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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 1  |  Page : 30-38

A comparative analysis of sonographic carotid artery Doppler indices in type 2 diabetics and non-diabetics


1 Department of Radiology, Lagos State University Teaching Hospital, Lagos, Nigeria
2 Obstetrics and Gynaecology, Lagos State University College of Medicine and Teaching Hospital, Lagos, Nigeria
3 Department of Obstetrics and Gynecology, Lagos State University Teaching Hospital, Lagos, Nigeria

Date of Submission12-Jun-2021
Date of Acceptance16-Jul-2021
Date of Web Publication14-Oct-2021

Correspondence Address:
Dr. Faosat Olayiwola Jinadu
Department of Radiology, Lagos State University Teaching Hospital, Lagos.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jhrr.jhrr_10_21

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  Abstract 

Background and Aim: Diabetes mellitus type 2 is a chronic metabolic disorder of global concern with signs of hyperglycemia due to insulin resistance, relative lack of insulin, or both. Stroke is a possible complication of this metabolic disorder as a result of advanced carotid artery atherosclerosis, which diabetic patients develop with attendant carotid blood flow changes. The present study evaluated sonographic carotid artery blood flow velocities in individuals with type 2 diabetics and compared with values in normoglycemic controls. Materials and Methods: This was a prospective case–control study, in which we evaluated carotid Doppler indices in 125 consenting confirmed type 2 diabetics (cases) and 125 age- and gender-matched normoglycemic healthy controls for a period of 6 months (October 2019 to March 2020). The diabetics (cases) were recruited using systematic sampling method and the controls via convenience sampling. Demographic data and anthropometric measurements as well as ultrasound findings were entered into a Microsoft Office Excel Database and analyzed using International Business Machines (IBM) Statistical Package for Social Sciences (SPSS) Version 21. Tables, scatter-plot graphs, and bar charts were used in showing and evaluating the findings. Pearson’s correlation coefficient was used to assess correlation between two continuous variables. Results: The mean age of type 2 diabetics was 67.06±9.8 years, whereas that of the non-diabetics was 66.98±10.7. Females were in majority in both groups (64 in diabetics and 70 in non-diabetics). There were 61 males in the diabetics and 55 males in the non-diabetics. The mean carotid blood flow velocities in the diabetics and non-diabetics were, respectively, as follows: common carotid artery (CCA) end-diastolic velocity (EDV) 21.03±2.3 and 25.22±2.5, CCA peak systolic velocity (PSV) 81.70±4.1 and 83.60±3.6, internal carotid artery (ICA) EDV 17.99±5.6 and 21.57±2.0, ICA PSV 69.30±5.1 and 73.87±2.1, and ICA/CCA PSV ratio 0.83±01 and 0.91±0.1. Conclusion: Type 2 diabetics had significantly lower carotid blood flow velocities than non-diabetics. This suggests that proper management and compliance with care may reduce the development of features of atherosclerosis in type 2 diabetics.

Keywords: Carotid blood flow velocities, carotid Doppler indices, diabetes mellitus


How to cite this article:
Nwokorie EC, Jinadu FO, Ottun TA, Olumodeji AM. A comparative analysis of sonographic carotid artery Doppler indices in type 2 diabetics and non-diabetics. J Health Res Rev 2022;9:30-8

How to cite this URL:
Nwokorie EC, Jinadu FO, Ottun TA, Olumodeji AM. A comparative analysis of sonographic carotid artery Doppler indices in type 2 diabetics and non-diabetics. J Health Res Rev [serial online] 2022 [cited 2024 Mar 2];9:30-8. Available from: https://www.jhrr.org/text.asp?2022/9/1/30/328254


  Introduction Top


Diabetes mellitus (DM) is a metabolic disorder characterized by the chronic presence of hyperglycemia due to defective insulin secretion, defective insulin action, or both.[1] DM is a leading cause of morbidity and mortality world over.[2] The prevalence of DM has been increasing steadily all over the world.[3] The prevalence of DM is expected to rise in the developing countries of Asia and Africa due to urbanization, obesity, and increased body weight, and the rise in prevalence is more for type 2 than for type 1.[2]

