European Journal of Cardiovascular Medicine

Hypertension remains one of the most significant modifiable risk factors for acute ischemic stroke, contributing substantially to global morbidity and mortality. According to the World Health Organization, hypertension—characterized by persistently elevated blood pressure—affects over one billion people worldwide and is a major contributor to premature death, particularly in low- and middle-income countries. In India, the overall prevalence of hypertension is estimated at 22.6%, with higher rates in men (24.1%) than women (21.2%), and a significant increase with advancing age.(1)

Hypertension, diabetes mellitus (DM), and dyslipidaemia are key components of metabolic syndrome and are strongly associated with an increased risk of cardiovascular and cerebrovascular diseases. The coexistence of these conditions accelerates the development of atherosclerosis, leading to vascular complications such as increased carotid artery intima-media thickness (CIMT), endothelial dysfunction, and plaque formation. Studies have shown that individuals with both hypertension and diabetes have a two to four times higher risk of developing ischemic stroke compared to those without these comorbidities. Dyslipidaemia further compounds this risk by contributing to abnormal lipid metabolism and vascular inflammation. Stroke, including both ischemic and haemorrhagic subtypes, is a leading cause of death and long-term disability worldwide. Approximately 15 million people suffer a stroke each year, of whom five million die and another five million are left permanently disabled.(2)

One of the early markers of vascular injury in hypertensive individuals is increased CIMT, which is measured using high-resolution B-mode ultrasound. CIMT serves as a well-established surrogate marker of subclinical atherosclerosis and is predictive of future cardiovascular and cerebrovascular events.(3)

Given the growing burden of stroke in India, particularly in North Indian populations, there is a critical need to investigate the interplay between CIMT and metabolic risk factors in hypertensive patients. This study was undertaken to assess the prevalence of acute stroke (ischemic and haemorrhagic) among hypertensive individuals and to compare CIMT between hypertensive stroke patients and hypertensive controls without stroke. Additionally, the study aims to explore the association of CIMT with key metabolic risk factors diabetes mellitus and dyslipidaemia in a tertiary care hospital in Kanpur, North India.

This case-control study was conducted at a tertiary care hospital in Kanpur, North India. The sample size was calculated using standard statistical formulas for case-control studies, assuming a 62% prevalence of carotid intima-media thickness (CIMT) >0.9 mm among cases and 38% among controls. With a 95% confidence level and 80% power, the estimated sample size was 98 per group, which was rounded to 100 per group to account for potential non-response, bringing the total study population to 200.

The study population was divided into two groups: 100 cases, consisting of hypertensive patients diagnosed with acute ischemic or haemorrhagic stroke (confirmed by clinical evaluation and imaging, with Glasgow Coma Scale score ≥12), and 100 controls, comprising hypertensive individuals with no history of stroke, transient ischemic attacks, or other cerebrovascular events. All participants had essential hypertension as defined by the Eighth Joint National Committee (JNC 8) guidelines (blood pressure ≥140/90 mmHg or on antihypertensive medication). Both groups could include patients with coexisting type 2 diabetes mellitus (T2DM) and dyslipidaemia. Key exclusion criteria included patients with malignant or resistant hypertension, hypertensive emergencies or urgencies, thyroid disorders, chronic kidney or liver disease, and known cases of primary systemic illnesses.

Data and data Collection procedure information on age, sex, weight, height and body mass index (BMI) and past medical history was collected through patient interviews and medical records. The data collection procedure was meticulously planned and executed to ensure accuracy, consistency, and reliability. After patient recruitment and obtaining informed consent, the following steps were followed:

Carotid Intima-Media Thickness (CIMT) Measurement-Equipment and Technical Considerations-Ultrasound Machine:  High-resolution B-mode ultrasonography with a 7–12 MHz linear array transducer. Standardized Software: CIMT measurement will be performed using automated edge-detection software to minimize observer variability. Patient Positioning-Supine with the head slightly extended and rotated ~30° opposite to the examined side. Ultrasound Examination Process-Probe Placement & Image Acquisition-A generous amount of ultrasound gel will be applied to minimize air interference. The probe will be placed longitudinally along the carotid artery without excessive pressure (to avoid compressing the artery). The far wall of the common carotid artery (CCA), carotid bulb, and ICA will be visualized in three standardized angles (anterior, lateral, and posterior views).

