International Journal of Cardiology and Cardiovascular Research

IJCCR

Vol. 3(1), pp. 024-030, June, 2016. www.premierpublishers.org. ISSN: 2146-3133

Research Article

Characteristics of coronary artery ectasia and its

association with carotid intima-media thickness and
high sensitivity C-reactive protein
Osama Sanad1, Eman Al-Keshk2, Ahmed Ramzy3, Mohammed A.Tabl4, Ahmed Bendary5
1,2,3,4,5

Cardiology department, Benha university hospital, Benha faculty of medicine, Egypt.

This study was conducted to uncover the relation between coronary artery ectasia (CAE) and
markers of atherosclerosis. A total of 1611 coronary angiograms were prospectively examined
to find out patients with CAE. Those patients were divided into 2 groups: Mixed CAE with
stenotic coronary artery disease (CAD) group 1 and pure CAE group 2. Two control groups
of age-adjusted subjects were selected consecutively in a 1:1 fashion; one with normal
coronaries group 3 (Pure CAE: normal coronaries) and the other with obstructive CAD only
group 4 (Mixed CAE: obstructive CAD). All recruited subjects underwent carotid intima-media
thickness (IMT) and high sensitivity C-reactive protein (hs-CRP) level measurements. Out of
examined angiograms, 35 subjects showed mixed CAE group 1 and 26 showed pure CAE
group 2. Age and gender-adjusted logistic regression analysis model revealed that significant
independent predictors for CAE were: hypertension, smoking, absence of DM and hs-CRP level
> 3 mg/L. Mean carotid IMT was significantly higher in group 2 than group 3 and in group 4 than
group 1 (10.1 versus 0.40.2 mm and 1.40.4 versus 10.2 mm respectively, P < 0.001 for both).
Mean hs-CRP level was significantly higher in group 1 than group 4 and in group 2 than group 3
(72 versus 30.8 mg/L and 62 versus 10.6 mg/L respectively, P < 0.001 for both). We
concluded that atherosclerosis may not be the only plausible explanation for CAE.

Keywords: Coronary artery ectasia; Carotid intima-media thickness; high sensitivity C-reactive protein; Atherosclerosis.

INTRODUCTION
Coronary artery ectasia (CAE), sometimes known as
dilated
coronopathy,
is
relatively
uncommon
angiographic finding (Lam and Ho, 2004). This condition
is diagnosed if the diameter of a dilated segment of an
artery is 1.5 times greater than the diameter of the
adjacent normal segments of the artery (Hartnell et al,
1985). Markis et al, 1976 introduced the following
classification of CAE based on the extent of coronary
affection: type I, diffuse ectasia of two or three vessels;
type II, diffuse disease in one vessel and localized
disease in another one; type III, diffuse ectasia of one
vessel only; and type IV, localized or segmental ectasia.
Coronary angiography remains the main diagnostic tool
for CAE (Mavrogeni, 2010).The clinical presentation and
the long-term cardiac complications have long been

thought to be associated with the severity of the coexisting obstructive coronary lesion, despite the fact that
pure coronary ectasia (without obstructive coronary
lesions) can be implicated in angina or myocardial
infarction (Demopoulos et al, 1997).

*Corresponding author: Ahmed Bendary Msc, Cardiology

department, Benha university hospital, Benha faculty of
medicine, Egypt, Postal code no. 13518. E-mail:
dr_a_bendary@hotmail.com, Cellular: 01220778216, Tel.:
002013319014
Coauthors:
osamasanad@hotmail.com1,
2
emansaeed6767@yahoo.com , aramzy1977@yahoo.com3,
mshafytabl@yahoo.com4

Coronary artery ectasia and markers of atherosclerosis

Bendary et al.

024

Regardless of the severity and extent of CAE, the

etiology, prognosis, morbidity, and mortality related to this
pathology are still a matter of debate and whether CAE is
a unique clinical finding or a state resulting from other
entities is still unknown (Amirzadegan et al, 2014).
Despite the fact that about 50% of cases are due to
atherosclerosis and histopathological examination of
ectatic segments has revealed mainly destruction of the
media layer of the artery (Yetkin et al, 2005). Its still not
clear which additional factors promote the development
of ectasia in these patients (Cohen and OGara, 2008).
Carotid artery intimamedia thickness (IMT) is widely
used as a surrogate marker for atherosclerotic disease.
Carotid IMT measured by ultrasonography has been
shown to be correlated with coronary artery disease as
dened by angiography (elik et al, 2007). Hs-CRP level
is gaining acceptance now as on-the-horizon marker for
possible inflammatory pathophysiologic origin of
atherosclerotic vascular disease (Ozbay et al, 2006).
Therefore, studying carotid IMT and hs-CRP in those
patients could give insights into pathogenic mechanisms
of CAE.

