Intensive Lipid-lowering Therapy Ameliorates Novel Calcification Markers and GSM Score in Patients with Carotid Stenosis

Molecular Pathways of Vulnerable Carotid Plaques at Risk of Ischemic Stroke: A Narrative Review

The concept of vulnerable carotid plaques is pivotal in understanding the pathophysiology of ischemic stroke secondary to large-artery atherosclerosis. In macroscopic evaluation, vulnerable plaques are characterized by one or more of the following features: microcalcification; neovascularization; lipid-rich necrotic cores (LRNCs); intraplaque hemorrhage (IPH); thin fibrous caps; plaque surface ulceration; huge dimensions, suggesting stenosis; and plaque rupture. Recognizing these macroscopic characteristics is crucial for estimating the risk of cerebrovascular events, also in the case of non-significant (less than 50%) stenosis. Inflammatory biomarkers, such as cytokines and adhesion molecules, lipid-related markers like oxidized low-density lipoprotein (LDL), and proteolytic enzymes capable of degrading extracellular matrix components are among the key molecules that are scrutinized for their associative roles in plaque instability. Through their quantification and evaluation, these biomarkers reveal intricate molecular cross-talk governing plaque inflammation, rupture potential, and thrombogenicity. The current evidence demonstrates that plaque vulnerability phenotypes are multiple and heterogeneous and are associated with many highly complex molecular pathways that determine the activation of an immune-mediated cascade that culminates in thromboinflammation. This narrative review provides a comprehensive analysis of the current knowledge on molecular biomarkers expressed by symptomatic carotid plaques. It explores the association of these biomarkers with the structural and compositional attributes that characterize vulnerable plaques.

The Role of Osteopontin in Atherosclerosis and Its Clinical Manifestations (Atherosclerotic Cardiovascular Diseases)-A Narrative Review

Atherosclerotic cardiovascular diseases (ASCVDs) are the most common and severe public health problem nowadays. Osteopontin (OPN) is a multifunctional glycoprotein highly expressed at atherosclerotic plaque, which has emerged as a potential biomarker of ASCVDs. OPN may act as an inflammatory mediator and/or a vascular calcification (VC) mediator, contributing to atherosclerosis progression and eventual plaque destabilization. In this article, we discuss the complex role of OPN in ASCVD pathophysiology, since many in vitro and in vivo experimental data indicate that OPN contributes to macrophage activation and differentiation, monocyte infiltration, vascular smooth muscle cell (VSMC) migration and proliferation and lipid core formation within atherosclerotic plaques. Most but not all studies reported that OPN may inhibit atherosclerotic plaque calcification, making it "vulnerable". Regarding clinical evidence, serum OPN levels may become a biomarker of coronary artery disease (CAD) presence and severity. Significantly higher OPN levels have been found in patients with acute coronary syndromes than those with stable CAD. In limited studies of patients with peripheral artery disease, circulating OPN concentrations may be predictive of future major adverse cardiovascular events. Overall, the current literature search suggests the contribution of OPN to atherosclerosis development and progression, but more robust evidence is required.

Novel Biomarkers and Imaging Indices for the "Vulnerable Patient" with Carotid Stenosis: A Single-Center Study

BACKGROUND

We investigated the relationship of matrix metalloproteinases (MMPs), cardio-ankle vascular index (CAVI), and Gray-Scale Median (GSM) score with the severity and vulnerability of carotid atherosclerosis and major adverse cardiovascular events (MACE) during follow-up of carotid artery revascularization.

METHODS

We enrolled 262 patients undergoing carotid revascularization therapy (GRT), 109 asymptomatic patients with low-grade carotid stenosis (40-70%) receiving conservative treatment (GCT), and 92 age- and sex-matched control subjects without carotid atherosclerosis (GCO). All participants underwent carotid ultrasound and we assessed at baseline clinical parameters, metabolic profile, CAVI, GSM, and circulating levels of hsCRP, MMP-3,-7,-9, and TIMP-1.

RESULTS

Both GRT and GCT presented with elevated CAVI, MMPs, and TIMP-1 levels compared to GCO (p < 0.001). The escalation highly correlated to the presence of symptoms or paralleled the degree of carotid stenosis (p < 0.001). During follow-up (mean duration: 55 months), 51 GRT patients experienced MACE unrelated to the revascularization procedure. Within GRT, diabetes (HR: 2.07; CI: 1.55-2.78, p < 0.001), smoking (HR: 1.67; CI: 1.35-1.95, p < 0.001), high CAVI (HR: 1.22; CI: 1.09-1.43, p = 0.023) and MMP-9 (HR: 1.44; CI: 1.29-2.15, p = 0.005), and low GSM (HR: 1.40; CI: 1.16-2.12, p = 0.002) independently predicted MACE occurrences, despite the optimum medical therapy.

