Cardiometabolic risk factors and their association with carotid intima media thickness among patients with type 2 diabetes mellitus

TL;DR

This study examines how controlling cardiometabolic risk factors affects carotid intima media thickness in type 2 diabetes patients in a developing country.

Contribution

The study provides insights into cardiometabolic risk factor control in a single center in a developing country context.

Findings

Poor control of cardiometabolic risk factors was associated with increased carotid intima media thickness.

The study highlights the importance of managing these risk factors to prevent cardiovascular complications.

Findings suggest a need for improved diabetes and cardiovascular risk management in similar settings.

Abstract

Comment to Weerarathna TP, Lekamwasam S, Kodikara I, Wasana KGP, Fonseka L. Control of cardiometabolic risk factors and their association with carotid intima media thickness among patients with type 2 diabetes mellitus-single center experience in a developing country. (Turk J Med Sci. 2024 Jan 11; 54 (3): 545–554)

Full text

In a recent issue, Weerarathna et al. published a study titled “Control of cardiometabolic risk factors and their association with carotid intima media thickness among patients with type 2 diabetes mellitus-single center experience in a developing country” [1]. The aim of the study was to investigate the degree of atherosclerotic cardiovascular disease (ASCVD) risk factor control and its association with carotid intima-media thickness (CIMT) in patients with type 2 diabetes mellitus [1]. CIMT was used as a sonographic surrogate marker of preclinical atherosclerosis. The study enrolled 300 patients (209 women and 91 men), with a mean age of 62 years (SD: 10) [1]. CIMT was measured at the far wall of the common carotid artery (CCA) [1]. The study found statistically significant differences in CIMT between optimally controlled triglyceride (TG) and suboptimally controlled TG group (p = 0.027), as well as between the groups with and without nonalcoholic fatty liver disease (NAFLD) (p = 0.045), after adjustment for age and duration of diabetes [1]. The authors concluded, “This study indicates that LDL-C, TG, and the presence of NAFLD are significant predictors of chronic arterial injury in patients with T2DM” [1]. Several critical details regarding the CIMT measurement methodology are missing, preventing a balanced evaluation of the study’s results.

1. Cardiac synchronization

Importantly, CIMT measurements need to be synchronized with the cardiac cycle and performed during the end-diastolic phase [2,3]. Due to vessel diameter variations, consequent to different cardiac phases, mean differences of up to 0.041 mm between systolic and diastolic phases have been reported [3]. However, Weerarathna et al. [1] did not address this critical methodological aspect.

2. Manual versus semiautomated based measurement

The measurements in Weerarathna et al.’s study [1] appear to have been performed manually, rather than using semiautomated methods, thereby introducing an additional source of inaccuracy [4]. Furthermore, Weerarathna et al. [1] did not report on intra- and interoperator variability [5,6].

3. Measurement protocols

CIMT measurement protocols vary between centers: one recommendation is to measure at the far wall of the CCA, near the CA bifurcation [2]. It should be noted that the recommendation to measure CIMT at the far wall is primarily based on technical reasons, particularly the higher spatial resolution it provides [2]. However, atherosclerosis presents asymmetrically [7], and measuring a single predetermined CA segment may coincide with a normal area, overlooking segments with atherosclerotic changes. Therefore, measuring CIMT at multiple sites, including both arterial walls and various CA segments (e.g., CCA, bifurcation, and internal CA), may yield a more accurate assessment [8–10].

In summary, minor inaccuracies caused by suboptimal measurement protocols or techniques can quickly accumulate, resulting in an inaccurate CIMT estimate (with a normal reference range of 0.6 to 0.9 mm). More importantly, such submillimeter inaccuracies can be consequently sufficient to misclassify patients into different CIMT categories. A meticulous and detailed measurement protocol needs to be in place when using CIMT. In light of these considerations, the CIMT data and related conclusions of Weerarathna et al.’s study [1] should be analyzed with caution.