Generally, the injurious effects of DM are separated into macrovascular (stroke, coronary artery disease, and peripheral arterial disease) and microvascular complications, which include diabetic nephropathy, neuropathy, and retinopathy.[4] Though there is an average asymptomatic period of 5 years, many type 2 diabetics present clinically with complications, and ischemic stroke risk triples with diabetes ≥ 10 years.[5] Macrovascular complications of diabetes are mainly represented by atherosclerotic disease, which develops over the course of 50 years and progresses faster in patients with DM.[6]

Atherosclerotic lesions appear earlier in diabetics than in the general population; are more extensive; and are more often associated with complicated plaques such as ulceration, calcification, and thrombosis.[2] Atherosclerotic complication of DM leading to stenosis with its attendant blood flow changes commonly affects carotid arteries which can be assessed by imaging modalities.[7] It is known that there is an association between ischemic stroke and carotid artery stenosis with diabetics being three times more likely to develop carotid stenosis than non-diabetics.[8]

Atherosclerosis, a cause of carotid artery blood flow velocity changes and stenosis, has a predilection for extracranial carotid artery.[9] Duplex Doppler ultrasound (DUS) examination which assesses blood flow velocity is basic for the diagnosis of extracranial carotid artery stenosis.[10] Peak systolic velocity (PSV), end-diastolic velocity (EDV), as well as internal carotid artery/common carotid artery PSV ratio (ICA/CCA PSV ratio) are important blood flow velocity parameters (Doppler indices) assessed on DUS, and blood flow velocity is used to evaluate the severity of carotid stenosis.[11] DUS is the most used of all imaging modalities available for carotid arterial stenosis diagnosis[12] because it requires no radiation or intravenous contrast and is inexpensive when compared with computed tomography angiography and magnetic resonance angiography.

PSV and EDV are important parameters in the assessment of carotid artery stenosis, and they can be assessed with the aid of Doppler waveform analysis.[13] Society of Radiologists in Ultrasound developed a consensus for the diagnosis and stratification of ICA stenosis:[14] normal ICA PSV is <125 cm/s with no plaque or intimal thickening seen sonographically and additional criteria include ICA/CCA PSV ratio <2.0 and ICA EDV <40 cm/s; for <50% ICA stenosis PSV is < 125 cm/s with plaque or intimal thickening visible sonographically and additional criteria include ICA/CCA PSV ratio <2.0 and ICA EDV <40 cm/s; for 50–69% ICA stenosis, PSV is 125–230 cm/s with plaque seen sonographically.

Due to the increasing prevalence of type 2 DM and its attendant complications, this study evaluated carotid artery blood flow velocities (EDV, PSV, and ICA/CCA PSV ratio) in individuals with type 2 diabetics and compared the same with values in normoglycemic controls.


  Materials and Methods Top


This was a hospital-based, prospective, case–control study in the Lagos State University Teaching Hospital over a 6-month period (from October 1, 2019 to March 31, 2020). The study population included consenting confirmed type 2 diabetics, being managed by the endocrinology clinic of the LASUTH, Ikeja, who met the inclusion criteria. The control group comprised members of staff and general outpatient attendees who volunteered and met the inclusion criteria. Both groups were age (±1)- and gender-matched.

The study inclusion criteria consisted of individuals with confirmed type 2 DM (as cases) and non-diabetics (as controls), who were non-hypertensive [blood pressure (BP) <140/90 mmHg] and 18 years and above in age. Individuals with hyperlipidemia, known hypertensive (BP ≥ 140/90 mmHg), with history of use of oral contraceptives within a year prior to the study, who refused to consent, with clinical evidence of heart failure or stroke, pregnancy, cigarette smoking, near occlusion of the carotid vessels, total occlusion of the carotid vessels or neck scars or wounds were excluded from the study. The controls who met the inclusion criteria were drawn consecutively at random from volunteers (members of staff of the hospital and general outpatient department attendees).

