What We Have Learned from the Recent Meta-analyses on Diagnostic Methods for Atherosclerotic Plaque Regression

Efficacy of acupuncture in patients with carotid atherosclerosis: a randomized controlled clinical trial

BACKGROUND

The current clinical management of carotid atherosclerosis is based on the control of risk factors and medicine. However, the risk of adverse events associated with the medicine resulting in concerns and low medication compliance makes it necessary to seek a safer alternative therapy. This study assessed the effectiveness and safety of acupuncture as a treatment for carotid atherosclerosis.

METHODS

In this randomized controlled trial, patients with carotid atherosclerotic plaques were included and randomly assigned (1:1) to receive real acupuncture or sham acupuncture for 12 weeks. The follow-up period was 12 weeks. The primary outcome included carotid intima-media thickness (cIMT), plaque score (PS), plaque volume (PV) and grey-scale median (GSM). Secondary outcome was pulse wave velocity (PWV). Adverse events results were recorded as safety outcomes.

RESULTS

From January 2021 to February 2022, 60 eligible patients were included. 55 patients (91.7%) completed the intervention and the 12-week follow-up and there was no statistical difference in demographics between the groups. At the end of treatment, the real acupuncture group had significantly reduced PS (P = 0.002), PV (P = 0.000), and improved GSM (P = 0.044). There was no significant difference in the reduction in cIMT (Left cIMT: P = 0.338, Right cIMT: P = 0.204) and PWV between the groups (the left BS: P = 0.429; the left ES: P = 0.701; the right BS: P = 0.211; the right ES: P = 0.083). Three mild adverse reactions occurred during the study.

CONCLUSION

This study found that acupuncture had a certain effect on reducing the thickness and volume of carotid plaque and improving the stability of plaque with minor side effects. These findings suggest that acupuncture may be a potential alternative therapy for carotid atherosclerosis.

TRIAL REGISTRATION

This trial has been registered at ClinicalTrials.gov (ChiCTR2100041762). Submitted 30 December 2020, Registered 4 January 2021 Prospectively registered.

Evidence of Carotid Atherosclerosis Vulnerability Regression in Real Life From Magnetic Resonance Imaging: Results of the MAGNETIC Prospective Study

Background Atherosclerosis vulnerability regression has been evidenced mostly in randomized clinical trials with intensive lipid-lowering therapy. We aimed to demonstrate vulnerability regression in real life, with a comprehensive quantitative method, in patients with asymptomatic mild to moderate carotid atherosclerosis on a secondary prevention program. Methods and Results We conducted a single-center prospective observational study (MAGNETIC [Magnetic Resonance Imaging as a Gold Standard for Noninvasive Evaluation of Atherosclerotic Involvement of Carotid Arteries]): 260 patients enrolled at a cardiac rehabilitation center were followed for 3 years with serial magnetic resonance imaging. Per section cutoffs (95th/5th percentiles) were derived from a sample of 20 consecutive magnetic resonance imaging scans: (1) lipid-rich necrotic core: 26% of vessel wall area; (2) intraplaque hemorrhage: 12% of vessel wall area; and (3) fibrous cap: (a) minimum thickness: 0.06 mm, (b) mean thickness: 0.4 mm, (c) projection length: 11 mm. Patients with baseline magnetic resonance imaging of adequate quality (n=247) were classified as high (n=63, 26%), intermediate (n=65, 26%), or low risk (n=119, 48%), if vulnerability criteria were fulfilled in ≥2 contiguous sections, in 1 or multiple noncontiguous sections, or in any section, respectively. Among high-risk patients, a conversion to any lower-risk status was found in 11 (17%; P=0.614) at 6 months, in 16 (25%; P=0.197) at 1 year, and in 19 (30%; P=0.009) at 3 years. Among patients showing any degree of carotid plaque vulnerability, 21 (16%; P=0.014) were diagnosed at low risk at 3 years. Conclusions This study demonstrates with a quantitative approach that vulnerability regression is common in real life. A secondary prevention program can promote vulnerability regression in asymptomatic patients in the mid to long term.

Choice of imaging to evaluate carotid stenosis and guide management

Carotid artery disease is a cause of ischemic stroke and is associated with cognitive decline. Besides the evaluation of the degree of stenosis, it is also crucial to assess the morphology of the atherosclerotic plaque, for a prompt and accurate diagnosis, and to make the best decision for the patient. On top of noninvasive duplex ultrasound (DUS) and invasive digital subtraction angiography (DSA), compute tomography angiography (CTA) and magnetic resonance angiography (MRA) are often used effectively as noninvasive imaging tools to study carotid stenoses. This review describes the fundamental characteristics of carotid artery plaques, and how they can be best evaluated with currently available imaging methods.

Management of High-Risk Atherosclerotic Patients by Statins May Be Supported by Logistic Model of Intima-Media Thickening

While the use of statins in treating patients with atherosclerosis is an undisputed success, the questions regarding an optimal starting time for treatment and its strength remain open. We proposed in our earlier paper published in Int. J. Mol. Sci. (2019, 20) that the growth of intima-media thickness of the carotid artery follows an S-shape (i.e., logistic) curve. In our subsequent paper in PLoS ONE (2020, 15), we incorporated this feature into a logistic control-theoretic model of atherosclerosis progression and showed that some combinations of patient age and intima-media thickness are better suited than others to start treatment. In this study, we perform a new and comprehensive calibration of our logistic model using a recent clinical database. This allows us to propose a procedure for inferring an optimal age to start statin treatment for a particular group of patients. We argue that a decrease in the slope of the IMT logistic growth curve, induced by statin treatment, is most efficient where the curve is at its steepest, whereby the efficiency means lowering the future IMT levels. Using the procedure on an aggregate group of severely sick men, 38 years of age is observed to correlate with the steepest point of the logistic curve, and, thus, it is the preferred time to start statin treatment. We believe that detecting the logistic curve’s steepest fragment and commencing statin administration on that fragment are courses of action that agree with clinician intuition and may support decision-making processes.

