COMPARISON OF THE DIAMETER AND CAROTID INTIMA MEDIA THICKNESS IN DIABETIC PATIENTS WITH AND WITH METABOLIC SYNDROME ON ULTRASOUND

Objective: This objective of this study was to compare the diameter and intima media thickness of carotid arteries in diabetic patients with and without metabolic syndrome on ultrasound examination. Methodology: This cross sectional study was conducted at Radiology department of Lahore General Hospital (LGH) and completed in 6 months using non-probability purposive sampling. We took 100 cases, 50 diabetic patients (group-A) without metabolic syndrome and 50 diabetics with metabolic syndrome (group-B). All patients 20-90 years of age of either sex presenting with confirmed type 2 diabetes mellitus with and without metabolic syndrome were taken in this study. Patients with stroke due to secondary causes like trauma, impaired coagulation or tumor were excluded from this study. Patient’s age, gender, IMT, and diameter of Right CCA, Left CCA, Right ICA and Left ICA were measured and compared in both study groups. Results: In this study mean age of patients in group – A was 49.04 ± 9.78 years and in group-B the mean age 53.72 ± 53.72 years. Intima media thickness (IMT) of right and left CCA and right ICA was statistically higher in group-B (1.10 ± 0.2, 1.09 ± 0.21 and 0.47 ±0.02) as compared to group-A (0.79±0.12, 0.78±0.13 and 0.45±0.03), p-value < 0.001 while IMT of left ICA was statistically same in both groups (in group-A 0.46±0.03 and group B was 0.47±0.03), p-value > 0.05. Diameter of right and left CCA was significantly higher in group-B (6.79±0.1 and 6.66 ± 0.297) as compared to group-A (6.52±0.19 and 6.47±0.32), p-value < 0.001 and diameter of right ICA and left ICA was statistically same in both groups, p-value > 0.05. Conclusion: Since diabetic patients with metabolic syndrome are at greater risk of developing increased CCA-IMT and increase in CCA-IMT is associated with all subtypes of ischemic stroke, carotid plaque and cardiovascular deaths. So early detection is needed to identify individuals at risk and further prospective studies are recommended to demonstrate the regression of carotid IMT with management of metabolic syndrome in Type 2 DM patients.


INTRODUCTION
Diabetes mellitus (DM) is a major health problem worldwide with its increasing prevalence with more than 180 million people worldwide and would be 366 million diabetic patients by the year 2030 1 .Type 2 diabetes mellitus (T2DM) affects approximately 24 million individuals and is a major cause of morbidity and mortality due to cardiovascular complications. 2 The incidence of cardiovascular disease (CVD) is more common in patients with type 2 diabetes than in the general population. Dyslipidemia, an established risk factor for CVD, is strikingly common in patients with type 2 diabetes, affecting almost 50% of this population. 2 The prevalence of dyslipidemia has increased globally with the advent of newer lifestyles over the past decades. The frequency and patterns of dyslipidemia and the extent of blood lipid abnormality in the general population especially diabetics have drawn considerable attention. 3 The metabolic syndrome is extremely common worldwide and can be found in approximately one-third of patients with essential hypertension in whom it is a major cause of cardiovascular and renal events, even in the absence of overt diabetes. 4 Traditional and nontraditional cardiovascular (CVD) risk factors associated with metabolic syndrome are present long before the onset of clinical diabetes, which raises the question about their major role in development of diabetes and CVD. 5,6 Patients with type-2 diabetes mellitus have greater incidence of carotid intima media thickness and they are at risk for developing atherosclerosis. 7 This study is designed to compare the diameter and intima media thickness of carotid arteries in diabetic patients with and without metabolic syndrome at Lahore General Hospital Lahore.

MATERIALS AND METHODS
This cross sectional study was done at Radiology department of LGH and was completed in 6 months using non-probability purposive sampling. Using purposive sampling we took 100 cases, 50 diabetic patients (group-A) without metabolic syndrome and 50 diabetics with metabolic syndrome (group-B). All patients 20-90 years of age of either sex presenting with confirmed type 2 diabetes mellitus with and without metabolic syndrome were taken in this study.Patients with stroke due to secondary causes like trauma, impaired coagulation or tumor were excluded from this study. The variables included in the study will be age, gender, Cholesterol, Triglycerides, duration of DM and Fasting Glucose were taken. IMT, and diameter of Right CCA, Left CCA, Right ICA and Left ICA were measured using high resolution ultrasound scanner equipped with a linear array transducer.
All collected data was entered in computer programme SPSS version 20 and analyzed through this software. Mean ± standard deviation will be calculated for quantitative data and frequency and percentage was calculated for categorical data. Mann Whiteny U test was applied to compare both study groups for their quantitative data. P-value < 0.05 will be considered as significant.