CONCLUSIONS

Novel imaging and biochemical biomarkers were positively associated with atherosclerosis severity, while CAVI, MMP-9, and low GSM showed a positive, independent relationship with MACE after carotid revascularization, describing "vulnerable patients".

[Evaluation of carotid atherosclerotic plaques by vascular plaque quantification (VPQ) technology of three-dimensional ultrasonography]

OBJECTIVE

To analyze the feasibility of using vascular plaque quantification (VPQ) to evaluate carotid atherosclerotic plaques and to observe the effect of statins on carotid atherosclerotic plaques.

METHODS

Patients with carotid plaques from January 2016 to September 2018 in Peking University First Hospital Neurology Department were recruited and underwent three-dimonsional ultrasound (3DUS). Their gray scale median (GSM) and other parameters of carotid plaques were measured with VPQ. The patients were divided into low GSM group (GSM < 40) and high GSM group (GSM≥40). The clinical characteristics and plaque characteristics of the patients in the two groups were compared to analyze the stability of plaques. According to whether taking statins or not, the patients were further divided into statin group and non-statin group, plaque GSM and other parameters of their carotid plaques were measured and the changes of carotid plaques at the end of 3 months and 2 years were observed.

RESULTS

A total of 120 patients were enrolled, including 79 males and 41 females, with an average age of (65.39±9.11) years. The patients were divided into low GSM group (31 cases) (GSM < 40) and high GSM group (89 cases) (GSM≥40). The stenosis of the lumen in the low GSM group was more severe (the area stenosis rate was 41.32%±21.37% vs. 29.79%±17.16%, P < 0.05). The nor-malized wall index (NWI) of plaque in low GSM group was significantly higher than that in high GSM group (0.61 ±0.14 vs. 0.52±0.12, P < 0.01). A total of 77 patients, including 51 males and 26 females, aged (64.96±9.58) years, were enrolled to observe the statin effects on carotid plaque. They were divided into statin group (n=56) and non-statin group (n=21) according to whether taking statins or not. At the baseline and 3-month follow-up, there were no significant differences in carotid plaque volume, area, degree of luminal stenosis and GSM between the two groups (P>0.05). At the end of the 2-year follow-up, GSM increased in the statin group [median 10.00 (2.00, 28.00)] but decreased in the non-statin group [median －7.00 (－11.00, 5.50)], with a statistically significant difference between the two groups (P < 0.01). There was no significant increase in carotid plaque volume in the statin group, while there was a slight increase in the non-statin group, but there was no significant difference between the two groups [median increase in plaque volume was 0.00 (－30.00, 40.00) mm³ in the statin group and 30.00 (10.00, 70.00) mm³ in the non-statin group, P>0.05].

CONCLUSION

The VPQ technology of 3DUS can be used to evaluate carotid atherosclerotic plaques. Patients with low GSM (GSM < 40) have more severe vascular stenosis and higher normalized wall index. VPQ technology can also be used to observe the effect of statins on carotid plaque, the GSM of plaques increase in patients who are taking moderate-intensity statin treatment for two years.

Association of serum levels of osteopontin and osteoprotegerin with adverse outcomes after endovascular revascularisation in peripheral artery disease

Background

Osteoprotegerin (OPG) and osteopontin (OPN) are vascular calcification inhibitors with a known role in the atherosclerotic and inflammatory process. We investigated their relationship with adverse outcomes (restenosis/adverse cardiovascular events) after endovascular revascularisation of patients with peripheral arterial disease (PAD).

Methods

203 consecutive patients were enrolled in the PAD group (PADG) and 78 age and sex-matched subjects with less than two cardiovascular risk factors served as control group (COG). PADG underwent standard medical assessment at baseline and 12 months after the procedure. During follow up major adverse cardiovascular events (MACEs) including arterial restenosis with need for reintervention were documented and the PADG was divided accordingly into two subgroups.