The ethical clearance was obtained from the Institutional Ethics Committee GSVM Medical college Kanpur ref.no. EC/228/May/2024 dated 15/5/2024. The data was analysis by using Statistical package for social sciences, version‑26 (SPSS‑26, IBM,Chicago, USA) was used for data analysis. The continuous variables were presented in mean ± standard deviation (SD), whereas Chi‑square test was used to test the association between two categorical variables. P <0.05 was considered statistically significant.

Most patients were aged 51-70 years (48% stroke, 47% non-stroke), followed by 31-50 years (31% vs. 29%). Only 6% and 7% were under 30. The Mean age was similar in stroke (53.75 ± 15.30 years) and non-stroke groups (53.98 ± 15.94 years). Males comprised 54% of stroke, while females accounted for 46%. Residence distribution showed 60% of stroke with higher secondary education at 30% in both groups.

Table 1 Distribution of Stroke Group Population in Infarct and Haemorrhage with Carotid Intima-Media Thickness (CIMT (n=100)

Among the 100 hypertensive stroke patients, 61% had ischemic infarcts and 39% had haemorrhagic strokes. A significant proportion of infarct cases (68.85%) had CIMT >0.9 mm, indicating increased subclinical atherosclerosis, whereas most haemorrhagic stroke cases (58.97%) had CIMT <0.9 mm. (Table 1)

Table 2 Association of lipid profile with Carotid Intima-Media Thickness (CIMT) in study subject (N=200)

Assesses the correlation between lipid profile and carotid intima-media thickness (CIMT) in hypertensive patients. Individuals with CIMT >0.9 mm exhibited significantly higher prevalence of dyslipidemia, including total cholesterol >200 mg/dL (70.6%), triglycerides >150 mg/dL (68.5%), and LDL >130 mg/dL (68.6%), Conversely, HDL <40 mg/dL showed no significant association with CIMT (p=0.396) (Table 2).

Table 3 Association of Diabetic parameters with Carotid Intima-Media Thickness (CIMT) in study subject (N=200)

Patients with CIMT >0.9 mm had significantly higher frequencies of poor glycemic control, including FBS >126 mg/dL (66.2%), PPBS >200 mg/dL (67.2%), and HbA1c >10% (64.7%). These associations were statistically significant, with p-values of 0.015, 0.004, and 0.022 respectively. Interestingly, even patients with a shorter duration of diabetes (<10 years) showed increased CIMT. (table 3)

Table 4. Association of Hypertension with Carotid Intima-Media Thickness (CIMT) in study subject (N=200)

Patients with Stage II systolic blood pressure (SBP >160 mmHg) and Stage II diastolic blood pressure (DBP >100 mmHg) showed a higher prevalence of CIMT >0.9 mm (56.6% and 55.8%, respectively). Additionally, CIMT >0.9 mm was more common in patients with hypertension for more than 10 years (66.4%) (table 4)

Table 5 Association between Carotid Intima-Media Thickness (CIMT) and hypertension with metabolic risk factors (N=200)

Those with hypertension and type 2 diabetes mellitus (DM) most frequently had CIMT <0.9 mm (54 cases), while patients with hypertension, type 2 DM, and dyslipidaemia had the highest occurrence in the 0.9–1.1 mm CIMT range (54 cases). Notably, CIMT >1.1 mm was more common in patients with multiple metabolic conditions. (table 5)

The mean CIMT was significantly higher in ischemic stroke patients (1.03 ± 0.11 mm) compared to haemorrhagic stroke patients (0.98 ± 0.13 mm). Among patients with CIMT values exceeding 0.9 mm, 68.2% were diagnosed with ischemic strokes, whereas only 31.8% had haemorrhagic strokes. This difference was statistically significant (χ² = 4.20, p = 0.040), suggesting that elevated CIMT may serve as a predictive marker for ischemic stroke. This difference suggests that increased CIMT is more strongly associated with ischemic stroke, reinforcing its role as a marker of atherosclerotic burden and cerebrovascular risk.  many study report similar finding (4)(5)(6)