Technique

Screening of the volunteers was done using Accu-Chek Active Glucometer (Ser-No. GB06183755, Art No. 0699377001). Any volunteer with a fasting blood glucose value equal or greater than 7.0 mmol/L (126 mg/dL) was excluded from the study. The BP of all the participants was measured using a mercury sphygmomanometer (Accoson, England). Participants with BP of <140/90 mmHg or who were not known hypertensives were recruited into the study.

To screen for hyperlipidemia, the procedure was explained to all the participants and consent was obtained from them. They were instructed to fast for at least 10 h overnight after which venous blood was collected under aseptic condition. Fully Automated Clinical Chemistry Analyser (Miura 200, Italy) was used in the laboratory to assay the lipid profile components: total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides. Participants with either or all components higher than normal were excluded from this study.

The participants’ BP was measured after 5 min rest in a sitting position using a mercury sphygmomanometer (Accoson, England) with appropriate cuff size. The BP was recorded in millimeter mercury (mmHg). Following overnight fasting, Accu-Chek Active Glucometer (Ser-No. GB06183755, Art No. 0699377001) with Accu-Chek Active test strips was used to screen the controls for hyperglycemia under aseptic conditions. A properly calibrated high-quality universal portable weight scale (Bangalore) was used to measure weights of all the participants in kilograms (kg) with light clothing and without shoes. The participants’ height in meters (m) was measured without shoes, caps, or head tie using a stadiometer with the participant in the erect position and backing the rule. These measurements were documented in the study proforma. Body mass index (BMI) was calculated as weight/height.[2] According to Truswell,[15] BMI was graded as: underweight (<18.50), normal weight (18.50–24.99), overweight (25.00–29.99), obese (≥30).

Extracranial carotid artery ultrasound scans

Carotid artery scan was done, using a high-resolution General Electric Logiq C5 Premium machine (China, 2015) with a linear probe frequency range of 6–12 MHz with Doppler facility, by a single radiologist designated by the researchers to prevent inter-observer errors. This examination took an average of 35 min per participant, and each participant rested for 5–10 min prior to the examination.

Participants removed anything that may interfere with the scanning such as necklace and lie supine with their head slightly hyper-extended using a pillow and neck rotated 45° away from the side under study to ensure adequate exposure of the neck. Acoustic gel was applied on the neck skin to remove air to ensure good ultrasound waves transmission.

On B-mode, the CCA was located lateral to the thyroid gland and medial to the internal jugular vein in the transverse plane above the clavicle and the linear probe was directed caudally to display as much of the CCA as possible. The probe was then rotated through 90o into longitudinal plane to follow the artery distally until it bifurcates into ICA posteriorly and external carotid artery anteriorly.

The probe was moved posteriorly and laterally to locate ICA which was assessed in longitudinal and transverse planes. Pulsed Doppler scan in the longitudinal plane was done after initial color Doppler assessment for the carotid arteries course and patency. The pulse repetition frequency (PRF) in pulsed Doppler was the same as in color Doppler, and the lowest possible PRF without velocity aliasing was used.[16] Sample gate of 2–3 mm was used. Optimal Doppler settings of gain, steer, focus, frequency, and wall filter were employed with the angle of insonation less than 60°.[17]

Image acquisition

On placement of pulsed wave Doppler sample gate in the center of vessel of interest with proper Doppler settings, the blood velocities were measured at three points 2 cm proximal to the CCA bulb and 2 cm above the bulb in the ICA. This was to avoid turbulent flow in the region of CCA bifurcation. Three consecutive Doppler wave forms of the same pattern were considered as the correct spectral pattern.

