Hypertension Research (2013) 36, 902–909

& 2013 The Japanese Society of Hypertension All rights reserved 0916-9636/13
www.nature.com/hr

ORIGINAL ARTICLE

Carotid plaque score and intima media thickness as

predictors of stroke and mortality in hypertensive
patients
Tatsuo Kawai, Mitsuru Ohishi, Yasushi Takeya, Miyuki Onishi, Norihisa Ito, Ryosuke Oguro,
Koichi Yamamoto, Kei Kamide and Hiromi Rakugi

The mean intima media thickness (IMT) and plaque score from carotid ultrasonography are both widely used to evaluate
macrovascular atherosclerotic change. The present study sought to examine which parameter more effectively predicts patient
prognosis. This hospital-based cohort study included 356 patients with essential hypertension (mean age: 62.4±0.6). We
investigated how the mean IMT and plaque score correlated with various parameters, including pulse wave velocity (PWV), and
we assessed the ability of the mean IMT and plaque score to predict cardiovascular events and total mortality. The mean IMT
and plaque score significantly correlated with systemic atherosclerotic change, target organ damage, age and PWV. Subjects
with a higher mean IMT and subjects with higher plaque scores showed higher frequencies of stroke and total mortality. In
addition, subjects with marginal thickening of the intima media (meanX0.7) showed a significantly higher frequency of stroke
than subjects with a mean IMT of o0.7. After adjustment for traditional risk factors, plaque score was significantly and
independently predictive of stroke, and the predictive ability of the plaque score for the onset of stroke was equivalent to that
of PWV. The mean IMT and plaque score showed a nonsignificant trend of higher risk of mortality after adjustment for
traditional risk factors. The mean IMT and plaque score were significantly correlated with systemic atherosclerotic change.
We revealed that plaque score predicted the onset of stroke more accurately than the mean IMT, and the accuracy of this
prediction was equivalent to that from PWV in hypertensive patients. We also showed that marginal thickening of the intima
media (as measured by mean IMT) may be a predictor of stroke.
Hypertension Research (2013) 36, 902–909; doi:10.1038/hr.2013.61; published online 4 July 2013

Keywords: cardiovascular disease; carotid ultrasonography; intima media thickness; plaque score; prognosis

INTRODUCTION evaluated by carotid ultrasonography.10,11 However, several

Hypertension is one of the strongest and most prevalent risk factors investigators have suggested that IMT cannot qualitatively evaluate
for cardiovascular diseases (CVDs),1,2 including stroke3 and ischemic atherosclerotic changes, for example, lesions with a necrotic core, and
heart disease.4 To prevent these conditions, we must assess systemic that other parameters should be used to more precisely estimate the
atherosclerotic change during hypertension management. Many atherosclerotic state.12 Studies have also indicated that plaque score is
methods have been reported to be useful for assessing arterial correlated with CVD.13,14 A review suggested that plaque score
functions. For example, the presence of proteinuria or fundic could predict coronary heart disease and might be more
sclerotic change have been reported to reflect microvascular representative of atherosclerosis than mean IMT.15 Furthermore,
atherosclerosis. Similarly, the resistive index has been reported to Ershova et al.16 reported that plaque number, plaque score and
reflect vascular resistance;5 reactive hyperemia has been reported to markers of percent area of stenosis were more sensitive than mean
reflect endothelial function;6 and pulse wave velocity (PWV) has been IMT for cardiovascular risk estimation in patients with familial
reported to reflect arterial stiffness.7 hypercholesterolemia.
Carotid ultrasonography is a simple and noninvasive method that However, it has not been clearly demonstrated which parameter in
is extensively used for evaluating atherosclerotic change8 and is a carotid ultrasonography can best predict patient prognosis in relation
well-studied method for detecting macrovascular atherosclerosis.9 to stroke, coronary heart disease and mortality among hypertensive
Mean intima media thickness (IMT) has been shown to be strongly patients. Previously, we reported that increased aortic stiffness
associated with CVD and has become the most common marker evaluated by carotid-femoral PWV (cfPWV) is more prognostic of

Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, Suita, Japan
Correspondence: Professor M Ohishi, Department of Geriatric Medicine and Nephrology, Osaka University Graduate School of Medicine, 2-2 Yamadaoka (B6), Suita,
Osaka 565-0871, Japan.
E-mail: [email protected]
Received 13 December 2012; revised 6 March 2013; accepted 8 March 2013; published online 4 July 2013
 Carotid plaque score and stroke in hypertension
T Kawai et al
903

cardiovascular events among hypertensive patients than several previously reported;19 to obtain the plaque score, protruding lesions with an
noninvasive atherosclerotic evaluations in a hospital-based cohort IMT X1.1 mm were defined as atheromatous plaque. Plaque score was
study.17 In the current study, we conducted sub-analyses of the same calculated by summing all the plaque thickness measurements in both
cohort as studied in our previous study17 and investigated whether carotid arteries (S1 to S4).
mean IMT and plaque score correlated differently with various
parameters, including PWV. We also assessed the hypothesis Target organ damage and associated clinical conditions
that plaque score was the more sensitive surrogate marker for We evaluated target organ damage (TOD) and associated clinical conditions
systemic atherosclerotic change and could more accurately predict according to the 2007 guidelines for arterial hypertension management from
the European Society of Hypertension and the European Society of
cardiovascular events among hypertensive patients. Furthermore, we
Cardiology.20 Cerebrovascular disease was assessed by brain MRI, CT and
assessed the correlation between marginal thickening of the intima neurological findings. Coronary artery disease was assessed by ECG,
media (as determined by mean IMT) and the onset of cardiovascular echocardiogram and typical symptoms. Lacunar infarcts were evaluated by
events. brain MRI. Patients with diabetes mellitus were diagnosed according to the
following diagnosis criteria of the American Diabetes Association: fasting
METHODS plasma glucose at or above 126 mg dl 1, HbA1c X6.5%, a 2-h value in an oral
Study subjects and study design glucose tolerance test at or above 200 mg dl 1, a random plasma glucose
This hospital-based cohort study was part of the Non-Invasive Atherosclerotic concentration X200 mg dl 1 in the presence of symptoms, or if the patient
Evaluation in Hypertension (NOAH) study,17 in which a total of 813 serial was taking drugs for diabetes. Patients were diagnosed with hyperlipidemia
outpatients who had been diagnosed with essential hypertension were under the following conditions: total cholesterol X220 mg dl 1, low-density
sequentially recruited between January 1998 and June 2004 at Osaka lipoprotein cholesterol X140 mg dl 1, triglycerides X150 mg dl 1, or if the
University Medical Hospital. A total of 356 serial outpatients who had been patient was taking drugs for hyperlipidemia.
diagnosed with essential hypertension and had undergone carotid Doppler
ultrasonography were sequentially recruited in this study. Patients showing PWV measurement
arterial fibrillation or having malignant diseases were excluded. The study We assessed cfPWV as a representative PWV to evaluate arterial stiffness. For
protocol was approved by the hospital ethics committee, and written informed the PWV measurements, participants visited the hospital in the morning and
consent was obtained from all participants. were instructed not to take any antihypertensive drugs, nitrate or aspirin for
8 h preceding their visit. Measurements were performed in a controlled
Follow-up evaluation environment at 22±2 1C with each patient in the supine position after
Clinical follow-up was conducted by clinical visits, mailed questionnaires and 30 min of rest: a model FCP-4731 pulsimeter (Fukuda Denshi, Tokyo, Japan)
telephone contact every September starting in 2003. As we could not contact that allowed on-line pulse wave recording and automatic calculation was used
