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Aldridge ME, Do K, Oo T, Naqvi TZ. Carotid Intima-Media Thickness and Plaque Assessment by Trained Medical Residents: Validation and Preliminary Testing of a Training Protocol. J Am Soc Echocardiogr 2013; 26:1457-64. [DOI: 10.1016/j.echo.2013.08.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2012] [Indexed: 11/15/2022]
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Caviezel S, Dratva J, Schaffner E, Teynor A, Baumstark MW, Schindler C, de Groot E, Burdet L, Rothe T, Pons M, Gaspoz JM, Rochat T, Künzli N, Probst-Hensch N, Schmidt-Trucksäss A. Variability and reproducibility of carotid structural and functional parameters assessed with transcutaneous ultrasound – Results from the SAPALDIA Cohort Study. Atherosclerosis 2013; 231:448-55. [DOI: 10.1016/j.atherosclerosis.2013.10.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 08/26/2013] [Accepted: 10/06/2013] [Indexed: 01/19/2023]
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Kaya H, Ertaş F, Oylumlu M, Bilik MZ, Yıldız A, Yüksel M, Polat N, Acet H, Işık F, Ülgen MS. Relation of epicardial fat thickness and brachial flow-mediated vasodilation with coronary artery disease. J Cardiol 2013; 62:343-7. [PMID: 23810068 DOI: 10.1016/j.jjcc.2013.05.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 05/09/2013] [Accepted: 05/11/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The purpose of this study is to investigate the presence of a statistical association between epicardial fat thickness (EFT) and coronary artery disease (CAD) and between flow-mediated vasodilation (FMD) and CAD. METHODS We measured the EFT and FMD in 64 subjects with suspected stable angina pectoris. The patients were separated into two groups according to their coronary angiography results: 34 patients with CAD and 30 patients with normal coronary arteries (NCA). RESULTS EFT was significantly higher in the patients with CAD than the NCA group (6.43 ± 0.90 mm vs. 5.35 ± 0.75 mm, p<0.001) while FMD was significantly lower in the patients with CAD than those in the NCA group (6.41 ± 2.51% vs. 8.33 ± 3.45%, p=0.015). No significant correlation was found between EFT and FMD. After adjustment for EFT, FMD, age, sex, ejection fraction, glucose, and low-density lipoprotein cholesterol through multivariate logistic regression analysis, EFT (odds ratio: 6.325, 95% confidence interval 2.289-17.476, p<0.001) and age (odds ratio: 1.093, 95% confidence interval 1.008-1.185, p=0.032) remained significant predictors of CAD. A cut-off value of EFT≥5.8mm predicted the presence of CAD with 77% sensitivity and 70% specificity. CONCLUSION An echocardiographic EFT assessment is independently associated with the presence of CAD. Thus, EFT may be helpful in cardiometabolic risk stratification and therapeutic interventions.
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Affiliation(s)
- Hasan Kaya
- Department of Cardiology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey.
| | - Faruk Ertaş
- Department of Cardiology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Mustafa Oylumlu
- Department of Cardiology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Mehmet Zihni Bilik
- Department of Cardiology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Abdulkadir Yıldız
- Department of Cardiology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Murat Yüksel
- Department of Cardiology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Nihat Polat
- Department of Cardiology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Halit Acet
- Department of Cardiology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Ferhat Işık
- Department of Cardiology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey
| | - Mehmet Sıddık Ülgen
- Department of Cardiology, Dicle University, Faculty of Medicine, Diyarbakır, Turkey
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Arnab B, Biswadip G, Arindam P, Shyamash M, Anirban G, Rajan P. Anti-CCP antibody in patients with established rheumatoid arthritis: Does it predict adverse cardiovascular profile? J Cardiovasc Dis Res 2013; 4:102-6. [PMID: 24027365 DOI: 10.1016/j.jcdr.2012.09.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Accepted: 09/17/2012] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Rheumatoid arthritis (RA) is an independent risk factor for adverse cardiovascular (CV) events that accounts for a significant proportion of mortality among these patients. Anti-CCP antibodies are associated with higher frequency of extra-articular manifestations and poorer outcomes in RA. AIMS To determine the role of anti-cyclic citrullinated peptide (CCP) antibody as an independent risk factor for developing CV complications as documented by carotid intima medial thickness and abnormal echocardiography in established RA patients. MATERIALS AND METHODS Eighty patients of RA having disease duration of at least 3 years participated in this hospital-based, cross-sectional, and observational study. Forty patients were anti-CCP antibody positive. Patients of established RA having known CV risk factors, known heart disease, or family history of premature ischemic heart disease were excluded. RESULTS Anti-CCP positive group had early morning stiffness, tender and swollen joint count, and c-reactive protein (CRP) level significantly higher than those in anti-CCP negative group. Average intima-medial thicknesses of common carotid arteries were also significantly higher among anti-CCP positive group (P = 0.029) and were positively correlated with patients' age and disease duration. Lower left ventricular ejection fraction and left ventricular diastolic dysfunction were more commonly dispersed among the anti-CCP positive patients with P values of 0.01 and 0.034, respectively. Mild pericardial thickening was documented among 12.5% patients of anti-CCP positive group, while none of the anti-CCP negative patients had similar findings in echocardiography. CONCLUSION This study stressed on the important role of anti-CCP antibody in myocardial dysfunction due to inflammation in RA patients. Both atherosclerotic vascular involvement and cardiac abnormalities including pericardial, myocardial, and endocardial involvements were higher among anti-CCP positive RA patients. Hence, patients with high titer of anti-CCP antibody associated with prolonged disease duration and increased disease activity should be evaluated for CV morbidity more meticulously.
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Affiliation(s)
- Banerjee Arnab
- Department of Medicine, Medical College and Hospital, Kolkata 700 073, West Bengal, India
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Rapid Screening for Subclinical Atherosclerosis by Carotid Ultrasound
Examination: The HAPPY (Heart Attack Prevention Program for You)
Substudy. Glob Heart 2013; 8:83-9. [DOI: 10.1016/j.gheart.2013.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Association of socioeconomic status, truncal fat and sICAM-1 with carotid intima-media thickness in adolescents: The HELENA study. Atherosclerosis 2013; 228:460-5. [DOI: 10.1016/j.atherosclerosis.2013.03.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2012] [Revised: 02/24/2013] [Accepted: 03/08/2013] [Indexed: 11/22/2022]
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Albu A, Fodor D, Bondor C, Poantă L. Arterial stiffness, carotid atherosclerosis and left ventricular diastolic dysfunction in postmenopausal women. Eur J Intern Med 2013; 24:250-4. [PMID: 23276453 DOI: 10.1016/j.ejim.2012.11.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2012] [Revised: 11/04/2012] [Accepted: 11/28/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Postmenopausal women have an increased cardiovascular morbidity that may be due to the increase in classical cardiovascular risk factors and also to the arterial structure and function alterations. The aim of our study was to evaluate the association of aortic pulse wave velocity (PWV), and carotid intima-media thickness (IMT), with left ventricular diastolic dysfunction (LVDD) in postmenopausal women. PATIENTS AND METHODS In 96 women without overt cardiovascular disease (age 62±7.7 years), and with normal left ventricular systolic function, aortic PWV was assessed by using an oscillometric device, intima-media thickness was measured by B-mode ultrasonography and the parameters of left ventricular diastolic function were evaluated by a transthoracic echocardiographic study. RESULTS LVDD, defined as an E/A ratio≤1 was found in 50 patients (52%). All of them had mild LVDD. In these patients we found significant increase in age (p<0.001), aortic PWV (p<0.001), carotid IMT (p=0.002) and plaque score (p=0.004) when compared with patients without LVDD. In a logistic regression analyzed, after adjusting for age, only aortic PWV was a significant predictor of LVDD (2.15, 95% CI 1.39-3.31, p=0.0006). CONCLUSIONS This study among postmenopausal women provides evidence that increased arterial stiffness as measured by aortic PWV and not carotid IMT may be a marker or a risk factor for LVDD, independent of other classical risk factors.
