Background
Methods
Participants and baseline procedures
Carotid ultrasound imaging
Follow-up and outcomes assessment
Statistical analyses
Results
Baseline characteristics according to carotid atherosclerosis parameters
Characteristics | All patients (n = 478) | 1st-tertile CCA-IMT ≤ 0.95 mm (n = 149) | 2nd-tertile CCA-IMT 1.00–1.10 mm (n = 186) | 3rd-tertile CCA-IMT ≥ 1.15 mm (n = 143) | p-value |
---|---|---|---|---|---|
Age (years) | 60.0 (9.1) | 55.3 (9.4) | 60.7 (8.5) | 63.8 (7.3) | < 0.001 |
Male sex (%) | 36.0 | 27.5 | 37.1 | 43.4 | 0.017 |
Body mass index (kg/m2) | 29.5 (4.8) | 29.7 (5.1) | 29.8 (4.7) | 29.0 (4.8) | 0.23 |
Smoking, current/past (%) | 44.2 | 38.9 | 40.5 | 54.5 | 0.012 |
Physical activity (% active) | 22.1 | 24.2 | 23.1 | 23.2 | 0.91 |
Diabetes duration (years) | 8 (3–15) | 6 (3–15) | 8 (4–16) | 10 (4–15) | 0.12 |
Chronic diabetic complications (%) | |||||
Cerebrovascular disease | 9.0 | 2.0 | 9.1 | 16.1 | < 0.001 |
Coronary artery disease | 16.1 | 11.4 | 16.7 | 20.3 | 0.11 |
Peripheral artery disease | 16.5 | 7.4 | 11.8 | 32.2 | < 0.001 |
Retinopathy | 33.5 | 28.9 | 34.4 | 37.1 | 0.31 |
Nephropathy | 29.3 | 26.8 | 30.1 | 30.8 | 0.73 |
Peripheral neuropathy | 29.9 | 24.2 | 28.5 | 37.8 | 0.035 |
Diabetes treatment (%) | |||||
Metformin | 88.1 | 87.9 | 90.9 | 84.6 | 0.22 |
Sulfonylureas | 43.7 | 43.6 | 46.2 | 40.6 | 0.59 |
Insulin | 48.1 | 47.7 | 44.6 | 53.1 | 0.31 |
Aspirin | 92.2 | 91.8 | 91.9 | 93.0 | 0.92 |
Dyslipidemia (%) | 88.1 | 87.9 | 88.2 | 88.1 | 0.99 |
Statins use (%) | 77.0 | 75.2 | 75.3 | 81.1 | 0.37 |
Arterial hypertension (%) | 85.8 | 77.9 | 89.2 | 89.5 | 0.004 |
Number of anti-hypertensive drugs | 3 (1–3) | 2 (1–3) | 3 (1–3) | 3 (2–4) | < 0.001 |
Blood pressures (mmHg)a | |||||
Clinic SBP | 140 (19) | 135 (16) | 142 (19) | 144 (19) | < 0.001 |
Clinic DBP | 79 (10) | 79 (9) | 79 (12) | 78 (10) | 0.70 |
Laboratory variablesa | |||||
Fasting glycemia (mmol/l) | 8.1 (2.7) | 8.0 (2.8) | 7.8 (2.8) | 8.4 (2.6) | 0.14 |
HbA1c (%) | 7.7 (1.5) | 7.6 (1.4) | 7.6 (1.6) | 7.8 (1.5) | 0.28 |
Triacylglycerol (mmol/l) | 1.9 (1.5) | 1.9 (1.4) | 2.0 (1.7) | 1.8 (1.1) | 0.72 |
HDL-cholesterol (mmol/l) | 1.1 (0.3) | 1.1 (0.3) | 1.1 (0.3) | 1.1 (0.3) | 0.80 |
LDL-cholesterol (mmol/l) | 2.8 (0.9) | 2.7 (0.9) | 2.7 (0.7) | 3.0 (0.9) | 0.018 |
Glomerular filtration rate (ml/min/1.73 m2) | 82 (20) | 88 (19) | 81 (20) | 76 (20) | < 0.001 |
Albuminuria (mg/24 h) | 14 (7–38) | 12 (7–38) | 13 (7–36) | 16 (8–41) | 0.32 |
Outcomesb | |||||
Total CVEs | 116 (25.8) | 19 (12.6) | 46 (26.4) | 51 (41.1) | < 0.001 |
All-cause mortality | 115 (23.8) | 26 (16.8) | 43 (22.4) | 46 (33.7) | 0.006 |