RESULTS
In this study mean age of patients in group -A was 49.04 ± 9.78 years and in group-B the mean age 53.72 ± 53.72 years. The mean body mass index in group A and group B was 27.55 and 36.38 respectively, with higher BMI in group-B, p-value < 0.001. The mean Cholesterol level of patients in group -A was 179.56 ± 60.08 and in group-B the mean cholesterol was 324.68 ± 61.57, p-value < 0.01. The mean triglycerides level in group-A and group -B was 150.20 ± 48.37 and 186.28 ± 42.12 respectively, with higher mean triglycerides in group-B, p-value < 0.001. The mean duration of diabetes was higher in group-B (11.40 ± 4.06 months) as compared to group-A (3.40 ± 3.02 months), p-value < 0.001. Moreover mean Fasting glucose in group-A (126.12±67.83) and group-B (295.40 ± 94.79) was also comparable, p-value < 0.001.
Intima media thickness (IMT) of right and left CCA and right ICA was statistically higher in group-B (1.10 ± 0.2, 1.09 ± 0.21 and 0.47 ±0.02) as compared to group-A (0.79±0.12, 0.78±0.13 and 0.45±0.03), p-value < 0.001 while IMT of left ICA was statistically same in both groups (in group-A 0.46±0.03 and group B was 0.47±0.03), p-value > 0.05. Diameter of right and left CCA was significantly higher in group-B (6.79±0.1 and 6.66 ± 0.297) as compared to group-A (6.52±0.19 and 6.47±0.32), p-value < 0.001 and diameter of right ICA and left ICA was statistically same in both groups, pvalue > 0.05.   10 A study reported significantly high mean thickness was observed in the common carotid intima media (0.824 ± 0.155 mm) but not in the internal carotid arteries in group II patients (patients with non blood pressure component metabolic syndrome) compared to group I (without metabolic syndrome) patients (0.708 ± 0.113 mm). Group II also had a significant number of patients with increased lesion intima media thickness (≥ 1.1 mm). 7 We in this study found that intima media thickness (IMT) of right and left CCA and right ICA was statistically higher in group-B (1.10 ± 0.2, 1.09 ± 0.21 and 0.47 ±0.02) as compared to group-A (0.79±0.12, 0.78±0.13 and 0.45±0.03), p-value < 0.001 while IMT of left ICA was statistically same in both groups (in group-A 0.46±0.03 and group B was 0.47±0.03), p-value > 0.05. Diameter of right and left CCA was significantly higher in group-B (6.79±0.1 and 6.66 ± 0.297) as compared to group-A (6.52±0.19 and 6.47±0.32), p-value < 0.001 and diameter of right ICA and left ICA was statistically same in both groups, pvalue > 0.05. One more study was conducted and they compared hypertensive (group-I) and hypertensive with metabolic syndrome (group-II) and they reported that we observed in patients of the second group significantly increased values for anthropometric parameters such as body mass index( p<0.001), waist circumference ( p<0.001) and waist-hip ratio ( p<0.001) compared to the first group. The differences between groups considering the levels of total cholesterol ( p<0.001),triglycerides ( p<0.001), LDL-cholesterol ( p<0.001), and HDL-cholesterol ( p<0.001) were also statistically significant. The patients from the second group had significantly increased carotid IMT values compared to the patients from the first group (1.27±0.03 mm vs.1.00±0.03 mm, p<0.001). The study revealed that metabolic syndrome is associated with structurallyfunctional changes of arterial vessels (increased IMT). These findings are in consistent to our finding when we compared these parameters within our population. Furthermore it is also supported that Common carotid intima-media thickness (IMT) and distensibility are markers of structural and functional vessel wall properties. Both parameters have been found in population-based studies to be associated with cardiovascular risk factors and prevalent cardiovascular disease. 11 Hence in the light of our findings and some evidence from literature we found that metabolic syndrome with Type 2 DM is associated with greater carotid IMT values than in those diabetics free from metabolic syndrome. Further prospective studies are recommended to demonstrate the regression of carotid IMT with management of metabolic syndrome in Type 2 DM patients.

CONCLUSION
Since diabetic patients with metabolic syndrome are at greater risk of developing increased CCA-IMT and increase in CCA-IMT is associated with all subtypes of ischemic stroke, carotid plaque and cardiovascular deaths. So early detection is needed to identify individuals at risk and further prospective studies are recommended to demonstrate the regression of carotid IMT with management of metabolic syndrome in Type 2 DM patients.