Prevalence, impact, and predictive value of detecting subclinical coronary and carotid atherosclerosis in asymptomatic adults: the BioImage study

Diameter Reduction Determined Through Carotid Ultrasound Associated With Cardiovascular and All-Cause Mortality: A Single-Center Experience of 38 201 Consecutive Patients in Taiwan

Background

Few studies have evaluated the prognostic significance of diameter‐based carotid sonographic measurements for mortality. We investigated whether a reduction in diameter of different carotid anatomical segments is associated with cardiovascular and all‐cause mortality in a hospital‐based cohort with universal health care.

Methods and Results

We conducted a retrospective cohort study of 38 201 patients who underwent carotid duplex ultrasound at a medical center in Taiwan. Carotid sonographic parameters were the diameter reduction percentage in carotid bifurcation, the internal carotid artery, the common carotid artery, and the external carotid artery and the overall carotid atherosclerotic burden score, determined by summing the scores from all segments. The vital status was ascertained by linking data to National Death Registry until 2017. During a median follow‐up of 4.2 years, 5644 participants died, with 1719 deaths attributable to cardiovascular diseases. The multivariable‐adjusted hazard ratios (HRs; 95% CIs) for cardiovascular mortality were 1.33 (1.16‒1.53), 1.58 (1.361.84), and 1.89 (1.58, 2.26) for participants with 30% to <40%, 40% to <50%, and ≥50% reduction in carotid bifurcation diameter, respectively, compared with participants with <30% diameter reduction (P for trend <0.001). The corresponding HRs (95% CIs) for all‐cause mortality were 1.25 (1.16‒1.34), 1.42 (1.31‒1.54), and 1.60 (1.45‒1.77), respectively. Diameter reduction at other carotid sites and the carotid atherosclerotic burden score exhibited the same dose–response relationship.

Conclusions

This study suggests that reduction in carotid artery diameter, which can be determined through routinely available sonography, is an independent risk factor for all‐cause and cardiovascular mortality.

Coronary artery calcium burden, carotid atherosclerotic plaque burden, and myocardial blood flow in patients with end-stage renal disease: A non-invasive imaging study combining PET/CT and 3D ultrasound

BACKGROUND

Imaging-based measures of atherosclerosis such as coronary artery calcium score (CACS) and coronary flow reserve (CFR) as well as carotid atherosclerotic plaque burden (cPB) are predictors of cardiovascular events in the general population. The objective of this study was to correlate CACS, cPB, myocardial blood flow (MBF), and CFR in patients with end-stage renal disease (ESRD).

METHODS AND RESULTS

39 patients (mean age 53 ± 12 years) with ESRD prior to kidney transplantation were enrolled. MBF and CFR were quantified at baseline and under hyperemia by 13N-NH3-PET/CT. CACS was calculated from low-dose CT scans acquired for PET attenuation correction. cPB was assessed by 3D ultrasound. Uni- and multivariate regression analyses between these and clinical parameters were performed. Median follow-up time for clinical events was 4.4 years. Kaplan-Meier survival estimates with log-rank test were performed with regards to cardiovascular (CV) events and death of any cause. CACS and cPB were associated in ESRD patients (r = 0.48; p ≤ 0.01). While cPB correlated with age (r = 0.43; p < 0.01), CACS did not. MBFstress was negatively associated with age (r = 0.44; p < 0.01) and time on dialysis (r = 0.42; p < 0.01). There were negative correlations between MBFstress and CACS (r = - 0.62; p < 0.001) and between MBFstress and cPB (r = - 0.43; p < 0.01). Age and CACS were the strongest predictors for MBFstress. CFR was impaired (< 2.0) in eight patients who also presented with higher cPB and higher CACS compared to those with a CFR > 2.0 (p = 0.06 and p = 0.4). In contrast to MBFstress, there was neither a significant correlation between CFR and CACS (r = - 0.2; p = 0.91) nor between CFR and cPB (r = - 0.1; p = 0.55). CV event-free survival was associated with reduced CFR and MBFstress (p = 0.001 and p < 0.001) but not with cPB or CACS.

CONCLUSIONS

CACS, cPB, and MBFstress are associated in patients with ESRD. Atherosclerosis is earlier detected by MBFstress than by CFR. CV event-free survival is associated with impaired CFR and MBFstress.

Carotid Plaque Composition Assessed by CT Predicts Subsequent Cardiovascular Events among Subjects with Carotid Stenosis

BACKGROUND AND PURPOSE

Currently, the characteristics of carotid plaques are considered important factors for identifying subjects at high risk of stroke. This study aimed to test the hypothesis that carotid plaque composition assessed by CTA is associated with an increased risk of future major adverse cardiovascular events among asymptomatic subjects with moderate-to-severe carotid artery stenosis.

MATERIALS AND METHODS

This single-center, retrospective cohort study included 194 carotid plaques from 176 asymptomatic subjects with moderate-to-severe carotid artery stenosis. The association of CTA-determined plaque composition with the risk of subsequent adverse cardiovascular events was analyzed.

RESULTS

During a median follow-up of 41 months, the adverse cardiovascular event incidence among 194 carotid plaques was 19.6%. There were significant differences in plaque Hounsfield units (P < .001) and spotty calcium presence (P < .001) between carotid plaques from subjects with and without subsequent adverse cardiovascular events. Multivariable analysis revealed carotid plaque Hounsfield unit density (P < .001) and spotty calcium (P < .001) as independent predictors of subsequent adverse cardiovascular events. In association with moderate carotid artery stenosis, the plaque Hounsfield unit values were significantly lower among carotid plaques from subjects who experienced subsequent adverse cardiovascular events (P = .002), strokes (P = .01), and cardiovascular deaths (P = .04); the presence of spotty calcium was significantly associated with the occurrence of adverse cardiovascular events (P = .001), acute coronary syndrome (P = .01), and cardiovascular death (P = .04).

CONCLUSIONS

Carotid plaque Hounsfield unit density and spotty calcium were independent predictors of a greater risk of adverse cardiovascular event occurrence.

Imaging-guided evaluation of subclinical atherosclerosis to enhance cardiovascular risk prediction in asymptomatic low-to-intermediate risk individuals: A systematic review

Carotid intima-media thickness (cIMT), plaque quantification and coronary artery calcium (CAC) scoring have been suggested to improve risk prediction of cardiovascular disease (CVD), particularly for asymptomatic individuals classified as low-to-intermediate risk. We aimed to compare the predictive value of cIMT, carotid plaque identification, and CAC scoring for identifying sub-clinical atherosclerosis and assessing future risk of CVD in asymptomatic, low-to-intermediate risk individuals. We conducted a comprehensive search of Ovid (Embase and Medline), Cochrane Central Register of Controlled Trials (CENTRAL) and Medline complete (EBSCO health). A total of 30 papers were selected and data were extracted. Comparisons were made according to the cIMT measurement (mean, maximum), carotid plaque evaluation (presence or area), and CAC scoring. CVD event rates, hazard ratios (HR), net reclassification index (NRI), and c-statistic of the markers were compared. There were 27 studies that reported cIMT, 24 reported carotid plaque, and 6 reported CAC scoring. Inclusion of CAC scores yielded the highest HR ranging from 1.45 (95% CI, 1.11-1.88, p = 0.006) to 3.95 (95% CI, 2.97-5.27, p < 0.001), followed by maximum cIMT (HR 1.08; 95% CI, 1.06-1.11, p < 0.001 to 2.58; 95% CI, 1.83-3.62, p < 0.001) and carotid plaque presence (HR 1.21; 95% CI, 0.5-1.2, p = 0.39 to 2.43; 95% CI, 1.7-3.47, p < 0.001). The c-statistic enhanced predictive value by a minimum increase of 0.7. Finally, the NRI ranked higher with CAC (≥11.2%), followed by carotid plaque (≥2%) and cIMT (3%). CAC scoring was superior compared to carotid plaque and cIMT measurements in asymptomatic individuals classified as being at low-to-intermediate risk.

Carotid plaque thickness is increased in chronic kidney disease and associated with carotid and coronary calcification

BACKGROUND

Chronic kidney disease accelerates both atherosclerosis and arterial calcification. The aim of the present study was to explore whether maximal carotid plaque thickness (cPTmax) was increased in patients with chronic kidney disease compared to controls and associated with cardiovascular disease and severity of calcification in the carotid and coronary arteries.

METHODS

The study group consisted of 200 patients with chronic kidney disease stage 3 from the Copenhagen Chronic Kidney Disease Cohort and 121 age- and sex-matched controls. cPTmax was assessed by ultrasound and arterial calcification by computed tomography scanning.