several subjects or their relatives, the follow-up rate of the NOAH study cohort in accordance with a previously reported method.21 Three measurements were
was 94.3%. taken at intervals of 2 min and averaged. The intra-observer coefficient of
The questionnaire included events related to hypertensive complications and variation was 2.8±1.2%, which was calculated using three measurements each
cause of death. Patient responses were confirmed by checking the responses from seven healthy men.
against patient medical sheets. The primary end points were the following: new
onset of stroke (paralysis and diagnosis with CT and/or MRI); new onset of Statistical analysis
CVD, including angina pectoris (typical chest pain with ST segment changes Data were analyzed using JMP ver. 9.0.1 (SAS, Cary, NC, USA) and are
on electrocardiograms); myocardial infarction (ST segmental elevation and presented as the mean±s.e.m. An event-free curve was estimated using the
42-fold creatinine kinase elevation); heart failure (diagnosed using American Kaplan–Meier method. The Wilcoxon test was used to compare differences in
Heart Association criteria); or rupture of an aortic aneurysm (diagnosed by event-free rates between groups of subjects with different IMT and plaque
ultrasound echography or CT). The average follow-up duration was 6.4±0.2 scores. A Cox proportional hazards model was used to detect the relative risks
years, which was measured as the interval from the initial evaluation to event of IMT and plaque score on the prognoses. Analysis of variance and Student’s
onset or September 2010. t-test were used to test for significant differences among groups of patients
with different mean IMT or plaque scores. A P-value o0.05 was considered
Blood pressure Measurements significant.
Conventional blood pressure measurements were made by trained observers
with an electronic sphygmomanometer (HEM-705IT or HEM-711, OMRON). RESULTS
Following the guidelines for hypertension management, clinic blood pressure During a mean follow-up period of 6.4±0.2 years, 37 individuals had
was measured at least twice in the sitting position after a 5-min rest. If the a stroke, 24 individuals developed CVD and 37 individuals died.
difference between the readings was o5 mm Hg, the average of the two Table 1 shows the baseline clinical characteristics of the patients. First,
readings was recorded. If the difference was 45 mm Hg, additional measure-
we divided our subjects into three groups according to the level of the
ments were performed to obtain stable readings, and the average of two stable
mean IMT (IMTX1.0, n ¼ 85; 1.04IMTX0.7, n ¼ 168; IMTo0.7,
readings was recorded.
n ¼ 103) and compared the characteristics among these three groups.
Subjects with a higher mean IMT showed significantly a higher male-
Renal function
to-female ratio, age, prevalence of diabetes mellitus, plaque score,
Estimated glomerular filtration rate (eGFR) was calculated using the following
equation:
smoking index, and pulse pressure, and they showed a significantly
eGFR (ml min 1 1.73 m 2) ¼ 194  creatinine( 1.094)  age( 0.287) lower eGFR and high-density lipoprotein cholesterol level (Table 1).
(  0.739 if female).18 We also divided the subjects into three groups according to the plaque
score (plaque score ¼ 0, n ¼ 171; 0oplaque scoreo5, n ¼ 116; plaque
Ultrasonographic determination scoreX5, n ¼ 69) and compared the characteristics among these three
A trained technician examined the echocardiograms and carotid ultrasono- groups. Subjects with a higher plaque score showed a significantly
grams (Power Vision 6000; Toshiba, Tokyo, Japan) and used the mean of three higher age, IMT, ratio of current smoking, smoking index,
examinations as a representative measurement. Plaque score and the mean systolic blood pressure, pulse pressure and uric acid, and they showed
IMT of the carotid artery were determined by carotid ultrasonography as a significantly lower eGFR (Table 1).