Results

During 12-month follow-up, 82 MACE were recorded (MACE subgroup). The rest of 124 PAD patients remained free of MACE (non-MACE subgroup). At baseline, OPG (9.89 ± 2.85 ng/ml vs 3.47 ± 1.95 ng/ml, p < 0.001) and OPN (79.99 ± 38.29 ng/ml vs 35.21 ± 14.84 ng/ml, p < 0.001) levels were significantly higher in PADG compared to COG, as well as in MACE subgroup compared to non-MACE subgroup (13.29 ± 3.23 ng/ml vs 10.86 ± 3 ng/ml and 96.45 ± 40.12 ng/ml vs 78.1 ± 38.29 ng/ml, respectively). An independent association of PAD with OPG and OPN was found in the whole patient cohort. Although OPG and OPN were significantly related to MACE incidence in the univariate analysis, multiple logistic regression analysis failed to detect any independent predictor of MACE within the PADG.

Conclusion

Baseline high OPG and OPN levels were independently associated with PAD presence. Even higher levels of those biomarkers were detected among PAD patients with MACE, however, their prognostic role should be further clarified.

Echolucent carotid plaques becomes more echogenic over time - a 3D ultrasound study

OBJECTIVES

We aimed to detect changes in carotid artery atherosclerotic plaque volume and echogenicity over time in patients with an acute thromboembolic event and in patients with chronic atherosclerotic disease, both treated with statin, using a novel 3D ultrasound system.

METHODS

We included two cohorts of patients; 70 patients, naïve to statin treatment, admitted with acute, first-time myocardial infarction (aMI) and 69 patients who had been on statin treatment for a minimum of 6-months with chronic peripheral arterial disease (cPAD). 3D ultrasound examination was performed at baseline and after 3- and 12-months. Plaque volume was quantified in 3D ultrasound plaque acquisitions and echogenicity was assessed using gray-scale median (GSM) and normalized with adventitia as reference.

RESULTS

The aMI group had darker plaques than the cPAD group at baseline (mean GSM: 60.98, standard deviation (SD): 24.09 vs 71.75, SD: 21.55; P=0.006), 3-months (63.64, SD: 20.47 vs 73.44, SD: 20.46; P=0.006) and at 12-months follow-up (59.25, SD: 18.07 vs 71.02, SD: 22.31; P=0.004). The differences were not significant after adjusting for traditional risk factors. Dividing both groups by the median GSM, the darkest half of the aMI group's had an increase in GSM mainly within the first 3-months (10.49, CI95%: 2.45 - 18.53; P=0.012) and hereafter remained unchanged at 12-months follow-up (-0.53, CI95%: -7.28 - 6.22, P=0.875). In the darkest cPAD group GSM also increased within 3-months (8.14, CI95%: 1.85 - 14.32, P=0.012) and hereafter stabilised till 12-months (-2.54, CI95%: -9.62 - 4.53, P=0.475). Plaque volume did not change in the aMI group from baseline (median: 55.41mm³, interquartile range (IQR): 24.24 - 84.31) to 12-months (58.67mm³, IQR: 31.81 - 93.51) (P=0.220) whereas there was a small decrease in the cPAD group from baseline (71.63mm³, IQR: 40.12 - 135.61) to 12-months (67.73mm³, IQR: 31.00 - 122.38) (P=0.026).

CONCLUSION

Assessed with the novel 3D matrix ultrasound system echolucent carotid plaque had increasing GSM within a 3-months period, indicating stabilization of the more vulnerable plaques in aMI and cPAD patients. Plaque volume decreased over 12-months follow-up in long-term statin treated patient with cPAD, but not during the first 12 months statin therapy in patients with aMI.

The Association of Arterial Stiffness With Significant Carotid Atherosclerosis and Carotid Plaque Vulnerability

Arterial stiffness and its valid index, the cardio-ankle vascular index (CAVI), have emerged as predictors of adverse cardiovascular outcomes. We investigated the relationship of the CAVI with significant carotid stenosis (> 50%) and the related cerebrovascular symptoms or carotid plaque echogenicity, assessed by ultrasound gray-scale median (GSM) score, at baseline and after carotid artery stenting (CAS). We prospectively enrolled 113 patients with carotid stenosis (70-99% for asymptomatic and > 50% for symptomatic participants) eligible for CAS. Age- and sex-matched individuals (n = 38) served as controls (CON). Clinical data, CAVI, and biochemical profile were obtained at baseline. Clinical assessment and CAVI measurement were performed 6 months after CAS. Compared with the CON group, the CAS group had a higher incidence of co-morbidities (diabetes, hypertension, and hyperlipidemia), higher CAVI values (9.94 ± 2.14 vs 7.85 ± .97 m/sec, P < .001), but a better lipid profile due to increased prescription of statins. The symptomatic CAS subgroup showed higher CAVI ( P < .001), high-sensitivity C-reactive protein ( P = .048), and osteoprotegerin ( P = .002) levels than the asymptomatic one. In multivariate analysis, CAVI at baseline was independently associated with the presence of significant carotid atherosclerosis (β = .695, P < .001), cerebrovascular events (β = .474, P < .001), and GSM score (β = −.275, P = .042). Raised CAVI values were independently associated with significant carotid stenosis and plaque vulnerability.

