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Year : 2019  |  Volume : 32  |  Issue : 1  |  Page : 14-17

Aortic stiffness is increased with premature coronary artery disease: a tissue Doppler imaging study

Department of Cardiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission25-Aug-2017
Date of Acceptance11-Nov-2017
Date of Web Publication17-Apr-2019

Correspondence Address:
Nader Nabil
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mmj.mmj_569_17

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The objective of this study was to review the relationship of the aortic wall structure velocities evaluated by tissue Doppler imaging echocardiography in coronary artery disease (CAD).
Materials and methods
Data resources included Medline directories (PubMed, Medscape, Research Direct) and all material available in the internet from 1985 to 2017. The original search offered 104 articles, of which 47 fulfilled the inclusion standards. The articles analyzed aortic rigidity in patients with early CAD. Studies that did not fulfill the inclusion criteria were excluded. Research quality evaluation included determining whether honest authorization was gained, eligibility conditions were specified, appropriate settings were used, enough information was present, and whether assessment measures were described. Evaluations were created by organized review with the results tabulated.
Altogether, 47 possibly relevant magazines were included. The studies suggested that aortic rigidity is increased in patients with early CAD.
Increased aortic rigidity has been named a predictor of cardiovascular incidents. Our conclusions verify this finding. Pulse-wave tissue Doppler imaging of the ascending aorta is an easily available way for estimating aortic flexible properties, and early aortic velocities are correlated with recently defined variables of aortic rigidity. Thus, early aortic velocities may show increased aortic rigidity in patients with early CAD. The medical use of the parameter needs further investigation.

Keywords: aortic, ascending aorta, coronary artery disease, echocardiography, structure

How to cite this article:
Emara AM, El Shafey WE, Nabil N. Aortic stiffness is increased with premature coronary artery disease: a tissue Doppler imaging study. Menoufia Med J 2019;32:14-7

How to cite this URL:
Emara AM, El Shafey WE, Nabil N. Aortic stiffness is increased with premature coronary artery disease: a tissue Doppler imaging study. Menoufia Med J [serial online] 2019 [cited 2020 Sep 22];32:14-7. Available from: http://www.mmj.eg.net/text.asp?2019/32/1/14/256126

  Introduction Top

The normal aging process is associated with a rise in vascular rigidity, which is accelerated by atherosclerosis, hypertension, and diabetes mellitus. It has been discovered that increased aortic rigidity is a risk factor for cardiovascular (CV) diseases and is a predictor of CV morbidity and mortality. Furthermore, arterial stiffening is increased in people with a family background of early coronary artery disease (CAD), which might indicate a hereditary predisposition to CAD [1].

Arterial stiffness, regarded as an unbiased predictor of all-cause and CV mortality in hypertensive patients, is recommended as an instrument for the evaluation of subclinical organ damage [2].

Arterial rigidity has a primary effect on the hemodynamics of coronary blood flow. It causes an elevated pulse pressure, which results in a far more pulsatile flow than the laminar circulation, and thus reduces the coronary perfusion during diastole. Furthermore, an increased pulse pressure may increase both preload and after-fill of kept ventricle, eventually promoting kept ventricle hypertrophy and subendocardial ischemia [3]. Clinically, arterial elasticity can be assessed by several systems including arteriography, MRI, computed tomography angiography, and pulse-wave velocity (PWV) [2].

However, allergy to the contrasting agent and potential risk of radiation limits the use of some methods. Doppler echocardiographic technology is beneficial for the reason that it is a straightforward, noninvasive, nonradioactive, financial, and highly repeatable imaging modality. Tissue Doppler imaging (TDI) is an ultrasound technology developed to look at the low-velocity movement of tissues. Previously, it has been shown that TDI is a good tool to assess arterial rigidity [4].

However, the immediate correlation of CAD is hard to look at as almost all of these patients are old and also have comorbidities such as hypertension and diabetes mellitus. Analysis of these variables in patients with early CAD may produce valuable information as almost all of these patients do not have confounding factors that increase aortic rigidity. Thus, the purpose of this research was to search the relationship of the aortic wall membrane velocities evaluated by TDI echocardiography with CAD. It offers a revision on the overall relationship of aortic rigidity evaluated by TDI echocardiography with CAD.

  Materials and Methods Top

Search strategy

We examined papers on TDI in the evaluation of aortic rigidity in CAD from digital databases: Thrombosis consultant (A Venous and Arterial Thrombosis Source For Healthcare Experts), JACC (Journal of the American College of Cardiology), Medscape, Blood Circulation, Pathology describes website, American Journal of Hypertension, and Journal of Cardiology. We used aortic rigidity/early CAD and aortic rigidity/TDI. Furthermore, the search was performed in the digital directories from 1985 to 2017. The ethical Committee of the faculty of medicine Menoufia university accepted the study.