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 Carotid plaque score and stroke in hypertension
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Table 1 Baseline clinical characteristics of the study population and comparison of baseline characteristics among groups with different mean
IMT/ plaque score

Mean IMT Plaque score

Total o0.7 0.7–1.0 0 P-value 0 0–5 X5 P-value

Number 356 103 168 171 171 116 69

Sex (male/female) 189/167 42/61 88/80 83/88 0.0005 83/88 61/55 45/24 0.0636
Age (years old) 62.4±0.6 56.1±1.2 63.5±0.9 59.4±0.9 o0.0001 59.4±0.9 64.0±1.1 67.4±1.2 o0.0001
BMI (kg m 2) 24.0±0.2 23.6±0.3 23.9±0.3 24.2±0.3 0.3190 24.2±0.3 23.9±0.4 23.5±±0.4 0.4201
Diabetes mellitus (n) 117 (32.9%) 25 (24.3%) 57 (33.9%) 54 (31.6%) 0.0452 54 (31.6%) 37 (31.9%) 26 (37.7%) 0.6367
Dyslipidemia (n) 186 (52.2%) 61 (59.2%) 79 (47.0%) 95 (55.6%) 0.1377 95 (55.6%) 63 (54.3%) 28 (40.6%) 0.0948
eGFR (ml min 1 1.73 m 2) 72.4±1.3 84.2±2.7 68.8±1.6 75.6±1.8 o0.0001 75.6±1.8 72.1±2.6 65.3±2.5 0.0126
Plaque score 2.96±0.25 1.12±0.23 2.84±0.28 0.79±0.01 o0.0001 0.79±0.01 0.83±0.01 0.96±0.02 o0.0001
Current smoking (n) 113 (31.7%) 37 (36.3%) 49 (29.5%) 42 (24.6%) 0.5151 42 (24.6%) 36 (31.0%) 35 (50.7%) 0.0006
Smoking index (n  year) 448.9±33.6 439.2±43.5 474.6±55.5 369.3±51.0 0.0032 369.3±51.0 434.0±52.1 667.5±75.0 0.0038
SBP (mm Hg) 136.4±1.1 134.5±2.0 135.4±1.4 136.4±1.7 0.0621 136.4±1.7 133.3±1.4 141.5±2.6 0.0263
DBP (mm Hg) 80.5±0.6 81.0±1.3 80.0±0.8 81.3±1.0 0.7886 81.3±1.0 79.2±1.0 80.5±1.5 0.3498
Pulse pressure (mm Hg) 56.0±0.8 53.4±1.3 55.3±1.1 55.1±1.1 0.0048 55.1±1.1 54.2±1.2 61.0±1.8 0.0045
Triglyceride (mg dl 1) 142.2±4.8 153.7±11.5 136.6±6.3 150.1±8.4 0.3049 150.1±8.4 137.6±7.2 130.9±6.4 0.2667
HDL cholesterol (mg dl 1) 54.6±0.8 57.5±1.7 55.3±1.2 55.3±1.2 0.0014 55.3±1.2 55.9±1.6 50.6±1.6 0.0585
LDL cholesterol (mg dl 1) 120.9±1.8 117.0±4.1 120.8±2.5 117.8±2.5 0.1962 117.8±2.5 124.2±3.4 122.9±4.0 0.2587
Uric acid (mg dl 1) 5.4±0.1 5.1±0.2 5.5±0.1 5.1±0.1 0.0540 5.1±0.1 5.5±0.1 5.7±0.2 0.0106
HbA1c (%) 5.9±0.1 5.8±0.2 5.8±0.1 5.9±0.1 0.4198 5.9±0.1 5.8±0.2 6.0±0.2 0.6521

Abbreviations: BMI, body mass index; DBP, diastolic blood pressure; HDL, high-density lipoprotein; IMT, intima media thickness; LDL, low-density lipoprotein; SBP, systolic blood pressure.
Values are expressed as mean±s.e.m. or numbers.