Pharmacological Primary Cardiovascular Prevention and Subclinical Atherosclerosis in Men: Evidence from the Aragon Workers' Health Study

The objective of this study is to describe the profile of primary preventive treatment for cardiovascular disease in adult males and to analyze the association between treatment profile and subclinical atherosclerosis. We selected male workers who had undergone ultrasound imaging and had no previous history of cardiovascular disease (n = 2138). Data on the consumption of primary cardiovascular drugs from the previous year were obtained. We performed bivariate analyses to compare patient characteristics according to cardiovascular treatment and the presence of subclinical atherosclerosis, and logistic regression models to explore the association between these two variables. Among participants with no personal history of cardiovascular disease, subclinical atherosclerosis was present in 77.7% and 31.2% had received some form of preventive treatment. Of those who received no preventive treatment, 73.6% had subclinical atherosclerosis. Cardiovascular preventive treatment was associated only with CACS > 0 (odds ratio (OR), 1.37; 95% confidence interval (95% CI), 1.06-1.78). Statin treatment was associated with a greater risk of any type of subclinical atherosclerosis (OR, 1.73) and with CACS > 0 (OR, 1.72). Subclinical atherosclerosis existed in almost 75% of men who had no personal history of cardiovascular disease and had not received preventive treatment for cardiovascular disease.

Role of non-statin lipid-lowering therapy in coronary atherosclerosis regression: a meta-analysis and meta-regression

BACKGROUND

Several studies have investigated the association between non-statin lipid-lowering therapy and regression of atherosclerosis. However, these studies were mostly small and their results were not always robust. The objectives were: (1) to define if a dual lipid-lowering therapy (statin + non-statin drugs) is associated with coronary atherosclerosis regression, estimated by intravascular ultrasound (IVUS); (2) to assess the association between dual lipid-lowering-induced changes in low density lipoprotein cholesterol (LDL-C) and non-high-density-lipoprotein cholesterol (non-HDL-C) levels and atherosclerosis regression.

METHODS

A meta-analysis including trials of non-statin lipid-lowering therapy, reporting LDL-C, non-HDL-C and total atheroma volume (TAV) with a minimum of 6 months of follow-up was performed. The primary endpoint was defined as the change in TAV measured from baseline to follow-up, comparing groups of subjects on statins alone versus combination of statin and non-statin drugs. The random-effects model and meta-regression were performed.

RESULTS

Eight eligible trials of non-statin lipid-lowering drugs (1759 patients) were included. Overall, the dual lipid-lowering therapy was associated with a significant reduction in TAV [- 4.0 mm3 (CI 95% -5.4 to - 2.6)]; I2 = 0%]. The findings were similar in the stratified analysis according to the lipid-lowering drug class (ezetimibe or PCSK9 inhibitors). In the meta-regression, a 10% decrease in LDL-C or non-HDL-C levels, was associated, respectively, with 1.0 mm3 and 1.1 mm3 regressions in TAV.

CONCLUSION

These data suggests the addition of ezetimibe or PCSK9 inhibitors to statin therapy results in a significant regression of TAV. Reduction of coronary atherosclerosis observed with non-statin lipid-lowering therapy is associated to the degree of LDL-C and non-HDL-C lowering. Therefore, it seems reasonable to achieve lipid goals according to cardiovascular risk and regardless of the lipid-lowering strategy used (statin monotherapy or dual treatment).

A comparison of transcranial Doppler and magnetic resonance imaging for long term changes in middle cerebral artery stenosis

OBJECTIVES

Intracranial arterial stenosis may progress or regress, of which the diagnosis is important to predict the risk of stroke or to evaluate the response of treatment. Transcranial Doppler (TCD) seems to be useful for this purpose, however, optimal diagnostic criteria have not been validated yet. Our study was designed to compare TCD changes with magnetic resonance angiography (MRA) to validate optimal TCD criteria for progression or regression of middle cerebral artery (MCA).

PATIENTS AND METHODS

We prospectively enrolled patients who visited our neurology department due to MCA stenosis on TCD examination. Brain MRA was used to identify patients with stenosis of the same site of MCA. Progression or regression was defined by change of MRA grading (normal, mild, moderate, severe or occlusion). Various criteria of mean flow velocity (MFV) difference and percent change were assessed. To register more patients for reliable analysis, additional patients with the same inclusion criteria were recruited retrospectively. All patients enrolled in the study were symptomatic or asymptomatic atherosclerotic MCA stenosis.

RESULTS

Eighteen patients were enrolled and 21 MCAs with completed follow-up TCD and MRA were analyzed (mean age 68.4 years, mean follow-up 17.8 months). In addition, 40 MCAs from 30 retrospective patients were also analyzed (mean age 65.7 years, mean follow-up 22.3 months). Among assessed criteria, the most optimal cutoff value for the progression of stenosis was 20 cm/s, at which the sensitivity and specificity were 100% and 91% in prospective group, and were 80% and 93% in retrospective group. In the % difference analysis, prospective group showed sensitivity 100% and specificity 82% in the 20% cutoff. The retrospective group showed sensitivity 80% and specificity 93% in the 15% cutoff. However, results of the regression group were not consistent.

CONCLUSIONS

Diagnosis of progression of MCA stenosis with serial TCD examination is feasible and MFV change of 20 cm/s and % change of 15-20% are suggested as optimal cut-off value but not in the regression. These criteria would be useful for the clinical research and real-world practice.