Predictive Value of Associations Between Carotid Arterial Sclerosis and Left Ventricular Diastolic Dysfunction in Patients with Cardiovascular Risk Factors

Is Stiffness Parameter β Useful for the Evaluation of Atherosclerosis?~ Its Clinical Implications, Limitations, and Future Perspectives ~

Atherosclerosis comprises two components, atherosis and sclerosis, characterized by morphological wall thickening and functional stiffening, respectively, of the arterial wall. In recent years, much interest has been directed to the role of functional changes in large arteries, i.e., increased stiffness or decreased elasticity, on the development of cardiovascular diseases. In fact, the clinical evaluation of arterial stiffness is increasingly performed in patients with cardiovascular risk factors. Local arterial stiffness is measured using an ultrasound technique implemented with an echo-tracking system at the common carotid and femoral arteries. Several indices of local arterial stiffness are obtained by ultrasound, among which stiffness parameter β is unique because it is the least affected by blood pressure at the time of measurement. Evidence from cross-sectional studies indicates that increased stiffness parameter β is associated with a number of cardiovascular risk factors, such as older age, smoking, insufficient physical activity, hypertension, obesity, metabolic syndrome, insulin resistance, type 2 diabetes, chronic kidney disease, and comorbid cardiovascular disease. Results from several prospective observational studies also suggest that carotid stiffness parameter β is a useful surrogate marker of cardiovascular events and/or mortality, although the results differ depending on the characteristics of the study subjects. Furthermore, several interventional studies have shown that carotid stiffness parameter β improved after lifestyle modification or drug treatment. In this review, we summarize the current evidence of stiffness parameter β of the carotid artery and discuss its clinical implications as a marker of vascular health or as a predictor of cardiovascular outcomes.

Subclinical left ventricular dysfunction assessed by two-dimensional speckle tracking echocardiography in asymptomatic patients with carotid stenosis

The relationship between subclinical left ventricular (LV) dysfunction and atherosclerosis may have been underestimated in the past, which might be responsible for the high incidence of premature death in individuals with carotid stenosis. We sought to evaluate the underlying myocardial dysfunction in asymptomatic carotid stenosis patients using speckle tracking echocardiography (STE). Fifty patients with carotid stenosis ≥ 50% and a preserved LV ejection fraction (LVEF), and 45 controls without carotid stenosis who were matched in terms of vascular comorbidities were enrolled. All participants underwent carotid ultrasound and echocardiographic examination. The global LV longitudinal strain (GLS) was measured using STE. Compared with the control group, the e' of the mitral annular velocity and GLS were decreased in asymptomatic carotid stenosis patients (p < 0.05), however, the LVEF was well preserved. Based on a predefined cutoff for subclinical LV systolic dysfunction that was defined at a GLS <  - 18%, this dysfunction was detected in 22 patients with carotid stenosis (44%) and in 10 patients in the control group (22%) (p < 0.05). The GLS was negatively correlated with the levels of low-density lipoprotein cholesterol (r =  - 0.356, p < 0.05) and triglyceride (r =  - 0.396, p < 0.05). In conclusion, LV diastolic and systolic functioning were significantly decreased in patients with asymptomatic carotid stenosis, and dyslipidemia likely contributed to the subclinical LV dysfunction in these patients. Our findings indicated the importance of detecting LV subclinical dysfunction and early intervention in this patient population.

Cardiovascular Remodeling after Endovascular Treatment for Thoracic Aortic Injury

BACKGROUND

Thoracic endovascular aortic repair (TEVAR) currently represents the gold standard of treatment for thoracic aortic injury (TAI). Nevertheless, there is an ongoing debate surrounding its safety and subsequent cardiovascular effects. Our aim is to assess heart and vascular structure and function remodeling after TEVAR in TAI young patients.

METHODS

We evaluated 20 patients (18 men, age 41 ± 14 years, 11 treated with Gore CTAG, 9 with Medtronic Valiant) with office and 24-hr blood pressure (BP) with specific vascular stiffness analysis (Mobil-O-Graph), aortic diameters (computed tomography scan) and left ventricular mass index (LVMI echocardiogram). Evaluation was done after a median time of 5.0 ± 3.5 years from the trauma.

RESULTS

After TAI 12 patients (55%) developed hypertension. When patients were divided according to treating time, those treated for more than 3 years show higher LVMI, PWV, and ascending aorta dilatation.