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Affiliation(s)
- A Albu
- 2nd Internal Medicine Clinic, University of Medicine and Pharmacy, Cluj-Napoca, Romania.
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Comparative Effectiveness of Risk Markers for Cardiovascular Risk Assessment in Intermediate-Risk Individuals: Coronary Artery Calcium vs “The Rest”? CURRENT CARDIOVASCULAR IMAGING REPORTS 2013. [DOI: 10.1007/s12410-013-9193-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Differential impact of metabolic syndrome on subclinical atherosclerosis according to the presence of diabetes. Cardiovasc Diabetol 2013; 12:41. [PMID: 23452437 PMCID: PMC3599532 DOI: 10.1186/1475-2840-12-41] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Accepted: 02/22/2013] [Indexed: 12/24/2022] Open
Abstract
Background Metabolic syndrome (MS) is associated with increased risks of diabetes and atherosclerotic cardiovascular disease. However, data on the impact of MS and its individual components on subclinical atherosclerosis (SCA) according to diabetes status are scarce. Methods Surrogate markers of SCA, brachial–ankle pulse wave velocity (baPWV), and carotid intima–medial thickness (IMT) and plaque were assessed in 2,560 subjects (60 ± 8 years, 33% men) who participated in baseline health examinations for a community-based cohort study. Results The participants included 2,149 non-diabetics (84%) and 411 diabetics (16%); 667 non-diabetics (31%) and 285 diabetics (69%) had MS, respectively. Diabetics had significantly higher baPWV and carotid IMT, and more plaques than non-diabetics (p < 0.001, respectively). Individuals with MS had significantly higher baPWV and carotid IMT than those without MS only among non-diabetics (p < 0.001, respectively). Among MS components, increased blood pressure was significantly associated with the exacerbation of all SCA markers in non-diabetics. The number of MS components was significantly correlated with both baPWV and carotid IMT in non-diabetics (baPWV: r = 0.302, p < 0.001; carotid IMT: r = 0.217, p < 0.001). Multiple regression showed both MS and diabetes were significantly associated with baPWV (p < 0.001, respectively), carotid IMT (MS: p < 0.001; diabetes: p = 0.005), and the presence of plaque (MS: p = 0.041; diabetes: p = 0.002). Conclusions MS has an incremental impact on SCA in conditions without diabetes. The identification of MS and its individual components is more important for the risk stratification of CVD in non-diabetic individuals.
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Mohler ER, Sibley AA, Stein R, Davila-Roman V, Wyatt H, Badellino K, Rader DJ, Klein S, Foster GD. Endothelial function and weight loss: comparison of low-carbohydrate and low-fat diets. Obesity (Silver Spring) 2013; 21:504-9. [PMID: 23404949 PMCID: PMC3630284 DOI: 10.1002/oby.20055] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 08/10/2012] [Indexed: 01/22/2023]
Abstract
OBJECTIVE The effect of weight loss on obesity-associated endothelial dysfunction is not clear because of conflicting data, demonstrating both improvement and no change in endothelial function after weight loss in obese subjects. A 2-year prospective study (n = 121) was conducted to examine: (1) the effect of obesity and weight loss (either a low-carbohydrate or and low-fat diet) on flow mediated vasodilatation (FMD), a measure of endothelial function. DESIGN AND METHODS Participants reduced body weight by 7.1% ± 4.4%, 8.7% ± 6.8%, 7.1% ± 7.8%, and 4.1% ± 7.7% at 3, 6, 12, and 24 months, respectively with no significant differences between the low-fat and low-carbohydrate groups. RESULTS Endothelial function was inversely correlated with waist circumference, triglyceride level, and directly correlated with leptin in obese persons prior to weight loss. These weight losses did not confer any improvements in FMD. There were no differences between the low-fat and low-carbohydrate diets in FMD at any time point. At 6 months (r = 0.26, P = 0.04) and 1 year (r =0.28, P = 0.03), there were positive correlations between change in FMD and change in leptin but not at 2 years. CONCLUSION There was no significant improvement in endothelial function after 7.1% ± 7.8% weight loss at 1 year and 4.1% ± 7.7% at 2 years, achieved by either a low carbohydrate or a low fat diet.
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Affiliation(s)
- Emile R Mohler
- Department of Medicine, Cardiovascular Division, Section of Vascular Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA.
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Risk of first-time heart disease higher for hormone therapy users with metabolic syndrome. Menopause 2013; 20:244-7. [DOI: 10.1097/gme.0b013e3182850c5d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rollefstad S, Kvien TK, Holme I, Eirheim AS, Pedersen TR, Semb AGP. Treatment to lipid targets in patients with inflammatory joint diseases in a preventive cardio-rheuma clinic. Ann Rheum Dis 2012; 72:1968-74. [PMID: 23264359 DOI: 10.1136/annrheumdis-2012-202789] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To perform cardiovascular risk stratification in patients with inflammatory joint diseases (IJD) and treat to lipid targets according to recommendations. METHODS We initiated a preventive cardio-rheuma clinic based on the unmet need of adequate cardiovascular prevention in IJD patients. A full cardiovascular risk stratification was performed at the first consultation (history of conventional risk factors and of cardiovascular disease, lipid measurement, blood pressure and ultrasound examination of both carotid arteries), and the patient was classified to either a primary or secondary cardiovascular prevention regime, or to have a low risk (no intervention). Lipid-lowering treatment was adjusted until at least two lipid targets were achieved. RESULTS Of the 426 patients referred, 36.6% had a systematic coronary risk evaluation less than 5% (no lipid-lowering intervention). The remaining 270 patients ((rheumatoid arthritis (RA), n=165; ankylosing spondylitis (AS), n=70; and psoriatic arthritis (PsA), n=35) were assigned to either primary (n=63) or secondary prevention (n=207). There were significant differences between the patient groups regarding age (p<0.001), sex (p<0.001) and disease duration (p<0.001). Lipid changes in IJD patients were: total cholesterol -1.86±1.20 mmol/l (p<0.001); low-density lipoprotein cholesterol -1.74±1.11 (p<0.001); high-density lipoprotein cholesterol 0.01±0.30 (p=0.61); triglycerides -0.28±0.72 (p<0.001). The proportions of patients reaching at least two lipid targets were for RA 92.1%, AS 90.0% and PsA 82.9%. No serious adverse events were observed. CONCLUSIONS There was indication for cardiovascular prevention in a high proportion of IJD patients referred for cardiovascular risk stratification. Treatment to lipid targets was successful in approximately 90% of patients with IJD.
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Ukawa T, Takayanagi T, Morimoto H, Higashi Y, Idei N, Yoshizumi M, Tsuji T. Novel non-invasive method of measurement of endothelial function: enclosed-zone flow-mediated dilatation (ezFMD). Med Biol Eng Comput 2012; 50:1239-47. [PMID: 23054376 DOI: 10.1007/s11517-012-0955-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2011] [Accepted: 09/13/2012] [Indexed: 01/22/2023]
Abstract
Measurement of flow-mediated dilatation (FMD) is the conventional non-invasive method for assessment of endothelial function; however, it requires an expensive ultrasound system and high levels of technical skill. Therefore, we developed a novel method for measurement of endothelial function, namely, measurement of ezFMD. ezFMD estimates the degree of vasodilatation from the oscillation signals transmitted to a sphygmomanometer cuff attached to the upper arm. The objective of this study was to validate the principle underlying the measurement of ezFMD, and to evaluate the repeatability of the ezFMD measurements. We observed the blood vessel behavior and oscillometric pattern in ten subjects. When the cuff was inflated to the level of the mean blood pressure, the oscillation amplitude increased with increasing degree of vasodilatation. In experiment to evaluate the repeatability of the ezFMD measurement, the average difference between the paired measurements was 3.7 %, the standard deviation was 11.5 %, and the average coefficient of variation value for the 11 paired measurements was 23.7 %. These results suggest the validity of the principle underlying the measurement of the ezFMD for the assessment of endothelial function. And, this study suggests that the repeatability of the ezFMD measurements is superior to that of the conventional measurement of FMD.
