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Johri AM, Nambi V, Naqvi TZ, Feinstein SB, Kim ESH, Park MM, Becher H, Sillesen H. Recommendations for the Assessment of Carotid Arterial Plaque by Ultrasound for the Characterization of Atherosclerosis and Evaluation of Cardiovascular Risk: From the American Society of Echocardiography. J Am Soc Echocardiogr 2020; 33:917-933. [PMID: 32600741 DOI: 10.1016/j.echo.2020.04.021] [Citation(s) in RCA: 135] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Atherosclerotic plaque detection by carotid ultrasound provides cardiovascular disease risk stratification. The advantages and disadvantages of two-dimensional (2D) and three-dimensional (3D) ultrasound methods for carotid arterial plaque quantification are reviewed. Advanced and emerging methods of carotid arterial plaque activity and composition analysis by ultrasound are considered. Recommendations for the standardization of focused 2D and 3D carotid arterial plaque ultrasound image acquisition and measurement for the purpose of cardiovascular disease stratification are formulated. Potential clinical application towards cardiovascular risk stratification of recommended focused carotid arterial plaque quantification approaches are summarized.
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Affiliation(s)
| | | | | | | | - Esther S H Kim
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Margaret M Park
- Cleveland Clinic Heart and Vascular Institute, Cleveland, Ohio
| | - Harald Becher
- University of Alberta Hospital, Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Henrik Sillesen
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
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Gurunathan S, Shanmuganathan M, Hampson R, Khattar R, Senior R. Role of adjuvant carotid ultrasound in women undergoing stress echocardiography for the assessment of suspected coronary artery disease. Open Heart 2020; 7:e001188. [PMID: 32587105 PMCID: PMC7319702 DOI: 10.1136/openhrt-2019-001188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Revised: 03/10/2020] [Accepted: 04/29/2020] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Due to the low prevalence of obstructive coronary artery disease (CAD) in women, stress testing has a relatively low predictive value for this. Additionally, conventional cardiovascular risk scores underestimate risk in women. This study sought to evaluate the role of atherosclerosis assessment using carotid ultrasound (CU) in women attending for stress echocardiography (SE). METHODS This was a prospective study in which consecutive women with recent-onset suspected angina, who were referred for clinically indicated SE, underwent CU. RESULTS 415 women (mean age 61±10 years, 29% diabetes mellitus, mean body mass index 28) attending for SE underwent CU. 47 women (11%) had inducible wall motion abnormalities, and carotid disease (CD) was present in 46% (carotid plaque in 41%, carotid intima-media thickness >75th percentile in 15%). Women with CD were older (65 vs 58 years, p<0.001), and more likely to have diabetes (41% vs 21%, p=0.001), hypertension (67% vs 36%, p<0.01) and a higher pretest probability of CAD (59% vs 41%, p<0.001). 40% of women classified as low Framingham risk were found to have evidence of CD.The positive predictive value of SE for flow-limiting CAD was 51%, but with the presence of carotid plaque, this was 71% (p<0.01). Carotid plaque (p=0.004) and ischaemia (p=0.01) were the only independent predictors of >70% angiographic stenosis. In women with ischaemia on SE and no carotid plaque, the negative predictive value for flow-limiting disease was 88%.During a follow-up of 1058±234 days, there were 15 events (defined as all-cause mortality, non-fatal myocardial infarction, heart failure admissions and late coronary revascularisation). Age (HR 1.07 (1.00-1.15), p=0.04), carotid plaque burden (HR 1.65 (1.36-2.00), p<0.001) and ischaemic burden (HR 1.41 (1.18-1.68), p<0.001) were associated with outcome. There was a stepwise increase in events/year from 0.3% when there were no ischaemia and atherosclerosis, 1.1% when there was atherosclerosis and no ischaemia, 2.2% when there was ischaemia and no atherosclerosis and 10% when there were both ischaemia and atherosclerosis (p<0.001). CONCLUSION CU significantly improves the accuracy of SE alone for identifying flow-limiting disease on coronary angiography, and improves risk stratification in women attending for SE, as well identifying a subset of women who may benefit from primary preventative measures.