CONCLUSIONS

Our study shows that TEVAR for TAI is associated with heart and vascular remodeling. The presence of TEVAR modifies aortic functional properties and could induce an increase in BP that can promote aortic and cardiac damage, even in young patients.

Ascending Aortic Strain Analysis Using 2-Dimensional Speckle Tracking Echocardiography Improves the Diagnostics for Coronary Artery Stenosis in Patients With Suspected Stable Angina Pectoris

Background

Arterial stiffening and atherosclerosis tend to coexist. Strain imaging, using a 2‐dimensional speckle tracking (2D‐ST) method, has been used for arterial stiffness assessment and early identification of atherosclerosis. We investigated whether the ascending aortic strain assessed by 2D‐ST echocardiography at rest can predict the presence of coronary artery disease (CAD).

Methods and Results

Two hundred seventy‐one consecutive patients with suspected stable angina pectoris sequentially underwent exercise treadmill testing, 2‐dimensional echocardiography, M‐mode echocardiography, 2D‐ST echocardiography, and coronary angiography. Circumferential ascending aortic strain (CAAS) and radial ascending aortic strain were assessed by 2D‐ST echocardiography. Ninety‐two patients with coronary lumen area stenosis ≥70% were categorized as having significant CAD. Global CAAS was significantly lower in patients with significant CAD (7.41±2.30% versus 11.54±4.03%; P<0.001) and remained an independent predictor of significant CAD (odds ratio, 0.64 [0.54–0.75]; P<0.001) after multivariate regression. Based on the receiver operating characteristic curve for diagnosing significant CAD, the optimal cut‐off value of global CAAS was ≤9.22% (sensitivity, 86%; specificity, 70%; area under curve=0.82; P<0.001). Global CAAS decreased with increasing severity of CAD and was significantly associated with 3‐vessel disease (odds ratio, 0.58 [0.42–0.79]; P<0.001). Diagnostics for significant CAD were remarkably better for global CAAS combined with exercise treadmill testing than for exercise treadmill testing alone (area under curve=0.88 versus 0.78; P<0.001).

Conclusions

Global CAAS assessed by 2D‐ST echocardiography at rest was able to predict the presence of significant CAD and identify multivessel disease. In addition, global CAAS combined with exercise treadmill testing remarkably improved the diagnostics for significant CAD.

Association of arteriosclerosis and/or atherosclerosis with hypertensive target organ damage in the community-dwelling elderly Chinese: the Northern Shanghai Study

Objective

Vascular abnormality includes two forms, arteriosclerosis (ARS) and atherosclerosis (ATS), which coexist in patients with cardiovascular (CV) diseases. However, whether their combination may lead to a worsening status in those patients remains unclear. We therefore aimed to investigate the association of ARS and/or ATS with hypertensive target organ damage (TOD).

Methods

From June 2014 to August 2015, a total of 1,599 community-dwelling elderly subjects (aged >65 years) from northern Shanghai were recruited. Vascular measurements, such as carotid–femoral pulse wave velocity (cf-PWV), ankle–brachial index (ABI) and carotid plaque, were conducted on each participant, and ARS was defined as cf-PWV >12 m/s, while ATS was defined as participants who have carotid plaque or ABI <0.9. Within the framework of comprehensive CV examinations, CV risk factors were assessed, and asymptomatic TOD was evaluated by measuring participants’ left ventricular mass index (LVMI), peak transmitral pulsed Doppler velocity/early diastolic tissue Doppler velocity (E/Ea), urinary albumin–creatinine rate (UACR) and estimated glomerular filtration rate (eGFR).

Results

Although LVMI, E/Ea and eGFR were significantly different among subjects with or without ARS and/or ATS (P<0.02), in full adjustment model, only E/Ea showed the independent and significant difference (P=0.023). Moreover, E/Ea was significantly different between participants with ARS or ATS and those without ARS or ATS (P=0.045), while there was no significant difference between participants with ARS and ATS and those without ARS or ATS (P=0.28). Similar results were obtained in the multivariate logistic regression of left ventricular diastolic dysfunction (LVDD). With similar adjustment, LVDD was significantly associated with ATS (P=0.01) but not with ARS (P=0.99).

