Dr. Blanchard, Basic questions on CIMT

Owen Lowe said:

I've tried my best to keep up on the discussions about CIMT - but admit
much of it has gone over my head or the back'n'forth with Dr. Chung has
confused what I thought I was learning about it. If you have the time,
would you mind answering (in layman's terms) some questions? (I've
attempted some Google-ing of the subject but haven't been successful in
limiting the results to what I'm looking for.)

1) What is the proceedure for having a CIMT done?

To the patient, it is like having a carotid ultrasound done. The main
difference is that instead of focusing on doppler (flow) information, the
technician looks very closely and measures the thickness of the intimal
layer of the artery. This layer largely comprises of endothelial cells
which inherently do not "pile up" on each other but prefer to grow as a
sheet that is one-cell thick. So when this layer becomes thicker, it
implies that there are "other" cells that should not be there (ie foam cells
aka lipid-laden macrophages). A good picture of what is measured is shown
on the link that Dr. Blanchard had provided earlier:

http://www.autrec.com/

Quoted message said:

2) The results of the test tell the doctor and patient, what?

Whether the intimal layer in the carotid arteries are of normal "thin"
thickness.

Quoted message said:

I
understand it's a measurment of the carotid artery, which is then acting
as a general indicator for the entire body's vascular condition - does
it measure the existing "flow" (for lack of a better term) as well as
provide a measure of what would be considered an unimpaired "flow"?

No.

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3) In your opinion, why is it that the coronary arteries are the ones
that bring us to a screaching halt with ruptures - is it just that the
heart is much more susceptable to blood supply interuptions over other
organs?

No. The brain is just as susceptible (actually more susceptible) to blood
flow interruptions.

The reason is the anatomy (how the coronaries are constructed with very
little preexisting functional collaterals)

Quoted message said:

And the carotid is larger and requires a more severe rupture to
affect the brain?

The Circle of Willis prevents blockage in any one carotid or vertebral
artery from interrupting blood flow to the brain.

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4) Have you seen actual improvements in "flow" that you feel have saved
patient's lives in the short term (meaning we all gotta die someday from
something)?

CIMT measurements are not about flow.

Quoted message said:

Briefly, what are your treatment strategies for reversal?

I won't write for him.

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Hope these questions aren't too pedestrian for the group or causing you
to rewrite subject matter to any great degree. Thank you, in advance,
Dr. Blanchard.

Sorry, I interjected on behalf of Dr. Blanchard. However, I anticipate his
answers to your queries will be similar to the above except for his specific
practices for reversing intimal disease.

--
Dr. Andrew B. Chung, MD/PhD
Board-Certified Cardiologist
http://www.heartmdphd.com

On Thu, 06 Nov 2003 23:21:53 -0800, Owen Lowe <[email hidden]>

Quoted message said:

I've tried my best to keep up on the discussions about CIMT - but admit
much of it has gone over my head or the back'n'forth with Dr. Chung has
confused what I thought I was learning about it. If you have the time,
would you mind answering (in layman's terms) some questions? (I've
attempted some Google-ing of the subject but haven't been successful in
limiting the results to what I'm looking for.)

1) What is the proceedure for having a CIMT done?

Because CIMT measurements are at the limits of resolution of our equipment,
they are demanding and must be highly standardized. Without going into the
detail of the protocol I have established with the help of others (because
I don't know if you are asking me to), the procedure is painless, does not
use needles, and requires you to sit in a comfortable chair for about 30
minutes. You are asked to hold very still and not move from your original
position unless asked. You are able to stand up and stretch after the right
side is complete, in about 15 minutes. The procedure is performed the same
way on the left side of the neck and also takes about another 15 minutes.

CIMT measurments require an ultrasound transducer to be placed gently onto
the skin, over the neck arteries. There is a small amount of water soluble,
hypoallergenic gel applied to the transducer facing, and is easily wiped
off with a towelette when the examination is complete.

Quoted message said:

2) The results of the test tell the doctor and patient, what? I
understand it's a measurment of the carotid artery, which is then acting
as a general indicator for the entire body's vascular condition - does
it measure the existing "flow" (for lack of a better term) as well as
provide a measure of what would be considered an unimpaired "flow"?

CIMT tells the doctor and patient how much atherosclerosis an individual
has.