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Affiliation(s)
- Teiji Ukawa
- Nihon Kohden Corporation, Tokyo 161-8560, Japan.
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Laing ST, Smulevitz B, Vatcheva KP, Rentfro AR, McPherson DD, Fisher-Hoch SP, McCormick JB. High prevalence of subclinical atherosclerosis by carotid ultrasound among Mexican Americans: discordance with 10-year risk assessment using the Framingham risk score. Echocardiography 2012; 29:1224-32. [PMID: 22747630 DOI: 10.1111/j.1540-8175.2012.01774.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Framingham risk scores (FRS) were validated in a mostly Caucasian population. Evaluation of subclinical atherosclerosis by carotid ultrasound may improve ascertainment of risk in nonwhite populations. This study aimed to evaluate carotid intima-media thickness (cIMT) and carotid plaquing among Mexican Americans, and to correlate these markers with coronary risk factors and the FRS. METHODS/RESULTS Participants (n = 141) were drawn from the Cameron County Hispanic Cohort. Carotid artery ultrasound was performed and cIMT measured. Carotid plaque was defined as areas of thickening >50% of the thickness of the surrounding walls. Mean age was 53.1 ± 11.7 years (73.8% female). Most were overweight or obese (88.7%) and more than half (53.2%) had the metabolic syndrome. One third (34.8%) had abnormal carotid ultrasound findings (either cIMT ≥75th percentile for gender and age or presence of plaque). Among those with abnormal carotid ultrasound, the majority were classified as being at low 10-year risk for cardiovascular events. Carotid ultrasound reclassified nearly a third of the cohort as being at high risk. This discordance between 10-year FRS and carotid ultrasound was noted whether risk was assessed for hard coronary events or global risk. Concordance between FRS and carotid ultrasound findings was best when long-term (30-year) risk was assessed and no subject with an abnormal carotid ultrasound was categorized as low risk by the 30-year FRS algorithm. CONCLUSIONS Integration of carotid ultrasound findings to coronary risk assessments and use of longer term prediction models may provide better risk assessment in this minority population, with earlier initiation of appropriate therapies.
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Affiliation(s)
- Susan T Laing
- Division of Cardiology, Department of Internal Medicine, University of Texas Health Science Center-Houston, Houston, TexasDivision of Epidemiology, School of Public Health, Brownsville Campus, University of Texas Health Science Center-Houston, Brownsville, TexasCollege of Nursing, University of Texas at Brownsville, Brownsville, Texas
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Mazzoccoli G, Fontana A, Grilli M, Dagostino MP, Copetti M, Pellegrini F, Vendemiale G. Idiopathic deep venous thrombosis and arterial endothelial dysfunction in the elderly. AGE (DORDRECHT, NETHERLANDS) 2012; 34:751-760. [PMID: 21598017 PMCID: PMC3337930 DOI: 10.1007/s11357-011-9265-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2010] [Accepted: 05/05/2011] [Indexed: 05/30/2023]
Abstract
Arterial and venous thrombosis have always been regarded as different pathologies and epidemiological studies have examined the association between venous thrombosis and indicators of atherosclerosis and/or arterial thromboembolic events. We measured the flow-mediated dilation (FMD), a well-known marker of arterial endothelial dysfunction, in young-middle-aged and old-aged patients with and without unprovoked deep venous thrombosis (DVT). The aim of this study was to investigate whether DVT was a significant predictor for impaired FMD, considering all the patients and young-middle-aged (age < 65 years) and old-aged (age ≥ 65 years) patients separately. FMD was measured in the brachial artery on a population of 120 subjects with the same atherosclerosis risk factors, 68 male and 52 female, 70 young-middle-aged subjects (mean age ± SD 49.5 ± 10.5 years) and 50 old-aged subjects (76.2 ± 7.7 years). Patients with DVT showed a significant decrease of FMD compared to patients without DVT (6.8 ± 5.5% vs. 10.9 ± 3.5%, p < 0.001). Moreover, old-aged patients showed a significant decrease of FMD compared to the young-middle-aged subjects (7.4 ± 4.1% vs. 9.8 ± 5.3%, p = 0.005). In the whole study population, DVT was strongly associated with FMD (risk factors adjusted β = -4.14, p < 0.001). A significant interaction between age and the presence of DVT on predicting FMD was found (p = 0.003) suggesting a differential behavior of DVT as predictor of FMD. In young-middle-aged group, multivariate model confirmed that DVT was the most significant predictor of continuous FMD (β = -6.06, p < 0.001). On the contrary, DVT was no more a predictor of FMD in the old age group (β = -0.73, p = 0.556). Furthermore, old-aged patients without DVT showed a statistically significant decrease of FMD compared to the young-middle-aged subjects without DVT (8.2 ± 2.1% vs. 12.6 ± 2.7%, p<0.001) and old-aged patients with DVT showed a not statistically significant decrease of the FMD compared to the young-middle-aged patients with DVT (6.7 ± 5.3% vs. 6.8 ± 5.7%, p = 0.932). In conclusion, young-middle-aged patients with spontaneous DVT show an impaired FMD, whereas this impairment in old-aged subjects is evident independently from the presence or absence of DVT. Aging per se may be associated with physiologic abnormalities in the systemic arteries and with endothelial dysfunction.
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Affiliation(s)
- Gianluigi Mazzoccoli
- Unit of Internal Medicine, Department of Medical Sciences, Scientific Institute and Regional General Hospital “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
| | - Andrea Fontana
- Unit of Biostatistics, Scientific Institute and Regional General Hospital “Casa Sollievo della Sofferenza”, S.Giovanni Rotondo, Italy
| | - Massimo Grilli
- Unit of Internal Medicine, Department of Medical Sciences, Scientific Institute and Regional General Hospital “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
| | - Mariangela Pia Dagostino
- Unit of Internal Medicine, Department of Medical Sciences, Scientific Institute and Regional General Hospital “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
| | - Massimiliano Copetti
- Unit of Biostatistics, Scientific Institute and Regional General Hospital “Casa Sollievo della Sofferenza”, S.Giovanni Rotondo, Italy
| | - Fabio Pellegrini
- Unit of Biostatistics, Scientific Institute and Regional General Hospital “Casa Sollievo della Sofferenza”, S.Giovanni Rotondo, Italy
- Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, Chieti, Italy
| | - Gianluigi Vendemiale
- Unit of Internal Medicine, Department of Medical Sciences, Scientific Institute and Regional General Hospital “Casa Sollievo della Sofferenza”, San Giovanni Rotondo, Italy
- Unit of Geriatrics, Department of Medical Sciences, University of Foggia, Foggia, Italy
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Schier R, Hinkelbein J, Marcus H, Mehran R, El-Zein R, Hofstetter W, Swafford J, Riedel B. Preoperative microvascular dysfunction: a prospective, observational study expanding risk assessment strategies in major thoracic surgery. Ann Thorac Surg 2012; 94:226-33. [PMID: 22571880 DOI: 10.1016/j.athoracsur.2012.03.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 03/12/2012] [Accepted: 03/19/2012] [Indexed: 11/19/2022]
Abstract
BACKGROUND Brachial artery reactivity testing (BART)--a surrogate test of microvascular function--predicts cardiac risk in the nonsurgical population and associates it with adverse outcome after vascular surgery. This pilot study investigated BART-derived variables, including flow-mediated dilation (FMD), in preoperative risk stratification for major thoracic surgery. METHODS After institutional review board approval, BART was performed in 63 patients before major thoracic surgery. Ultrasonography recorded two-dimensional images and Doppler flow signals of the brachial artery preoperatively at baseline and after induced reactive hyperemia. Variables derived using BART were correlated with preoperative risk factors, established risk scores, and postoperative complications. RESULTS The median preoperative FMD value in patients without postoperative complications was 11.5%. This value was used to delineate all patients into two groups: low (FMD < 11.5%) and high (FMD ≥ 11.5%) FMD cohorts. Patients in the low FMD group experienced more postoperative complications: 54% versus 30% had one or more adverse postoperative event, and 11% versus 0% had three or more adverse postoperative events (p < 0.001), respectively. The low FMD group required longer intensive care unit (3.9 ± 2.0 days versus 0.9 ± 0.3 days; p = 0.015) and hospital (14.0 ± 3.3 days versus 6.8 ± 0.6 days; p = 0.007) stays. This cutoff point for FMD accurately predicted 71% of the patients with adverse postoperative events, achieving 71.4% (95% confidence interval, 54.7 to 88.2) sensitivity and 48.6% (95% confidence interval, 32.0 to 65.1) specificity. CONCLUSIONS Using BART, preoperative microvascular dysfunction can be identified in patients at increased risk for postoperative complications. These data suggest that larger observational studies and studies exploring preoperative optimization strategies aimed at improving microvascular function are warranted.