RESULTS

Carotid plaques were present in 58% of patients (n = 115) compared with 40% of controls (n = 48), p = 0.002. Among participants with plaques, cPTmax (median, interquartile range) was significantly higher in patients compared with controls (1.9 (1.4-2.3) versus 1.5 (1.2-1.8) mm), p = 0.001. Cardiovascular disease was present in 9% of patients without plaques (n = 85), 23% of patients with cPTmax 1.0-1.9 mm (n = 69) and 35% of patients with cPTmax >1.9 mm (n = 46), p = 0.001. Carotid and coronary calcium scores >400 were present in 0% and 4%, respectively, of patients with no carotid plaques, in 19% and 24% of patients with cPTmax 1.0-1.9 mm, and in 48% and 53% of patients with cPTmax >1.9 mm, p<0.001.

CONCLUSIONS

This is the first study showing that cPTmax is increased in patients with chronic kidney disease stage 3 compared to controls and closely associated with prevalent cardiovascular disease and severity of calcification in both the carotid and coronary arteries.

Machine learning models for screening carotid atherosclerosis in asymptomatic adults

Carotid atherosclerosis (CAS) is a risk factor for cardiovascular and cerebrovascular events, but duplex ultrasonography isn’t recommended in routine screening for asymptomatic populations according to medical guidelines. We aim to develop machine learning models to screen CAS in asymptomatic adults. A total of 2732 asymptomatic subjects for routine physical examination in our hospital were included in the study. We developed machine learning models to classify subjects with or without CAS using decision tree, random forest (RF), extreme gradient boosting (XGBoost), support vector machine (SVM) and multilayer perceptron (MLP) with 17 candidate features. The performance of models was assessed on the testing dataset. The model using MLP achieved the highest accuracy (0.748), positive predictive value (0.743), F1 score (0.742), area under receiver operating characteristic curve (AUC) (0.766) and Kappa score (0.445) among all classifiers. It’s followed by models using XGBoost and SVM. In conclusion, the model using MLP is the best one to screen CAS in asymptomatic adults based on the results from routine physical examination, followed by using XGBoost and SVM. Those models may provide an effective and applicable method for physician and primary care doctors to screen asymptomatic CAS without risk factors in general population, and improve risk predictions and preventions of cardiovascular and cerebrovascular events in asymptomatic adults.

Clinical- and omics-based models of subclinical atherosclerosis in healthy Chinese adults: a cross-sectional exploratory study

BACKGROUND

Classical risk factors, such as fasting cholesterol, blood pressure (BP), and diabetes status are used today to predict the risk of developing cardiovascular disease (CVD). However, accurate prediction remains limited, particularly in low-risk groups such as women and younger individuals. Growing evidence suggests that biomarker concentrations following consumption of a meal challenge are better and earlier predictors of disease development than biomarker concentrations.

OBJECTIVE

To test the hypothesis that postprandial responses of circulating biomarkers differ between healthy subjects with and without subclinical atherosclerosis (SA) in an Asian population at low risk of coronary artery disease (CAD).

METHODS

One hundred healthy Chinese subjects (46 women, 54 men) completed the study. Subjects consumed a mixed-meal test and 164 blood biomarkers were analyzed over 6 h by using a combination of chemical and NMR techniques. Models were trained using different methodologies (including logistic regression, elastic net, random forest, sparse partial least square) on a random 75% subset of the data, and their performance was evaluated on the remaining 25%.

RESULTS

We found that models based on baseline clinical parameters or fasting biomarkers could not reliably predict SA. By contrast, an omics model based on magnitude and timing of postprandial biomarkers achieved high performance [receiving operating characteristic (ROC) AUC: 91%; 95% CI: 77, 100). Investigation of key features of this model enabled derivation of a considerably simpler model, solely based on postprandial BP and age, with excellent performance (AUC: 91%; 95% CI: 78, 100).

CONCLUSION

We report a novel model to detect SA based on postprandial BP and age in a population of Asian subjects at low risk of CAD. The use of this model in large-scale CVD prevention programs should be explored. This trial was registered at ClinicalTrials.gov as NCT03531879.

Present and future of coronary risk assessment

The search for subclinical atherosclerosis is carried out in several arterial districts using ultrasonography and computed tomography (CT). Coronary calcium assessed by computerized tomography (calcium score) is a well-validated marker of atherosclerosis and able to correlate with the extent of coronary artery disease and the risk of cardiovascular events. The evaluation of carotid atherosclerosis by ultrasonography is a technically simple and low-cost solution. However, the literature does not provide a sufficient number of evidence to clarify the clinical impact of carotid atherosclerosis and in particular the risk of developing cardiac events. According to the researchers of the Progression of Early Subclinical Atherosclerosis (PESA) study, subclinical atherosclerosis research should preferably be carried out in the femoral district, which is more easily affected by atherosclerosis. Pending the data from the PESA study, which will better clarify the role of ultrasound applied in non-coronary districts, the coronary calcifications seems to be a reasonable solution. It is possible that in the future imaging techniques (CT-PET) capable of studying the extent and functional status of coronary atherosclerosis will further improve the identification of the risk of cardiovascular events.

Clinical Significance of Carotid Intima-Media Complex and Carotid Plaque Assessment by Ultrasound for the Prediction of Adverse Cardiovascular Events in Primary and Secondary Care Patients

Recently published recommendations from the American Society of Echocardiography on 'Carotid Arterial Plaque Assessment by Ultrasound for the Characterization of Atherosclerosis and Evaluation of Cardiovascular Risk' provoked discussion once more on the potential clinical applications of carotid intima-media complex thickness (CIMT) and carotid plaque assessment in the context of cardiovascular risk in both primary and secondary care patients. This review paper addresses key issues and milestones regarding indications, assessment, technical aspects, recommendations, and interpretations of CIMT and carotid plaque findings. We discuss lacks of evidence, limitations, and possible future directions.

The beneficial effect over 3 years by pictorial information to patients and their physician about subclinical atherosclerosis and cardiovascular risk: Results from the VIPVIZA randomized clinical trial

•

VIPVIZA is a pragmatic randomized controlled trial performed within the regular primary health care and targeting both individuals and physicians.

•

Beneficial effects on risk for cardiovascular disease regardless of sex and education level 3 years after providing pictorial information of subclinical atherosclerosis in addition to regular preventive information.

•

The results indicate that the intervention effect is a combined effect of pharmacological treatment and lifestyle modification.

•

The intervention effect was observed in the intermediate risk group, the group where most CVD events occur and in which sufficient prevention is often overlooked.

Objective

Non-adherence to guidelines and preventive measures is a major challenge, particularly so to obtain long-term adherence to lifestyle changes and recommended medication. The objective was to investigate if pictorial information regarding subclinical carotid atherosclerosis provided to individuals and physicians gave sustained effects on cardiovascular risk beyond the previously reported effect after 1 year and up to 3 years.

Methods

A Prospective Randomized Open Blinded End-point (PROBE) trial. Within a CVD prevention program in Västerbotten County, Sweden, 3532 healthy individuals aged 40, 50 or 60 years were enrolled and 1:1 randomized to intervention (n = 1749; pictorial information with additional prevention materials to participants and physicians) or control group (n = 1783; no pictorial information to participants and physicians). Preventive measures were managed within primary care. Participants were investigated at baseline during 2013–2016 and at follow-up after 1 and 3 years.

Results

A beneficial effect on cardiovascular risk was observed at 3-year follow-up; Framingham Risk Score (FRS) was 13.38 for the intervention group and 14.08 for the control group (p = 0.047) and SCORE was 1.69 vs. 1.82 (p = 0.022). The effect observed at 1-year was sustained over 3 years after adjustment for sex and education and more pronounced among participants with a severe atherosclerotic picture at baseline.

Conclusions

This study provides evidence of sustained beneficial effects on the adherence to prevention guidelines over 3 years of pictorial information about subclinical carotid atherosclerosis, resulting in lower cardiovascular risk regardless of sex and educational level. Direct visualization of the underlying still subclinical atherosclerotic disease, rather than just indirect information about risk factors and statistical risk of future myocardial infarction, stroke and death, is one way to tackle the problem of non-adherence to prevention of cardiovascular diseases.