On a frozen image, the spectral wave pattern generated was used to measure PSV at the forward peak of the systolic component and EDV at the end of the diastolic component [Figure 1] and [Figure 2] on both sides. The mean of the velocities were calculated and recorded.
Figure 1: Ultrasound image showing normal spectral Doppler velocity waveform in the right ICA and points of estimation (calipers) of PSV and EDV

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Figure 2: Ultrasound image showing normal spectral Doppler velocity waveform in the right CCA and points of estimation (calipers) of PSV and EDV

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Statistical analysis

The demographic data and anthropometric measurements with ultrasound findings were entered in a Microsoft Office Excel database. Analysis was done using International Business Machines (IBM) Statistical Package for Social Sciences (SPSS) version 21 (New York, USA). Continuous variables were shown as mean ± standard deviation (M±SD). Categorical variables were shown as percentages. The mean of two continuous variables was compared using independent Student’s t-test and that of more than two variables using analysis of variance (ANOVA) F-test at 5% level of significance. Probability value (P-value) less than 0.05 was deemed significant. The variables were represented in tables, scatter-plot graphs, and bar charts. Pearson’s correlation coefficient was used to assess correlation between two continuous variables. Ethical approval was obtained from the Health Research and Ethics Committee of the Lagos State University Teaching Hospital.


  Results Top


One hundred and twenty five (125) consenting confirmed type 2 diabetics had CCA ultrasound evaluation of blood flow velocities. There were more females in both groups (diabetics 64; non-diabetics 70). The mean ages of the participants were 67.06±9.8 and 66.98±10.2 for the diabetics and non-diabetics, respectively. More of the diabetics were overweight (52) and obese (38) when compared with the non-diabetics (48) and (28), respectively [Table 1].
Table 1: Socio-demographic data of participants

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The carotid blood flow velocities were significantly lower in the diabetics (P < 0.001) [Table 2]. Males had significantly higher CCA EDV on the right and left in the diabetics. Similar values were seen in the non-diabetics, though not significant. The age group ≥ 80 years had significantly lower right CCA EDV and left CCA EDV in the diabetics (right P < 0.001, left P < 0.001). The non-diabetics age group 50–59 years had significant lower right CCA EDV and left CCA EDV (right P < 0.001, left P < 0.001). Obese individuals had lower CCA EDV values than the overweight in both groups, and these were significant on both sides in the diabetics (right P < 0.001, left P = 0.002) and on the right in the non-diabetics (P = 0.015) [Table 3].
Table 2: Mean comparison of carotid blood flow velocities in type 2 diabetics and non-diabetics

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Table 3: Mean comparison of CCA EDV according to gender, age group, and BMI in type 2 diabetics and non-diabetics

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The male diabetics had significantly lower CCA PSV values on the right (P = 0.007), whereas on the left, the females had significantly lower values (P < 0.001). It also showed that the males had significantly lower values in the non-diabetics on both sides (right P = 0.004 and left P = 0.002). Considering the age relationship, the age group ≥80 years had significantly lower right CCA PSV and left CCA PSV in the diabetics (right P < 0.001 and left P < 0.001), whereas significantly lower right CCA PSV and left CCA PSV were seen in the age group 40–49 years in the non-diabetics (right P < 0.001 and left P < 0.001). Significantly lower right CCA PSV and left CCA PSV were observed in the obese in the diabetics (right P = 0.042 and left P = 0.034). Similar observations were also seen on the left CCA PSV in the non-diabetics (P < 0.001) [Table 4].
Table 4: Mean comparison of CCA PSV according to gender, age group, and BMI in type 2 diabetics and non-diabetics

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The right ICA/CCA PSV ratio was significantly higher in the male non-diabetics (P ≤ 0.001). However, no significant change was seen on the left side between males and females (P = 0.960) in the non-diabetics. Similarly, no significant change was seen on the right side between males and females in the diabetics (P = 0.659). [Table 5] showed significantly higher ICA/CCA PSV ratio on both sides in the age group 40–49 years in the diabetics (right P < 0.001, left P = 0.002). Similarly, significantly higher left ICA/CCA PSV ratio was seen in the age group ≥ 80 in the diabetics. In addition, significantly higher ICA/CCA PSV ratio was seen on both sides in the age group 40–49 years in the non-diabetics (right P < 0.001, left P < 0.001). A significantly higher left ICA/CCA PSV ratio was seen in the age group ≥80 in the non-diabetics (P < 0.001). Also observed was non-significantly lower right ICA/CCA PSV ratio in the overweight in both groups (diabetics P = 0.692; non-diabetics P = 0.072).
Table 5: Mean comparison of ICA/CCA PSV ratio according to gender, age group, and BMI in type 2 diabetics and non-diabetics