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Affiliation(s)
- Robert Schier
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany.
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Waller AH, Gardin JM. Does Cardiovascular Ultrasound Have a Role in Assessment of Cardiovascular Risk in Asymptomatic Persons? CURRENT CARDIOVASCULAR RISK REPORTS 2012. [DOI: 10.1007/s12170-012-0225-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Gerhard-Herman M, Smoot LB, Wake N, Kieran MW, Kleinman ME, Miller DT, Schwartzman A, Giobbie-Hurder A, Neuberg D, Gordon LB. Mechanisms of premature vascular aging in children with Hutchinson-Gilford progeria syndrome. Hypertension 2011; 59:92-7. [PMID: 22083160 DOI: 10.1161/hypertensionaha.111.180919] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Hutchinson-Gilford progeria syndrome is a rare, segmental premature aging syndrome of accelerated atherosclerosis and early death from myocardial infarction or stroke. This study sought to establish comprehensive characterization of the fatal vasculopathy in Hutchinson-Gilford progeria syndrome and its relevance to normal aging. We performed cardiovascular assessments at a single clinical site on the largest prospectively studied cohort to date. Carotid-femoral pulse wave velocity was dramatically elevated (mean: 13.00±3.83 m/s). Carotid duplex ultrasound echobrightness, assessed in predefined tissue sites as a measure of arterial wall density, was significantly greater than age- and sex-matched controls in the intima-media (P<0.02), near adventitia (P<0.003), and deep adventitia (P<0.01), as was internal carotid artery mean flow velocity (P<0.0001). Ankle-brachial indices were abnormal in 78% of patients. Effective disease treatments may be heralded by normalizing trends of these noninvasive cardiovascular measures. The data demonstrate that, along with peripheral vascular occlusive disease, accelerated vascular stiffening is an early and pervasive mechanism of vascular disease in Hutchinson-Gilford progeria syndrome. There is considerable overlap with cardiovascular changes of normal aging, which reinforces the view that defining mechanisms of cardiovascular disease in Hutchinson-Gilford progeria syndrome provides a unique opportunity to isolate a subset of factors influencing cardiovascular disease in the general aging population.
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Affiliation(s)
- Marie Gerhard-Herman
- Division of Cardiology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
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69
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Roman MJ, Kizer JR, Best LG, Lee ET, Howard BV, Shara NM, Devereux RB. Vascular biomarkers in the prediction of clinical cardiovascular disease: the Strong Heart Study. Hypertension 2011; 59:29-35. [PMID: 22068872 DOI: 10.1161/hypertensionaha.111.181925] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
We compared the ability of separately measured intimal-medial thickness and atherosclerotic plaque to predict incident cardiovascular disease. American Indian men and women from the Strong Heart Study who were free of cardiovascular disease were evaluated with carotid ultrasound and cardiovascular disease risk factor assessment. End-diastolic intimal-medial thickness of the common carotid arteries was measured and averaged. Arterial mass (cross-sectional area) was calculated from intimal-medial thickness and end-diastolic diameter. Atherosclerosis was defined by focal plaque (discrete thickening >50% relative to the adjacent wall) and the number of carotid segments containing plaque (plaque score); 2441 participants (age 63±8 years) were followed-up for a mean of 7.7±2.8 years, during which time 495 experienced incident cardiovascular disease events. Time-to-event analyses were performed in groups stratified according to diabetes and hypertension status. Cardiovascular disease events were predicted by presence and extent of atherosclerosis in all groups; intima-medial thickness and arterial mass were only associated with outcomes when neither hypertension nor diabetes was present. Unequivocal evidence of atherosclerosis (plaque) and its extent (plaque score) are independently associated with incident cardiovascular disease events in individuals without preexisting cardiovascular disease regardless of diabetes and hypertension status. Hypertension-related increases in intima-media thickness and arterial mass appear to limit their use as measures of early or diffuse atherosclerosis and, hence, association with cardiovascular disease outcomes. These findings support the utility of separate assessment of focal atherosclerosis and intimal-medial thickness in epidemiological studies, trials, and risk stratification protocols.
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Affiliation(s)
- Mary J Roman
- Division of Cardiology, Weill Cornell Medical College, 525 East 68th Street, New York, NY 10021, USA.
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70
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McCue MC, Marlatt KL, Kelly AS, Steinberger J, Dengel DR. Evaluation of gender differences in endothelium-independent dilation using peripheral arterial tonometry. Clin Physiol Funct Imaging 2011; 32:94-8. [PMID: 22296628 DOI: 10.1111/j.1475-097x.2011.01060.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND A change in peripheral arterial tonometry (PAT) in response to reactive hyperaemia is often used to provide a non-invasive measure of endothelium-dependent dilation (EDD). Reactive hyperaemia does not allow one to quantify endothelium-independent dilation (EID), which is part of overall vascular function. Although most research examining vascular function and cardiovascular disease has focused on EDD, there is evidence that cardiovascular risk factors may impair EID. PURPOSE To examine the microvascular vasodilation response to nitroglycerin (NTG) in healthy adults using PAT. METHODS Microvascular responses to reactive hyperaemia and NTG were evaluated in 86 (41 female and 45 male) healthy subjects (age 37 ± 5 years). Beat-to-beat plethysmographic measurements of finger arterial pulse waves were recorded for 5 min following reactive hyperaemia. After a 10-min rest period, sublingual NTG (0.4 mg) was administered and PAT signal changes were measured for 10 min. Peak reactive hyperaemic index (RHI) and peak NTG-mediated index (NMI) were determined in all subjects. RESULTS There were no significant gender differences in peak RHI (females: 2.07 ± 0.56 versus males: 1.91 ± 0.58, P = 0.20). Mean peak NMI for all subjects was 2.78 (± 1.49). Peak NMI was significantly greater in females than in males (3.11 ± 1.59 versus 2.50 ± 1.34, P = 0.05). Time to peak NMI was not significantly different between genders (7 min, 28 s [± 1 min, 47 s], versus 7 min, 14 s [± 1 min, 49 s], P = 0.58). CONCLUSION In this population of healthy adults, peak NMI was significantly greater in females than in males. These findings suggest that gender differences exist in the microvascular vasodilation responses to NTG using PAT.
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Affiliation(s)
- Meghan C McCue
- School of Kinesiology, University of Minnesota, Minneapolis, MN 55455, USA.