Deep Learning-Based Measurement of Total Plaque Area in B-Mode Ultrasound Images

Measurement of total-plaque-area (TPA) is important for determining long term risk for stroke and monitoring carotid plaque progression. Since delineation of carotid plaques is required, a deep learning method can provide automatic plaque segmentations and TPA measurements; however, it requires large datasets and manual annotations for training with unknown performance on new datasets. A UNet++ ensemble algorithm was proposed to segment plaques from 2D carotid ultrasound images, trained on three small datasets (n = 33, 33, 34 subjects) and tested on 44 subjects from the SPARC dataset (n = 144, London, Canada). The ensemble was also trained on the entire SPARC dataset and tested with a different dataset (n = 497, Zhongnan Hospital, China). Algorithm and manual segmentations were compared using Dice-similarity-coefficient (DSC), and TPAs were compared using the difference ( ∆TPA), Pearson correlation coefficient (r) and Bland-Altman analyses. Segmentation variability was determined using the intra-class correlation coefficient (ICC) and coefficient-of-variation (CoV). For 44 SPARC subjects, algorithm DSC was 83.3-85.7%, and algorithm TPAs were strongly correlated (r = 0.985-0.988; p < 0.001) with manual results with marginal biases (0.73-6.75) mm ² using the three training datasets. Algorithm ICC for TPAs (ICC = 0.996) was similar to intra- and inter-observer manual results (ICC = 0.977, 0.995). Algorithm CoV = 6.98% for plaque areas was smaller than the inter-observer manual CoV (7.54%). For the Zhongnan dataset, DSC was 88.6% algorithm and manual TPAs were strongly correlated (r = 0.972, p < 0.001) with ∆TPA = -0.44 ±4.05 mm ² and ICC = 0.985. The proposed algorithm trained on small datasets and segmented a different dataset without retraining with accuracy and precision that may be useful clinically and for research.

Multiethnic Genome-Wide Association Study of Subclinical Atherosclerosis in Individuals With Type 2 Diabetes

BACKGROUND

Coronary artery calcification (CAC) and carotid artery intima-media thickness (cIMT) are measures of subclinical atherosclerosis in asymptomatic individuals and strong risk factors for cardiovascular disease. Type 2 diabetes (T2D) is an independent cardiovascular disease risk factor that accelerates atherosclerosis.

METHODS

We performed meta-analyses of genome-wide association studies in up to 2500 T2D individuals of European ancestry (EA) and 1590 T2D individuals of African ancestry with or without exclusion of prevalent cardiovascular disease, for CAC measured by cardiac computed tomography, and 3608 individuals of EA and 838 individuals of African ancestry with T2D for cIMT measured by ultrasonography within the CHARGE (Cohorts for Heart and Aging Research in Genomic Epidemiology) Consortium.

RESULTS

We replicated 2 loci (rs9369640 and rs9349379 near PHACTR1 and rs10757278 near CDKN2B) for CAC and one locus for cIMT (rs7412 and rs445925 near APOE-APOC1) that were previously reported in the general EA populations. We identified one novel CAC locus (rs8000449 near CSNK1A1L/LINC00547/POSTN at 13q13.3) at P=2.0×10-8 in EA. No additional loci were identified with the meta-analyses of EA and African ancestry. The expression quantitative trait loci analysis with nearby expressed genes derived from arterial wall and metabolic tissues from the Genotype-Tissue Expression project pinpoints POSTN, encoding a matricellular protein involved in bone formation and bone matrix organization, as the potential candidate gene at this locus. In addition, we found significant associations (P<3.1×10-4) for 3 previously reported coronary artery disease loci for these subclinical atherosclerotic phenotypes (rs2891168 near CDKN2B-AS1 and rs11170820 near FLJ12825 for CAC, and rs7412 near APOE for cIMT).

CONCLUSIONS

Our results provide potential biological mechanisms that could link CAC and cIMT to increased cardiovascular disease risk in individuals with T2D.

Affective brain patterns as multivariate neural correlates of cardiovascular disease risk

This study tested whether brain activity patterns evoked by affective stimuli relate to individual differences in an indicator of pre-clinical atherosclerosis: carotid artery intima-media thickness (CA-IMT). Adults (aged 30-54 years) completed functional magnetic resonance imaging (fMRI) tasks that involved viewing three sets of affective stimuli. Two sets included facial expressions of emotion, and one set included neutral and unpleasant images from the International Affective Picture System (IAPS). Cross-validated, multivariate and machine learning models showed that individual differences in CA-IMT were partially predicted by brain activity patterns evoked by unpleasant IAPS images, even after accounting for age, sex and known cardiovascular disease risk factors. CA-IMT was also predicted by brain activity patterns evoked by angry and fearful faces from one of the two stimulus sets of facial expressions, but this predictive association did not persist after accounting for known cardiovascular risk factors. The reliability (internal consistency) of brain activity patterns evoked by affective stimuli may have constrained their prediction of CA-IMT. Distributed brain activity patterns could comprise affective neural correlates of pre-clinical atherosclerosis; however, the interpretation of such correlates may depend on their psychometric properties, as well as the influence of other cardiovascular risk factors and specific affective cues.

Progression of Early Subclinical Atherosclerosis (PESA) Study: JACC Focus Seminar 7/8

Atherosclerosis starts early in life and progresses silently for decades. Considering atherosclerosis as a "systemic disease" invites the use of noninvasive methodologies to detect disease in various regions before symptoms appear. The PESA-(Progression of Early Subclinical Atherosclerosis) CNIC-SANTANDER study is an ongoing prospective cohort study examining imaging, biological, and behavioral parameters associated with the presence and progression of early subclinical atherosclerosis. Between 2010 and 2014, PESA enrolled 4,184 asymptomatic middle-aged participants who undergo serial 3-yearly follow-up examinations including clinical interviews, lifestyle questionnaires, sampling, and noninvasive imaging assessment of multiterritorial subclinical atherosclerosis (carotids, iliofemorals, aorta, and coronaries). PESA tracks the trajectories of atherosclerosis and associated disorders from early stages to the transition to symptomatic phases. A joint venture between the CNIC and the Santander Bank, PESA is expected to run until at least 2029, and its significant contributions to date are presented in this review paper.

Is There a Role of Coronary CTA in Primary Prevention? Current State and Future Directions

PURPOSE OF REVIEW

Information on subclinical atherosclerosis burden provides prognostic information on atherosclerotic cardiovascular disease (ASCVD) risk beyond what can be achieved by traditional risk factors alone and may therefore improve allocation of preventive treatment in primary prevention. The purpose of this review is to discuss the potential role and value of assessing subclinical atherosclerosis using coronary artery calcium (CAC) versus computed tomography angiography (CTA) among asymptomatic patients in the context of current primary prevention cholesterol guidelines.

RECENT FINDINGS

Since 2013, primary prevention cholesterol guidelines have lowered the treatment threshold for initiating statin therapy resulting in high statin eligibility and sensitivity for detecting ASCVD events. Thus, one of the main advantages of assessing subclinical atherosclerosis is to identify those individuals who are at so low ASCVD risk that preventive treatment may safely be withhold. Numerous studies have shown that both CAC and CTA provide highly valuable information on ASCVD risk in the individual patient. However, while extensive data exist regarding the ability of CAC to improve treatment allocation in the context of primary prevention guidelines, such data is sparse for CTA. Furthermore, there is no data to show that CTA improves risk classification and treatment allocation in primary prevention beyond what can be achieved by assessment of CAC. Although CTA provides important information regarding prognosis in symptomatic patients undergoing clinical CTA, there is no strong evidence to support its use in the primary prevention setting. Thus, the potential value of CTA in primary prevention is not clear and is currently not recommended by guidelines.

Biomarkers of fatty acid intake are independently associated with preclinical atherosclerosis in individuals with type 1 diabetes

PURPOSE

Information on the association between diet and cardiovascular disease (CVD) in type 1 diabetes (T1D) is scarce. We assessed the association between biomarkers of fatty acid (FA) intake and the presence of carotid plaques (a surrogate marker of future CVD events) in this high-risk population.

METHODS

Cross-sectional study in 167 consecutive T1D patients without CVD and with at least one of the following: ≥ 40 years, diabetic nephropathy, or ≥ 10 years of T1D duration with another CVD risk factor. The FA profile of erythrocyte membranes was determined by gas chromatography, and the number of carotid plaques (intima-media thickness ≥ 1.5 mm) was assessed by ultrasonography. Regression models were constructed adjusting for classical (age, gender, blood pressure, smoking habit, LDL-cholesterol, body mass index and statins) and T1D-specific risk factors (diabetes duration, HbA1c and chronic complications).

RESULTS

A total of 58.7% were men (mean age 48.3 ± 10.3 years, T1D duration 27.2 ± 10.1 years). Sixty-one patients (36.5%) showed carotid plaque. Linoleic acid decreased and all-C18:1trans increased with the number of carotid plaques (none, 1-2, ≥ 3 plaques; p for trend < 0.05). In multivariate regression models, linoleic acid remained inversely associated with the presence of plaque [1% increase of total FAs; OR 0.71 (0.53-0.95), p = 0.021] and ≥ 2 plaques [OR 0.70 (0.51-0.98), p = 0.039]; whereas, all-C18:1trans was positively associated with ≥ 3 plaques (0.1% increase of total FAs; OR 1.51 [1.05-2.16], p = 0.026).

CONCLUSIONS

Erythrocyte FA composition, as a biomarker of FA intake, was independently associated with preclinical atherosclerosis in T1DM. Our data support the potential role of an unfavorable pattern of fat intake and CVD risk in this population.