Cardiovascular mortality | 56 (11.6) | 9 (5.8) | 24 (12.5) | 23 (16.8) | 0.013 |
Retinopathy (incident/worsening) (n = 425) | 131 (50.4) | 44 (50.5) | 44 (42.5) | 43 (62.2) | 0.18 |
Renal composite | 156 (37.3) | 43 (32.3) | 63 (37.7) | 50 (42.5) | 0.15 |
Peripheral neuropathy (incident/worsening) (n = 419) | 83 (19.8%) | 22 (16.3%) | 35 (20.7%) | 26 (22.6%) | 0.43 |
Characteristics | All patients (n = 478) | Plaque score 0–1 point (n = 102) | Plaque score 2 points (n = 276) | Plaque score 3–4 points (n = 100) | p-value |
---|---|---|---|---|---|
Age (years) | 60.0 (9.1) | 54.3 (9.3) | 60.3 (8.2) | 65.3 (8.1) | < 0.001 |
Male sex (%) | 36.0 | 33.35 | 35.0 | 41.0 | 0.47 |
Body mass index (kg/m2) | 29.5 (4.8) | 30.4 (4.7) | 29.6 (4.9) | 28.1 (4.6) | 0.003 |
Smoking, current/past (%) | 44.2 | 34.3 | 43.8 | 55.0 | 0.012 |
Physical activity (% active) | 22.1 | 29.4 | 24.2 | 14.0 | 0.028 |
Diabetes duration (years) | 8 (3–15) | 6 (2–12) | 8 (3–15) | 10 (5–18) | 0.008 |
Chronic diabetic complications (%) | |||||
Cerebrovascular disease | 9.0 | 6.9 | 6.5 | 20.0 | < 0.001 |
Coronary artery disease | 16.1 | 8.8 | 17.0 | 23.0 | 0.024 |
Peripheral artery disease | 16.5 | 6.9 | 13.7 | 36.0 | < 0.001 |
Retinopathy | 33.5 | 24.5 | 32.5 | 47.0 | 0.003 |
Nephropathy | 29.3 | 33.3 | 27.1 | 32.0 | 0.41 |
Peripheral neuropathy | 29.9 | 19.6 | 28.9 | 42.0 | 0.002 |
Diabetes treatment (%) | |||||
Metformin | 88.1 | 86.3 | 89.5 | 85.0 | 0.42 |
Sulfonylureas | 43.7 | 41.2 | 43.7 | 45.0 | 0.85 |
Insulin | 48.1 | 42.2 | 49.1 | 51.0 | 0.39 |
Aspirin | 92.2 | 88.2 | 93.1 | 92.9 | 0.28 |
Dyslipidemia (%) | 88.1 | 79.4 | 89.5 | 94.0 | 0.003 |
Statins use (%) | 77.0 | 64.7 | 78.3 | 87.0 | 0.001 |
Arterial hypertension (%) | 85.8 | 78.4 | 86.6 | 91.0 | 0.031 |
Number of anti-hypertensive drugs | 3 (1–3) | 2 (1–3) | 2 (1–3) | 3 (2–4) | < 0.001 |
Blood pressures (mmHg) | |||||
Clinic SBPa | 140 (19) | 139 (19) | 141 (19) | 141 (19) | 0.62 |
Clinic DBPa | 79 (10) | 80 (9) | 79 (11) | 76 (11) | 0.006 |
Laboratory variables | |||||
Fasting glycemia (mmol/l)a | 8.0 (2.7) | 8.0 (3.1) | 8.1 (2.7) | 8.1 (2.6) | 0.92 |
HbA1c (%)a | 7.7 (1.5) | 7.7 (1.6) | 7.7 (1.5) | 7.5 (1.4) | 0.35 |
Triacylglycerol (mmol/l)a | 1.9 (1.5) | 1.8 (1.2) | 1.9 (1.6) | 2.0 (1.4) | 0.35 |
HDL-cholesterol (mmol/l)a | 1.1 (0.3) | 1.1 (0.3) | 1.1 (0.3) | 1.1 (0.3) | 0.95 |
LDL-cholesterol (mmol/l)a | 2.8 (0.9) | 2.8 (0.9) | 2.8 (0.9) | 2.8 (0.8) | 0.90 |
Glomerular filtration rate (ml/min/1.73 m2) | 82 (20) | 88 (20) | 82 (20) | 74 (19) | <0.001 |
Albuminuria (mg/24 h) | 14 (7–38) | 17 (9–43) | 13 (7–32) | 15 (7–46) | 0.10 |