Conclusion

In the community-dwelling elderly Chinese, among hypertensive TOD, LVDD was significantly associated with ATS but not with ARS. The proportion of patients with LVDD was not significantly different despite the presence of both ATS and ARS, when compared to patients with ATS alone.

Carotid artery intima-media thickness is closely related to impaired left ventricular function in patients with coronary artery disease: a single-centre, blinded, non-randomized study

Background

Atherosclerosis is the underlying cause of the majority of myocardial infarctions and ischemic strokes. Carotid intima-media thickness (IMT) is a surrogate measure of atherosclerotic cardiovascular disease. Left ventricular (LV) function can be accurately assessed by 2D speckle-tracking strain echocardiography (2D-STE). The aim of this study was to assess the relationship between carotid IMT and LV dysfunction assessed by strain echocardiography in patients with coronary artery disease (CAD).

Methods

Thirty-one patients with symptoms of CAD were examined with coronary angiography, cardiac echocardiography and carotid ultrasound. Layer-specific longitudinal strains were assessed from endo-, mid- and epicardium by 2D-STE. LV global longitudinal strain (LVGLS) was averaged from 16 longitudinal LV segments in all 3 layers. LVGLS results were compared with coronary angiography findings in a receiver operating curve (ROC) to determine the cut-off for normal and pathological strain values. The calculated optimal strain value was compared to maximal carotid IMT measurements.

Results

The ROC analysis for strain versus coronary angiography was: area under curve (AUC) = 0.91 (95% CI 0.80 – 1.0), cut-off value for endocardial LVGLS: -16.7%. Further analyses showed that increased carotid IMT correlated with low absolute strain values (p = 0.006) also when adjusted for hypertension, smoking, hyperlipidemia, diabetes and BMI (p = 0.02).

Conclusions

In this study increased carotid IMT values were associated with decreased LV function assessed by strain measurements. These findings support the use of carotid IMT measurements to predict the risk of coronary heart disease.

Influence of a family history of type 2 diabetes, demographic and clinical data on carotid intima-media thickness in patients with type 1 diabetes: a cross-sectional study

Background

Intima-media thickness (IMT) of the common carotid artery is a surrogate end point of cardiovascular disease (CVD). Identifying the factors associated with a higher IMT may contribute to the identification of subjects with higher CVD risk. Our objective was to compare the common carotid IMT of type 1 diabetes patients to healthy control subjects. The secondary objective was to determine factors associated with a higher carotid IMT.

Methods

We conducted a cross-sectional study between March 2009 and October 2013, comprising 127 type 1 diabetes patients and 125 control subjects matched by age, gender and body mass index (BMI). Carotid IMT was measured using semi-automated edge detection software.

Results

Type 1 diabetes patients had a higher median IMT compared with control subjects (0.538; IQR: 0.500-0.607 vs 0.513 mm; IQR: 0.481-0.557, respectively p = 0.001). Women with type 1 diabetes had a higher median IMT difference compared to the control group (0.537; IQR: 0.495-0.596 vs 0.502 mm; IQR: 0.472-0.543, respectively p = 0.003) than did men with type 1 diabetes (0.547; IQR: 0.504-0.613 vs 0.528 mm; IQR: 0.492-0.575, respectively p = 0.2). Age and diabetes duration had an additive effect on the IMT of type 1 diabetes patients. Multivariate gamma regression model analysis showed that in type 1 diabetes patients, the IMT was associated with age (Exp (β) = 1.006, p < 0.001), duration of diabetes (Exp (β) = 1.004, p = 0.001), BMI (Exp (β) = 1.005, p = 0.021), family history of type 2 diabetes (Exp (β) = 1.044, p = 0.033), total cholesterol (Exp (β) = 0.999, p = 0.001) and creatinine clearance (Exp (β) = 1.000, p = 0.043).

Conclusions

Patients with type 1 diabetes have increased IMT, a marker of subclinical atherosclerosis. The CVD risk may be similar between men and women with type 1 diabetes, suggesting a loss of gender protection. Also, CVD risk may be higher in those with a family history of type 2 diabetes. Prospective studies are needed to confirm the predictive value of these findings and the causal effect between IMT and CVD in patients with type 1 diabetes.

Carotid atherosclerosis and right ventricular diastolic dysfunction in a sample of hypertensive Nigerian patients

AIM

To determine the association of carotid atherosclerosis and right ventricular diastolic dysfunction (DD) among treated hypertensive Nigerian patients.