Multimodality imaging for the prevention of cardiovascular events: Coronary artery calcium and beyond

Atherosclerotic cardiovascular disease (ASCVD) has been the leading cause of death worldwide for more than a decade. Prevention is of utmost importance to reduce related mortality. The innovations in cardiovascular imaging technology, in addition to our improved understanding of coronary atherosclerosis pathogenesis, have resulted in cardiovascular imaging becoming one of the most influential tools for diagnosis and risk stratification in ASCVD. Although numerous publications have emerged on this topic, data that guide routine cardiology clinical practice currently focus on the utility of a limited number of such modalities, namely arterial ultrasonography and computed tomography. Herein, current evidence with respect to the role of multimodality cardiovascular imaging on ASCVD prevention will be reviewed.

Imaging techniques in atherosclerosis

Cardiovascular imaging techniques have revolutionized the management of coronary atherosclerosis. Due to this, the assessment of the presence and extension of atherosclerotic disease in the different arterial territories is much simpler, with the advantage that they are non-invasive techniques. This chapter summarises the usefulness of the different cardiovascular imaging modalities in the diagnosis and prognostic stratification of the cardiovascular patient.

Triglyceride/High-Density Lipoprotein Cholesterol Ratio: A Clue to Metabolic Syndrome, Insulin Resistance, and Severe Atherosclerosis

High serum levels of triglycerides (Tg) and low levels of high-density lipoprotein cholesterol (HDL-C) are characteristic of the Metabolic Syndrome (MetS). We assessed the ratio of Tg to HDL-C as a way to identify MetS and insulin resistance. We also evaluated its association with severity of carotid atherosclerosis. Data were analyzed from three cohorts totaling 13,908 participants. MetS was defined according to the International Diabetes Federation criteria. Optimal cut-off for Tg/HDL-C ratio was obtained using Youden's index in receiver-operating characteristic (ROC) curve analyses. The risk of MetS and IR in those with a Tg/HDL-C ratio above the optimum cutoff was evaluated by logistic regression analysis. A Tg/HDL-C ratio above the optimal cutoff level significantly increased the odds ratio for MetS in the three cohorts (OR 6.00, 4.04, and 3.50, least in the healthy population), identified insulin resistance defined by the homeostatic model of insulin resistance (HOMA-IR) (p < 0.0001), and was strongly associated with atherosclerosis severity (p = 0.0001). Tg/HDL-C ratio identifies persons with MetS, insulin resistance, and severe atherosclerosis. It should be used more widely to identify patients at high risk. This is clinically important because insulin resistance is treatable.

Ultrasound Methods in the Evaluation of Atherosclerosis: From Pathophysiology to Clinic

Atherosclerosis is a key pathological process that causes a plethora of pathologies, including coronary artery disease, peripheral artery disease, and ischemic stroke. The silent progression of the atherosclerotic disease prompts for new surveillance tools that can visualize, characterize, and provide a risk evaluation of the atherosclerotic plaque. Conventional ultrasound methods-bright (B)-mode US plus Doppler mode-provide a rapid, cost-efficient way to visualize an established plaque and give a rapid risk stratification of the patient through the Gray-Weale standardization-echolucent plaques with ≥50% stenosis have a significantly greater risk of ipsilateral stroke. Although rather disputed, the measurement of carotid intima-media thickness (C-IMT) may prove useful in identifying subclinical atherosclerosis. In addition, contrast-enhanced ultrasonography (CEUS) allows for a better image resolution and the visualization and quantification of plaque neovascularization, which has been correlated with future cardiovascular events. Newly emerging elastography techniques such as strain elastography and shear-wave elastography add a new dimension to this evaluation-the biomechanics of the arterial wall, which is altered in atherosclerosis. The invasive counterpart, intravascular ultrasound (IVUS), enables an individualized assessment of the anti-atherosclerotic therapies, as well as a direct risk assessment of these lesions through virtual histology IVUS.

Work Shift, Lifestyle Factors, and Subclinical Atherosclerosis in Spanish Male Workers: A Mediation Analysis

(1) Background: Working night shifts has been associated with altered circadian rhythms, lifestyle habits, and cardiometabolic risks. No information on the potential association of working shift and the presence of atherosclerosis is available. The aim of this study was to quantify the association between different work shifts and the presence of subclinical atherosclerosis objectively measured by imaging. (2) Methods: Analyses were conducted on the baseline data of the Aragon Workers Health Study (AWHS) cohort, including information on 2459 middle-aged men. Categories of shift work included central day shift, rotating morning-evening or morning-evening-night shift, and night shift. The presence of atherosclerotic plaques was assessed by 2D ultrasound in the carotid and femoral vascular territories. Multivariable logistic models and mediation analysis were conducted to characterize and quantify the association between study variables. (3) Results: Participants working night or rotating shifts presented an overall worse cardiometabolic risk profile, as well as more detrimental lifestyle habits. Workers in the most intense (morning-evening-night) rotating shift presented higher odds of subclinical atherosclerosis (odds ratio: 1.6; 95% confidence interval: 1.12 to 2.27) compared to workers in the central shift, independently of the presence of lifestyle and metabolic risk factors. A considerable (21%) proportion of this association was found to be mediated by smoking, indicating that altered sleep-wake cycles have a direct relationship with the early presence of atherosclerotic lesions. (4) Conclusions: Work shifts should be factored in during workers health examinations, and when developing effective workplace wellness programs.

Breast Arterial Calcification: A Potential Biomarker for Atherosclerotic Cardiovascular Disease Risk?

PURPOSE OF REVIEW

We aimed to summarize the current evidence regarding the association between breast arterial calcification (BAC) and atherosclerotic cardiovascular disease (ASCVD) in women and discuss the potential role of BAC in the risk stratification and preventive approaches for ASCVD.

RECENT FINDINGS

BAC has emerged as a potential women-specific risk marker for ASCVD. Although BAC presents as a medial calcification of the arteries, notably different from the intimal atherosclerotic process, current evidence supports a correlation between BAC and ASCVD risk factors or subclinical and clinical ASCVD, such as coronary artery disease or stroke. As millions of women undergo mammograms each year, the potential clinical application of BAC in enhanced ASCVD risk estimation, with no additional cost or radiation, has tremendous appeal. Although further research regarding optimal risk assessment and management in women with BAC is required, the presence of BAC should prompt healthy cardiovascular lifestyle modifications.

Carotid Plaque Burden by 3-Dimensional Vascular Ultrasound as a Risk Marker for Patients with Metabolic Syndrome

Our aim was to analyse the associations between carotid plaque burden (CPB), cardiovascular risk factors (CVRF), and surrogate markers of CV risk in subjects with metabolic syndrome (MetS). We consecutively included 75 asymptomatic outpatients with MetS components, <60 years old and non-smokers. We determined the presence of CVRF, left ventricular hypertrophy (LVH), carotid intima-media thickness (cIMT), albumin-creatinine ratio (ACR), coronary artery calcium score (CACS) and CPB by 3-dimensional vascular ultrasound (3DVUS) for comparison. A total of 50 (67%) subjects had MetS defined by harmonized criteria. A CPB >0 mm³ and a CACS >0 AU were the risk biomarkers most frequently observed (72% and 77%, respectively), followed by LVH (40%). CPB and CACS revealed association with cardiovascular risk (r = 0.308; p = 0.032 and r = 0.601 p < 0.01, respectively), and CPB also showed association with the burden of CVRF (r = 0.349; p = 0.014). CPB by 3DVUS was a prevalent CV risk marker, directly associated with CVRF and cardiovascular risk in MetS subjects.

Genetic Risk Stratification: A Paradigm Shift in Prevention of Coronary Artery Disease

•

CAD is a pandemic that can be prevented. Conventional risk factors are inadequate to detect who is at risk early in the asymptomatic stage.

•

Genetic risk for CAD can be determined at birth, and those at highest genetic risk have been shown to respond to lifestyle changes and statin therapy with a 40% to 50% reduction in cardiac events.

•

Genetic risk stratification for CAD should be brought to the bedside in an attempt to prevent this pandemic disease.

Coronary artery disease (CAD) is a pandemic disease that is highly preventable as shown by secondary prevention. Primary prevention is preferred knowing that 50% of the population can expect a cardiac event in their lifetime. Risk stratification for primary prevention using the American Heart Association/American College of Cardiology predicted 10-year risk based on conventional risk factors for CAD is less than optimal. Conventional risk factors such as hypertension, cholesterol, and age are age-dependent and not present until the sixth or seventh decade of life. The genetic risk score (GRS), which is estimated from the recently discovered genetic variants predisposed to CAD, offers a potential solution to this dilemma. The GRS, which is derived from genotyping the population with a microarray containing these genetic risk variants, has indicated that genetic risk stratification based on the GRS is superior to that of conventional risk factors in detecting those at high risk and who would benefit most from statin therapy. Studies performed in >1 million individuals confirmed genetic risk stratification is superior and primarily independent of conventional risk factors. Prospective clinical trials based on risk stratification for CAD using the GRS have shown lifestyle changes, physical activity, and statin therapy are associated with 40% to 50% reduction in cardiac events in the high genetic risk group (20%). Genetic risk stratification has the advantage of being innate to an individual’s DNA, and because DNA does not change in a lifetime, it is independent of age. Genetic risk stratification is inexpensive and can be performed worldwide, providing risk analysis at any age and thus has the potential to revolutionize primary prevention.