Study selection

All of the studies were individually assessed for addition. These were included if they fulfilled the next criteria:

  1. Published in British language

    1. Released in peer-reviewed publications
    2. Targeted on the relationship between of aortic rigidity evaluated by TDI echocardiography with CAD
    3. If a report had several magazines on certain aspects, we used the latest publication providing the most relevant data.

Data removal

Studies that did not match the above criteria were excluded: articles without peer-review, not within nationwide research program, character comments, and studies not centered on the relationship between aortic rigidity and early CAD.

Quality evaluation

The grade of all the studies was evaluated. Critical indicators included research design, attainment of honest approval, proof of a power computation, specified eligibility requirements, appropriate controls, satisfactory information, and given assessment measures. It had been expected that confounding factors would be reported and handled for and appropriate data evaluation manufactured in addition to a conclusion of lacking data.

Data synthesis

An organized review was performed with the results tabulated.

  Results Top

Data sources included English language citation in the past 30 years from the database of abstracts of reviews from 1985 to 2017 updates from expert reviews and literature surveillance. A total of 47 studies were included in the review, as they were deemed eligible by fulfilling the inclusion criteria. This article presents 17 accepted studies (all were published in English) reporting findings on tissue Doppler and aortic stiffness (AS) in CAD. These studies form the basis of our best evidence synthesis. The majority of the studies discussed the role of tissue Doppler in the diagnosis of AS and its role in prediction of CAD. The studies were analyzed with respect to the study design using the classification of the U.S. Preventive Services Task Force and UK National Health Service protocol for evidence-based medicine [Figure 1].
Figure 1: Flowchart of study selection.

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Role of tissue Doppler imaging in evaluation of aortic rigidity in coronary artery disease

The role of TDI in evaluation of aortic rigidity in CAD was looked into in five studies [Table 1].
Table 1: Tissue Doppler and aortic stiffness in coronary artery disease

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  Discussion Top

Arterial stiffness occurs as a consequence of biological aging and arteriosclerosis. Increased arterial stiffness is associated with an increased risk of CV events such as myocardial infarction and stroke, the two leading causes of death in the developed world [9].

It has been revealed that increased AS is a risk factor for CV diseases and also is a predictor of CV morbidity and mortality [10].

However, studies looking into the direct relationship between arterial stiffening and anatomical steps of atherosclerosis (such as carotid intima width) have reported contradictory results [10],[11].

Mulders et al. [1] demonstrated that PWV is increased in people with a positive family history for premature CAD. The creators figured that PWV measurements can be used in risk stratification of people with a possible hereditary predisposition to premature CAD.

It is not clear whether aortic rigidity is merely a bystander or a dynamic player that accelerates atherosclerotic changes. Carotid–femoral PWV is the greatest validated way for noninvasive quantification of arterial rigidity [12].

Echocardiography and MRI-derived indices of aortic rigidity are also defined and also have shown good relationship with PWV measurements [13].

Lately, Sen et al. [14] reported that aortic propagation velocities are low in CAD patients in comparison with non-CAD individuals and were correlated with aortic rigidity parameters.

Vitarelli et al. [5] demonstrated that aortic rigidity index, aortic systolic velocity (SAo), early aortic velocity (EAo), and aortic wall structure peak systolic radial pressure were statistically low in hypertensive patients in comparison with the control group.

In another research, aortic pressure, aortic distensibility, and SAo and EAo velocities of ascending aorta were significantly low in individuals with CAD and diabetes mellitus. The relationship of SAo, EAo, and late aortic velocities with left ventricular ejection fraction and stroke amount is not more developed [15].

Güngör et al. [6] explained that even though left ventricular ejection fraction was low in the CAD group, in subgroup evaluation they discovered that EAo velocities were low in individuals with CAD and maintained left ventricular systolic function set alongside the controls.

Previously, the relationship of ejection fraction with SAo velocities has been proven. This correlation is reasonable as the heart stroke volume mainly triggers enlargement of the aorta, which is displayed as the SAo speed in aortic TDI evaluation [15].

Güngör et al. [6] discovered that SAo velocities were similar in the CAD and control groupings, which might show that the result of reduced ejection fraction was little in their evaluations. In addition, they demonstrated that in individuals with early CAD aortic rigidity index was higher and aortic distensibility was lower, indicating arterial stiffening in this patient population. Furthermore, a pulse-wave TDI parameter, early on diastolic speed, EAo was significantly low in the CAD group. In multivariate logistic regression analysis, EAo speed and high-density lipoprotein cholesterol levels were correlated with premature CAD. The rate of recurrence of hypertension and diabetes mellitus, which might cause arterial stiffening, was lower in the study population. Lack of confounding factors in the analysis groups has led to better interpretation of the relationship of CAD [6].