Next, to investigate the relationship of the mean IMT and plaque (P ¼ 0.0398 and P ¼ 0.0005, respectively). The rates of coronary heart
score with TOD, we divided our subjects into three groups according disease did not significantly differ between subjects with a higher IMT
to the level of TOD and compared the mean IMT and plaque score and those with a lower IMT (P ¼ 0.6696) or between subjects in
among these three groups. Subjects with associated clinical conditions different plaque score groups (P ¼ 0.6449). Subjects with a higher
(0.916±0.020) showed a significantly higher IMT than subjects with mean IMT and plaque score showed higher mortality rates
TOD (0.860±0.012; P ¼ 0.0058) and subjects without TOD (P ¼ 0.0299 and P ¼ 0.0005, respectively) (Figure 3a). Notably,
(0.683±0.009; Po0.0001). Subjects with TOD also showed a subjects with a mean IMT of X0.7 showed a significantly higher
significantly higher IMT than subjects without TOD (Po0.0001). frequency of stroke than subjects with a mean IMTo0.7, although
Similarly, the plaque scores of the subjects with associated clinical subjects with a mean IMT value of X1.0 did not show a different
conditions (5.787±0.688) were significantly higher than those of frequency of stroke from subjects with a mean IMTo1.0 (Figure 3b).
either the subjects with TOD (2.728±0.290; P ¼ 0.0002) or the Subjects who experienced a stroke showed a significantly higher age,
subjects without TOD (0.568±0.132; Po0.0001). Subjects with plaque score, mean IMT, systolic blood pressure (SBP) and diastolic
TOD also showed significantly higher plaque scores than subjects blood pressure, and showed a significantly lower eGFR than subjects
without TOD (Po0.0001) (Figure 1a). who did not experience a stroke (Table 2). Subjects who died in the
To assess the relationship of the IMT and plaque score with cardiac follow-up period showed a significantly higher male-to-female ratio,
atherosclerotic change and microvascular atherosclerotic change, we age, plaque score, mean IMT, smoking index and pulse pressure, and
compared the IMT and plaque score of subjects with and without left they showed a significantly lower BMI and eGFR than subjects who
ventricular hypertrophy and subjects with and without proteinuria. did not die in the follow-up period (Table 2).
Subjects with left ventricular hypertrophy showed a significantly Finally, we examined whether the IMT and plaque score could
higher IMT (0.873±0.021 vs. 0.819±0.011; P ¼ 0.0119) and higher predict the onset of stroke or mortality and whether this prediction
plaque scores (4.334±0.680 vs. 2.613±0.248; P ¼ 0.0305) than was independent of other traditional risk factors (age, sex, diabetes
subjects without left ventricular hypertrophy. Subjects with protei- mellitus and dyslipidemia) and systolic blood pressure. The Cox
nuria also showed a significantly higher IMT (0.872±0.023 vs. proportional hazards model with the end point of stroke indicated
0.823±0.010; P ¼ 0.0305) and higher plaque scores (4.276±0.729 that plaque score was significantly and independently predictive of
vs. 2.774±0.264; P ¼ 0.0279) than subjects without proteinuria stroke. In contrast, the Cox proportional hazards model with the end
(Figure 1b). We also investigated the relationship of the IMT and point of death indicated that the IMT and plaque score showed only
plaque score with arterial stiffness evaluated by PWV, and we showed nonsignificant trends of higher risk of mortality after adjustment for
that both the IMT (R2 ¼ 0.1032, Po0.0001) and plaque score traditional risk factors and SBP (Table 3). Additionally, to compare
(R2 ¼ 0.2012, Po0.0001) were significantly correlated with PWV the predictive ability of the IMT or plaque score with that of PWV,
(Figure 2). In addition, both the IMT (R2 ¼ 0.1612, Po0.0001) and which is well known to be correlated with the onset of cardiovascular
plaque score (R2 ¼ 0.0612, Po0.0001) were significantly correlated events, we classified our subjects into three groups according to their
with age (Figure 2). tertile of cfPWV. The Cox proportional hazards model with the end
Kaplan–Meier analysis revealed that subjects with a higher mean point of stroke showed that after adjustment for traditional risk
IMT and plaque score showed a higher frequency of stroke factors and SBP, the relative risk among the first tertile of cfPWV

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 Carotid plaque score and stroke in hypertension
T Kawai et al
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IMT (mm) plaque score

p = 0.0058 p = 0.0002

p < 0.0001 p < 0.0001

1 7
p < 0.0001 p < 0.0001

0.9
6
0.8
5
0.7

0.6
4
0.5
3
0.4

0.3 2

0.2
1
0.1

0 0
normal target organ associated clinical normal target organ associated clinical
damage conditions damage conditions

IMT (mm) plaque score

1 p = 0.0119 p = 0.0305 7

0.9 p = 0.0095 p = 0.0279

6
0.8
5
0.7

0.6
4
0.5
3
0.4

0.3 2

0.2
1
0.1

0 0
LVH (-) LVH (+) proteinuria proteinuria LVH (-) LVH (+) proteinuria proteinuria
(-) (+) (-) (+)

Figure 1 (a) Comparisons of the IMT (left) and the plaque score (right) among subjects without target organ damage (TOD), with TOD, and with associated
clinical conditions. (b) Comparisons of the IMT (left) and the plaque score (right) between subjects with and without left ventricular hypertrophy, and
between subjects with and without proteinuria.