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Affiliation(s)
- Sothinathan Gurunathan
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
| | - Mayooran Shanmuganathan
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
| | | | - Rajdeep Khattar
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Roxy Senior
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
- Department of Cardiology, Royal Brompton and Harefield NHS Foundation Trust, London, UK
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Ahmadvazir S, Pradhan J, Khattar RS, Senior R. Sex-based impact of carotid plaque in patients with chest pain undergoing stress echocardiography. Heart 2020; 106:1819-1823. [PMID: 32444505 DOI: 10.1136/heartjnl-2019-316507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Revised: 03/14/2020] [Accepted: 03/22/2020] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Women with suspected angina without history of coronary artery disease (CAD) less frequently have flow-limiting stenosis (FL-CAD) and more often have microvascular disease, affecting predictive accuracy of stress echocardiography (SE) for detection of FL-CAD. We postulated that carotid plaque burden (CPB) assessment would improve detection of FL-CAD and risk stratification. METHODS Consecutive consenting patients assessed by SE on clinical grounds for new-onset chest pain also underwent simultaneous carotid ultrasound. Patients were followed for major adverse events (MAE): all-cause mortality, non-fatal myocardial infarction and unplanned revascularisation. Carotid plaque presence and burden (CPB) were assessed. RESULTS After a mean of 2617±469 days (range 17-3740), of 591 recruited patients, 573 (97%) outcome data (314 females) were obtainable. Despite lower pretest probability of CAD in females versus males (14.9±0.8 vs 20.5±1.3, respectively, p<0.0001), prevalence of myocardial ischaemia was similar (p=0.08). Females also had lower prevalence of both carotid plaque (p<0.0001) and FL-CAD (p<0.05). CPB improved the positive predictive value of SE for detection of FL-CAD (from 34.5% to 60%) in females but not in males. Absence of CPB in females with myocardial ischaemia ruled out FL-CAD in 93% versus 57% in males. CPB was the only independent predictor of MAE (p=0.012) in females, whereas in males both SE (p<0.0001) and CPB (p=0.003) remained significant. CONCLUSION In females with new-onset stable angina without a history of cardiovascular disease, CPB improved the predictive accuracy of myocardial ischaemia for flow-limiting CAD. However, CPB provided incremental risk stratification in both sexes.
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Affiliation(s)
- Shahram Ahmadvazir
- Department of Cardiovascular Research, Northwick Park Hospital, Harrow, UK
- Department of Cardiology, Royal Brompton Hospital, London, UK
| | - Jiwan Pradhan
- Department of Cardiovascular Research, Northwick Park Hospital, Harrow, UK
| | | | - Roxy Senior
- Department of Cardiovascular Research, Northwick Park Hospital, Harrow, UK
- Department of Cardiology, Royal Brompton Hospital, London, UK
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Long-Term Prognostic Value of Simultaneous Assessment of Atherosclerosis and Ischemia in Patients with Suspected Angina: Implications for Routine Use of Carotid Ultrasound during Stress Echocardiography. J Am Soc Echocardiogr 2020; 33:559-569. [DOI: 10.1016/j.echo.2019.11.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 11/17/2019] [Accepted: 11/23/2019] [Indexed: 11/30/2022]
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Franco-Gutiérrez R, Pérez-Pérez AJ, Franco-Gutiérrez V, Testa-Fernández AM, López-López A, Pérez-Férnandez R, López-Reboiro ML, Regueiro-Abel M, Crespo-Leiro MG, González-Juanatey C. Usefulness of carotid ultrasonography in the assessment of coronary artery disease extension in patients undergoing exercise echocardiography. Echocardiography 2018; 36:336-344. [PMID: 30592779 DOI: 10.1111/echo.14251] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/30/2018] [Accepted: 12/04/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES To evaluate whether carotid disease is associated with coronary artery disease (CAD) extension in patients undergoing treadmill exercise stress echocardiography (EE). METHODS We retrospectively studied 156 patients without previous vascular disease who underwent EE, carotid ultrasonography, and coronary angiography between 2002 and 2013. Low-, intermediate-, and high-risk EE were defined as negative, localized ischemia, and multivessel/extensive ischemia EE respectively; carotid disease according to Mannheim and American Society of Echocardiography Consensus and CAD extension from zero to three vessel disease as stenosis ≥50% by visual assessment. RESULTS Of the 156 patients, 67 (42.9%), 43 (27.6%), 22 (14.1%), and 24 (15.4%) had zero, one, two, and three vessel disease respectively. Age (P = 0.047), male sex (P = 0.010), diabetes mellitus (P = 0.039), smoking habit (P = 0.015), fasting plasma glucose (P = 0.021), European Systematic COronary Risk Evaluation (P = 0.003), pretest CAD probability (P = 0.003), high-risk EE (P < 0.001), and carotid plaque presence (CP) (P < 0.001) were associated in univariate analysis with more extensive CAD. Predictors of CAD extension in multivariate analysis were high-risk EE (odds ratio [OR] 2.42, P < 0.001), CP presence (OR 1.75, P = 0.004), and pretest CAD probability >65% (OR 1.49, P = 0.023). CP was also associated with multivessel CAD in the 53 patients with low- or intermediate-risk EE (P = 0.001). CONCLUSIONS CP is associated with CAD extension in patients with ischemic heart disease suspicion undergoing EE. Patients with CP could benefit from a more aggressive therapeutic strategy regarding patients without carotid disease and similar risk EE, especially in intermediate- and/or low-risk test where guidelines recommend initially optimal medical treatment.