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71
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Ultrasound Imaging of Carotid Intima-Media Thickness: an Office-Based Tool to Assist Physicians in Cardiovascular Risk Assessment. Curr Atheroscler Rep 2011; 13:431-6. [DOI: 10.1007/s11883-011-0200-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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72
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Kothawade K, Bairey Merz CN. Microvascular coronary dysfunction in women: pathophysiology, diagnosis, and management. Curr Probl Cardiol 2011; 36:291-318. [PMID: 21723447 PMCID: PMC3132073 DOI: 10.1016/j.cpcardiol.2011.05.002] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Women exhibit a greater symptom burden, more functional disability, and a higher prevalence of no obstructive coronary artery disease compared to men when evaluated for signs and symptoms of myocardial ischemia. Microvascular coronary dysfunction (MCD), defined as limited coronary flow reserve and/or coronary endothelial dysfunction, is the predominant etiologic mechanism of ischemia in women with the triad of persistent chest pain, no obstructive coronary artery disease, and ischemia evidenced by stress testing. Evidence shows that approximately 50% of these patients have physiological evidence of MCD. MCD is associated with a 2.5% annual major adverse event rate that includes death, nonfatal myocardial infarction, nonfatal stroke, and congestive heart failure. Although tests such as adenosine stress cardiac magnetic resonance imaging may be a useful noninvasive method to predict subendocardial ischemia, the gold standard test to diagnose MCD is an invasive coronary reactivity testing. Early identification of MCD by coronary reactivity testing may be beneficial in prognostication and stratifying these patients for optimal medical therapy. Currently, understanding of MCD pathophysiology can be used to guide diagnosis and therapy. Continued research in MCD is needed to further advance our understanding.
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73
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Vriz O, Bossone E, Bettio M, Pavan D, Carerj S, Antonini-Canterin F. Carotid Artery Stiffness and Diastolic Function in Subjects without Known Cardiovascular Disease. J Am Soc Echocardiogr 2011; 24:915-21. [DOI: 10.1016/j.echo.2011.05.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2010] [Indexed: 11/24/2022]
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Nambi V. Carotid intima media thickness. J Am Soc Echocardiogr 2011; 24:A25. [PMID: 21791274 DOI: 10.1016/j.echo.2011.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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75
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Roman MJ, Howard BV, Howard WJ, Mete M, Fleg JL, Lee ET, Devereux RB. Differential impacts of blood pressure and lipid lowering on regression of ventricular and arterial mass: the Stop Atherosclerosis in Native Diabetics Trial. Hypertension 2011; 58:367-71. [PMID: 21788602 DOI: 10.1161/hypertensionaha.111.172486] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The relative impacts of lowering blood pressure versus lowering low-density lipoprotein (LDL) cholesterol on regression of ventricular and arterial mass have not been systematically examined. Changes in left ventricular mass and arterial mass (common carotid artery cross-sectional area) after 36 months of simultaneous lowering of systolic blood pressure and LDL cholesterol were examined in the Stop Atherosclerosis in Native Diabetics Trial of standard versus aggressive LDL cholesterol and blood pressure targets in American Indians with type 2 diabetes mellitus. The 2 treatment groups were combined to examine changes in left ventricular and arterial mass over a spectrum of achieved blood pressure and lipid levels. Among the combined group of 413 Stop Atherosclerosis in Native Diabetics Trials participants, systolic blood pressure, LDL cholesterol, and left ventricular mass were all significantly reduced, whereas arterial mass significantly increased, after 36 months of therapy (P<0.001 for all). In linear regression models, a decrease in arterial mass was significantly related to achieved systolic blood pressure and, to a lesser extent, achieved LDL cholesterol, after adjustment for important covariates. Left ventricular mass progressively decreased with lower achieved levels of systolic blood pressure, independent of baseline levels of left ventricular mass. In conclusion, achieved levels of systolic blood pressure are important determinants of the extent of regression of arterial and ventricular mass during prolonged therapy in diabetic individuals. Achieved levels of LDL cholesterol influence regression of arterial but not ventricular mass. Our findings suggest that there is no threshold of systolic blood pressure below which regression of cardiovascular target organ damage cannot be achieved.
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Affiliation(s)
- Mary J Roman
- Division of Cardiology, Weill Cornell Medical College, 525 East 68th St, New York, NY 10021, USA.
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76
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Thijssen DHJ, Scholten RR, van den Munckhof ICL, Benda N, Green DJ, Hopman MTE. Acute change in vascular tone alters intima-media thickness. Hypertension 2011; 58:240-6. [PMID: 21670415 DOI: 10.1161/hypertensionaha.111.173583] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Atherosclerosis is a lifelong process involving artery wall thickening. Increased wall thickness has been widely adopted as a preclinical surrogate marker of atherosclerosis. A prerequisite for such a surrogate marker is that it is a structural characteristic of the vessel wall that is not subject to acute changes. The purpose of this study was to examine the acute effects of vasodilator drug administration on wall thickness of the carotid and superficial femoral arteries. High-resolution ultrasound was used to examine carotid and femoral artery diameters and wall thickness in 15 young (25±4 years of age) and 15 older (70±6 years of age) healthy men who were administered sublingual glyceryl trinitrate. Diameter and wall thickness were collected before and across a 10-minute period after glyceryl trinitrate administration. Glyceryl trinitrate induced a significant increase in carotid and femoral artery diameter and a decrease in wall thickness in both young and older men (both P<0.001). The latter was significantly larger than in young men (both P<0.01). The changes in carotid artery wall thickness in both young (35±23 μm) and older men (71±46 μm) approximate those considered prognostically relevant. Collectively, our data suggest that vasodilator drug administration induces a rapid and marked decrease in wall thickness, which mirrors conduit artery vasodilation in both young and older men. This finding confirms the presence of acute changes in wall thickness and has important implications for future studies that assess artery wall characteristics as a surrogate measure of atherosclerosis.
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Affiliation(s)
- Dick H J Thijssen
- Department of Physiology, Radboud University Nijmegen Medical Centre, 6525 EZ Nijmegen, The Netherlands.
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77
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Marlatt KL, McCue MC, Kelly AS, Metzig AM, Steinberger J, Dengel DR. Endothelium-independent dilation in children and adolescents. Clin Physiol Funct Imaging 2011; 31:390-3. [PMID: 21771259 DOI: 10.1111/j.1475-097x.2011.01030.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Peak brachial artery dilation post-nitroglycerin (NTG) administration occurs between 3 and 5 min in adults. The purpose of this study was to identify the time to peak dilation response to sublingual NTG (0·3 mg) in youth. Endothelium-independent dilation (EID) was measured in 198 healthy (113 males, 85 females) youth (6-18 years) via ultrasound imaging of the brachial artery following NTG administration. Time to peak EID was 268 s following NTG administration, with no significant (P = 0·6) difference between males and females. There was a significant (P<0·001) difference between EID post-NTG at the 3 versus 4 min, 4 versus 5-min, and 3 versus 5 min time points. Peak EID (males: 24·8 ± 0·5 versus females: 25·3 ± 0·6%, P = 0·6) was not significantly different after accounting for baseline diameter. Peak response to NTG administration occurs between 4 and 5 min. The results demonstrate the importance of measuring EID up to 5-min post-NTG administration in youth.
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Affiliation(s)
- Kara L Marlatt
- Laboratory of Integrative Human Physiology, School of Kinesiology, University of Minnesota, Minneapolis, MN 55455, USA.