Association of serum hemoglobin level with the risk of carotid plaque beyond metabolic abnormalities among asymptomatic adults without major adverse clinical events: a cross-sectional cohort study

BACKGROUND

The serum hemoglobin (Hb) level is closely related to adverse clinical outcomes. However, data on the association of Hb levels with subclinical atherosclerosis beyond metabolic abnormalities are limited.

METHODS

This study evaluated the association among serum Hb level, metabolic syndrome (MetS), and the risk of carotid plaque formation in asymptomatic adults without a history of major adverse clinical events.

RESULTS

A total of 2560 participants (mean age: 60 ± 8 years, 32.9% men) were stratified into four groups based on Hb quartiles, as follows: ≤ 12.8 g/dL (group I), 12.9-13.6 g/dL (group II), 13.7-14.5 g/dL (group III), and ≥ 14.6 g/dL (group IV). The overall prevalence of MetS and carotid plaque was 37.2% and 33.4%, respectively. The prevalence of MetS increased with increasing Hb level (group I: 27.4% vs. group II: 35.9% vs. group III: 42.6% vs. group IV: 44.1%, p < 0.001). The prevalence of carotid plaque was 34.3%, 28.1%, 32.8%, and 39.5% in groups I, II, III, and IV, respectively. Univariate logistic regression analysis showed that MetS was associated with an increased risk of carotid plaque (odds ratio [OR] 1.568, 95% confidence interval [CI] 1.326-1.856, p < 0.001). Only group II showed a lower risk of carotid plaque than group I (OR 0.750, 95% CI 0.596-0.943, p = 0.014). Multiple logistic regression models showed consistent results after adjusting for clinical factors, including MetS and its individual components.

CONCLUSION

Serum Hb level is associated with the risk of carotid plaque beyond MetS and its components in a relatively healthy adult population.

Heart Disease and Stroke Statistics-2021 Update: A Report From the American Heart Association

BACKGROUND

The American Heart Association, in conjunction with the National Institutes of Health, annually reports the most up-to-date statistics related to heart disease, stroke, and cardiovascular risk factors, including core health behaviors (smoking, physical activity, diet, and weight) and health factors (cholesterol, blood pressure, and glucose control) that contribute to cardiovascular health. The Statistical Update presents the latest data on a range of major clinical heart and circulatory disease conditions (including stroke, congenital heart disease, rhythm disorders, subclinical atherosclerosis, coronary heart disease, heart failure, valvular disease, venous disease, and peripheral artery disease) and the associated outcomes (including quality of care, procedures, and economic costs).

METHODS

The American Heart Association, through its Statistics Committee, continuously monitors and evaluates sources of data on heart disease and stroke in the United States to provide the most current information available in the annual Statistical Update. The 2021 Statistical Update is the product of a full year's worth of effort by dedicated volunteer clinicians and scientists, committed government professionals, and American Heart Association staff members. This year's edition includes data on the monitoring and benefits of cardiovascular health in the population, an enhanced focus on social determinants of health, adverse pregnancy outcomes, vascular contributions to brain health, the global burden of cardiovascular disease, and further evidence-based approaches to changing behaviors related to cardiovascular disease.

RESULTS

Each of the 27 chapters in the Statistical Update focuses on a different topic related to heart disease and stroke statistics.

CONCLUSIONS

The Statistical Update represents a critical resource for the lay public, policy makers, media professionals, clinicians, health care administrators, researchers, health advocates, and others seeking the best available data on these factors and conditions.

The association of Chlamydia pneumoniae infection with atherosclerosis: Review and update of in vitro and animal studies

Previous studies have tended to relate Chlamydia pneumoniae (Cpn) infection to atherosclerosis. However, while serological studies have mostly reinforced this hypothesis, inconsistent and even contradictory findings have been reported in various researches. Recent papers have pointed to the significance of Cpn in atherosclerotic lesions, which are regarded as the initiator and cause of chronic inflammation. This bacterium develops atherosclerosis by phenotypic changes in vascular smooth muscle cells, dysregulation of endothelin-1 in the vascular wall, and releasing pro-inflammatory cytokines from Toll-like receptor-2 (TLR2). Furthermore, Cpn infection, particularly under hyperlipidemic conditions, enhances monocyte adhesion to endothelium; changes the physiology of the host, e.g., cholesterol homeostasis; and activates the Low-density lipoprotein (LDL) receptor, which is the initial step in atherogenesis. On the other hand, it has been reported that Cpn, even without the immune system of the host, has the ability to stimulate arterial thickening. Moreover, there is evidence that Cpn can increase the impact of the classical risk factors such as hyperlipidemia, pro-inflammatory cytokines, and smoking for atherosclerosis. Furthermore, animal studies have shown that Cpn infection can induce atherosclerotic, which alongside hyperlipidemia is a co-risk factor for cardiovascular disease. Although the exact link between Cpn and atherosclerosis has not been determined yet, previous studies have reported possible mechanisms of pathogenesis for this bacterium. Accordingly, investigating the exact role of this infection in causing atherosclerosis may be helpful in controlling the disease.

Prevalence of Silent Atherosclerosis and Other Comorbidities in an Outpatient Cohort of Adults Living with HIV: Associations with HIV Parameters and Biomarkers

People living with HIV (PLWH) are at risk of noninfectious comorbidities. It is important to individualize those at higher risk. In a single-center cohort of PLWH, we performed a cross-sectional analysis of comorbidities, diagnosed according to standard procedures. The primary endpoint was the prevalence of subclinical carotid/coronary atherosclerosis. Secondary endpoints were its association with selected inflammatory/immune activation biomarkers and with other comorbidities. Associations were examined by using Chi-square or Fisher's exact test for categorical variables and Student or Wilcoxon tests for quantitative variables, and a stepwise multivariate logistical model was performed for further exploration. Among 790 participants [median age: 49.8 years (interquartile range, IQR: 44.5-55.6), 77.1% males, median CD4: 536/mm³ (IQR: 390-754), 83.6% with undetectable viral load], asymptomatic atherosclerosis was found in 26% and was associated in multivariate analysis with older age, longer known duration of infection, higher sCD14, and lower adiponectin levels. Hypertension was found in 33.5% of participants, diabetes in 19.4%, renal impairment in 14.6%, elevated low-density lipoprotein-cholesterol in 13.3%, elevated triglyceride/high-density lipoprotein (HDL)-cholesterol ratio in 6.6%, and osteoporosis in 7.9%. The presence of two or more comorbidities was found in 42.1% of participants and was associated in multivariate analysis with older age and longer exposure to antiretrovirals. Comorbidities were diversely associated with biomarkers: osteoporosis with higher IL-6, renal impairment with higher sCD14, hypertension with higher D-dimer, diabetes and elevated triglyceride/HDL-cholesterol ratio both with lower adiponectin and lower 25-hydroxyvitamin D. Asymptomatic atherosclerosis and multimorbidity were frequent in a cohort of middle-aged, well-controlled, PLWH and were associated with traditional and HIV-specific factors. Associations between morbidities and inflammatory/immune activation biomarkers were diverse.

Should We Target Global Risk or Risk Factors?

PURPOSE OF REVIEW

Recent evidence has shaped the new guidelines for the management of dyslipidemia. The importance of accurate risk estimation, subclinical disease detection, and contemporary dyslipidemia management approaches are discussed in this review.

RECENT FINDINGS

Risk prediction helps determine the intensity of management strategies and identify high-risk patients. To overcome the pitfalls of the current risk prediction systems, incorporating genetic scores, biomarkers, and imaging is being explored. Key initiating event in atherogenesis is low-density lipoprotein cholesterol (LDL-C) retention in the arterial wall. Recent dyslipidemia guidelines agree that LDL-C is the primary target, but management approaches vary. Guidelines are shaped by new studies that show the benefits of high-intensity lipid lowering, especially for patients at very high-risk. Global risk assessment should be performed in all individuals for cardiovascular disease prevention. Main target should be the causal risk factors, particularly LDL-C which is one of the most important modifiable causal factors. Lower LDL-C goals will help prevent further events in very high-risk patients.

Complement C5 Protein as a Marker of Subclinical Atherosclerosis

BACKGROUND

The mechanisms underlying early atherosclerotic plaque formation are not completely understood. Moreover, plasma biomarkers of subclinical atherosclerosis are lacking.

