Wards of K.S. HEGDE CHARITABLE
HOSPITAL under Medicine, Cardiology and Neurology and patients in
M.I.C.U.(Medical Intensive Care Unit) and C.C.U.(Cardiac Care Unit) diagnosed
as having stroke and / or CAD.
CONTROLS - Patients attending outpatient department in Medicine, Cardiology
Duration of study – From November 2008 to june 2010
50 cases of CAD
50 cases of stroke (both ischaemic and haemorrhagic)
Controls - Healthy adults more than 30 years of age without present and past
history of CAD, stroke and no risk factors for atherosclerotic disease like diabetes
mellitus, hypertension, dyslipidemia, obesity.
7.2 INCLUSION CRITERIA
1. Age more than 30 years (both male and female).
2. Present or past diagnosis of CAD.
3. Present or past diagnosis of stroke.
7.3 EXCLUSION CRITERIA
1. Age less than 30 years of age.
2. Cases / controls who are not giving consent.
7.4 DIAGNOSIS OF CAD-
Clinical features, ECG changes, increased cardiac enzymes, ECHO changes
and coronary angiography suggesting CAD.
DIAGNOSIS OF STROKE-
Clinical features, CT brain (plain or contrast) or MRI brain (plain or contrast)
After selecting the cases, a detailed questionnaire which includes a detailed
history, physical examination and relevant investigations are done for each case.
Controls are also analysed with relevant investigations.
After confirming the diagnosis of CAD and stroke, cases will undergo
measurement of IMT of distal CCA at its posterior wall bilaterally. Cases of CAD
will undergo coronary angiography to see the extent of the disease.
Controls will also undergo measurements of IMT of distal CCA at its posterior
For measurement of IMT - B-mode USG scan using 11MHz probe is used and
whenever required to see plaques, plaque ulceration, lumen stenosis Colour
Doppler scan is used.
A written informed consent will be obtained from all CAD and stroke patients and
7.6 TYPE OF STUDY – Case control study
7.7 STATISTICS - Multivariate logistic regression analysis using SPSS software.
7.8 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR
TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS ?
IF SO, PLEASE DESCRIBE BRIEFLY ?
Yes. Coronary angiography, B-mode USG scan / Colour Doppler scan.
7.9 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR
INSTITUTION IN CASE OF 7.8 ?
IMT - Intima media thickness
CAD - Coronary artery disease
ICA - Internal carotid artery
CCA - Common carotid artery
TIA’s – Transient ischaemic attacks
8 LIST OF REFERENCES
1. GUPTA H., BHARGAVA K., BANSAL M., TANDON S., KASLIWAL
R. R. Carotid Intima Media Thickness and Coronary Artery Disease : An
Indian Perspective, Asian Cardiovascular Thoracic Annuals 2003;11:217-
2. BOTS M.L., HOES A.W., KOUDSTAAL P.J., HOFMAN A, GROBBEE
D.E. Common Carotid Intima Media Thickness and Risk of Stroke and
Myocardial Infarction - The Rotterdam Study Circulation 1997;96:1432-
3. O'LEARY D.H.,POLAK J.F., KRONMAL R.A., SAVAGE P.J.,
BORHANI N.O., KITTNER S.J., TRACY R. et al Thickening of Carotid
wall - A marker for atherosclerosis in the elderly. Cardiovascular Health
Study Collaberative Research Group Accepted October 11, 1995.
4. GRANER M., VARPULA M., KAHRI J., SALONEN R.M.,
NYYSSONEN K., NIEMINEN M.S. et al, Association of Carotid Intima
media thickness with Angiographic Severity and Extent of coronary artery
disease, American Journal of Cardiology 2006,97:624-629
5. TSIVGOULIS G., VEMMOS K., PAPAMICHAEL C., SPENGOS K.,
MANIOS E., STAMATELOPOULOS K. et al Common Carotid artery
Intima Media thickness and the risk of stroke recurrence, Stroke
6. KABLAK-ZIEMBICKA A., TRACZ W., PRZEWLOCKI T., PIENIAZEK
P., SOKOLWSKI A., KONIECZYNSKA M. Association of Increased
Carotid Intima media thickness with the Extent of Coronary artery disease.
