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DOI: 10.1055/s-2003-40058
Intima-Media-Dicke der Karotisarterien: Früher Indikator für Arteriosklerose und therapeutischer Endpunkt
Intima Media Thickness of the Carotid Arteries: Early Pointer to Arteriosclerosis and Therapeutic EndpointPublikationsverlauf
eingereicht: 4. Oktober 2002
angenommen: 19. Februar 2003
Publikationsdatum:
20. Juni 2003 (online)
![](https://www.thieme-connect.de/media/ultraschall/200303/lookinside/thumbnails/10.1055-s-2003-40058-1.jpg)
Zusammenfassung
Frühe arteriosklerotische Gefäßwandprozesse sind erkennbar an einer Zunahme der arteriellen Wanddicke. Die Verdickung des Intima-Media-Komplexes stellt einen nicht-invasiven und gut reproduzierbaren Messparameter für Arterienwandumbauprozesse dar, der im Bereich der Karotiden mithilfe hochauflösender Ultraschallmethoden einfach bestimmt werden kann. Bezogen auf Messungen der Intima-Media-Dicke (IMD) der Karotisarterien kommen aber verschiedene Arbeitsgruppen zu unterschiedlichen Ergebnissen. Die Ursache hierfür könnte in der Auswahl der Messregionen (unterschiedliche Segmente und Gefäßabschnitte der Karotisarterie, sondennahe/sondenferne Gefäßwand), in der unterschiedlichen Interpretation der Grenzflächenechos des Intima-Madia-Komplexes oder in der unterschiedlichen Beziehung zwischen sonographischen und anatomischen Gefäßwandstrukturen der sondennahen und -fernen Arterienwand begründet sein. Messungen der IMD an der sondennahen Karotiswand erfassen nur Teile der Media zusammen mit einer von Ultraschallartefakten beeinflussten Intimaschicht und nicht den totalen Intima-Media-Komplex. Es gibt zwei verschiedene Verfahren zur IMD-Messung: 1) mehrfache manuelle Messungen in unterschiedlichen Segmenten der Karotisarterien an der sondennahen und der sondenfernen Gefäßwand und 2) automatische, computerunterstützte Messungen, welche an der sondenfernen Gefäßwand der distalen Arteria carotis communis vorgenommen werden. Bei der manuellen Messtechnik liegen die Intra- und Interbeobachtervariabilitäten bei 0,09 bis 0,13 mm und 0,12 und 0,18 mm (absolute Differenzen zwischen den Messwerten). Die Reproduzierbarkeit ist am besten, wenn die manuellen IMD-Messungen an der sondenfernen Wand der A. carotis communis in einer Entfernung von 1 cm vom Bulbus und an geraden parallelen Wandechos, die keine lokale Verdickung aufweisen, durchgeführt wird. Die Variabilität ist außerdem bei der automatischen Methode geringer als beim manuellen Ausmessen der IMD. IMD-Werte der A. carotis communis sind altersabhängig. Im jüngeren Lebensalter (20- bis 30-jährige Personen) liegt die IMD im Durchschnitt bei 0,5 mm, während sie bei älteren Personen (60- bis 70-jährige) durchschnittlich 0,9 mm beträgt. Darüber hinaus korreliert die IMD der Karotiden mit anderen Risikofaktoren wie z. B. dem systolischen Blutdruck, den Serumlipiden und dem Rauchen. Außerdem besteht bei Männern und Frauen eine positive Beziehung zwischen IMD der Karotiden und der Existenz sowie dem Ausmaß der koronaren Herzkrankheit. Aufgrund der Tatsache, dass in großen klinischen Studien eine Korrelation zwischen IMD und kardiovaskulären Ereignissen wie z. B. Herzinfarkt und Schlaganfall gefunden wurde, hat die FDA den zweidimensionalen Ultraschall als valide Technik in klinischen Arteriosklerosestudien anerkannt. Es konnte gezeigt werden, dass sich durch die Verabreichung verschiedener blutdruck- und lipidsenkender Medikamente die Regression oder eine verlangsamte Progression von Verdickungen der Intima-Media-Schicht der Karotiden erzielen lässt. In Ergänzung zu IMD-Messungen der Karotiden als prädiktiver Faktor zukünftiger kardiovaskulärer Ereignisse steigt dieses Risiko drastisch im Falle der Existenz von Plaques im Bereich der Karotiden an. Im klinischen Alltag sollte daher aus Sicht der Autoren dieser Arbeit die hochauflösende Duplexsonographie sowohl zur Untersuchung der IMD der A. carotis communis als auch zur Erfassung von Plaques und Stenosen eingesetzt werden. Zusammenfassend kann gesagt werden, dass sich die hochauflösende Duplexsonographie zur Erfassung, Quantifizierung und Verlaufsbeobachtung von strukturellen Veränderungen der Arterienwand eignet. Die Empfindlichkeit dieser Methode ist ausreichend für den Einsatz in klinischen Studien, die sich mit der Progression und der Regression früher arteriosklerotischer Veränderungen in den extrakraniellen Karotisarterien befassen. Darüber hinaus kann die IMD der A. carotis als therapeutischer Endpunkt verwandt werden.