compared with the third tertile of cfPWV was 3.24 (P ¼ 0.0238), and (as previously reported) and were significantly positively correlated
the relative risk among the second tertile of cfPWV compared with with age, smoking index, pulse pressure, TOD, left ventricular mass
the third tertile of cfPWV was 1.81 (P ¼ 0.2722). Similarly, the Cox index and proteinuria and that they were negatively correlated with
proportional hazards model with the end point of death showed that eGFR. We also showed that the subjects who experienced a stroke or
after adjustment for traditional risk factors and SBP, the relative risk who died in the follow-up period had a higher plaque score and mean
among the first tertile of cfPWV compared with the third tertile of IMT. We also revealed differences between the IMT and plaque scores
cfPWV was 15.18 (P ¼ 0.0001), and the relative risk among the concerning the correlations with systemic atherosclerotic change and
second tertile of cfPWV compared with the third tertile of cfPWV was prognosis.
5.33 (P ¼ 0.0569). IMT and plaque score are well known to reflect macrovascular
atherosclerosis,9 and PWV is well known to reflect arterial stiffness.7
DISCUSSION Although these parameters are widely used as surrogate markers for
The mean IMT and plaque score have both been widely used as CVDs, there have been no studies, to our knowledge, that compare
surrogate markers for systemic atherosclerotic change. In this study, the predictive ability for cardiovascular events among IMT, plaque
we showed that both markers were strongly correlated with each other score and PWV. We compared the predictive ability of IMT or plaque

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 Carotid plaque score and stroke in hypertension
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2 2
R2 = 0.1612, P < 0.0001 R2 = 0.1032, P < 0.0001
1.8 1.8

1.6 1.6

1.4 1.4

IMT (mm)
IMT (mm)
1.2 1.2

1 1

0.8 0.8

0.6 0.6

0.4 0.4

0.2 0.2
20 30 40 50 60 70 80 90 5 6 7 8 9 10 11 12 13 14 15
Age (years) PWV (m/sec)

35 35
R2 = 0.0612, P < 0.0001 R2 = 0.2021, P < 0.0001
30 30

25 25

Plaque score
Plaque score

20 20

15 15

10 10

5 5

0 0

20 30 40 50 60 70 80 90 5 6 7 8 9 10 11 12 13 14 15
Age (years) PWV (m/sec)

Figure 2 (a) Scatter plots and regression graphs showing significant correlations of the IMT with age (left) and with PWV (right). (b) Scatter plots and
regression graphs showing significant correlations of the plaque score with age (left) and with PWV (right).

score with that of PWV for the onset of stroke and total mortality in plaque score could be a more effective marker than the mean IMT
the present cohort. We showed that the relative risk of stroke that was for predicting stroke in patients with essential hypertension. Stroke is
predicted by plaque score was equivalent to that predicted by PWV, influenced by the duration and severity of pressure overload caused
which was previously reported to be an independent predictor of all by longitudinal increase in blood pressure,31 which are factors that are
CVD including stroke.17 This result indicated that plaque score could also predicted by PWV.27 Hence, the stronger correlation between
predict the onset of stroke as well as PWV, although PWV could plaque score and PWV might explain why plaque score more
predict death more accurately than plaque score or IMT. accurately predicted stroke onset.
As many study subjects were already receiving medical treatment Notably, subjects with a mean IMT of X0.7 showed significantly
for hypertension, we could not show significant correlations higher frequency of stroke than subjects with a mean IMT of o0.7;
of SBP and diastolic blood pressure with other parameters; however, however, subjects with a mean IMT of X1.0 did not show a difference
pulse pressure was significantly correlated with the mean IMT and in their frequency of stroke compared with subjects with a mean IMT
plaque score. Pulse pressure reportedly rises as the aorta stiffens with of o1.0. IMT reflects adaptive arterial wall changes in response to
aging or atherosclerotic disease progression.22,23 Increased pulse shear stress. Previous studies indicated that the IMT is mainly
pressure is also reportedly associated with CVD.24–26 Our results correlated with hypertension,32 thus the mean IMT in hypertensive
revealed that both the plaque score and the mean IMT were patients is thought to be influenced by routine high blood pressure.
significantly correlated with the PWV; additionally, the coefficient Therefore, unlike in cases of other subjects with high cardiovascular
of determination between the PWV and the plaque score was larger risk (for example, those with diabetes and hypercholesterolemia),
than that between the PWV and the mean IMT (0.2021 vs. 0.1032). marginal thickening of the mean IMT could predict CVD in
As PWV represents arterial stiffness,27 our result suggests that plaque hypertensive patients. However, because only 24 of our subjects
score reflects increased arterial stiffness more strongly than developed coronary heart disease, we did not show a significant
mean IMT. correlation between coronary heart disease and either the mean IMT
It is controversial as to which index, the mean IMT or the plaque or the plaque score, although such correlations were reported in
score, predicts stroke more accurately. Previous analyses of subjects previous studies.11,33
with various conditions have shown plaque score28 and IMT29 to be This study has several limitations. First, this cohort study was
more significantly correlated with abnormal cerebral findings hospital-based and included a relatively small number of patients. In
evaluated by brain MRI. Lee et al.30 reported that both the IMT addition, because the present study was conducted at a university
and the plaque score were associated with acute ischemic stroke in medical hospital that specializes in hypertensive treatment and serves
patients with type 2 diabetes. In the present study, both the mean many high-risk patients who are referred to the hospital from general
IMT and the plaque score were significantly correlated with the onset physicians, our study cohort consisted of high-risk patients. We think
of stroke. We also showed that the plaque score, but not the mean this is the reason why the event rate in this study was high (B4% per
IMT, was significantly correlated with the onset of stroke even after year) compared with other cohort studies such as the candesartan
adjustment for other traditional risk factors, indicating that the antihypertensive survival evaluation in Japan (CASE-J) trial34 or a