Among stroke patients, 68% had total cholesterol levels exceeding 200 mg/dL, compared to only 41% of non-stroke patients. This difference was found to be highly statistically significant (χ² = 14.69, p = 0.0001), indicating that hypercholesterolemia plays a crucial role in stroke risk, likely through its contribution to atherosclerosis and cerebrovascular disease. A significant association was noted between elevated CIMT and dyslipidaemic parameters—total cholesterol (p = 0.0022), triglycerides (p = 0.018), and LDL (p = 0.024).Similar result foun in many study (7)(8)(4)(9)

Body mass index (BMI) was not significantly associated with CIMT progression, as indicated by a p-value of 0.732. This suggests that BMI alone does not play a direct role in determining CIMT thickness in hypertensive individuals. Instead, other metabolic factors such as dyslipidaemia, insulin resistance, and glycemic control may have a stronger influence on arterial remodelling and atherosclerosis progression and though obese individuals had marginally higher CIMT. Similar result revealed in many study (10)(11)(6)

Significant associations were found between CIMT and both Stage II systolic (SBP ≥160 mmHg) and diastolic (DBP ≥100 mmHg) hypertension (p = 0.022 and 0.006, respectively), as well as hypertension duration >10 years (p = 0.017). these finding align (12)(6)(13)

The patients with hypertension and type 2 diabetes mellitus (DM), the majority (54 individuals) had a CIMT of <0.9 mm, while 37 had CIMT between 0.9–1.1 mm, and 19 had CIMT >1.1 mm. Conversely, among those with hypertension, type 2 DM, and dyslipidaemia, the highest proportion (54 individuals) fell within the 0.9–1.1 mm CIMT range, followed by 24 individuals in the <0.9 mm category and 12 in the >1.1 mm range. Overall, 78 participants had CIMT <0.9 mm, 91 had CIMT between 0.9–1.1 mm, and 31 had CIMT >1.1 mm. The findings indicate that patients with additional metabolic risk factors, such as dyslipidaemia, tend to have higher CIMT values, suggesting a possible correlation between increased CIMT and the presence of multiple metabolic conditions. Our study showed that patients with both diabetes and dyslipidaemia had the highest prevalence of CIMT >0.9 mm. similar finding of these study (14)(15)(6)(6)(16)

Our findings revealed significantly higher CIMT values in patients with ischemic stroke compared to those with haemorrhagic stroke, emphasizing its predictive value for atherothrombotic cerebrovascular events. Moreover, metabolic risk factors such as diabetes mellitus, dyslipidaemia (elevated total cholesterol, LDL, triglycerides), and prolonged, severe hypertension showed a strong correlation with increased CIMT. Patients with coexisting diabetes and dyslipidaemia demonstrated the highest CIMT values, indicating a cumulative vascular burden. Although BMI alone did not show significant association, its interplay with other metabolic parameters may still contribute to vascular remodelling.