METHODS

This was a single center cross-sectional study performed at the Cardiology Clinic of LAUTECH Teaching Hospital, Ogbomoso, Nigeria between January and December 2012. The study included 122 hypertensive Nigerians (mean age, 57.3±14.7 years, 36.9% women). Patients' clinical, demographic, and echocardiographic parameters were obtained. Diastolic dysfunction was assessed with the trans-tricuspid Doppler flow.

RESULTS

Patients with DD were significantly older than those with normal diastolic function. Mean and maximum carotid intima media thickness measurements were significantly higher among patients with right ventricular DD than in those with normal diastolic function. Mean systolic blood pressure (148.3±31.9 vs 128.0±2.8 mm Hg, P=0.049) and interventricular septal thickness in diastole (12.8±2.3 vs 11.6±2.8 mm, P=0.048) were significantly higher and tricuspid annular pulmonary systolic excursion (33.6±4.9 vs 23.0±4.2 mm, P=0.035) was significantly lower in patients with right ventricular DD than in those with normal diastolic function. Carotid intima media thickness measurements were correlated with early trans-tricuspid Doppler flow and early transtricuspid diastolic flow/late right atrial transtricupsid diastolic flow ratio.

CONCLUSION

Right ventricular DD in hypertensive patients was significantly correlated with increased carotid atherosclerosis. Carotid intima media thickness measurements may therefore be a surrogate marker for DD in hypertensive subjects.

Arterial stiffness, carotid atherosclerosis and left ventricular diastolic dysfunction in postmenopausal women

BACKGROUND

Postmenopausal women have an increased cardiovascular morbidity that may be due to the increase in classical cardiovascular risk factors and also to the arterial structure and function alterations. The aim of our study was to evaluate the association of aortic pulse wave velocity (PWV), and carotid intima-media thickness (IMT), with left ventricular diastolic dysfunction (LVDD) in postmenopausal women.

PATIENTS AND METHODS

In 96 women without overt cardiovascular disease (age 62±7.7 years), and with normal left ventricular systolic function, aortic PWV was assessed by using an oscillometric device, intima-media thickness was measured by B-mode ultrasonography and the parameters of left ventricular diastolic function were evaluated by a transthoracic echocardiographic study.

RESULTS

LVDD, defined as an E/A ratio≤1 was found in 50 patients (52%). All of them had mild LVDD. In these patients we found significant increase in age (p<0.001), aortic PWV (p<0.001), carotid IMT (p=0.002) and plaque score (p=0.004) when compared with patients without LVDD. In a logistic regression analyzed, after adjusting for age, only aortic PWV was a significant predictor of LVDD (2.15, 95% CI 1.39-3.31, p=0.0006).

CONCLUSIONS

This study among postmenopausal women provides evidence that increased arterial stiffness as measured by aortic PWV and not carotid IMT may be a marker or a risk factor for LVDD, independent of other classical risk factors.

An integrative view on the carotid artery alterations in metabolic syndrome

BACKGROUNDS

Metabolic syndrome (MetS) is a multiple risk factor paradigm widely considered in risk management. We aimed to investigate carotid artery alterations in MetS and the underlying risk factors.

MATERIALS AND METHODS

A total of 400 Chinese subjects were recruited, divided into control (n = 200) and MetS (n = 200) groups. Clinical and laboratory characteristics were collected. All subjects underwent carotid ultrasonography.

RESULTS

Cardiovascular risk profiles were worse in the MetS than control group (all P < 0.05). After adjusting for MetS and age, the MetS group showed significantly increased mean intima-media thickness (IMT(mean)) and significantly impaired carotid elastic properties (all P < 0.05), as compared to control group. Waist circumference (WC) was positively correlated with IMT(mean) (r = 0.130, P = 0.038), systolic carotid diameter (r = 0.139, P = 0.026) and diastolic carotid diameter (r = 0.168, P = 0.007). systolic blood pressure (SBP) and diastolic blood pressure were positively correlated with IMT(mean) (r = 0.201, P = 0.004; r = 0.168, P = 0.008, respectively), but negatively with arterial compliance coefficient (r = -0.421, P < 0.001; r = -0.230, P < 0.001, respectively). Serum level of high-density lipoprotein (HDL) negatively correlated with IMT(mean) (r = -0.195, P = 0.002). Plaque index was positively correlated with fasting blood glucose (r = 0.205, P = 0.001) after adjusting for the other risk factors. Significantly impaired carotid elastic properties (all P < 0.05) independently correlated with IMT(mean) . Furthermore, age (β = 0.255, P < 0.001), SBP (β = 0.224, P < 0.001), WC (β = 0.202, P < 0.001) and high-density lipoprotein cholesterol (HDL-C) (β = -0.163, P = 0.001) were independently associated with IMT(mean).