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78
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Nambi V, Chambless L, He M, Folsom AR, Mosley T, Boerwinkle E, Ballantyne CM. Common carotid artery intima-media thickness is as good as carotid intima-media thickness of all carotid artery segments in improving prediction of coronary heart disease risk in the Atherosclerosis Risk in Communities (ARIC) study. Eur Heart J 2011; 33:183-90. [PMID: 21666250 DOI: 10.1093/eurheartj/ehr192] [Citation(s) in RCA: 124] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
AIMS Carotid intima-media thickness (CIMT) and plaque information can improve coronary heart disease (CHD) risk prediction when added to traditional risk factors (TRF). However, obtaining adequate images of all carotid artery segments (A-CIMT) may be difficult. Of A-CIMT, the common carotid artery intima-media thickness (CCA-IMT) is relatively more reliable and easier to measure. We evaluated whether CCA-IMT is comparable to A-CIMT when added to TRF and plaque information in improving CHD risk prediction in the Atherosclerosis Risk in Communities (ARIC) study. METHODS AND RESULTS Ten-year CHD risk prediction models using TRF alone, TRF + A-CIMT + plaque, and TRF + CCA-IMT + plaque were developed for the overall cohort, men, and women. The area under the receiver operator characteristic curve (AUC), per cent individuals reclassified, net reclassification index (NRI), and model calibration by the Grønnesby-Borgan test were estimated. There were 1722 incident CHD events in 12 576 individuals over a mean follow-up of 15.2 years. The AUC for TRF only, TRF + A-CIMT + plaque, and TRF + CCA-IMT + plaque models were 0.741, 0.754, and 0.753, respectively. Although there was some discordance when the CCA-IMT + plaque- and A-CIMT + plaque-based risk estimation was compared, the NRI and clinical NRI (NRI in the intermediate-risk group) when comparing the CIMT models with TRF-only model, per cent reclassified, and test for model calibration were not significantly different. CONCLUSION Coronary heart disease risk prediction can be improved by adding A-CIMT + plaque or CCA-IMT + plaque information to TRF. Therefore, evaluating the carotid artery for plaque presence and measuring CCA-IMT, which is easier and more reliable than measuring A-CIMT, provide a good alternative to measuring A-CIMT for CHD risk prediction.
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Affiliation(s)
- Vijay Nambi
- Section of Atherosclerosis and Vascular Medicine, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
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79
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Amin AM, Nawito ZO, Atfy RA, El-Hadidi KT. Tc-99m sestamibi lower extremity muscle scan, is it a useful screening tool for assessment of preclinical atherosclerosis in rheumatoid arthritis patients? Rheumatol Int 2011; 32:2075-81. [DOI: 10.1007/s00296-011-1926-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2010] [Accepted: 03/27/2011] [Indexed: 11/28/2022]
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80
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Rubin MF, Rosas SE, Chirinos JA, Townsend RR. Surrogate markers of cardiovascular disease in CKD: what's under the hood? Am J Kidney Dis 2011; 57:488-97. [PMID: 21168944 DOI: 10.1053/j.ajkd.2010.08.030] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 08/09/2010] [Indexed: 01/19/2023]
Abstract
Although clinical cardiovascular outcomes, such as heart attack, stroke, and sudden cardiac death, have a dramatic onset, they result from prolonged exposure to an ever-growing array of risk factors. Several noninvasive procedures are available to assess the cumulative effect of these exposures with the goal of more precisely estimating a person's cardiovascular risk. These include ankle-brachial index, which provides an estimation of obstruction in major-vessel lumen caliber; carotid ultrasound, which evaluates carotid intima-media thickness and plaque, visibly quantifying atherosclerotic burden; aortic pulse wave velocity, which provides a measure of large-artery stiffness; and echocardiography, which measures left ventricular mass, providing a measure of subclinical hypertensive heart disease. In this narrative review, we discuss the role of each of these measures, with a particular emphasis on patients with chronic kidney disease.
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81
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Johnson HM, Stein JH. Measurement of carotid intima-media thickness and carotid plaque detection for cardiovascular risk assessment. J Nucl Cardiol 2011; 18:153-62. [PMID: 21132418 DOI: 10.1007/s12350-010-9319-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Heather M Johnson
- University of Wisconsin School of Medicine and Public Health, Madison, WI 53792, USA
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82
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Meairs S, Hennerici M, Mohr J. Ultrasonography. Stroke 2011. [DOI: 10.1016/b978-1-4160-5478-8.10044-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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83
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Dogan S, Kastelein JJP, Grobbee DE, Bots ML. Mean Common or Mean Maximum Carotid Intima-Media Thickness as Primary Outcome in Lipid-Modifying Intervention Studies. J Atheroscler Thromb 2011; 18:946-57. [DOI: 10.5551/jat.8623] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Lethen H, Tries HP, Kersting S, Bramlage P, Lambertz H. Improvement of Coronary Microvascular Function After Angiotensin Receptor Blocker Treatment With Irbesartan in Patients With Systemic Hypertension. J Clin Hypertens (Greenwich) 2010; 13:155-61. [DOI: 10.1111/j.1751-7176.2010.00401.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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85
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Mazzoccoli G, Notarsanto I, de Pinto GD, Dagostino MP, De Cata A, D'Alessandro G, Tarquini R, Vendemiale G. Anti-tumor necrosis factor-α therapy and changes of flow-mediated vasodilatation in psoriatic and rheumatoid arthritis patients. Intern Emerg Med 2010; 5:495-500. [PMID: 20845087 DOI: 10.1007/s11739-010-0458-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2010] [Accepted: 08/31/2010] [Indexed: 01/18/2023]
Abstract
For a long time, the endothelial covering of the vessels has been considered an inert surface. On the contrary, the endothelial cells are active and dynamic elements in the interaction between blood and tissues. The control of the vessel basal tone is obtained by the complex balance between the relaxing and contracting endothelial factors. Previous clinical studies show that patients suffering from rheumatoid arthritis and other autoimmune rheumatologic pathologies are at high risk of death being prematurely affected by atherosclerosis and cardiovascular diseases. Blocking tumor necrosis factor (TNF)-α by biological drugs improves the endothelial function. The aim of our study was to evaluate the effects of two anti-TNF-α drugs (infliximab and etanercept) on the endothelial function by evaluating the flow-mediated dilatation (FMD), which was measured in the brachial artery before and after treatment and after 8-12 weeks. We enrolled 36 patients (average age 52 ± 9.8 years, 12 men and 24 women), 25 of them were affected by rheumatoid arthritis (RA) and 11 were affected by psoriatic arthritis (PsA) and they were divided into three groups: 10 patients were treated with etanercept, 13 patients were treated with infliximab, 13 patients were treated with DMARDs. We measured the common carotid intimal-medial thickness (ccIMT) and the endothelial function was evaluated by FMD measurement in the brachial artery, before treatment, 1 h after the beginning of treatment and after 8-12 weeks. No statistically significant difference between the three groups was found for the ultrasonographic evaluation of the carotid IMT. On the contrary, the differences between FMD values before and after the treatment in the patients treated with etanercept (13.1 ± 0.01 vs. 18.8 ± 0.01%, p < 0.01) and in the patients treated with infliximab (11.8 ± 0.09 vs. 16.7 ± 0.09%, p < 0.01) were statistically significant. Long-term evaluation for infliximab and etanercept was performed by comparing the FMD values, respectively, 8 and 12 weeks after the first treatment. After 8 weeks, FMD value was similar to the value recorded at enrollment in the infliximab group (11.9 ± 0.03 vs. 13.54 ± 0.04%, p = 0.236) and the FMD values in the etanercept group after 12 weeks showed a not statistically significant reduction of vasodilatating effect (13.01 ± 0.03 vs. 15.67 ± 0.02%, p = 0.197). In conclusion, the use of biological drugs in patients affected by autoimmune arthritis can modify the endothelial function, as indicated by the induced FMD changes, but the long-term effect tends to be considerably reduced.
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Affiliation(s)
- Gianluigi Mazzoccoli
- Department of Internal Medicine, Scientific Institute and Regional General Hospital Casa Sollievo della Sofferenza, Opera di Padre Pio da Pietrelcina, Cappuccini Avenue, 71013 S. Giovanni Rotondo (FG), Italy.