PATIENTS AND METHODS

Study design
This is a single center, prospective observational casecontrol study that included selection of cases proved to
have CAE through consecutive examination of coronary
angiograms done at the catheterization laboratory at
Benha University Hospital over a period of 18 months
(from September 2014 to February 2016). We aimed
primarily to study clinical and angiographic characteristics
of CAE patients in addition to studying the association
between it and both carotid intima-media thickness and
hs-CRP levels as surrogate markers for atherosclerotic
disease. Cases proved to have CAE were divided into 2
groups: mixed CAE with obstructive CAD group 1 and
pure CAE group 2. Two control groups were included
for comparisons: a group of age-adjusted subjects with
normal coronary angiograms, selected consecutively in a
1:1 fashion (Pure CAE: normal coronaries) group 3 and
another group of age-adjusted subjects with obstructive
CAD without ectasia selected consecutively in a 1:1
fashion (Mixed CAE: obstructive CAD) group 4. Patients
with CAE associated with cardiomyopathies, valvular and
congenital heart diseases were excluded to make sure
that all patients are being evaluated exclusively for
possible CAD. Patients with iatrogenic CAE due to
previous coronary interventions (either percutaneous
coronary intervention PCI or coronary artery bypass
graft CABG) were also excluded. The study was
approved by the local ethics committee at our institution
and an informed consent was obtained from each
participant.

Coronary angiogram analysis

Coronary angiograms done in the defined study period
were prospectively analyzed by experienced cardiologists
(two for each angiogram) at Benha University Hospital to
find out those patients with CAE. CAE was defined
according to the landmark Coronary Artery Surgery Study
(CASS) as a dilatation of coronary artery 1.5 times in
diameter when compared to the adjacent normal
segment, with localized ectasia defined as < 1 cm in
length and diffuse ectasia 1 cm in length (Ringqvist et
al, 1985). The hemodynamic specialist and both
physicians in charge of the case agreed on an estimated
"normal" caliber when such segment does not exist
(Bermdez et al, 2003). Obstructive CAD was defined as
any luminal stenosis 50% (Kong and Rosati, 1980).

Analyses were done using Philips AlluraXper FD 20

medical system software.
Carotid intima media thickness (IMT) measurement
Within 10 days of coronary angiography, all recruited
subjects underwent carotid Doppler to determine carotid

IMT. Ultrasonography was performed with a GE Vivid 7

system equipped with a 13 MHz linear array imaging
probe. The transducer was manipulated so that the near
and far walls of the CCA became parallel to the
transducer footprint, and the lumen diameter was
maximized in the longitudinal plane. An area 1 cm
proximal to the carotid bifurcation was identied. The IMT
measurement was obtained from four adjacent sites at
1mm intervals, and the average of the four
measurements was used for analyses (Figure 1). All
measurements were performed by investigators blinded
to clinical and angiographic data. Upper normal average
IMT is estimated to be up to 0.8 mm (elik et al, 2007).
Hs-CRP level measurement
Blood samples were withdrawn from all recruited subjects
after completion of coronary angiography and sera were
obtained by centrifugation of the blood for 10 minutes and
then stored in several aliquots at - 70 C until assayed.
Highly sensitive CRP was measured using STAT-FAX
reader using Accu-bind microplate ELISA kits provided by
Monbind Inc. lake fores, CA92630 USA. The test was
done by investigators blinded to clinical and angiographic
data. The normal range of hsCRP level is considered 3
mg/l or less (Saglam et al, 2008).
STATISTICAL ANALYSIS
Data management and statistical analysis were
performed using Statistical Package for Social Sciences
(SPSS) vs. 21.
Numerical data were summarized using means and
standard deviations or medians and ranges. Categorical

Coronary artery ectasia and markers of atherosclerosis

Int. J. Cardiol. Cardiovasc. Res.

025

Figure 1. Case no. 3, group 1: Male, 67 years old, hypertensive and smoker, with
history of dyslipidemia. He is not diabetic and gives no family history of premature
CAD. His coronary angiography revealed mixed CAE (type III) with obstructive CAD
(Panel A and B). His average carotid IMT is 1.2 mm (Panel C)
IMT: intima-media thickness, CAD: coronary artery disease, CAE: coronary artery
ectasia.