CONCLUSION

Carotid alterations consequent upon MetS ultimately developed subclinical and clinical atherosclerosis, the underlying risk factors for which were abdominal obesity, hypertension, ageing and low level of HDL-C.

Visit-to-visit blood pressure variations: new independent determinants for carotid artery measures in the elderly at high risk of cardiovascular disease

Recently, visit-to-visit variability in systolic blood pressure (SBP) has been shown to be a predictor of stroke. In this study, we investigated the relationship of visit-to-visit blood pressure (BP) variations (based on 12 visits once a month) with intima-media thickness (IMT) and stiffness in common carotid artery among the 201 high-risk elderly (female 75%) at cardiovascular disease. Max-IMT was significantly positively correlated with age, smoking, renin-angiotensin system inhibitor use, coefficient of variation (CV), and delta (maximum-minimum) in SBP, and CV in diastolic BP (DBP) but was significantly negatively correlated with female, high-density lipoprotein (HDL), and minimum in SBP. Stiffness parameter β was significantly positively correlated with age, standard deviation (SD), CV, maximum, and delta in SBP, and SD, CV, and delta in DBP but was significantly negatively correlated with smoking, HDL, average, and minimum in DBP. In a multiple regression analysis, delta SBP (P < .001) was associated with max-IMT independently of average SBP. CV (P < .05) and delta (P < .05) in SBP, and CV (P < .001) and delta (P < .01) in DBP were associated with stiffness parameter β independently of average BP. In the high-risk elderly, exaggerated visit-to-visit BP fluctuations were significant indicators for carotid artery atherosclerosis and stiffness independently of average BP.

Telmisartan improves morphologic and functional changes in both left ventricular myocardium and carotid arterial wall in patients with hypertension: assessment by tissue Doppler imaging and carotid ultrasonography

OBJECTIVE

The aim of the present study was to clarify the beneficial effects of telmisartan on the morphologic and functional changes in left ventricular (LV) myocardium and carotid arterial wall in patients with hypertension (HT) using tissue Doppler imaging and carotid ultrasonography.

METHODS

Telmisartan (20-40 mg daily) was administered to 35 previously untreated patients with HT. Conventional and pulsed tissue Doppler echocardiography were performed after medication had been continued for 1-2 months with normal values for blood pressure (BP) (phase I) and for 12 months (phase II). Subclinical atherosclerosis also was determined by measuring the intima-media thickness (IMT) and stiffness β of the left and right common carotid arteries using B- and M-mode ultrasonography.

RESULTS

In the phase II, the LV mass index and isovolumic relaxation time were lower, the peak systolic and early diastolic mitral annular motion velocities were greater compared to the phase I. The stiffness β and mean IMT were lower in the phase II than in the phase I. On multivariate regression analyses, age, BP, and LV diastolic variables emerged as stronger predictors of carotid arterial IMT and stiffness β.

CONCLUSIONS

The 1-year use of telmisartan improved LV hypertrophy, regional LV myocardial contraction and relaxation, and carotid atherosclerosis in patients with HT. Our results support cardio- and arterioprotective benefits from continuous long-term telmisartan monotherapy, and combined analysis of tissue Doppler imaging and carotid ultrasonography may be a useful tool for understanding ventriculoarterial coupling in patients with HT.

Expression of STAMP2 in monocytes associates with cardiovascular alterations

BACKGROUND

Metabolic and inflammatory pathways crosstalk at many levels. In this study, we aimed to investigate the expression of six-transmembrane protein of prostate 2 (STAMP2) in macrophages and tried to search for the association between the decreased STAMP2 expression, if any, and carotid atherosclerosis as well as cardiac adaptations.