Outcomesb | |||||
Total CVEs | 116 (25.8) | 15 (15.2) | 59 (22.3) | 42 (50.1) | < 0.001 |
All-cause mortality | 115 (23.8) | 16 (15.5) | 55 (19.3) | 44 (46.3) | < 0.001 |
Cardiovascular mortality | 56 (11.6) | 7 (6.8) | 29 (10.2) | 20 (21.0) | 0.005 |
Retinopathy (incident/worsening) (n = 425) | 131 (50.4) | 22 (35.8) | 81 (53.5) | 28 (60.5) | 0.16 |
Renal composite | 156 (37.3) | 34 (38.6) | 81 (32.5) | 41 (51.2) | 0.044 |
Peripheral neuropathy (incident/worsening) (n = 419) | 83 (19.8%) | 19 (20.4%) | 48 (19.4%) | 16 (20.8%) | 0.95 |
Endpoints occurrence during follow-up
Risks associated with carotid atherosclerosis parameters
Outcomes | Age and sex adjusted | Multivariate adjusteda | ||
---|---|---|---|---|
Carotid atherosclerosis parameters | HR (95% CI) | p-value | HR (95% CI) | p-value |
Total cardiovascular events (n = 116) | ||||
CCA-IMT (0.1 mm increment) | 1.30 (1.15–1.46) | < 0.001 | 1.15 (1.02–1.31) | 0.024 |
CB-IMT (0.1 mm increment) | 1.31 (1.14–1.51) | < 0.001 | 1.15 (1.00–1.33) | 0.058 |
ICA-IMT (0.1 mm increment) | 1.31 (1.14–1.51) | < 0.001 | 1.18 (1.02–1.37) | 0.023 |
CCA-IMT (highest vs. lowest tertile) | 2.89 (1.64–5.10) | < 0.001 | 1.83 (1.01–3.32) | 0.045 |
CB-IMT (highest vs. lowest tertile) | 2.75 (1.59–4.75) | < 0.001 | 1.83 (1.03–3.23) | 0.039 |
ICA-IMT (highest vs. lowest tertile) | 2.13 (1.24–3.65) | 0.006 | 1.53 (0.88–2.67) | 0.13 |
CCA-IMT (> 1.0 mm) | 1.54 (1.02–2.32) | 0.041 | 1.22 (0.80–1.86) | 0.36 |
CB-IMT (> 1.2 mm) | 2.25 (1.41–3.60) | 0.001 | 1.72 (1.05–2.80) | 0.030 |
ICA-IMT (> 0.8 mm) | 2.12 (1.38–3.25) | 0.001 | 1.70 (1.09–2.66) | 0.020 |
Carotid plaque score (≥ 3 points) | 2.27 (1.51–3.43) | < 0.001 | 1.51 (0.97–2.33) | 0.065 |
All-cause mortality (n = 115) | ||||
CCA-IMT (0.1 mm increment) | 1.16 (1.02–1.32) | 0.024 | 1.05 (0.92–1.20) | 0.47 |
CB-IMT (0.1 mm increment) | 1.07 (0.93–1.24) | 0.36 | 0.97 (0.83–1.13) | 0.65 |
ICA-IMT (0.1 mm increment) | 1.07 (0.94–1.22) | 0.32 | 1.02 (0.89–1.17) | 0.79 |
CCA-IMT (highest vs. lowest tertile) | 1.36 (0.81–2.29) | 0.24 | 0.96 (0.56–1.63) | 0.87 |
CB-IMT (highest vs. lowest tertile) | 1.26 (0.77–2.04) | 0.36 | 0.95 (0.57–1.59) | 0.85 |
ICA-IMT (highest vs. lowest tertile) | 1.16 (0.72–1.89) | 0.54 | 1.05 (0.63–1.74) | 0.86 |
CCA-IMT (> 1.0 mm) | 1.25 (0.83–1.88) | 0.28 | 1.08 (0.71–1.63) | 0.72 |
CB-IMT (> 1.2 mm) | 1.23 (0.80–1.88) | 0.34 | 0.98 (0.63–1.53) | 0.92 |
ICA-IMT (> 0.8 mm) | 1.08 (0.73–1.60) | 0.69 | 0.98 (0.65–1.48) | 0.92 |
Carotid plaque score (≥ 3 points) | 1.95 (1.30–2.91) | 0.001 | 1.39 (0.90–2.14) | 0.14 |
Renal composite outcome (n = 156) | ||||