Figure 2. Schematic representation of the study groups

CAE: coronary artery ectasia, CAD: coronary artery disease.

data were summarized as numbers and percentages.

Comparisons between the 4 groups with respect to
normally distributed numeric variables were done using
one way analysis of variance (ANOVA) followed by
Bonferroni post hoc test for pair wise comparison. Nonnormally distributed numeric variables were compared by
Kruskalwallis test (non parametric analogue for ANOVA).
For categorical variables, differences were analyzed with
chi square test a. Stepwise logistic regression was done
to give adjusted odds ratio and measure magnitude of the
effect of different factors on the development of CAE. All
p-values are two-sided. P-values < 0.05 were considered
significant.

RESULTS
Study population
During the study period, there were 61 patients with CAE
out of 1611 coronary angiograms performed (3.78%). Of
those, 35 patients (57%) showed mixed CAE with
obstructive CAD group 1 and 26 patients (43%) showed
pure CAE with no obstructive CAD group 2 (Figure 2).
Of all patients found to have CAE, the mean age was
5614 years. Eighty four percent were males, 67% were
hypertensive, 16% had history of DM, 72% were
smokers, 46% had dyslipidemia, 48% were obese and

Coronary artery ectasia and markers of atherosclerosis

Bendary et al.

026

Table 1. Clinical characteristics of the studied groups*

Group 1
No
Age (yrs.)

Mean SD

Gender

Male

Group 2

No

55.413.1

Group 3

No

55.914.4

Group 4

No

60.015.9

P value

59.915.4

0.407

30

85.7

21

80.8

14

53.8

14

40.0

<0.001

HTN

24

68.6

17

65.4

26.9

10

28.6

<0.001

DM

14.3

19.2

17

65.4

25

71.4

<0.001

Smoking

25

71.4

19

73.1

26.9

12

34.3

<0.001

Dyslipidemia

17

48.6

11

42.3

13

50.0

17

48.6

0.945

Obesity

16

45.7

13

50.0

14

53.8

16

45.7

0.911

Family history of
premature CAD

17

48.6

13

50.0

12

46.2

16

45.7

0.986

Nitrate therapy
duration (Days)

Median
(range)

30
(7-150)

45
(3-150)

30
(3-90)

30
(3-120)

0.163

*Similar letter superscripts in table indicate statistically significant difference.

DM: diabetes mellitus, HTN: hypertension, p < 0.05 is significant.

Table 2. Significant predictors of CAE*

OR

95% CI for OR
Lower

Upper

P value

HTN

20.3

2.7

154.6

0.004

Absence of DM

23.3

3.0

166.7

0.002

Smoking

8.0

1.3

48.8

0.024

hs-CRP 3mg/L

4.4

2.2

8.6

<0.001

*Adjusted for age and gender

OR: odds ratio, CI: confidence interval. DM; diabetes mellitus, HTN: hypertension, hs-CRP: high sensitivity Creactive protein

49% had family history of premature CAD. The median

duration of nitrate therapy in those patients was 45
(range: 3- 150) days. Clinical characteristics of studied
patients are illustrated in (Table 1).

independent predictors for development of CAE are:

hypertension, absence of DM, smoking and hs-CRP level
> 3mg/L (Table 2).
Angiographic data

Predictors of CAE
An age and gender-adjusted logistic regression model
has been done using CAE as dependent factor, while
age, gender, risk factor data (DM, HTN, smoking, obesity,
dyslipidemia and family history of premature CAD),
carotid IMT 8 mm and hs-CRP value 3 mg/L were
used as independent factors. It was found that significant

Among patients proved to have CAE, we found that the

most common type according to Markis classification is
type III (48%) followed by type IV (36%) and then type I
(16%). Of note, no patients were found to have type II
CAE in our study.
The most commonly affected vessel was RCA (59%)
followed by LAD (36%) then LCX (20%) and finally left

Coronary artery ectasia and markers of atherosclerosis

Int. J. Cardiol. Cardiovasc. Res.