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86
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Sarkola T, Redington A, Keeley F, Bradley T, Jaeggi E. Transcutaneous very-high-resolution ultrasound to quantify arterial wall layers of muscular and elastic arteries: Validation of a method. Atherosclerosis 2010; 212:516-23. [DOI: 10.1016/j.atherosclerosis.2010.06.043] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2010] [Revised: 06/21/2010] [Accepted: 06/29/2010] [Indexed: 10/19/2022]
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Chousos I, Perrea D, Kyriaki D, Liatis S, Katsilambros N, Makrilakis K. Acute hyperhomocysteinaemia blunts endothelial dependent and endothelial independent vasodilatation in diabetic patients. Diab Vasc Dis Res 2010; 7:186-94. [PMID: 20472601 DOI: 10.1177/1479164110369687] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The aim of this study was to investigate the effects of acute, methionine-induced hyperhomocysteinaemia on endothelial function of skin microcirculation in diabetic compared with non-diabetic persons. Endothelial- and non-endothelial-dependent vasodilatation of the skin microcirculation were evaluated in 20 persons with type 2 diabetes (59.95+/-2.36 years old) and 24 age- and gender-matched controls using laser Doppler flowmetry, during fasting and four hours after 0.1 g/kg methionine-induced acute hyperhomocysteinaemia. Methionine loading caused a comparable increase of homocysteine in the two groups. Four hours after induction of acute hyperhomocysteinaemia, endothelial-dependent vasodilatation (acetylcholine effect) was lower in the diabetic patients compared with the controls ([mean+/-SEM] 8.09+/-1.18-fold increase in diabetic patients vs. 11.11+/-1.33-fold increase in controls, p=0.027). The same was observed for the endothelial-independent vasodilatation (sodium-nitroprusside effect, 7.55+/-0.80-fold increase in the diabetic patients vs. 12.19+/-1.26-fold increase in controls, p=0.008). Acute hyperhomocysteinaemia causes a decreased response of both endothelial-dependent and endothelial-independent vasodilatation of the skin microcirculation in diabetic compared with non-diabetic persons. These alterations might contribute to the vascular complications of hyperhomocysteinaemia in diabetes, and especially the microvascular ones.
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Affiliation(s)
- Ilias Chousos
- First Department of Propaedeutic Medicine, University of Athens Medical School, Athens, Greece
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Aortic pulse pressure is associated with carotid IMT in chronic kidney disease: report from Chronic Renal Insufficiency Cohort. Am J Hypertens 2009; 22:1235-41. [PMID: 19779470 DOI: 10.1038/ajh.2009.156] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Patients with chronic kidney disease (CKD) have a disproportionate risk of cardiovascular disease. This study was designed to assess the association between two noninvasive measures of cardiovascular risk, pulse wave analysis (PWA), and carotid intima-media thickness (IMT), in a cohort of CKD patients enrolled in the Chronic Renal Insufficiency Cohort (CRIC) study. METHODS Three hundred and sixty-seven subjects with CKD enrolled in the CRIC study at the University of Pennsylvania site (mean age 59.9 years, blood pressure 129/74 mm Hg, estimated glomerular filtration rate 48 ml/min/1.73 m2, IMT 0.8 mm) had both carotid IMT and PWA measurements. Carotid ultrasound was also used to determine the presence of plaque. PWA was used to determine augmentation index (AI), amplification ratio (AMPR), aortic pulse pressure (C_PP), and central aortic systolic pressure (C_SP). RESULTS IMT was significantly associated with all PWA-derived measures. However, on multivariable linear regression analysis, only AMPR (regression coefficient -0.072, P = 0.006), C_PP (regression coefficient 0.0025, P < 0.001), and C_SP (regression coefficient 0.0017, P < 0.001) remained significantly associated with IMT. The prevalence of carotid plaque in the cohort was 59%. Of the PWA-derived measures, only C_PP was significantly associated with the presence of carotid plaque (P < 0.001). CONCLUSIONS PWA-derived measures are associated with carotid IMT and plaque in the CKD. Of these measures, C_PP was most associated with carotid IMT and plaque.
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89
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Screening for subclinical coronary artery disease measuring carotid intima media thickness. Am J Cardiol 2009; 104:1383-8. [PMID: 19892054 DOI: 10.1016/j.amjcard.2009.07.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2009] [Revised: 07/02/2009] [Accepted: 07/02/2009] [Indexed: 11/23/2022]
Abstract
Traditional coronary risk assessment is based on major cardiovascular risk factors using the Framingham risk score. Carotid intima-media thickness (CIMT) measured by ultrasonography is a noninvasive test used to assess for the presence of coronary atherosclerosis. CIMT has been shown to be an independent predictor of future cardiovascular events and is used in research trials as a surrogate for the presence as well as regression of coronary artery disease. The objectives of this report are to review the published reports on CIMT and to help establish the role of CIMT as a screening tool for coronary artery disease in selected patients. CIMT measurement can modify cardiovascular risk prediction in patients initially classified with the Framingham risk score, with reclassification into higher or lower risk categories. It is most useful for refining risk assessment in patients at intermediate risk. The Screening for Heart Attack Prevention and Education (SHAPE) Task Force recommends screening all asymptomatic middle-aged and older men and women using noninvasive imaging. The American Society of Echocardiography established a consensus on the methodologic aspects of CIMT measurement. Sequential scanning of CIMT to assess atherosclerosis is currently not recommended, because of interscan variability and small expected changes over time. In conclusion, in the primary prevention of coronary artery disease, CIMT measurement reclassifies patients into higher or lower risk categories, allowing early appropriate management.
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90
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Postley JE, Perez A, Wong ND, Gardin JM. Prevalence and Distribution of Sub-Clinical Atherosclerosis by Screening Vascular Ultrasound in Low and Intermediate Risk Adults: The New York Physicians Study. J Am Soc Echocardiogr 2009; 22:1145-51. [DOI: 10.1016/j.echo.2009.07.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2009] [Indexed: 11/26/2022]
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91
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Palmieri V, Migliaresi P, Orefice M, Lupo T, Di Minno MND, Valentini G, Celentano A. High prevalence of subclinical cardiovascular abnormalities in patients with systemic lupus erythematosus in spite of a very low clinical damage index. Nutr Metab Cardiovasc Dis 2009; 19:234-240. [PMID: 19157818 DOI: 10.1016/j.numecd.2008.09.009] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2008] [Revised: 06/25/2008] [Accepted: 09/29/2008] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIM To evaluate the prevalence of subclinical cardiovascular (CV) abnormalities in systemic lupus erythematosus (SLE) stratified according to SLE-related organ damage using the Systemic Lupus International Collaborating Clinics (SLICC) damage index. METHODS AND RESULTS We selected SLE patients without clinically overt CV events (n=45, 56% with SLICC=0, 44% with SLICC=1-4). CV evaluation was performed using cardiac and vascular echo-Doppler techniques. Post-ischemic flow-mediated dilation (FMD) over nitroglycerine-mediated dilation (NMD) of the brachial artery <0.70 defined endothelial dysfunction. The prevalence of preclinical CV abnormalities (CVAbn, including at least one of the following-carotid atherosclerosis, left ventricular (LV) hypertrophy, low arterial compliance, LV wall motion abnormalities, aortic regurgitation, FMD/NMD<0.70)-was 64% (16/25) in patients with SLICC=0 and 80% (16/20) in those with SLICC>0 (p=not significant (NS)). In particular, the prevalence of carotid atherosclerosis (28% vs. 16%), of LV hypertrophy (12% vs. 6%) and of LV wall motion abnormalities (15% vs. 12%), of low global arterial compliance (18% vs. 10%), prevalence of aortic regurgitation (30% vs. 18%) and/or aortic valve fibrosclerosis (10% vs. 8%), FMD<10% (14+/-5% vs. 14%+/-6) and prevalence of FMD/NMD<0.70 (53% vs. 52%) were comparable in SLE patients with SLICC>0 and in those with SLICC=0 (all p=NS). Of the SLE patients without carotid atherosclerosis, LV hypertrophy, low arterial compliance, LV wall motion abnormalities and aortic regurgitation (n=17), endothelial dysfunction was detected in 50% of those with SLICC=0 (6/12) and in 40% of those with SLICC>0 (2/5, p=NS). CONCLUSIONS SLE patients with SLICC=0 often have an elevated CV risk profile due to subclinical manifestations of CV disease detectable by cardiac and vascular echo-Doppler evaluations.
