Carotid and femoral ultrasound morphology screening and cardiovascular events in low risk subjects: a 10-year follow-up study (the CAFES-CAVE study(1))

Atherosclerosis imaging and heart failure

Coronary atherosclerosis is the most important primary etiologic factor predisposing to the development of heart failure. The mechanisms by which coronary atherosclerosis lead to heart failure likely involve the initial development of regional myocardial dysfunction, later progressing to global ventricular failure and symptomatic congestive disease. A variety of imaging strategies have been investigated for their value in identifying and characterizing markers of atherosclerosis in the effort to detect early cardiac disease. Non-invasive imaging techniques for assessing anatomic or functional manifestations of atherosclerosis include carotid ultrasonography, coronary computed tomography, cardiovascular magnetic resonance imaging, brachial artery reactivity testing, and the ankle-brachial index. Many of these imaging methods are shown to have accuracy, reliability, and the potential to add value to an office-based cardiovascular risk assessment. Further development of such imaging methods could facilitate early intervention in the development of myocardial dysfunction while enhancing our understanding of the natural course of atherosclerotic disease.

The presence of a calcific plaque in the common carotid artery as a predictor of coronary atherosclerosis

Many contradictory reports have been published investigating the relationship between coronary artery disease (CAD) and the increased intima-media thickness (IMT) in the common carotid artery (CCA). However, only a limited number of studies evaluate the relationship between CAD and CCA disease as reflected by both the plaque morphology (fibrous and calcific plaques) and IMT. We have studied the associations between CAD and the wall morphology of CCA by B-mode ultrasound (US). One hundred and forty-four subjects, whose angiography was planned on the basis of suspected CAD, were included into the study. The patients were divided into 4 groups on the basis of B-mode US findings; Group I: normal, Group II: increased IMT (IMT >/= 0.8 mm and plaque absent), Group III: fibrous plaque, Group IV: calcific plaque. Coronary artery disease was diagnosed in 63 patients. A statistically significant correlation was found between CAD and CCA wall morphology (r =0.42, CI (95%) = 0.30-0.51, p<0.001). Positive predictive values were 45.0%, 48.4%, and 75.0% in patients with increased IMT, fibrous plaque, and calcific plaque, respectively. None of the women with normal CCA wall morphology had significant coronary artery lesion. With respect to the normal group, the risk for CAD increased by 4.3 fold with the existence of fibrous plaque (p=0.02) and by 9.9 fold with the existence of calcific plaque (p<0.001). It has been shown that the CCA wall morphology determined by B-mode US is correlated with CAD in patients with chest pain, and the presence of calcific plaque is a better predictor for CAD than that of fibrous plaque and increased IMT. Women with chest pain and normal CCA wall morphology may not need coronary angiography.

Prediction of major adverse cardiovascular events by age-normalized carotid intimal medial thickness

BACKGROUND

Increases in carotid intimal medial thickness (IMT), as measured by noninvasive ultrasonography, have been associated with increased risk of myocardial infarction and stroke, particularly in adults 65 years of age or older. We investigated the value of age-normalized carotid IMT measurements in predicting major adverse cardiovascular events in a population of patients referred for carotid IMT measurement.

METHODS

Since 1995, 727 patients had carotid IMT measured at the University of Virginia's Preventive Cardiology practice. We successfully contacted 706 of these patients to determine clinical outcomes; 21 patients were lost to follow-up. The 706 patients were entered into a database, age-specific quartiles of carotid thickness developed, and odds ratios were calculated with logistic regression.

RESULTS

Over a mean follow-up period of 4.78 years (range, 2.0-9.3 years), 20 patients had major adverse cardiovascular events: seven patients had myocardial infarctions; seven required revascularization; and six had a stroke or transient ischemic attack. The incidence of events directly correlated with age-normalized measurements of carotid bulb and internal carotid IMT. The highest quartile of carotid bulb IMT demonstrated an odds ratio for all events of 5.8 (95% confidence interval, 1.3-26.6; P = 0.023) when compared to the quartile with the lowest thickness (P = 0.007 for trend). A similar trend for quartiles of internal carotid IMT was also observed (P = 0.03). Common carotid IMT did not significantly predict events.

CONCLUSIONS

Age-normalized measurement of carotid bulb and internal carotid IMT may be helpful in determining which individuals would most benefit from aggressive risk-factor modification.

Subclinical Atherosclerosis and Incipient Regional Myocardial Dysfunction in Asymptomatic Individuals

OBJECTIVES

This study sought to determine whether increased carotid intima-media thickness (IMT) is related to reduced regional myocardial function in participants of the Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND

Carotid artery IMT is an established index of subclinical atherosclerosis, and tagged magnetic resonance imaging (MRI) can detect incipient alterations of segmental function that precede overt myocardial failure.