027

Figure 3. Box plot of Carotid IMT (mm) in different study groups

IMT; intima-media thickness

main coronary artery LMCA (3%). Notably, no patients

were found to have three-vessel affection in type I CAE
and no patients were found to have LMCA affection in
type III CAE.
Clinical presentation
The commonest clinical presentation among all patients
with CAE was stable angina (49%) followed by STEMI
(36%) and then Non-ST segment elevation acute
coronary syndromes NSTE-ACS (15%). Between
groups analysis showed a statistically significant
difference in the occurrence of STEMI between groups 1
and 4 (34% versus 11% respectively, P = 0.002),
between groups 2 and 3 (39% versus 4% respectively, P
= 0.002) and between groups 2 and 4 (39% versus 11%
respectively, P = 0.002). Of the 22 patients with CAE who
presented with STEMI, the predominant type of CAE was
type IV (17 patients), moreover, there was a good
correlation between MI territory and the ectatic vessel in
21 patients.
Carotid IMT
The mean carotid IMT among all patients with CAE was
10.2 mm. Between groups analysis showed a
statistically significant difference in the mean carotid IMT
between groups 1 and 4 (10.2 mm versus 1.40.4 mm
respectively, P < 0.001) and between groups 2 and 3
(10.1 mm versus 0.40.2 mm respectively, P < 0.001)
(Figure 3).
Hs-CRP levels
The mean hs-CRP level among all patients with CAE was
62 mg/L. Between groups analysis showed a statistically

significant difference in the mean hs-CRP level between

groups 1 and 2 (72 mg/L versus 62 mg/L respectively,
P < 0.001), between groups 1 and 4 (72 mg/L versus
30.8 mg/L respectively, P < 0.001) and between groups
2 and 3 (62 mg/L versus 10.6 mg/L respectively, P <
0.001) (Figure 4).

DISCUSSION
Coronary artery ectasia (CAE) remains an understudied
and underreported variant of CAD in the literature. Our
study is a prospective observational case-control one that
aimed mainly to describe clinical and angiographic
characteristics of CAE together with approaching the
mysterious domain of ectasias pathogenesis through
studying its association with carotid IMT and hs-CRP
levels.
Regarding clinical characteristics of patients with CAE,
our study showed male gender predominance (84% of
CAE). This observation goes, to a large extent, with those
of other large observational studies; Nyamu et al., 2003;
Nisar et al., 2013 and Amirzadegan et al., 2014 also
showed a striking male distribution of the phenomenon.
Importantly, an age- and gender-adjusted logistic
regression analysis in the present study showed that the
significant independent predictors for CAE are:
hypertension, absence of DM, smoking and hs-CRP
value 3 mg/L. Bermdez et al., 2003 did a similar
logistic regression model that revealed, like our results,
that the presence of DM is significantly related to
absence of CAE (OR = 0.65; 95% CI, 0.43-0.98, P =
0.03). They also found that male gender is significantly
associated with presence of CAE (OR = 3.33; 95% CI,
1.81-6.13, P < 0.01), a result not found in the current
study. Notably, they didnt have any work on markers of

Coronary artery ectasia and markers of atherosclerosis

Bendary et al.

028

Figure 4. Box plot of hs-CRP level (mg/L) in different study groups

HS-CRP: high sensitivity C-reactive protein.

atherosclerosis including carotid IMT or hs-CRP. This

gives novelty to the current study. The fact that patients
with CAE show minimal prevalence of DM, and that the
presence of DM is negatively associated with CAE is
noteworthy and actually, could not be easily explained.
However, one explanation might lie in the association of
diabetes with a reduction in endothelium-dependent
vasodilation, caused by alterations in the synthesis and
inhibition of nitric oxide, which seems to play a significant
role in the development of CAE. Diabetes mellitus
primarily affects the intimal, but not the medial layer of
the vessel, thus inducing a state of insidious and evolving
negative remodeling (Schoenhagen et al, 2001).
Our findings revealed that the most common type of CAE
(per Markis classification) was type-III (48%) and that the
most commonly affected vessel by the phenomenon was
RCA (59%). These results are concordant with the wealth
of data in the literature except for few studies that
showed type-IV CAE to be the most common (Ahmed et
al, 2013; Sultana et al, 2011) and others showing type-I is
the predominant type and LAD is the most frequently
affected vessel (Nyamu et al, 2003). Interestingly, the
above
mentioned
contradictory
data
regarding
angiographic distribution of CAE came exclusively from
Asian population, pointing to possible racial and/or
genetic differences in the vascular distribution of CAE.
A considerable proportion of patients with CAE (36%)
presented with STEMI in the current study; this comes to
be statistically significant when comparing this figure to
normal subjects group 3 (only 4%) and to those with
obstructive CAD without ectasia group 4 (11%) (P =
0.002). A similar result was provided by Amirzadegan et