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Stroke

1.0 1.0

0.9 0.9

0.8 0.8

0.7 0.7
0.7 > IMT PS = 0
1.0 > IMT > = 0.7 0.6 5 > PS > 0
0.6
IMT > = 1.0 PS >= 5
0.5 p = 0.0398 0.5 p = 0.0005

0 1000 2000 3000 4000 0 1000 2000 3000 4000

Days Days

Coronary heart disease

1.0 1.0

0.9 0.9

0.8 0.8

0.7 0.7
0.7 > IMT PS = 0
0.6 1.0 > IMT > = 0.7 0.6 5 > PS > 0
IMT > = 1.0 PS >= 5
0.5 p = 0.6696 0.5 P = 0.6449

0 1000 2000 3000 4000 0 1000 2000 3000 4000

Days Days

Total mortality

1.0 1.0

0.9 0.9

0.8 0.8

0.7 0.7
0.7 > IMT PS = 0
1.0 > IMT > = 0.7 0.6 5 > PS > 0
0.6
IMT > = 1.0 PS >= 5
0.5 p = 0.0299 0.5 p = 0.0005

0 1000 2000 3000 4000 0 1000 2000 3000 4000

Days Days

1.0 1.0

0.9 0.9

0.8 0.8

0.7 0.7

0.7 > IMT 1.0 > IMT

0.6 0.6
IMT >=0.7 IMT >=1.0
0.5 p = 0.0235 0.5 p = 0.0629

0 1000 2000 3000 4000 0 1000 2000 3000 4000

Days Days

Figure 3 (A) Kaplan–Meier analysis. Subjects with a higher mean IMT (a) and a higher plaque score (b) showed significantly higher incidences of stroke.
There were no significant differences in the incidence of coronary heart disease among subjects in different mean IMT groups (c) or in different plaque
score groups (d). Subjects with a higher mean IMT (e) or a higher plaque score (f) showed significantly higher mortality rates. (B) Kaplan–Meier analysis for
stroke. (a) Subjects with a higher IMT (IMTX0.7) showed a significantly higher incidence of stroke. (b) There were no significant differences in the
incidence of coronary heart disease between subjects with a higher IMT and those with a lower mean IMT.

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 Carotid plaque score and stroke in hypertension
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Table 2 Comparison of baseline characteristics between the subjects with or without the episode of stroke and death