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MESH Headings
- Adolescent
- Adult
- Aortic Valve Insufficiency/epidemiology
- Aortic Valve Insufficiency/etiology
- Aortic Valve Insufficiency/physiopathology
- Brachial Artery/diagnostic imaging
- Brachial Artery/physiopathology
- Cardiovascular Diseases/diagnostic imaging
- Cardiovascular Diseases/epidemiology
- Cardiovascular Diseases/etiology
- Cardiovascular Diseases/physiopathology
- Carotid Artery Diseases/epidemiology
- Carotid Artery Diseases/etiology
- Carotid Artery Diseases/physiopathology
- Compliance
- Echocardiography, Doppler, Color
- Endothelium, Vascular/diagnostic imaging
- Endothelium, Vascular/physiopathology
- Female
- Humans
- Hypertrophy, Left Ventricular/epidemiology
- Hypertrophy, Left Ventricular/etiology
- Hypertrophy, Left Ventricular/physiopathology
- Lupus Erythematosus, Systemic/complications
- Lupus Erythematosus, Systemic/diagnosis
- Lupus Erythematosus, Systemic/epidemiology
- Lupus Erythematosus, Systemic/physiopathology
- Male
- Middle Aged
- Nitroglycerin
- Prevalence
- Risk Assessment
- Severity of Illness Index
- Ultrasonography, Doppler
- Vasodilation
- Vasodilator Agents
- Ventricular Dysfunction, Left/epidemiology
- Ventricular Dysfunction, Left/etiology
- Ventricular Dysfunction, Left/physiopathology
- Young Adult
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Affiliation(s)
- V Palmieri
- Unit of Cardiology, Ospedale dei Pellegrini, ASL Napoli 1, Naples, Italy.
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92
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Najjar SS. IMT as a Risk Marker: The Plot Thickens. J Am Soc Echocardiogr 2009; 22:505-7. [DOI: 10.1016/j.echo.2009.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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93
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Zhang CY, Lu LJ, Li FH, Li HL, Gu YY, Chen SL, Bao CD. Evaluation of Risk Factors That Contribute to High Prevalence of Premature Atherosclerosis in Chinese Premenopausal Systemic Lupus Erythematosus Patients. J Clin Rheumatol 2009; 15:111-6. [DOI: 10.1097/rhu.0b013e31819d8489] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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94
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Azurmendi PJ, Fraga AR, Galan FM, Kotliar C, Arrizurieta EE, Valdez MG, Forcada PJ, Stefan JSS, Martin RS. Early renal and vascular changes in ADPKD patients with low-grade albumin excretion and normal renal function. Nephrol Dial Transplant 2009; 24:2458-63. [DOI: 10.1093/ndt/gfp136] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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95
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Affiliation(s)
- Prashant Kaul
- From the Division of Cardiovascular Medicine, and Duke Clinical Research Institute (P.K., P.S.D.); Duke University Medical Center, Durham, NC
| | - Pamela S. Douglas
- From the Division of Cardiovascular Medicine, and Duke Clinical Research Institute (P.K., P.S.D.); Duke University Medical Center, Durham, NC
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96
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Stein JH, Korcarz CE, Post WS. Use of Carotid Ultrasound to Identify Subclinical Vascular Disease and Evaluate Cardiovascular Disease Risk: Summary and Discussion of the American Society of Echocardiography Consensus Statement. ACTA ACUST UNITED AC 2009; 12:34-8. [DOI: 10.1111/j.1751-7141.2008.00021.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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97
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Espinola-Zavaleta N, Soto-López ME, Carreón-Torres E, Gamboa R, Mejía AM, Márquez-Velasco R, Bojalil R, Huesca-Gomez C, Reyes PA, Pérez-Méndez O. Altered Flow-Mediated Vasodilatation, Low Paraoxonase-1 Activity, and Abnormal High-Density Lipoprotein Subclass Distribution in Takayasu's Arteritis. Circ J 2009; 73:760-6. [DOI: 10.1253/circj.cj-08-0582] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | | | | | - Ricardo Gamboa
- Department of Physiology, Instituto Nacional de Cardiología "Ignacio Chávez"
| | - Ana M. Mejía
- Department of Hematology, Instituto Nacional de Cardiología "Ignacio Chávez"
| | | | - Rafael Bojalil
- Department of Immunology, Instituto Nacional de Cardiología "Ignacio Chávez"
| | | | - Pedro A. Reyes
- Department of Immunology, Instituto Nacional de Cardiología "Ignacio Chávez"
| | - Oscar Pérez-Méndez
- Department of Molecular Biology, Instituto Nacional de Cardiología "Ignacio Chávez"
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98
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Abstract
Rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) are associated with increased mortality, largely as a consequence of cardiovascular disease. Increased cardiovascular morbidity and mortality in patients with RA and SLE cannot be entirely explained by traditional risk factors, suggesting that the systemic inflammation that characterizes these diseases may accelerate atherosclerosis. We used carotid ultrasonography to investigate the prevalence and correlates to preclinical atherosclerosis in patients with RA and SLE. Because atherosclerosis is a systemic disease, assessment of carotid plaque by ultrasonography provides a robust, direct measure of systemic atherosclerosis. We observed a substantially increased prevalence of carotid plaque in RA and SLE patients compared with age- and sex-matched controls, which remained after adjustment for traditional risk factors. The presence of carotid atherosclerosis was associated with disease duration in both RA and SLE and damage in SLE. These data support the hypothesis that inflammation associated with RA and SLE contributes to accelerated atherosclerosis and argue that RA and SLE disease activity should be more aggressively managed.
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99
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Thelen AM, Kelly AS, Williamson EB, Dengel DR. Examining the time course of endothelium-independent dilation by nitroglycerin. ULTRASOUND IN MEDICINE & BIOLOGY 2008; 34:1217-1220. [PMID: 18420338 DOI: 10.1016/j.ultrasmedbio.2008.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2007] [Revised: 01/03/2008] [Accepted: 01/18/2008] [Indexed: 05/26/2023]
Abstract
Arterial smooth muscle function is commonly assessed by measuring the dilation response to sublingual nitroglycerin (NTG), and is referred to as endothelium-independent dilation (EID). The time point at which the brachial artery dilates maximally after NTG administration is generally believed to occur somewhere between three and five minutes. The aim of this study was to examine the time course of brachial artery dilation response to a single dose of sublingual NTG to identify the time point at which maximal dilation occurs and to assess factors effecting EID. Endothelial independent dilation was measured in 125 normal, healthy subjects (male = 67, female = 58) via high-resolution ultrasound on the brachial artery. Mean time to maximal EID was 279.0 +/- 26.9 s. There was a significant (p < 0.0001) difference between brachial EID at three minutes vs. five minutes post NTG. There was also a significant gender difference in EID response (p < 0.0001). The results of this study indicate that maximal EID occurs approximately five minutes after NTG administration. Measuring EID at three minutes after NTG administration likely underestimates the true dilation capacity of the artery.
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Affiliation(s)
- Andrea M Thelen
- St. Paul Heart Clinic, Laboratory of Preventive Vascular Medicine, St. Paul, MN, USA.
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100
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Ebbesson SO, Roman MJ, Devereux RB, Kaufman D, Fabsitz RR, MacCluer JW, Dyke B, Laston S, Wenger CR, Comuzzie AG, Romenesko T, Ebbesson LO, Nobmann ED, Howard BV. Consumption of omega-3 fatty acids is not associated with a reduction in carotid atherosclerosis: The Genetics of Coronary Artery Disease in Alaska Natives study. Atherosclerosis 2008; 199:346-53. [DOI: 10.1016/j.atherosclerosis.2007.10.020] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2007] [Revised: 10/18/2007] [Accepted: 10/24/2007] [Indexed: 10/22/2022]
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