al., 2014. On the opposite hand, some data (Bermdez et

al, 2003) revealed no significant difference in the
incidence of MI when comparing patients with CAE to
those without. Overall, the observations of association of
CAE with MI, albeit not significant in some series, are
convincing that this phenomenon is not a benign one.
To the best of our knowledge, there are very limited data
in the literature studying pathogenic mechanisms of the
usual form of CAE. These efforts are divided into two
main domains: the atherosclerotic theory (as surrogated
by carotid IMT) and/or the inflammatory theory (as
surrogated mainly by hs-CRP levels and other markers).
All groups studying hs-CRP levels in patients with CAE
provided a consistent result that hs-CRP is significantly
higher in patients with CAE compared to patients with
obstructive CAD and patients with normal coronaries
(Ozbay et al, 2006; Turhan et al, 2004; Ammar et al,
2013). Our results were identically similar to those in the
literature in that levels of hs-CRP were significantly
higher in those with mixed CAE group 1 than patients
with obstructive CAD without ectasia group 4 and in
patients with pure CAE group 2 when compared to those
with normal coronaries group 3. These data collectively
reflects a more intense inflammatory process in those
patients.
Despite the above mentioned work on levels of
inflammatory markers, atherosclerosis remains the most
widely accepted pathogenic theory underlying CAE.
Definite state-of-the-art proof of the atherosclerotic
hypothesis could come only from studies using coronary
artery in-vivo biopsies. However, such studies do not
exist due to understandable reasons related to major

Coronary artery ectasia and markers of atherosclerosis

Int. J. Cardiol. Cardiovasc. Res.

risks imposed. Therefore, many surrogate measures of

in-vivo atherosclerotic burden have been used in the
literature, and carotid IMT is one of the most widely
accepted.
Carotid IMT has been shown to be significantly higher in
CAE patients versus normal in one study (eliketal,
2007) supporting the above mentioned atherosclerotic
theory. However, a true threat to atherosclerosis as a
stand-alone explanation for CAE comes from the puzzling
results provided by Yetkin et al., 2005 who revealed that
carotid IMT was significantly lower in those with mixed
CAE than that measured in a similar number of patients
with obstructive CAD without ectasia. Interestingly, the
present study results came concordant with the
supporting component in the literature for the
atherosclerotic theory on one hand and with the puzzling
component on the other. We revealed a significantly
higher carotid IMT in patients with pure CAE group 2
that those with normal coronaries group 3 similar to
Celik et al., 2007. We also showed carotid IMT to be
significantly lower in those with mixed CAE with
obstructive CAD group 1 when compared to patients
with obstructive CAD without ectasia group 4; this was
similar to the puzzling results of Yetkin et al., 2005.
Significantly lower carotid IMT in patients with mixed CAE
and CAD than those with obstructive CAD alone (as
shown in our study) is suggesting that CAE may not
share the same pathological mechanism with
atherosclerosis. Explanation for such a discrepancy could
be as follows: first, we showed that absence of DM is a
significant predictor for CAE and it is well known that DM
is classically associated with increased carotid IMT
(Kawamori et al, 1992). Second, hs-CRP (as a surrogate
marker for inflammatory response) has been shown in
the present study to be significantly higher in patients
with mixed CAE and CAD than those with CAD alone.

CONCLUSION
At our institution, the significant independent clinical
predictors for development of CAE are: hypertension,
smoking, absence of DM and level of hs-CRP 3 mg/L.
Atherosclerosis is an important underlying pathogenic
mechanism for CAE but may not be the only plausible
one. Other additional factors may be involved such as
inflammatory response.

FUNDING
None

CONFLICTS OF INTERSET
None

029

AKNOWLEDEMENT
Authors thank all members of Cardiology department at
Benha Faculty of medicine.

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Accepted 17 June, 2016.
Citation: Sanad O, Al-Keshk E, Ramzy A, Tabl MA,
Bendary A (2016). Characteristics of coronary artery
ectasia and its association with carotid intima-media
thickness and high sensitivity C-reactive protein.
International Journal of Cardiology and Cardiovascular
Research, 3(1): 024-030.

Copyright: 2016 Bendary et al. This is an open-access

article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium,
provided the original author and source are cited.

Coronary artery ectasia and markers of atherosclerosis