Stroke Death

þ  P-value þ  P-value

Number 37 319 37 319

Sex (male/female) 21/16 168/151 0.6368 27/10 162/157 0.0105
Age (years old) 66.5±1.7 62.0±0.7 0.0089 71.0±1.7 61.4±0.7 o0.0001
BMI (kg m 2) 24.2±0.5 23.9±0.2 0.6162 22.6±0.5 24.1±0.2 0.0086
Diabetes mellitus (n) 10 (27.0%) 107 (33.5%) 0.4245 17 (46.0%) 100 (31.4%) 0.0735
Dyslipidemia (n) 22 (59.5%) 164 (51.4%) 0.3535 17 (46.0%) 169 (53.0%) 0.4176
eGFR (ml min 11.73 m 2) 67.6±2.8 73.0±1.4 0.0441 58.7±4.8 74.0±1.3 0.0018
plaque score 5.18±1.03 2.70±0.25 0.0124 6.72±1.38 2.53±0.22 0.0023
Mean IMT (mm) 0.91±0.03 0.82±0.01 0.0100 0.93±0.04 0.82±0.01 0.0026
current smoking (n) 9 (24.3%) 104 (33.1%) 0.2787 15 (41.7%) 98 (31.1%) 0.1991
smoking index (n  year) 459.2±106.1 447.7±35.5 0.4592 712.3±113.3 418.0±34.7 0.0085
SBP (mm Hg) 141.4±2.7 135.8±1.1 0.0310 140.8±4.0 135.9±1.1 0.1233
DBP (mm Hg) 83.5±1.7 80.1±0.7 0.0342 79.1±2.0 80.6±0.7 0.7713
Pulse pressure (mm Hg) 57.9±2.3 55.7±0.8 0.1906 61.8±2.9 55.3±0.8 0.0285
Triglyceride (mg dl 1) 153.0±15.7 140.9±5.1 0.2330 149.6±18.4 141.4±5.0 0.3348
HDL cholesterol (mg dl 1) 51.8±2.4 54.9±0.9 0.1233 54.4±3.1 54.6±0.9 0.5260
LDL cholesterol (mg dl 1) 120.2±5.5 121.0±1.9 0.5574 113.2±6.5 121.7±1.9 0.8929
Uric acid (mg dl 1) 5.6±0.3 5.3±0.1 0.1682 5.7±0.2 5.3±0.1 0.0694
HbA1c (%) 5.6±0.2 5.9±0.1 0.2352 5.7±0.2 5.9±0.1 0.5525

Values are expressed as mean±SEM or numbers.

Table 3 Cox proportional hazard model

IMT (X1.0/0.7–1.0/o0.7) Plaque score (X5/0–5/0)

End point: stroke
RR P-value RR P-value

Not adjusted X1.0/o0.7 3.23 0.018 X5/0 4.55 o0.001

0.7–1.0/o0.7 2.42 0.055 0–5/0 1.99 0.109
Adjusted for age, sex, DM, HL X1.0/o0.7 2.57 0.083 X5–0 4.12 0.001
0.7–1.0/o0.7 2.12 0.121 0–5/0 1.75 0.202
Adjusted for age, sex, DM, HL, SBP X1.0/o0.7 2.35 0.122 X5/0 3.86 0.002
0.7–1.0/o0.7 1.10 0.809 0–5/0 2.12 0.061

End point: death IMT (X1.0/0.7–1.0/ 0.74) Plaque score (X5/0–5/0)

RR P-value RR P -value
Not adjusted X1.0/o0.7 3.35 0.008 X5/0 3.48 0.002
0.7–1.0/o0.7 1.58 0.325 0–5/0 1.32 0.518
Adjusted for age, sex, DM, HL X1.0/o0.7 1.09 0.877 X5–0 2.11 0.065
0.7–1.0/o0.7 0.85 0.740 0–5/0 0.92 0.853
Adjusted for age, sex, DM, HL, SBP X1.0/o0.7 1.02 0.966 X5/0 2.15 0.066
0.7–1.0/o0.7 1.18 0.677 0–5/0 2.01 0.089

Abbreviations: IMT, intima media thickness; SBP, systolic blood pressure.

Japanese trial on the prognostic implication of PWV (J-TOPP).35 also revealed new evidence that the plaque score could more
Therefore, multi-center trials with a larger cohort are needed to accurately predict the onset of stroke in hypertensive patients, and
confirm the results of our study. Secondly, at enrollment, many we also showed that marginal increases in the mean IMT could be a
subjects had already been treated with various medications, such as predictor of stroke.
angiotensin receptor type II blockers, angiotensin-converting enzyme
inhibitors, or statins, which might contribute to better outcomes. ACKNOWLEDGEMENTS
In conclusion, we showed that both the mean IMT and the plaque This study was funded by the Osaka Medical Research Foundation for
score were significantly correlated with arterial stiffness and TOD. We Incurable Diseases.

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 Carotid plaque score and stroke in hypertension
T Kawai et al
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20 Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, Grassi G,

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