OBJECTIVES

The purpose of this study was to analyze the temporal and topologically resolved protein changes taking place in human aortas with early atherosclerosis to find new potential diagnostic and/or therapeutic targets.

METHODS

The protein composition of healthy aortas (media layer) or with early atheroma (fatty streak and fibrolipidic, media and intima layers) was analyzed by deep quantitative multiplexed proteomics. Further analysis was performed by Western blot, immunohistochemistry, real-time polymerase chain reaction, and enzyme-linked immunosorbent assay. Plasma levels of complement C5 were analyzed in relation to the presence of generalized (>2 plaques) or incipient (0 to 2 plaques) subclinical atherosclerosis in 2 independent clinical cohorts (PESA [Progression of Early Subclinical Atherosclerosis] [n = 360] and NEFRONA [National Observatory of Atherosclerosis in Nephrology] [n = 394]).

RESULTS

Proteins involved in lipid transport, complement system, immunoglobulin superfamily, and hemostasis are increased in early plaques. Components from the complement activation pathway were predominantly increased in the intima of fibrolipidic plaques. Among them, increased C5 protein levels were further confirmed by Western blot, enzyme-linked immunosorbent assay and immunohistochemistry, and associated with in situ complement activation. Plasma C5 was significantly increased in individuals with generalized subclinical atherosclerosis in both PESA and NEFRONA cohorts, independently of risk factors. Moreover, in the PESA study, C5 plasma levels positively correlated with global plaque volume and coronary calcification.

CONCLUSIONS

Activation of the complement system is a major alteration in early atherosclerotic plaques and is reflected by increased C5 plasma levels, which have promising value as a novel circulating biomarker of subclinical atherosclerosis.

Predictors for High-Risk Carotid Plaque in Asymptomatic Korean Population

Aims

High-risk carotid plaque remains an important risk factor for atherosclerotic cardiovascular disease (ASCVD). We sought to evaluate the characteristics of carotid plaque and to find out the predictors for high-risk carotid plaque in asymptomatic Koreans.

Methods

Subjects (n = 801) without a history of ASCVD from 12 university hospitals in Korea underwent carotid ultrasound. The images were standardized at core laboratory. Morphologic characteristics of plaque were analyzed with laboratory and clinical characteristics. High-risk carotid plaque features included the highest quartile of carotid plaque score (cPS), irregular plaque surface, and hypoechoic and ulcerated plaque.

Results

The carotid plaque prevalence was 22.1% (177/801 persons, 293 plaques). The plaque was increased with age (p < 0.001) and conventional ASCVD risk estimator (p < 0.001) and the most frequently found in bulb (n = 190, 64.8%). The number of the highest quartile of cPS was 44/177 (24.9%). Irregular plaque was seen in 20.8% out of total plaque (61/293) and was more frequent in the high-risk 10-year ASCVD risk group than in the low-risk group (36.1% vs. 15.8%, p = 0.023). Hypoechoic and ulcerated plaques were seen in 14.3% (42/293) and 2% (6/293), respectively. The independent predictors for high-risk plaque were age (β = 0.052, p < 0.001), HbA1c (β = 0.182, p = 0.004), male (β = 0.118, p = 0.006), hypertension (β = 0.090, p = 0.032), and multiple plaques (OR: 4.810 (two plaques) and 8.621 (three plaques), all p < 0.001).

Conclusions

This study suggests that high-risk carotid plaque was seen in 12.4% (99/801). The high-risk plaque was associated with diabetes control status reflected by the HbA1c level as well as traditional risk factors in asymptomatic Korean population.

Fe3O4@M nanoparticles for MRI-targeted detection in the early lesions of atherosclerosis

Atherosclerosis can lead to most cardiovascular diseases. Although some biomimetic nanomaterials coated by macrophage membranes have been reported in previous studies of atherosclerosis, to our knowledge, no studies regarding the detection of early lesions of atherosclerosis (foam cells) using such a strategy have yet been reported. In the present study, Fe₃O₄ biomimetic nanoparticles coated with a macrophage membrane (Fe₃O₄@M) were prepared to investigate the imaging effect on the early lesions of atherosclerosis (foam cells). The results showed that the Fe₃O₄@M particles are spheres with average diameters of approximately 300 nm. T1 and T2 relaxation values showed that the ratio of r2 to r1 was 26.09. The protein content accounted for approximately 27% of the total weight in Fe₃O₄@M, and Fe₃O₄@M nanoparticles exhibited high biosafety. Further testing showed that Fe₃O₄@M effectively targets early atherosclerotic lesions by the specific recognition of integrin α4β1 to VCAM-1. Taken together, Fe₃O₄@M is a promising contrast agent for the diagnosis of early stage atherosclerosis.

Carotid intraplaque neovascularization predicts coronary artery disease and cardiovascular events

AIMS

It is thought that the majority of cardiovascular (CV) events are caused by vulnerable plaque. Such lesions are rupture prone, in part due to neovascularization. It is postulated that plaque vulnerability may be a systemic process and that vulnerable lesions may co-exist at multiple sites in the vascular bed. This study sought to examine whether carotid plaque vulnerability, characterized by contrast-enhanced ultrasound (CEUS)-assessed intraplaque neovascularization (IPN), was associated with significant coronary artery disease (CAD) and future CV events.

METHODS AND RESULTS

We investigated carotid IPN using carotid CEUS in 459 consecutive stable patients referred for coronary angiography. IPN was graded based on the presence and location of microbubbles within each plaque (0, not visible; 1, peri-adventitial; and 2, plaque core). The grades of each plaque were averaged to obtain an overall score per patient. Coronary plaque severity and complexity was also determined angiographically. Patients were followed for 30 days following their angiogram. This study found that a higher CEUS-assessed carotid IPN score was associated with significant CAD (≥50% stenosis) (1.8 ± 0.4 vs. 0.5 ± 0.6, P < 0.0001) and greater complexity of coronary lesions (1.7 ± 0.5 vs. 1.3 ± 0.8, P < 0.0001). Furthermore, an IPN score ≥1.25 could predict significant CAD with a high sensitivity (92%) and specificity (89%). The Kaplan-Meier analysis demonstrated a significantly higher proportion of participants having CV events with an IPN score ≥1.25 (P = 0.004).

CONCLUSION

Carotid plaque neovascularization was found to be predictive of significant and complex CAD and future CV events. CEUS-assessed carotid IPN is a clinically useful tool for CV risk stratification in high-risk cardiac patients.

Coronary Calcium Score and Stratification of Coronary Artery Disease Risk in Patients with Atherosclerotic and Non-Atherosclerotic Ischemic Stroke

BACKGROUND

Ischemic Stroke (IS) and Coronary Artery Disease (CAD) frequently coexist and share atherosclerotic disease risk factors. According to the American Heart Association, IS subtypes may be considered CAD risk equivalents, but the evidence for non-atherosclerotic IS is uncertain. Additionally, the Coronary Calcium Score (CCS) is an accurate marker to address CAD risk; however, CCS distribution between IS subtypes is not well characterized.

OBJECTIVES

To compare the CCS between atherosclerotic and non-atherosclerotic IS groups; and to determine which covariates were associated with high CCS in IS.

METHODS

This cross-sectional design included all patients with IS, 45 to 70 years of age at the time of the stroke, consecutively admitted to a rehabilitation hospital between August 2014 and December 2016, without prevalent CAD. All patients underwent CT scanning for CCS measurement. CCS≥100 was considered a high risk for CAD, with a significance level of p<0.05.

RESULTS

From the 244 studied patients (mean age 58.4±6.8 years; 49% female), 164 (67%) had non-atherosclerotic etiology. The proportions of CCS≥100 were similar between the atherosclerotic and the non-atherosclerotic groups (33% [n=26] x 29% [n=47]; p= 0.54). Among all IS patients, only age ≥60 years was independently associated with CCS≥100 (OR 3.5; 95%CI 1.7-7.1), accounting for hypertension, dyslipidemia, diabetes, sedentarism, and family history of CAD.

CONCLUSION

Atherosclerotic IS did not present a greater risk of CAD when compared to non-atherosclerotic IS according to CCS. Only age ≥60 years, but not etiology, was independently associated with CCS≥100.

Association of LDLc to HDLc ratio with carotid plaques in a community-based population with a high stroke risk: A cross-sectional study in China

BACKGROUND AND AIMS

The association between low-density lipoprotein cholesterol (LDLc) to high-density lipoprotein cholesterol (HDLc) ratio (LDLc/HDLc) and carotid plaques remains controversial. We conducted a cross-sectional study to evaluate whether LDLc/HDLc is associated with carotid plaques in individuals with a high-stroke-risk.