METHODS

The MESA study is a prospective observational study including four ethnic groups free from clinical cardiovascular disease. Peak midwall systolic circumferential strain (ECC) and regional strain rates were calculated by harmonic phase from tagged MRI data of 500 participants. Systolic ECC and diastolic strain rate were regressed on IMT of the common carotid artery defined by ultrasound, with adjustments for body mass index, blood pressure, cholesterol, diabetes, smoking, left ventricular hypertrophy, C-reactive protein, age, and gender.

RESULTS

The mean participant age was 66 +/- 10 years (mean +/- SD). Among the 58 participants, 4% were male and the interquartile (25th to 75th percentile) range for IMT was 0.25 mm. Multiple linear regression analyses showed that increased IMT was related to reduced systolic regional function (less shortening ECC) in all myocardial regions (p < 0.05), except in the inferior wall. The analyses also showed that greater IMT was associated with a lower diastolic strain rate (diastolic reduced function) in all regions (p < 0.01), except in the anterior wall.

CONCLUSIONS

Greater carotid IMT is associated with alterations of myocardial strain parameters reflecting reduced systolic and diastolic myocardial function. These observations indicate a relationship between subclinical atherosclerosis and incipient myocardial dysfunction in a population free of clinical heart disease.

Association of subclinical wall changes of carotid, femoral, and popliteal arteries with obstructive coronary artery disease in patients undergoing coronary angiography

STUDY OBJECTIVES

To examine the association of occult atherosclerosis of carotid, femoral, and popliteal arteries with the presence and severity of obstructive coronary artery disease (CAD) in patients without a history or presence of cerebrovascular or peripheral arterial disease using ultrasound examination of peripheral arteries.

PATIENTS/METHODS

One hundred eighty-four such individuals underwent routine coronary angiography. Obstructive CAD was found in 103 cases, which comprised the patient group. The remaining 81 individuals comprised the control group. All were blindly examined by duplex ultrasonography in order to assess occult atherosclerosis, as indicated by the estimation of intima-media thickness of the carotid artery (IMTC), intima-media thickness of the femoral artery (IMTF), intima-media thickness of the popliteal artery (IMTP), and ultrasonic biopsy (UB) of the carotid and femoral arteries. For the individuals with positive coronary angiography findings, the severity of CAD was estimated by the number of the diseased vessels.

RESULTS

IMTC, IMTF, IMTP, and UB showed significant correlation with the presence of obstructive CAD, but only IMTC and IMTF were independent predictive factors, with specificity of 74% and 60% and sensitivity of 76% and 70%, respectively. Additionally, our analysis yielded a regression model that, for a given value of IMTC and IMTF, may estimate the probability of CAD: p (CAD) = e((- 4.765 + 3.36 IMTC + 1.91 IMTF))/1 + e((- 4.765 + 13.36 IMTC + 1.91 IMTF)). Patients with one-vessel disease had significantly lower IMTC (p < 0.001) and UB (p = 0.011) and lower IMTF (p = 0.057) than those with three-vessel disease.

CONCLUSIONS

The assessment of occult atherosclerosis by duplex ultrasonography in both the carotid and the femoral arteries is significantly associated with the presence and severity of CAD.

Ultrasound-detected carotid plaque as a screening tool for advanced subclinical atherosclerosis

BACKGROUND

There is great need for a simple, noninvasive tool that can be used in an office setting to screen for subclinical atherosclerosis. In patients referred for cardiovascular (CV) risk assessment, we evaluated the ability of ultrasound screening for carotid plaque to identify patients with advanced subclinical atherosclerosis.

METHODS

Consecutive asymptomatic patients without vascular disease referred by their physician for measurement of the ankle-brachial pressure index and carotid intima-media thickness (CIMT) were included. Carotid intima-media thickness was measured using the standardized ultrasound protocol from the Atherosclerosis Risk in Communities (ARIC) study. Advanced atherosclerosis was defined as CIMT > or = 75th percentile for age, sex, and race in ARIC.

RESULTS

The mean age of the 327 subjects was 55.4 years (SD 7.7 years). The 10-year Framingham CV risk was 5.1% (4.8%). In a multiple logistic regression model that included Framingham CV risk, ankle-brachial pressure index, and use of lipid-lowering medications, plaque presence significantly predicted advanced atherosclerosis (odds ratio 3.08, 95% CI 1.91-4.96, P < .001). In stepwise regression models that included age, body mass index, current tobacco use, family history of premature CV disease, fasting glucose, sex, systolic blood pressure, total/high-density lipoprotein cholesterol ratio, and use of antihypertensive and lipid-lowering medications, plaque presence independently predicted advanced atherosclerosis (P < .001).

CONCLUSION

Ultrasound detection of carotid plaque helped identify asymptomatic patients with advanced subclinical atherosclerosis. Screening for carotid plaque is easier than determination of CIMT and may help detect asymptomatic patients at increased CV risk.

