• Prevention & Screening
• Imaging Modalities
• Hypertensive Disease

• Prevention & Screening
• Endocrinology
• Diabetes & Metabolic Syndrome
• Imaging Modalities
• Hypertensive Disease

Hyuk-Iae Chang, MD, PhD, Severance Cardiovascular Hospital, Seoul, South Korea, presented the results of the Cardiovascular Risk factors managEment in Asymptomatic hypertensIVE Subjects (CREATIVES) study. CREATIVES was a prospective, observational study conducted between January 2010 and May 2011.

National Cholesterol Education Program-Adult Treatment Panel III (NCEP-ATP III) risk stratification that is based largely on the low-density lipoprotein cholesterol (LDL-C) level can overlook many patients with acute myocardial infarction (AMI) who would benefit from lifestyle modifications or statin therapy [Yoon YE et al. Prev Cardiol 2009].

Noninvasive imaging may improve risk prediction and primary prevention of coronary artery disease (CAD). However, existing guidelines on the imaging of asymptomatic CAD patients differ regarding the need for additional imaging studies in patients without established CAD [Ferket BS et al. J Am Coll Cardiol 2011].

Evidence supporting the use of noninvasive imaging includes a 3-year follow-up study, in which computed tomography (CT) imaging of coronary calcium increased compliance with statin use [Kalia NK, Budoff M. J Am Coll Cardiol 2012]. The EISNER trial also showed the ability and cost-effectiveness of imaging in spurring improvements in management of risk factors [Rozanski A et al. J Am Coll Cardiol 2011]. However, other studies have had different results [McEvoy JW et al. Arch Intern Med 2011].

Defining whether imaging studies have a role in guiding lipid therapy is important in light of the proven benefits of statins in the prevention of and treatment following AMI [Penning-van Beest FJ et al. Eur Heart J 2007; Chapman RH et al. Patient Prefer Adherence 2009]. The CREATIVES study assessed whether use of ultrasound scanning of carotid intima media thickness (CIMT) or plaque to classify asymptomatic hypertensive patients for their cardiovascular disease (CVD) risk encouraged beneficial behavioral changes.

Patients (n=347) were enrolled from 22 hospitals in South Korea. Patients included in the study had hypertension (defined as systolic blood pressure [SBP] ≥140 mm Hg or use of antihypertensive medication) and were aged 45 to 75 years (men) and 55 to 75 years (women). Patients with previously documented CAD, cerebrovascular, or peripheral arterial disease, and those with symptomatic heart failure were excluded.

Patients were considered to be high risk for CVD if they had a carotid plaque or CIMT >0.9 mm on ultrasound. Patients were surveyed with a questionnaire and scored based upon the health-related behaviors such as smoking, exercise, consumption of salty foods and vegetables, and medication compliance. The high- and non-high risk groups comprised 182 and 165 patients, respectively. Significant differences at baseline were present in average age (62±7 and 60±8 years, respectively; p<0.001), duration of hypertension (5.3±6.0 and 4.0±4.3 years; p=0.024), triglyceride level (138±71 and 156±96 mg/dL; p=0.040), use of antiplatelet agents (72% and 47%; p=0.030), and higher Framingham scores for high-risk patients (Table 1; p=0.005).

After carotid ultrasound examination, SBP and LDL-C were lowered in 26% and 52% of the high-risk patients, respectively, versus 6% and 24% of the non-high-risk patients, respectively. The findings persisted in patients classified as low- and moderate-risk by NCEP-ATP III criteria. Smoking, salty food intake, and medication compliance were improved in all patients after 6 months.

Multivariate analysis of the improvements in SBP and LDL-C revealed that classification as high-risk by carotid ultrasound was the sole independent factor associated with improved cholesterol level.

These findings that carotid ultrasound screening is associated with improved management of hyperlipidemia add support for the value of noninvasive imaging to screen for CVD risk in asymptomatic hypertensive patients. The benefits included improved physician behavior to reach target levels for SBP and LDL-C and improved health behaviors in both patient groups.

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