MATERIALS AND METHODS

A total of 97 unrelated Chinese subjects were recruited including 48 subjects with metabolic syndrome (MetS) and 49 controls. Clinical and biochemical characteristics were collected from subjects, with quantification of STAMP2 in monocyte/macrophages. All subjects underwent ultrasonography.

RESULTS

STAMP2 expression in macrophages was significantly decreased in MetS as compared with the control group (10.25 +/- 9.20 vs. 15.20 +/- 9.18, P = 0.009), especially in women patients. Partial correlation analysis showed that STAMP2 expression in macrophages correlated with BMI (r = -0.375, P = 0.045), age (r = 0.414, P = 0.026) and HDL (r = 0.377, P = 0.044) after controlling for systolic blood pressure (SBP). Furthermore, STAMP2 expression was correlated with PI (r = -0.454, P = 0.013), LVEF (r = -0.503, P = 0.005), LA-ESR (r = -0.424, P = 0.022), LA-S (r = 0.469, P = 0.010) and mitral E/A ratio (r = 0.492, P = 0.005) after controlling for SBP. Still, in multivariable analysis, STAMP2 expression was independently associated with IMT(mean), PI and mitral E/A ratio.

CONCLUSIONS

In MetS patients, especially women patients, STAMP2 expression was down-regulated in peripheral blood mononuclear cell, which was correlated with carotid atherosclerosis and cardiac adaptation.

Arterial stiffness and left-ventricular diastolic dysfunction: Guangzhou Biobank Cohort Study-CVD

Brachial-ankle pulse wave velocity (baPWV), a marker of arterial stiffness, is an established cardiovascular risk factor of ventricular stiffening. We studied the association of baPWV with left-ventricular (LV) diastolic function in a sub-study of the Guangzhou Biobank Cohort Study. In all, 378 Chinese subjects with a normal ejection fraction (>50%) had baPWV measurement by a noninvasive automatic waveform analyser, carotid intima-medial thickness (IMT) measurement by B-mode ultrasonography and cardiac diastolic function assessment by echocardiography. After adjusting for age, both baPWV and IMT were associated with LV mass index, posterior wall end-diastolic thickness and inter-ventricular end-diastolic thickness, but only baPWV was associated with deceleration time, atrial flow velocity and E/A ratio. Multivariable linear regression model showed that baPWV and mean arterial pressure, but not IMT, were significantly associated with E/A ratio (β=-0.02, P=0.03 and β=-0.36, P=0.02, respectively). The receiver operator characteristic curve showed that baPWV was better than pulse pressure or mean arterial pressure to detect LV diastolic dysfunction (E/A<1.0). Our study suggested that increased baPWV might be an independent risk factor or marker for diastolic dysfunction. Early detection of an intervention on increased baPWV may be important for prevention of cardiac diastolic dysfunction.

The combination of IMT and stiffness parameter beta is highly associated with concurrent coronary artery disease in type 2 diabetes

AIMS

The clinical implications of stiffness of the carotid artery (CA) have not been fully clarified in the prediction of coronary artery disease (CAD), although intima-media thickness (IMT) has been established as a surrogate marker. We examined the associations of stiffness parameter beta (ST) and IMT with concurrent CAD.

METHODS

IMT and ST were measured by ultrasound in 439 nondiabetic subjects as a control and 1528 type 2 diabetic subjects (T2DM) with or without CAD in a cross-sectional study.

RESULTS

Both IMT and ST significantly increased with age and group category, in the order of control, T2DM without CAD, and T2DM with CAD (p<0.001). The area under the curve on ROC analysis of ST for concurrent CAD was comparable to that for IMT. On multivariate logistic regression analysis, High IMT (>or=1.30 mm) and High stiffness (>or=20.0) had significant odds ratios for concurrent CAD (2.205, p<0.001 and 1.548, p<0.05, respectively). The group with High IMT and High Stiffness exhibited a stronger multivariate odds ratio (3.115, p=0.0001).

CONCLUSIONS

ST and IMT are associated with CAD and exhibited significant odds ratios for CAD. Our findings suggest that the combination of IMT and ST is a useful marker of atherosclerosis.