Biomarkers of endothelial dysfunction, cardiovascular risk factors and atherosclerosis in rheumatoid arthritis

Cardiovascular event rates are markedly increased in rheumatoid arthritis (RA), and RA atherogenesis remains poorly understood. The relative contributions of traditional and nontraditional risk factors to cardiovascular disease in RA await elucidation. The present study comprises three components. First, we compared biomarkers of endothelial dysfunction (vascular cell adhesion molecule [VCAM]-1, intercellular adhesion molecule [ICAM]-1 and endothelial leucocyte adhesion molecule [ELAM]-1) in 74 RA patients and 80 healthy control individuals before and after controlling for traditional and nontraditional cardiovascular risk factors, including high-sensitivity C-reactive protein (hs-CRP), IL-1, IL-6 and tumor necrosis factor-α. Second, we investigated the potential role of an extensive range of patient characteristics in endothelial dysfunction in the 74 RA patients. Finally, we assessed associations between biomarkers of endothelial dysfunction and ultrasonographically determined common carotid artery intima–media thickness and plaque in RA. The three biomarkers of endothelial dysfunction, as well as hs-CRP, IL-1, IL-6 and tumor necrosis factor-α, were higher in patients than in control individuals (P < 0.0001). Patients were also older, exercised less and had a greater waist circumference, blood pressure and triglyceride levels (P ≤ 0.04). Five patients had diabetes. Differences in endothelial function were no longer significant between patients and controls (P = 0.08) only after both traditional and nontraditional cardiovascular risk factors were controlled for. In the 74 RA patients, IL-6 predicted levels of all three biomarkers (P ≤ 0.03), and rheumatoid factor titres and low glomerular filtration rate (GFR) both predicted levels of VCAM-1 and ICAM-1, independent of traditional cardiovascular risk factors (P ≤ 0.02). VCAM-1 was associated with common carotid artery intima–media thickness (P = 0.02) and plaque (P = 0.04) in RA. Patients had impaired endothelial function, less favourable traditional cardiovascular risk factor profiles, and higher circulating concentrations of hs-CRP and cytokines compared with healthy control individuals. Both traditional and nontraditional cardiovascular risk factors contributed to the differences in endothelial function between RA patients and healthy control individuals. IL-6, rheumatoid factor titres and low GFR were independently predictive of endothelial dysfunction in RA. Disease-modifying agents that effectively suppress both cytokine and rheumatoid factor production, and interventions aimed at preserving renal function may attenuate cardiovascular risk in RA.

Blood pressure and atherosclerotic plaques in carotid, aortic and femoral arteries in elderly Finns with diabetes mellitus or impaired glucose tolerance

The aim of the study was to evaluate the occurrence of atheromatous plaques in carotid, aortic and femoral arteries, focusing on blood pressure (BP). The study subjects consisted of 65-year-old Finns drawn from a population-based cohort. Ultrasonographic measurements were performed on 54 diabetic subjects, 97 subjects with impaired glucose tolerance (IGT) and 57 normoglycaemic subjects (NGT). High systolic BP (SBP) was defined as >or=160 mmHg and high diastolic BP as >or=95 mmHg. High pulse pressure (PP) was defined as the highest tertile (>or=75 mmHg) of PP and high mean BP (MBP) as the highest tertile (>or=111 mmHg) of MBP. The prevalence of atheromatous plaques was 77% (160/208) in carotid arteries, 94% (195/208) in aorta and 77% (161/208) in femoral arteries. A total of 64% (134/208) of the subjects had plaques in both carotid and femoral arteries, and they were compared with those who had plaques in 0-1 of these arteries. In addition to male gender and long-lasting smoking, the occurrence of plaques in both carotid and femoral arteries were associated with high SBP and high MBP. According to the results of multiple regression analyses, the adjusted odds ratio for plaques in both carotid and femoral arteries was 3.1 (95% CI 1.5-6.5) in subjects with high SBP compared to those with lower SBP. When SBP was replaced by high MBP, the adjusted odds ratio for it was 2.3 (95% CI 1.1-4.8).

A New Approach for the Screening of Carotid Lesions: A ‘Fast-track’ Method with the Use of New Generation Hand-held Ultrasound Devices

OBJECTIVES

We assessed the usefulness of fast-track neck sonography with a new-generation hand-held ultrasound scanner in the detection of > or =60% carotid stenosis.

DESIGN

Patients with a past history of atherosclerotic disease or presence of risk factors were enrolled. All had fast-track carotid screening with a hand-held ultrasound scanner.

METHODS

Initial assessment was performed with our quick imaging protocol. A second examiner performed a conventional complete carotid duplex as gold-standard.

RESULTS

We enrolled 197 consecutive patients with a mean age of 67 years (range 35-94). A carotid stenosis >60% was detected in 13 cases (6%). The sensitivity, specificity, positive and negative predictive value of fast-track sonography was 100%, 64%, 17% and 100%, respectively. Concomitant power Doppler imaging during the fast-track method did not improve accuracy.

CONCLUSIONS

The use of a fast-track method with a hand-held ultrasound device can reduce the number of unnecessary carotid Duplex and enhance the screening efficiency without missing significant carotid stenoses.