CCA-IMT (0.1 mm increment) | 1.17 (1.05–1.30) | 0.005 | 1.11 (0.99–1.25) | 0.069 |
CB-IMT (0.1 mm increment) | 1.16 (1.03–1.30) | 0.013 | 1.12 (0.99–1.27) | 0.066 |
ICA-IMT (0.1 mm increment) | 1.18 (1.06–1.32) | 0.003 | 1.15 (1.01–1.29) | 0.028 |
CCA-IMT (highest vs. lowest tertile) | 1.48 (0.94–2.31) | 0.088 | 1.16 (0.72–1.65) | 0.71 |
CB-IMT (highest vs. lowest tertile) | 1.55 (1.03–2.35) | 0.037 | 1.38 (0.89–2.14) | 0.15 |
ICA-IMT (highest vs. lowest tertile) | 1.41 (0.92–2.16) | 0.12 | 1.16 (0.74–1.82) | 0.52 |
CCA-IMT (> 1.0 mm) | 1.37 (0.98–1.94) | 0.069 | 1.22 (0.85–1.74) | 0.28 |
CB-IMT (> 1.2 mm) | 1.31 (0.92–1.85) | 0.13 | 1.22 (0.84–1.76) | 0.29 |
ICA-IMT (> 0.8 mm) | 1.69 (1.20–2.39) | 0.003 | 1.55 (1.08–2.23) | 0.016 |
Carotid plaque score (≥ 3 points) | 1.68 (1.15–2.46) | 0.007 | 1.63 (1.09–2.43) | 0.017 |
Improvement in risk stratification with carotid atherosclerosis parameters
Outcomes | C-statistic | Integrated discrimination improvement index | ||||
---|---|---|---|---|---|---|
Carotid atherosclerosis parameters | AUC standard modela | Improvement in AUC | p-value | Absolute | Relative (%) | p-value |
Total cardiovascular events | 0.769 | |||||
CCA-IMT (continuous) | 0.00002 (− 0.009 to 0.009) | 0.99 | 0.008 (− 0.001 to 0.017) | 5.4 | 0.082 | |
CB-IMT (continuous) | 0.006 (− 0.005 to 0.018) | 0.27 | 0.009 (− 0.001 to 0.018) | 6.6 | 0.069 | |
ICA-IMT (continuous) | 0.006 (− 0.006 to 0.017) | 0.33 | 0.005 (− 0.005 to 0.016) | 3.6 | 0.32 | |
CCA-IMT (tertiles) | 0.003 (− 0.009 to 0.014) | 0.67 | 0.009 (0.002 to 0.016) | 5.5 | 0.016 | |
CB-IMT (tertiles) | 0.009 (− 0.006 to 0.024) | 0.25 | 0.011 (0.001 to 0.022) | 8.4 | 0.036 | |
ICA-IMT (tertiles) | 0.003 (− 0.006 to 0.013) | 0.48 | 0.001 (− 0.006 to 0.008) | 1.2 | 0.72 | |
CCA-IMT (> 1.0 mm) | 0.0001 (− 0.004 to 0.004) | 0.98 | 0.002 (− 0.001 to 0.004) | 1.2 | 0.18 | |
CB-IMT (> 1.2 mm) | 0.007 (− 0.007 to 0.021) | 0.33 | 0.010 (0 to 0.020) | 7.8 | 0.050 | |
ICA-IMT (> 0.8 mm) | 0.009 (− 0.007 to 0.024) | 0.29 | 0.008 (− 0.003 to 0.018) | 5.4 | 0.17 | |
Carotid plaque score (≥ 3 points) | 0.009 (− 0.006 to 0.023) | 0.24 | 0.014 (0.001 to 0.027) | 7.8 | 0.040 | |
Renal composite | 0.644 | |||||
ICA-IMT (continuous) | 0.018 (− 0.007 to 0.042) | 0.16 | 0.010 (− 0.001 to 0.020) | 18.5 | 0.070 | |
ICA-IMT (tertiles) | 0.009 (− 0.007 to 0.026) | 0.27 | 0.002 (− 0.004 to 0.008) | 1.9 | 0.57 | |
ICA-IMT (> 0.8 mm) | 0.022 (− 0.006 to 0.049) | 0.12 | 0.010 (− 0.001 to 0.020) | 14.8 | 0.071 | |
Carotid plaque score (≥ 3 points) | 0.014 (− 0.010 to 0.038) | 0.24 | 0.010 (0.0001 to 0.019) | 17.9 | 0.049 |