METHODS AND RESULTS

The study initially enrolled 5529 residents aged 40 years or older from Yangzhou, China in 2013-2014. All participants received a questionnaire interview, physical examination, and laboratory tests. Risk factors for stroke included hypertension, diabetes mellitus, dyslipidemia, atrial fibrillation, smoking, less exercise, overweight/obesity, and family stroke history. Subjects with at least three of the risk factors or a history of stroke/transient ischemic attack (TIA) were defined as a high-stroke-risk population. Carotid ultrasonography was only conducted for this high-stroke-risk population. Logistic regression was used to examine the association of LDLc/HDLc with the presence of carotid plaques. Final analysis included 839 high-stroke-risk subjects and 40.6% were identified to have carotid plaques. Subjects with the highest tertiles group of LDLc/HDLc had a higher proportion of carotid plaques than the other two groups (47.1% vs. 34.6% and 40.4%, P < 0.001). With each unit increase of LDLc/HDLc, the chance of having carotid plaques increased by 65% (OR 1.65, 95%CI 1.31-2.08) after adjusted for potential confounders. Among most subgroups, a higher LDLc/HDLc was significantly correlated with the presence of carotid plaques.

CONCLUSION

Higher LDLc/HDLc was significantly associated with the presence of carotid plaques in the Chinese population with a high risk of stroke.

Polyvascular disease: A narrative review of current evidence and a consideration of the role of antithrombotic therapy

BACKGROUND AND AIMS

Polyvascular disease (PVD) affects approximately 20% of patients with atherosclerosis and is a strong independent risk factor for ischemic outcomes. However, guidelines do not address screening or treatment for PVD, and there have been no PVD-specific trials. We reviewed subgroup analyses of large randomized controlled trials of more intense antithrombotic therapy to determine whether increased intensity of therapy improved ischemic outcomes in patients with PVD.

METHODS

MEDLINE, MEDLINE in-Process, EMBASE, and the Cochrane Library were queried for randomized controlled trials larger than 5000 patients evaluating secondary prevention therapies in patients with coronary artery disease or lower extremity peripheral artery disease.

RESULTS

Thirteen trials were included ranging in size from 7243 to 27,395 patients. In 9 trials (CHARISMA, TRA 2°P-TIMI 50, PEGASUS-TIMI 54, VOYAGER PAD, TRACER, EUCLID, TRILOGY ACS, PLATO, and COMPASS), patients in the PVD subgroup treated with increased-intensity antithrombotic therapy had similar or greater relative risk reductions for ischemic events in comparison with the general trial cohorts. In four trials (DAPT, THEMIS, APPRAISE-2, and ATLAS ACS 2 TIMI 51), the PVD subgroup had an increased hazard of ischemic events with increased-intensity therapy compared with the general trial cohorts.

CONCLUSIONS

More intense antithrombotic therapy in patients with PVD was associated with a similar relative risk reduction for ischemic events compared with patients without PVD. Therefore, patients with PVD benefit from a larger absolute risk reduction because of their higher baseline risk. Future trials in patients with atherosclerotic cardiovascular disease should intentionally include PVD patients to adequately assess treatment options for this under-studied, under-treated population.

Management of asymptomatic carotid stenosis

Patients with asymptomatic carotid stenosis (ACS) are at very high risk of coronary events, so they should all receive intensive medical therapy. What is often accepted as “best medical therapy” is usually suboptimal. Truly intensive medical therapy includes lifestyle modification, particularly smoking cessation and a Mediterranean diet. All patients with ACS should receive intensive lipid-lowering therapy, should have their blood pressure well controlled, and should receive B vitamins for lowering of plasma total homocysteine (tHcy) if levels are high; a commonly missed cause of elevated tHcy is metabolic B12 deficiency, which should be diagnosed and treated. Most patients with ACS would be better treated with intensive medical therapy than with either carotid endarterectomy (CEA) or stenting (CAS). A process called “treating arteries instead of treating risk factors” markedly reduced the risk of ACS in an observational study; a randomized trial vs. usual care should be carried out. The few patients with ACS who could benefit (~15%, or perhaps more if recent evidence regarding the risk of intraplaque hemorrhage is borne out) can be identified by a number of features. These include microemboli on transcranial Doppler, intraplaque hemorrhage, reduced cerebrovascular reserve, and echolucency of plaques, particularly “juxtaluminal black plaque”. No patient should be subjected to CAS or CEA without evidence of high-risk features, because in most cases the 1-year risk of stroke or death with intervention is higher with either CEA (~2%) or CAS (~4%) than with intensive medical therapy (~0.5%). Most patients, particularly the elderly, would be better treated with CEA than CAS. Most strokes can be prevented in patients with ACS, but truly intensive medical therapy is required.

Transatlantic Lipid Guideline Divergence: Same Data But Different Interpretations

Despite consensus that excessive circulating concentrations of apoB‐lipoproteins is a key driver for the atherosclerotic process and that treatments that low‐density lipoprotein cholesterol lowering by up‐regulation of low‐density lipoprotein cholesterol receptor expression reduces that risk, divergent viewpoints on interpretation of study data have resulted in substantial differences in European and American lipid guideline recommendations. This article explores those differences and highlights the importance of understanding guideline‐based lipid management to improve patient care and reduce the risk of clinical atherosclerotic cardiovascular disease.

Carotid plague formation is associated with ankle-brachial index in elderly people

AIMS

This study aimed at examining whether ankle-brachial index (ABI) and brachial-ankle pulse wave velocity (baPWV) were independently associated with carotid Intima-media thickness (CIMT) or carotid artery plaque (CAP) in elderly people.

METHODS

A cross-sectional analysis was performed in 155 individuals aged over 75 years who underwent the measurements of ABI and baPWV. Low ABI was defined as ABI ≤ 1.0. High baPWV was defined as baPWV > 2000 cm/s. The CIMT and CAP were measured with a B-mode tomographic ultrasound system.

RESULTS

Neither ABI nor baPWV was associated with CIMT in this elderly population. The group with low ABI (≤ 1.0) was significantly associated with a higher prevalence of carotid plaque (P = 0.001), while the relationship between baPWV and prevalence of carotid plaque was not found. Linear regression analysis showed that the value of ABI was significantly associated with the thickness of carotid plaque. Even in the full adjusted model, each 0.01unit ABI decreasing still increased 0.1663 mm of carotid plaque thickness (P = 0.004). Logistic Regression Analysis demonstrated that ABI lower than 1.0 had predictive value in the formation of carotid plaque with top quartile thickness (OR 2.834, 95% CI 1.131-7.099, P = 0.026). Furthermore, individuals with low ABI (≤ 1.0) were more likely to form hypoechoic carotid plaques according to ultrasonography.

CONCLUSION

Low ABI but not high baPWV was associated with the formation of carotid plaque. Furthermore, ABI was significantly associated with the thickness and morphology of carotid plaque in elderly people.

Absent atherosclerotic risk factors are associated with carotid stiffening quantified with ultrafast ultrasound imaging

OBJECTIVES

To evaluate carotid stiffening in participants without conventional cardiovascular risk factors (CVRFs) by using ultrafast pulse wave velocity (ufPWV).

METHODS

The present study enrolled 517 participants without conventional CVRFs (CVRF-Free total population). Subjects in this population were defined as current non-smokers with untreated blood pressure < 140/90 mmHg, fasting blood glucose (FBG) < 7.0 mmol/L, total cholesterol (TC) < 6.2 mmol/L, low-density lipoprotein cholesterol < 4.1 mmol/L, and high-density lipoprotein cholesterol ≥ 1.0 mmol/L. Participants in the subgroup with optimal CVRFs (CVRF-Optimal subgroup; n = 188) were defined as having blood pressure < 120/80 mmHg, TC < 5.2 mmol/L, and FBG < 5.6 mmol/L. Clinical interviews, physical examinations, serum draw, carotid intima-media thickness (cIMT), and ufPWV were evaluated. Adjusted odds ratios (ORs) with 95% confidence intervals and ordinal logistic regression models were used.

RESULTS

Carotid stiffening was present in 46.2-54.5% of CVRF-Free subjects. Age, male sex, and body mass index (BMI) were independently associated with carotid stiffening in both the CVRF-Free total population and CVRF-Optimal subgroup (OR for age = 1.10-1.11, OR for male sex = 2.65-7.19, OR for BMI = 1.34-1.62; p < 0.05). Carotid stiffening was associated with TC only in the CVRF-Free total population (OR for TC = 1.84; p = 0.034).

CONCLUSIONS

Many CVRF-Free individuals have carotid stiffening. ufPWV for atherosclerotic stiffening aids the assessment of early atherogenesis and may further clarify the true status of healthy adults without CVRFs.

KEY POINTS

• CVRF-Optimal individuals have a lower carotid stiffness than CVRF-Free populations. • ufPWV is a quantitative predictor for the early assessment of AS. • Absent major CVRFs cannot be considered low risk for carotid stiffening and atherosclerosis.