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Affiliation(s)
| | | | | | | | - Andrea López-López
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Lugo, Spain
| | - Ruth Pérez-Férnandez
- Department of Cardiology, Complejo Hospitalario Universitario A Coruña (CHUAC), A Coruna, Spain
| | | | | | - María Generosa Crespo-Leiro
- Department of Cardiology, Complejo Hospitalario Universitario A Coruña (CHUAC), Instituto Investigacion Biomedica A Coruña (INIBIC), Universidad da Coruña (UDC), A Coruna, Spain
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Franco-Gutiérrez R, Pérez-Pérez AJ, Franco-Gutiérrez V, Testa-Fernández AM, Vidal-Pérez RC, López-Reboiro ML, Puebla-Rojo VM, Santás-Álvarez M, Crespo-Leiro MG, González-Juanatey C. Usefulness of carotid ultrasonography in the diagnosis of coronary artery disease in patients undergoing exercise echocardiography. Cardiovasc Ultrasound 2018; 16:26. [PMID: 30296943 PMCID: PMC6176507 DOI: 10.1186/s12947-018-0143-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 09/12/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Relationship between carotid and coronary artery disease (CAD) in patients undergoing invasive and non-invasive test is unclear. The aim of the study is to evaluate whether carotid disease is associated with CAD in patients submitted to exercise echocardiography (EE) and if it improves the EE ability to predict CAD. METHODS We retrospectively studied 156 subjects without previous vascular disease who underwent EE, carotid ultrasonography and coronary angiography between 2002 and 2013. Positive EE was defined as exercise induced wall motion abnormalities, carotid disease according to Manheim and American Society of Echocardiography Consensus and significant CAD as stenosis ≥50%. RESULTS Eighty-nine (57.1%) subjects had significant CAD. Factors associated with CAD in multivariate analysis were fasting plasma glucose (odds ratio [OR] 1.02, p = 0.031), pre-test probability of CAD > 65% (OR 3.71, p < 0.001), positive EE (OR 10.51, p < 0.001) and carotid plaque (CP) presence (OR 2.95, p = 0.013). There was neither statistical significant difference in area under the curve after addition of CP to EE results (0.77 versus 0.81, p = 0.525) nor sensitivity, specificity, predictive values or efficiency. CP presence reclassified as very high-risk according to Systematic COronary Risk Evaluation 13 patients (34.2%) with negative EE and 22 (33.3%) without CAD. CONCLUSION CP is associated with CAD in patients undergoing EE, however its addition to EE does not improve CAD prediction, probably due to insufficient statistical power. CP reclassified one third of patients to very high-risk category despite negative EE or CAD absence, these subjects benefit from aggressive primary prevention interventions.