9 SIGNATURE OF THE
10 REMARKS OF THE GUIDE : Forwarded
11 NAME AND DESIGNATION OF Dr. L.N.Samaga
THE GUIDE: Professor
12 SIGNATURE OF THE GUIDE:
14 SIGNATURE OF CO-GUIDE:
15 HEAD OF THE DEPARTMENT: Dr. P.S.Prakash
Professor and Head of the Department
16 SIGNATURE OF THE HEAD OF
17 REMARKS OF CHAIRMAN AND PRINCIPAL:
Hospital number :
A. History of CAD:
Chest pain : Yes No Duration : Others:
Breathlessness : Yes No Duration : Others:
Orthopnea : Yes No Duration :
PND (Paroxysmal Nocturnal Dyspnea): Yes No Duration :
Cough and expectoration: Yes No Duration : Others:
Palpitation : Yes No Duration :
Syncope : Yes No Duration :
B. History of stroke:
Hemiparesis / Hemiplegia : Yes No Duration :
Facial weakness : Yes No Duration :
Dysarthria : Yes No Duration :
Dysphasia : Yes No Duration :
Numbness, Tingling : Yes No Duration :
Loss of Consciousness : Yes No Duration :
Headache : Yes No Duration :
Vomiting : Yes No Duration :
Seizures : Yes No Duration :
Giddiness : Yes No Duration :
Vertigo : Yes No Duration :
Dysphagia, Choking, Nasal regurgitation: Yes No Duration :
Ataxia : Yes No Duration :
Bowel, Bladder incontinence: Yes No Duration :
Diplopia : Yes No Duration :
TIA’s : Yes No Duration :
Fever : Yes No Duration :
Previous history of CAD, hospitalisation.
Previous history of stroke, hospitalisation.
Intermittent Claudication (symptoms of Peripheral Vascular Disease)
HISTORY OF MEDICATIONS
HISTORY OF RELEVANT SURGERIES
CABG(coronary Artery Bypass Graft)
PCI(Percutaneous Coronary Intervention)
Diet (fatty diet)
GENERAL PHYSICAL EXAMINATION
Blood pressure (supine position)
Markers of hyperlipidemia
Significant postural drop in blood pressure (systolic blood pressure more than 20mm of Hg and diastolic
blood pressure more than 10mm of Hg)
Jugular venous pulse
RELEVENT SYSTEMIC EXAMINATION
CENTRAL NERVOUS SYSTEM EXAMINATION:
Higher mental functions
Cranial nerve involvement (specify)
Attitude : Right: Left:
Bulk : Right: Left:
Tone : Right: Left:
Power : Right: Left:
Pupillary reflex : Right: Left:
Corneal reflex : Right: Left:
Gag reflex : Right: Left:
Jaw jerk : Right: Left:
Abdominal reflex : Right: Left:
Cremasteric reflex : Right: Left:
Deep tendon reflexes:
Biceps jerk : Right: Left:
Triceps jerk : Right: Left:
Supinator jerk : Right: Left:
Knee jerk : Right: Left:
Ankle jerk : Right: Left:
Plantar reflex : Right: Left:
Signs of meningeal irritation:
Cardiac dullness :Normal Obliterated
Precordial bulge : Yes No
Epigastric pulsation : Yes No
Apical impulse (specify) :
Systolic thrill : Yes No Area:
Palpable S1 (specify area) : Yes No
Palpable S2 (specify area) : Yes No
S1 characteristic (specify) :
S2 characteristic (specify) :
Presence of S3 or S4 (specify):
Systolic murmur (specify area and character) : Area: Characteristic:
Diastolic murmur (specify area and character) : Area: Characteristic:
Total leukocyte count
Differential leukocyte count
Erythrocyte sedimentation rate
Urine routine examination
Fasting blood sugar level
Postprandial blood sugar level
Fasting lipid profile
Serum electrolyte levels
Common carotid artery IMT measurement by B-mode USG scan
Colour Doppler scan to see evidence of-
CT (computed tomography) brain
MRI (magnetic resonance imaging) brain
20 RESULTS / DISCUSSION / ANALYSIS