Relation of carotid artery diameter with cardiac geometry and mechanics in heart failure with preserved ejection fraction

Abstract

Background: Central artery dilation and remodeling are associated with higher heart failure and cardiovascular risks. However, data regarding carotid artery diameter from hypertension to heart failure have remained elusive. We sought to investigate this issue by examining the association between carotid artery diameter and surrogates of ventricular dysfunction.

Methods and results: Two hundred thirteen consecutive patients including 49 with heart failure and preserved ejection fraction (HFpEF), 116 with hypertension, and an additional 48 healthy participants underwent comprehensive echocardiography and tissue Doppler imaging. Ultrasonography of the common carotid arteries was performed for measurement of intima-media thickness and diameter (CCAD). Cardiac mechanics, including LV twist, were assessed by novel speckle-tracking software. A substantial graded enlargement of CCAD was observed across all 3 groups (6.8 ± 0.6, 7.7 ± 0.73, and 8.7 ± 0.95 mm for normal, hypertension, and HFpEF groups, respectively; ANOVA P<0.001) and correlated with serum brain natriuretic peptide level (R(2)=0.31, P<0.001). Multivariable models showed that CCAD was associated with increased LV mass, LV mass-to-volume ratio (β-coefficient=10.9 and 0.11, both P<0.001), reduced LV longitudinal and radial strain (β-coeffficient=0.81 and -3.1, both P<0.05), and twist (β-coefficient=-0.84, P<0.05). CCAD set at 8.07 mm as a cut-off had a 77.6% sensitivity, 82.3% specificity, and area under the receiver operating characteristic curves (AUROC) of 0.86 (95% CI 0.80 to 0.92) in discriminating HFpEF. In addition, CCAD superimposed on myocardial deformation significantly expanded AUROC (for longitudinal strain, from 0.84 to 0.90, P of ΔAUROC=0.02) in heart failure discrimination models.

Conclusions: Increased carotid artery diameter is associated with worse LV geometry, higher brain natriuretic peptide level, and reduced contractile mechanics in individuals with HFpEF.

Keywords: cardiac mechanics; carotid artery diameter; heart failure; hypertension; remodeling; strain.

Figure 1.

(A) The exact site and annotation for measurements of the common coronary artery diameter (CCAD) (yellow arrow; intima‐media thickness [IMT], green arrow) and aortic root diameters, and the corresponding computed tomography scanning for validation of echocardiographic measurements in healthy control subjects (top) and patients with heart failure with preserved ejection fraction (HFpEF) (bottom). (B) A bull's‐eye illustration of integrated 3‐apical views of longitudinal strain by AFI (represented as GLS: left), as well as corresponding radial strain (left ventricular [LV] mid‐wall: middle) and degree of LV twist (right). GLS indicates global longitudinal strain; AFI, automatic function imaging.

Figure 2.

(A) Individual central artery intima‐media thickness (IMT), diameters, and remodeling. Both the hypertension (HTN) and heart failure with preserved ejection fraction (HFpEF) groups had higher IMT than the control group. Patients with HFpEF had significantly greater carotid artery diameters compared with both the control and HTN groups. The common carotid artery (CCA) remodeling (IMT‐to‐diameter ratio) was largest in the HTN group, indicating that the increase in the CCA diameter was greater than the increased IMT. The central artery compliance, ventriculoarterial coupling, and wall stress for both the carotid artery and left ventricular wall are shown (B, top). The fitting curve or linear regression used for comparison of the central pulse pressure (PP) and CCA diameter (left) and, central PP and arterial compliance, among study patients is shown (A, bottom). Compared with the healthy control and HTN groups, subjects with HFpEF had larger central artery pressure related to larger carotid artery diameter and poorer arterial compliance. SV indicates stroke volume.

Figure 3.

The area under the receiver operating characteristic curves used for diagnosing heart failure with preserved ejection fraction (HFpEF), based on 3 different modalities. A, Carotid artery intima‐media thickness (IMT), diameter, and remodeling were used. B, Left ventricular ejection fraction (LV EF) and diastolic measurements, including the lateral mitral annulus early diastolic velocity (E′), early mitral inflow velocity (E), and their ratio (E/E′), as well as carotid artery diameter superimposed on E/E′, are shown. C, Myocardial mechanics including longitudinal, radial, and circumferential strain (S) and LV twist are shown, as well with carotid artery diameter superimposed on longitudinal strain. The scatterplot between serum brain natriuretic peptide (BNP) level and common carotid artery diameter (CCAD) was further illustrated (D). PP indicates pulse pressure; SV, stroke volume.

Figure 4.

A schematic example of how carotid arterial diameter may change and remodeled in response to chronically elevated pressure load in the transition from hypertension to the development of heart failure is shown. The failure of arterial wall constraint against chronic, elevated high transmural pressure may result in progressively enlarged lumen diameter out of proportion to the compensatory increase of intima‐media thickness and, may ultimately lead to dilated carotid artery.

Figure 5.

(A) The observed AUROC for HFpEF in the original model using longitudinal myocardial deformation (strain) plus CCAD=0.8958. (B) By using 5‐fold cross‐validation, the cross‐validated ROC curve is similar in shape and area under ROC (0.8927) to the one obtained in (A), with goodness‐of‐fit P=0.36.