The medical use of aortic rigidity variables in CV disease risk prediction may be age-related and also have higher prognostic value in more youthful individuals aged less than 65 years [16].

  Conclusion Top

We found a relationship between M-mode and pulse-wave TDI guidelines of ascending aorta with early development of CAD.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Mulders TA, van den Bogaard B, Bakker A, Trip MD, Stroes ES, van den Born BJ, et al. Arterial stiffness is increased in families with premature coronary artery disease. Heart 2012; 98:490–494.  Back to cited text no. 1
Laurent S, Cockcroft J, van Bortel L, Boutouyrie P, Giannattasio C, Hayoz D, et al. European Network for non-invasive investigation of large arteries. Expert consensus document on arterial stiffness: methodological issues and clinical applications. Eur Heart J 2006; 27:2588–2605.  Back to cited text no. 2
Mottram PM, Haluska BA, Leano R, Carlier S, Case C, Marwick TH. Relation of arterial stiffness to diastolic dysfunction in hypertensive heart disease. Heart 2005; 91:1551–1556.  Back to cited text no. 3
Lu Q, Liu H. Correlation of ascending aorta elasticity and the severity of coronary artery stenosis in hypertensive patients with coronary heart disease assessed by M-mode and tissue Doppler echocardiography'. Cell Biochem Biophys 2015; 71:785–788.  Back to cited text no. 4
Vitarelli A, Giordano M, Germanò G, Pergolini M, Cicconetti P, Tomei F, et al. Assessment of ascending aorta wall stiffness in hypertensive patients by tissue Doppler imaging and strain Doppler echocardiography. Heart 2010; 96:1469–1474.  Back to cited text no. 5
Güngör B, Yilmaz H, Ekmekçi A, Özcan KS, Tijani M, Osmonov D, et al. Aortic stiffness is increased in patients with premature coronary artery disease: a tissue Doppler imaging study. J Cardiol 2014; 63:223–229.  Back to cited text no. 6
Yurtdaş M, Gen R, Özcan T, Aydın KMA. Assessment of the elasticity properties of the ascending aorta in patients with subclinical hypothyroidism by tissue Doppler imaging. Arq Bras Endocrinol Metabol 2013; 57:132–138.  Back to cited text no. 7
Eryol NK, Topsakal R, Ciçek Y, Abaci A, Oguzhan A, Basar E, et al. Color Doppler tissue imaging in assessing the elastic properties of the aorta and in predicting coronary artery disease. Jpn Heart J 2002; 43:219–230.  Back to cited text no. 8
Dietz J. Arterial stiffness and extracellular matrix. Adv Cardiol 2007; 44:76–95.  Back to cited text no. 9
Laurent S, Boutouyrie P, Asmar R, Gautier I, Laloux B, Guize L, et al. Aortic stiffness is an independent predictor of all-cause and cardio-vascular mortality in hypertensive patients. Hypertension 2001; 37:1236–1241.  Back to cited text no. 10
Blacher J, Guerin AP, Pannier B, Marchais SJ, Safar ME, London GM. Impact of aortic stiffness on survival in end-stage renal disease. Circulation 1999; 99:2434–2439.  Back to cited text no. 11
Asmar R, Benetos A, Topouchian J, Laurent P, Pannier B, Brisac AM, et al. Assessment of arterial distensibility by automatic pulse wave velocity measurement. Validation and clinical application studies. Hypertension 1995; 26:485–490.  Back to cited text no. 12
Redheuil A, Yu WC, Wu CO, Mousseaux E, de Cesare A, Yan R, et al. Reduced ascending aortic strain and distensibility: earliest manifestations of vascular aging in humans. Hypertension 2010; 55:319–326.  Back to cited text no. 13
Sen T, Tufekcioglu O, Ozdemir M, Tuncez A, Uygur B, Golbasi Z, et al. New echocardiographic parameter of aortic stiffness and atherosclerosis in patients with coronary artery disease: aortic propagation velocity. J Cardiol 2013; 62:236–240.  Back to cited text no. 14
Mahfouz BH, Elnoamany M. Impact of type 2 diabetes mellitus on aortic elastic properties in normotensive diabetes: doppler tissue imaging study. J Am Soc Echocardiogr 2006; 19:1471–1481.  Back to cited text no. 15
Cho SW, Kim BK, Kim JH, Byun YS, Goh CW, Rhee KJ, et al. Non-invasively measured aortic wave reflection and pulse pressure amplification are related to the severity of coronary artery disease. J Cardiol 2013; 62:131–137.  Back to cited text no. 16


  [Figure 1]

  [Table 1]


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