Artificial intelligence framework for predictive cardiovascular and stroke risk assessment models: A narrative review of integrated approaches using carotid ultrasound

RECENT FINDINGS

Cardiovascular disease (CVD) is the leading cause of mortality and poses challenges for healthcare providers globally. Risk-based approaches for the management of CVD are becoming popular for recommending treatment plans for asymptomatic individuals. Several conventional predictive CVD risk models based do not provide an accurate CVD risk assessment for patients with different baseline risk profiles. Artificial intelligence (AI) algorithms have changed the landscape of CVD risk assessment and demonstrated a better performance when compared against conventional models, mainly due to its ability to handle the input nonlinear variations. Further, it has the flexibility to add risk factors derived from medical imaging modalities that image the morphology of the plaque. The integration of noninvasive carotid ultrasound image-based phenotypes with conventional risk factors in the AI framework has further provided stronger power for CVD risk prediction, so-called "integrated predictive CVD risk models."

PURPOSE

of the review: The objective of this review is (i) to understand several aspects in the development of predictive CVD risk models, (ii) to explore current conventional predictive risk models and their successes and challenges, and (iii) to refine the search for predictive CVD risk models using noninvasive carotid ultrasound as an exemplar in the artificial intelligence-based framework.

CONCLUSION

Conventional predictive CVD risk models are suboptimal and could be improved. This review examines the potential to include more noninvasive image-based phenotypes in the CVD risk assessment using powerful AI-based strategies.

Antithrombotic treatment of asymptomatic carotid atherosclerosis: a medical dilemma

Carotid artery atherosclerosis (CAAS) is a common finding in asymptomatic subjects evaluated for cardiovascular (CV)-risk stratification. Besides the careful control of CV-risk factors, antithrombotic agents, and in particular aspirin, may be considered for primary prevention in patients at CV-risk. However, there is strong controversy on the use of aspirin in primary prevention. Even if several studies confirmed the association between CAAS and CV-events, CAAS is not universally recognized as an independent risk factor and the choice to use aspirin as primary prevention in these patients remains a medical dilemma. Here we review the available evidence on the prognostic value of asymptomatic CAAS for major CV-events and on the utility of antithrombotic agents in this population. We conclude that the detection of asymptomatic CAAS can not be considered as a direct indication to carry out primary prophylaxis with antithrombotic drugs, and the choice to use aspirin should be made only after the careful estimate of the individual's CV-and hemorrhagic risk.

Extent and characteristics of carotid plaques and brain parenchymal loss in asymptomatic patients with no indication for revascularization

BACKGROUND AND AIMS

Extent of subclinical atherosclerosis has been associated with brain parenchymal loss in community-dwelling aged subjects. Identification of patient-related and plaque-related markers could identify subjects at higher risk of brain atrophy, independent of cerebrovascular accidents. Aim of the study was to investigate the relation between extent and characteristics of carotid plaques and brain atrophy in asymptomatic patients with no indication for revascularization.

METHODS AND RESULTS

Sixty-four patients (aged 69 ± 8 years, 45% females) with carotid stenosis <70% based on Doppler flow velocity were enrolled in the study. Potential causes of cerebral damage other than atherosclerosis, including history of atrial fibrillation, heart failure, previous cardiac or neurosurgery and neurological disorders were excluded. All subjects underwent carotid computed tomography angiography, contrast enhanced ultrasound for assessment of plaque neovascularization and brain magnetic resonance imaging for measuring brain volumes. On multivariate regression analysis, age and fibrocalcific plaques were independently associated with lower total brain volumes (β = -3.13 and β = -30.7, both p < 0.05). Fibrocalcific plaques were also independently associated with lower gray matter (GM) volumes (β = -28.6, p = 0.003). On the other hand, age and extent of carotid atherosclerosis were independent predictors of lower white matter (WM) volumes.

CONCLUSIONS

WM and GM have different susceptibility to processes involved in parenchymal loss. Contrary to common belief, our results show that presence of fibrocalcific plaques is associated with brain atrophy.

Steno type 1 risk engine and preclinical atherosclerosis in Mediterranean individuals with type 1 diabetes

BACKGROUND AND AIMS

Tools to detect type 1 diabetes (T1D) individuals at overt cardiovascular disease (CVD) risk are scarce. We aimed to assess the usefulness of the score 'Steno Type 1 Risk Engine' (Steno-Risk) to identify T1D patients with advanced carotid atherosclerosis.

MATERIAL AND METHODS

T1D patients without CVD with at least one of the following were included: ≥40 years, diabetic nephropathy, or diabetes duration ≥10 years with ≥1 CVD risk factor. Intima-media thickness (IMT) and plaque presence (IMT ≥1.5 mm) were assessed by standardized B-mode ultrasonography. Steno-Risk was used to estimate 10-year risk (<10% low; 10%-20% moderate; ≥20% high risk). Associations between Steno-Risk and preclinical atherosclerosis were assessed after adjusting for other CVD risk factors.

RESULTS

We evaluated 302 patients (55% men, age 47.8 ± 9.8 years, T1D duration 26.3 ± 9.3 years). The prevalence of carotid plaque and ≥2 plaques were 36.4% and 19.2%, respectively; without sex differences. Age (57.4 ± 7.4 vs 37.1 ± 6.2 years), T1D duration (31.3 ± 10.4 vs 21.5 ± 7.1 years), hypertension (52.3% vs 6.3%), nephropathy (25.6% vs 5.1%) and retinopathy (53.5% vs 32.9%) were higher in high-risk (n = 86) vs low-risk participants (n = 79; P < .001 for all). Preclinical atherosclerosis (IMT and plaque) increased in parallel with Steno-Risk (P < .001). In logistic regression analysis, both age ≥40 years and Steno-Risk ≥20% were associated with the presence of plaque (OR 4.22 [1.57-11.36] and 3.79 [1.61-6.80]; respectively), but only high Steno-Risk remained independently associated with ≥2 plaques (OR 3.31 [1.61-6.80]).

CONCLUSION

Steno-Risk is independently associated with preclinical atherosclerosis. Further studies are needed to ascertain its usefulness in this high-risk population.

Measurement of carotid plaque burden

PURPOSE OF REVIEW

To describe the uses of measurement of carotid plaque burden, as total plaque area (TPA), total plaque volume (TPV), and vessel wall volume (VWV), which includes plaque burden and wall volume.

RECENT FINDINGS

Measurement of plaque burden is useful for risk stratification, research into the genetics and biology of atherosclerosis, for measuring effects of new therapies for atherosclerosis, and for treatment of high-risk patients with severe atherosclerosis.

SUMMARY

Measurement of plaque burden is far superior to measurement of carotid intima-media thickness (IMT) in many ways, and should replace it. Vessel wall volume can be measured in persons with no plaque as an alternative to IMT.

Prevalence of Non-Stenotic (<50%) Carotid Plaques in Acute Ischemic Stroke and Transient Ischemic Attack: A Systematic Review and Meta-Analysis

INTRODUCTION

Non-stenotic (<50%) carotid plaques have recently been recognized as a potential source of stroke. This meta-analysis aims to summarize the prevalence of non-stenotic carotid plaques in stroke patients in general and in patients with embolic stroke of undetermined source in particular.

METHODS

We performed a comprehensive systematic review of the literature and meta-analysis on acute ischemic stroke patients in whom carotid imaging was performed using the MEDLINE, Embase and Cochrane database, including studies published up to December 2019. Keywords were "stroke", "transient ischemic attack", "carotid", "plaque", "atherosclerosis" and "disease". Included studies had ≥10 patients with acute ischemic stroke and reported the prevalence of non-stenotic (<50%%stenosis) carotid plaques detected on any imaging modality.

RESULTS

We included forty-five studies (n = 18304 patients, 48.4% males, mean age 63.6 years) in our meta-analysis. Imaging modalities used were ultrasound (n = 26 studies), CT-angiography (n = 7), magnetic resonance-imaging (n = 8) and catheter angiography (n = 4). The overall prevalence of non-stenotic carotid plaques was 51% (95% CI: 43 - 59). 10 studies included mainly patients with embolic stroke of undetermined source (>50% of all patients). The pooled prevalence of non-stenotic carotid plaques in these studies was 55% (95% CI: 42 - 68). 23 studies explicitly reported ipsilateral non-stenotic carotid plaques, the pooled prevalence of which was 51% (95% CI: 45 - 59).

CONCLUSIONS

In this meta-analysis, non-stenotic carotid plaques were present in more than 50% of all acute ischemic stroke patients, with a slightly higher prevalence in ESUS patients. Given the potential role of non-stenotic carotid plaques in stroke etiology, particularly in ESUS, further research should aim to identify criteria that predict the stroke risk associated with non-stenotic carotid plaques.