1. Humayra S, Yahya N, Ning CJ, Raffali MAAF bin M, Mir IA, Mohamed AL, et al. Relationship between carotid intima-media thickness and white matter hyperintensities in non-stroke adults: a systematic review. Front Neuroanat. 2024 Jun 6;18:1394766.
2. World Health Organization. Hypertension [Internet]. [cited 2025 May 24]. Available from: https://www.who.int/health-topics/hypertension#tab=tab_1
3. Sibal L, Agarwal SC, Home PD. Carotid intima-media thickness as a surrogate marker of cardiovascular disease in diabetes. Diabetes Metab Syndr Obes Targets Ther [Internet]. 2011 [cited 2025 Feb 26];4:23. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC3064409/
4. Parmar DD. To assess correlation between carotid intima-media thickness and dyslipidemia in patients with stroke: A case control study. J Med Sci Clin Res. 2019;7(7):216–22.
5. Freitas D, Alves A, Pereira A, Pereira T. Increased intima-media thickness is independently associated with ischemic stroke. Arq Bras Cardiol. 2012;98(6):497–504.
6. Sun P, Liu L, Liu C, Zhang Y, Yang Y, Qin X, et al. Carotid intima-media thickness and the risk of first stroke in patients with hypertension. Stroke [Internet]. 2020 Feb 1 [cited 2025 Mar 15];51(2):379–86. Available from: https://pubmed.ncbi.nlm.nih.gov/31948356/
7. Guo HJ, Li CC, Bian XY, Hao Q. Correlation study on the relationship between dyslipidemia and carotid intima-media thickness in patients with diabetes mellitus. Pak J Med Sci [Internet]. 2023 May 1 [cited 2025 Mar 15];39(3):875. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC10214792/
8. Damle AJ, Thorat ST, Kasireddy SR, Yeleshwaram VR, Mehta PJ. Relation of carotid intima media thickness (CIMT) with fasting and postprandial triglyceride levels in subjects with type 2 diabetes mellitus. Int J Health Sci (Qassim). 2022 Apr 10;4100–18.
9. Kota S, Mahapatra G, Kota S, Naveed S, Tripathy P, Jammula S, et al. Carotid intima media thickness in type 2 diabetes mellitus with ischemic stroke. Indian J Endocrinol Metab [Internet]. 2013 [cited 2025 Mar 15];17(4):716. Available from: https://pubmed.ncbi.nlm.nih.gov/23961492/
10. Sharokh HD, Zakerkish M, Sina AH, Saki A, Forouzan F, Jenabi A. Diagnostic value of carotid artery intima-media thickness in patients with type 2 diabetes and its correlation with HbA1c levels. Jundishapur J Chronic Dis Care [Internet]. 2021 Apr 1 [cited 2025 Mar 15];10(2). Available from: https://brieflands.com/articles/jjcdc-111308
11. Purnamasari D, Abdaly MS, Azizi MS, Wijaya IP, Nugroho P. Carotid intima-media thickness among normoglycemia and normotension first-degree relatives of type 2 diabetes mellitus. Vasc Health Risk Manag [Internet]. 2019 [cited 2025 Mar 15];15:101. Available from: https://pmc.ncbi.nlm.nih.gov/articles/PMC6516049/
12. Gómez-Marcos MA, Recio-Rodríguez JI, Rodríguez-Sánchez E, Patino-Alonso MC, Magallón-Botaya R, Martínez-Vizcaino V, et al. Carotid intima-media thickness in diabetics and hypertensive patients. Rev Esp Cardiol (Engl Ed). 2011 Jul;64(7):622–5.
13. Naseh G, Fard MM, Kazemi T, Mirgholami A, Hashemi N, Saburi A. Comparison of carotid intima-media thickness in hypertensive patients and control group. J Cardiovasc Echogr [Internet]. 2016 Apr 1 [cited 2025 Mar 15];26(2):48–51. Available from: https://pubmed.ncbi.nlm.nih.gov/28465960/
14. Kumar A, Rathore A, Singh AK. Study of carotid intima media thickness (CIMT) in type 2 diabetes mellitus and its correlation with glycaemic control and inflammatory marker HsCRP [Internet]. 2020 [cited 2025 Mar 15]. Available from: http://imsear.searo.who.int/handle/123456789/203525
15. Pramayudha R, Achmad C, Erwinanto E, Martha JW, Akbar M. Correlation between HbA1c levels with carotid intima media thickness in newly diagnosed type 2 diabetes mellitus patients. Acta Cardiol Indones. 2019;5(2):111–8.
16. Alsiddig AM, Ali IA. Effects of smoking on intima-media thickness of the common carotid artery using ultrasonography. Artery Res [Internet]. 2024 Dec 1 [cited 2025 Mar 13];30(1):1–11. Available from: https://arteryresearch.biomedcentral.com/articles/10.1007/s44200-024-00044-w