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The mean duration of type 2 diabetes was 7.56 ± 1.6 years. The majority of type 2 diabetic participants had 7 years of duration of diabetes [Figure 3]. There was a negative non-significant correlation of CCA EDV with duration of diabetes (P = 0.185, r = −0.336) [Figure 4]. There was a positive non-significant correlation of CCA PSV with duration of diabetes (P = 0.0561, r=0.145) [Figure 5].
Figure 3: Histogram illustrating frequency distribution of duration of type 2 diabetes. Pearson’s correlation coefficient r= −0.336, P = 0.185

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Figure 4: Scatter-plot graph illustrating association of CCA EDV with duration of type 2 DM. Pearson’s correlation coefficient r= 0.145, P = 0.0561

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Figure 5: Scatter-plot graph illustrating association of CCA PSV with duration of type 2 diabetes

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  Discussion Top


The PSV and EDV are important parameters in the assessment of carotid artery stenosis and they can be assessed with the aid of Doppler waveform analysis.[13] Type 2 diabetes is a risk factor for carotid artery stenosis and a previous study done by AL-Equabi et al.[18] in Baghdad, Iraq involving 100 type 2 diabetics and 40 healthy adults, showed that ICA EDV is significantly lower in the diabetics than in the non-diabetics. This is in concordance with this study which found significantly lower ICA EDV in the diabetics (P < 0.001).

We also found that ICA PSV was significantly lower in the type 2 diabetics (P < 0.001). This is at variance with the findings by AL-Equabi et al.,[18] in which no significant difference was found in ICA PSV of diabetics and non-diabetics. This variation may have been due to our relatively smaller sample size.

The carotid blood flow velocities (CCA EDV, CCA PSV, CCA EDV, ICA PSV) in this study were observed to decrease significantly with age in the non-diabetics (P < 0.001). This is in consonance with reports by Yazici et al.[19] in Turkey involving 96 healthy adults, Scheel et al.[20] in Germany, and Özdemir et al.[21] in Turkey.

The CCA EDV, CCA PSV, and ICA EDV, all decreased significantly with higher BMI in the type 2 diabetics and controls. This is in concordance with the studies done by Güner et al.[22] and Özdemir et al.,[21] both of which revealed that carotid PSV and EDV were significantly lower in subjects with high BMI. The ICA/CCA PSV ratio increased significantly with age in the non-diabetics (P < 0.001). This is in disagreement with the study done by Kochanowicz et al.[23] among healthy subjects in Poland. They reported that the ICA/CCA PSV ratio increased non-significantly with age. This difference may have been racial in origin because their study was conducted in Poland. The carotid blood flow velocities showed non-significant correlation to duration of diabetes.

In conclusion, we observed that carotid arteries PSV values in type 2 diabetics and non-diabetics were similar. This suggests that adequate management of diabetics is associated with reduced risk of development of subclinical atherosclerosis. A study limitation was the lack of an objective assessment of drug compliance in the diabetics recruited to allow for further interpretation of our findings.

Acknowledgements

Nil.

Financial support and sponsorship

Nil.

Conflicts of interest

The authors report no conflict of interest.

Ethical policy and institutional review board statement

Ethical approval for this study was obtained from the Health Research and Ethics committee of the Lagos State University Teaching Hospital with Reference number LREC/06/10/1106.

Patient declaration of consent

Informed written consent was obtained from all the patients who took part in the study.

 
  References Top

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
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