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Affiliation(s)
- Raúl Franco-Gutiérrez
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - Alberto José Pérez-Pérez
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - Virginia Franco-Gutiérrez
- Department of Otolaryngology, Hospital Universitario Marqués de Valdecilla, Avenida Valdecilla n° 25, Santander, 39008 Spain
| | - Ana María Testa-Fernández
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - Rafael Carlos Vidal-Pérez
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - Manuel Lorenzo López-Reboiro
- Department of Internal Medicine, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, Lugo, 27003 Spain
| | - Víctor Manuel Puebla-Rojo
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - Melisa Santás-Álvarez
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
| | - María Generosa Crespo-Leiro
- Department of Cardiology, Complejo Hospitalario Universitario A Coruña (CHUAC), As Xubias de Arriba n° 84, A Coruña, 15006 Spain
- Intitituto de Investigación Biomédica A Coruña (INIBIC), Xubias de Arriba n° 84, A Coruña, 15006 Spain
- Universidad de La Coruña (UDC), Calle de la Maestranza n° 9, A Coruña, 15001 Spain
| | - Carlos González-Juanatey
- Department of Cardiology, Hospital Universitario Lucus Augusti (HULA), Avenida doctor Ulises Romero n° 1, 27003 Lugo, Spain
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Ahmadvazir S, Shah BN, Zacharias K, Senior R. Incremental Prognostic Value of Stress Echocardiography With Carotid Ultrasound for Suspected CAD. JACC Cardiovasc Imaging 2018; 11:173-180. [DOI: 10.1016/j.jcmg.2016.12.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 12/07/2016] [Accepted: 12/12/2016] [Indexed: 10/19/2022]
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Abstract
PURPOSE OF REVIEW Stress echocardiography (SE) is a well-established technique for the diagnosis and risk stratification of patients with known or suspected coronary artery disease (CAD). This review article summarizes the status of SE in CAD, including testing protocols, clinical efficacy and current use of newer technologies: myocardial perfusion, strain imaging, three-dimensional echocardiography and adjunctive carotid ultrasonography. RECENT FINDINGS Recent major findings in SE include the clinical value of myocardial perfusion imaging in multicentre studies, as well as when added to left ventricular (LV) wall motion assessment in clinical service. Additionally, SE has been shown to be more cost-effective than exercise ECG in patients with low-intermediate pre-test probability of CAD. Adjunctive atherosclerosis imaging by carotid ultrasonography (CU) to ischaemia testing by SE provides synergistic prognostic value, equivalent to hybrid imaging by PET-CT. Despite the development of newer and more expensive imaging modalities, SE remains the cornerstone for the assessment of CAD and has excellent clinical efficacy, is safe and is cost-effective.
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Affiliation(s)
- Sothinathan Gurunathan
- Department of Cardiology, Northwick Park Hospital, Harrow, UK
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK
- Biomedical Research Unit National Heart and Lung Institute, Imperial College, London, UK
| | - Roxy Senior
- Department of Cardiology, Northwick Park Hospital, Harrow, UK.
- Department of Cardiology, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK.
- Biomedical Research Unit National Heart and Lung Institute, Imperial College, London, UK.
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Rubio Patón R, Pacheco Tenza MI, Bernal Morell E, Bonaque González JC, Soto Ruiz RM, Castillo Moreno JA. Relación entre el grosor intimomedial carotídeo y el resultado del ecocardiograma de ejercicio en pacientes con sospecha de enfermedad coronaria. Rev Esp Cardiol (Engl Ed) 2017. [DOI: 10.1016/j.recesp.2016.09.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Rubio Patón R, Pacheco Tenza MI, Bernal Morell E, Bonaque González JC, Soto Ruiz RM, Castillo Moreno JA. Relationship Between Carotid Intima-media Thickness and the Results of Exercise Echocardiography in Patients With Suspected Coronary Disease. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2017; 70:781-783. [PMID: 28110909 DOI: 10.1016/j.rec.2016.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 10/05/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Ramón Rubio Patón
- Unidad de Imagen Cardiaca, Servicio de Cardiología, Hospital General Universitario Santa Lucía, Cartagena, Murcia, Spain.
| | | | - Enrique Bernal Morell
- Servicio de Medicina Interna, Hospital General Universitario Reina Sofía, Murcia, Spain
| | - Juan Carlos Bonaque González
- Unidad de Imagen Cardiaca, Servicio de Cardiología, Hospital General Universitario Santa Lucía, Cartagena, Murcia, Spain
| | - Rosa María Soto Ruiz
- Unidad de Imagen Cardiaca, Servicio de Cardiología, Hospital General Universitario Santa Lucía, Cartagena, Murcia, Spain
| | - Juan Antonio Castillo Moreno
- Unidad de Imagen Cardiaca, Servicio de Cardiología, Hospital General Universitario Santa Lucía, Cartagena, Murcia, Spain
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