Abstract
An early sign of atherosclerosis is hypertrophy of the arterial wall. Increased intima-media thickness (IMT) is a non-invasive marker of arterial wall alteration, which can easily be assessed in the carotid arteries by high-resolution B-mode ultrasound. There are important differences in B-mode measurements of carotid IMT between laboratories. These might concern on IMT image acquisition (in relation to the segment and/or the wall of measure) as well as determination of the echo boundary defining the IMT interfaces and the difference in relationship between anatomic and sonographic structures of the near and far arterial wall. Measurements derived from the near wall reflect thickness of a part of media and intima influenced by sonographic artefacts, rather than that of the total intima-media complex. Two main approaches are used for measuring IMT: 1) manual measurement at multiple extracranial carotid sites in near and far walls, and 2) automated computerized measurement, restricted to the far wall of the distal common carotid artery. Intra- and inter-observer variabilities have been found to vary in manual measurements between 0.09 to 0.13 mm and 0.12 to 0.18 mm (absolute differences). The best reproducibility of manual IMT-measurements is found at the far wall of the common carotid artery 1 cm from the bulb in the site of two parallel wall contures without local thickening. For automated measurements lower intra- and inter-observer variabilities have been reported. IMT of the common carotid artery is strongly influenced by age. For younger age groups (20 to 30 years) mean IMT values of 0.5 mm have been reported, while IMT values of 0.9 mm have been found for older subjects (60 to 70 years). Carotid IMT correlates with other risk factors such as systolic blood pressure, serum lipids and smoking, as well as being positively linked to the presence and extend of coronary artery disease in both women and men. The demonstration of a correlation between IMT and cardiovascular events such as stroke and myocardal infarction in clinical studies of atherosclerosis progression and cardiovascular outcomes have led to FDA accepting 2D ultrasound as a valid technique in clinical studies of atherosclerosis. Regression or slowing of progression of increased carotid IMT by various antihypertensive and lipid-lowering drugs agents have been reported. In addition to carotid IMT measurement as a predictive value of future vascular events the presence of plaques or stenosis in the carotid artery tree increases drastically the risk for cardiovascular events. Therefore the authors of this article propose the use of high resolution Duplex-Sonography for the assessment IMT of the common carotid artery as well as the detection of plaques and stenosis in clinical practice. In conclusion, high-resolution Duplex-sonography seems promising for the detection, quantification and serial investigations of structural alterations of the arterial wall. The method is sensitive enough to be applied in clinical studies of the progression and regression of early preintrusive atherosclerotic lesions in extracranial carotid arteries. Moreover IMT of the common carotid artery can be used as a therapeutic endpoint.
Schlüsselwörter
Intima-Media-Dicke - Nicht-invasive Techniken - B-mode - Arterienwand - Arteriosklerose
Key words
Intima-media thickness - non-invasive techniques - B-mode imaging - arterial wall - atherosclerosis
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Prof. Dr. M. Ludwig
Medizinische Universitäts-Poliklinik Bonn
Wilhelmstr. 35 - 37 · 53111 Bonn