Use of carotid intima-media thickness to identify patients with ischemic stroke and transient ischemic attack with low yield of cardiovascular sources of embolus on transesophageal echocardiography

BACKGROUND AND PURPOSE

Carotid intima-media thickness (CIMT) is associated with systemic atherosclerosis and cardioembolic conditions and predicts the risk of recurrent strokes. We sought to establish the relationship between CIMT and cardiovascular sources of embolus (CSE) on transesophageal echocardiography (TEE) and hypothesized that a noninvasive strategy of CIMT assessment and transthoracic echocardiography bubble study would identify patients with ischemic stroke or transient ischemic attack in whom TEE would provide little incremental diagnostic yield.

METHODS

In 180 patients with ischemic stroke or transient ischemic attack of undetermined origin referred for TEE, we prospectively performed CIMT measurement/plaque screen (Phase 1, n=96) or CIMT measurement/plaque screen and transthoracic echocardiography bubble study (Phase 2, n=84) before TEE. Phase 1 results were used to construct receiver operating characteristic curves to demonstrate the ability of CIMT to detect CSE on TEE and to identify the optimal CIMT cutoff value for prospective strategy testing (Phase 2).

RESULTS

In Phase 1, CIMT was found to correlate with TEE markers of aortic atherosclerosis, including complex aortic plaques, and combined CSE. The optimal CIMT cutoff for detection of CSE on TEE was 0.78 mm. In Phase 2, a positive noninvasive strategy test (CIMT >or=0.78 mm, +carotid plaque, and/or a positive transthoracic echocardiography bubble study) was present in 61%. The prevalence of CSE on TEE was significantly higher among those with a positive compared with a negative noninvasive strategy test (65% versus 9%, P<0.001), and this strategy had a sensitivity of 92% and a negative predictive value of 91% for the detection of any CSE on TEE.

CONCLUSIONS

In patients with stroke or transient ischemic attack of undetermined origin, a noninvasive strategy of CIMT assessment/plaque screen and transthoracic echocardiography bubble study can identify patients in whom further invasive evaluation with TEE will be of low diagnostic yield.

Impact of statin therapy on left ventricular function and carotid arterial stiffness in patients with hypercholesterolemia

BACKGROUND

Hypercholesterolemia is a well-established risk factor for the development of vascular events. Statins have pleiotropic effects beyond reducing the low-density lipoprotein-cholesterol (LDL-C) concentration. This study sought to determine whether treatment with pitavastatin affects latent regional left ventricular (LV) systolic and diastolic dysfunction and carotid arterial stiffness in patients with hypercholesterolemia and preserved LV ejection fraction (LVEF), using newly developed ultrasonic strain imaging and carotid ultrasonography.

METHODS AND RESULTS

A total of 30 patients with hypercholesterolemia (>or=220 mg/dl for serum total cholesterol, and/or >or=140 mg/dl for LDL-C) were randomized to either administration of pitavastatin (1 or 2 mg/day; n=15) or no statin therapy (n=15) for 12 months. LV systolic and diastolic functions were evaluated by measuring transmitral flow velocity, mitral annular motion velocity, and the myocardial strain and strain rate profiles using pulsed Doppler, tissue velocity, and ultrasonic strain imaging. Subclinical atherosclerosis also was determined by measuring the intima - media thickness (IMT) and stiffness beta of the left and right common carotid arteries using B- and M-mode ultrasonography. During the follow-up period, the mean peak systolic strains of the LV posterior and inferior walls increased from 39.2+/-15.9% to 51.5+/-17.7% (p<0.01) and 46.0+/-12.2% to 57.5+/-10.3% (p<0.01), respectively, in the pitavastatin group compared with the no statin group. The mean peak early diastolic strain rates of the LV posterior and inferior walls also increased from -6.5+/-2.9 s(-1) to -9.5+/-2.8 s(-1) (p<0.01) and -6.5+/-2.5 s(-1) to -9.1+/-2.7 s(-1) (p<0.01), respectively, in the pitavastatin group. The stiffness beta decreased from 5.6+/-2.5 to 4.1+/-0.8 (p<0.05) in the pitavastatin group, whereas there was no significant change in IMT.

CONCLUSIONS

One year of pitavastatin treatment improved not only carotid arterial stiffness but also regional LV systolic and diastolic function in patients with hypercholesterolemia and preserved LVEF. Ultrasonic strain imaging has the potential to become a sensitive tool for detecting the effects of early medical intervention on latent regional LV myocardial dysfunction in this patient population.