CIMT is often confused with carotid duplex evaluations. Although both
evaluations often use the same equipment and study the same arteries, the
two evaluations are different, like night and day.

Carotid duplex evaluations do not accurately measure how much
atherosclerosis is inside artery walls, but most often are performed to
measure how much flow blockage has occured from advanced atherosclerosis.
If the carotid duplex evaluation is indicating more than a certain
percentage (say... 90%), then a MRA (magnetic resonance arteriogram) or a
conventional angiogram is sometimes performed to make sure the carotid
duplex estimate is accurate. If a certain amount of flow blockage is
present, then a vascular surgeon is consulted for a possible carotid
endarterectomy.

Quoted message said:

3) In your opinion, why is it that the coronary arteries are the ones
that bring us to a screaching halt with ruptures - is it just that the
heart is much more susceptable to blood supply interuptions over other
organs? And the carotid is larger and requires a more severe rupture to
affect the brain?

Plaques, as a complication of atherosclerosis, are usually not big enough
to block flow inside the artery to either the brain or the heart. However,
the plaque can rupture like a boil, and expose its contents to the blood
rapidly flowing by. Usually a rupture by itself does not cause noticeable
symptoms, but it is the subsequent clotting of blood around the rupture
site that can result in sudden death. The clot starts small, at the site of
rupture and grows quickly, possibly under 30 seconds. The blood flow
rushing by this growing clot, feebly attached to the rupture site breaks
the clot off its base. Now the clot is free floating in the blood stream
and is swept off to a distant, smaller artery where it blocks the flow
completely. The blocked flow from the clot can cause sudden death if it is
lodged in the coronary artery, or sudden unconciousness if it is lodged in
a brain artery.

Quoted message said:

4) Have you seen actual improvements in "flow" that you feel have saved
patient's lives in the short term (meaning we all gotta die someday from
something)? Briefly, what are your treatment strategies for reversal?

I have seen improvements in a select few individuals within 6 months,
following plaque size only and not with CIMT.

However, CIMT was first shown to regress with lovastatin in 1994 with the
following study:
*Circulation. 1994 Oct;90(4):1679-87. *Comment in: *ACP J Club. 1995 May-
Jun;122(3):66-7.
*Circulation. 1995 Apr 1;91(7):2094.
*Effect of lovastatin on early carotid atherosclerosis and cardiovascular
events. Asymptomatic *Carotid Artery Progression Study (ACAPS) Research
Group.
*Furberg CD, Adams HP Jr, Applegate WB, Byington RP, Espeland MA, Hartwell
T, Hunninghake DB, *Lefkowitz DS, Probstfield J, Riley WA, et al.
*Department of Public Health Sciences, Bowman Gray School of Medicine,
Winston-Salem, NC 27157-1063.

after it was discovered by Pignoli and others in 1986:
Pignoli P, Tremoli E, Poli A, Oreste P, Paoletti R.
Intimal plus medial thickness of the arterial wall: a direct measurement
with ultrasound imaging.
Circulation. 1986 Dec;74(6):1399-406.

It has since then been used as a research tool by hundreds of investigators
and most pharmeceutical companies to determine if treatment "x"
successfully treats atherosclerosis.

I first learned about CIMT from Dr. Ward Riley at Bowman Gray School of
Medicine almost 1 year ago and underwent 8 months of intensive study to
settle on the protocol I perform now. Even with the protocol I currently
follow, which surpasses any other I know of, I do not anticipate to see a
reliable CIMT change for at least 12 months.

As to my treatment strategy: 1. educate the patient about cardiovascular
disease and that it can be reversed at any stage.
2. accurately and completely asses the carotid intima-media complex.
3. educate the patient how they can decrease the amount of atherosclerosis
they have.
4. support the patient's transition into atherosclerosis treatment.
5. accurately and completely asses the carotid intima-media complex
annually.
6. reasses the patient's treatment plan.

Quoted message said:

Hope these questions aren't too pedestrian for the group or causing you
to rewrite subject matter to any great degree. Thank you, in advance, Dr.
Blanchard.

I want to thank you for asking me.

--
~~~
Patrick Blanchard, M.D., A.B.F.P.
Board Certified in Family Practice
http://www.familydoctor.org/blanchard