The interplay between statins and adipokines. Is this another explanation of statins' 'pleiotropic' effects?

Statin therapy comprises an integral part of secondary and to a lesser extent of primary cardiovascular disease prevention. This is attributed not only to their lipid-lowering properties, but as well to a plethora of pleiotropic actions. Recently, the cytokines secreted by adipose tissue, the so-called adipokines, have been proved to play a critical role in various pathophysiological functions, among which inflammation and atherosclerosis development and vulnerability. The aim of this literature review was to summarize the effects of statins and the underlying mechanisms on the circulating levels of the most common adipokines regulating atherosclerosis process, as a part of their pleiotropic function. Up to now, robust evidence implicates a significant statin-induced reduction of pro-inflammatory adipokines IL-6, TNF-a and visfatin. Weak evidence from limited, small and mostly non-randomized studies suggest increased levels of anti-inflammatory adipokines apelin, vaspin and omentin-1 after statin therapy. In the rest of most known adipokines, statins have shown either controversial (adiponectin, retinol binding protein-4 and fetuin-A) or negligible effects (leptin and resistin) on their circulating levels. Therefore, statins may favourably alter the balance of inflammatory/anti-inflammatory adipokines, implicating a novel atheroprotective mechanism. However, the interplay between statins and adipokines is still not fully elucidated and its potential clinical relevance is warranted.

Biomarkers in unstable carotid plaque: Physiopathology and Prediction

AIMS

To study the role of cytokines and vascular inflammatory biomarkers in unstable carotid plaque.

BACKGROUND

Clinical studies showed that not only the degree of stenosis but also the type of carotid plaque can be responsible for ipsilateral ischemic stroke.

OBJECTIVE

The objective of this study is to suggest a role for vulnerable carotid atherosclerotic disease in the occurrence of ischemic stroke.

METHODS

PubMed, Embase, Cochrane library, and reference lists have been used to evaluate articles published until February 15, 2021.

RESULTS

Several factors may be involved in unstable plaque. Clinical studies support the involvement of brain inflammatory biomarkers as well as cytokines in the unstable carotid plaque.

CONCLUSIONS

Biomarkers could help to stratify patients with a vulnerable carotid plaque and to personalize the drug treatment. In this review, we briefly discuss the characteristics of vulnerable plaque and the role of biomarkers in the vulnerable carotid plaque.

Osteopontin and osteoprotegerin in atherosclerotic plaque - are they significant markers of plaque vulnerability?

Atherosclerosis (ATS) is still considered as a major, global health problem. For a deeper understanding of its pathogenesis, in the last years the research was translated from tissue visible events to molecular mechanisms. Osteopontin (OPN) and osteoprotegerin (OPG) are two molecules that have been associated with the initiation and progression of ATS lesions. The aim of our study was to assess the OPN and OPG expression in advanced stages of carotid ATS, to analyze the correlation between these markers and the ultrasonographic plaque properties, pointing out the identification of possible patterns that can predict plaque vulnerability and risks of restenosis. The study group comprised 49 consecutive patients (38 males and 11 females) diagnosed with carotid stenotic lesions by using ultrasonography. The carotid endarterectomy specimens were standardly processed for histopathological and immunohistochemical exams. The OPN and OPG expression was semi-quantitatively assessed. Our results sustained the relationship between histological American Heart Association (AHA) type and ultrasonographic classification (echogenic versus echolucent) (p<0.001). The semi-quantitative analysis showed that in most cases (31 plaques) OPG and OPN had opposite expressions, whereas in the remaining cases (18 plaques) the expression was similar. There were no correlations between low versus high expression of intra-plaque OPN and OPG (p=0.335). We found significant correlation for OPN and plaque echogenicity (p=0.011), but not for OPG (p=0.079). OPN expression (low versus high) was correlated with plaque type (stable versus unstable) (p=0.036), plaque ulceration (p=0.009) and inflammation (p<0.001). OPG expression (low versus high) did not reveal statistically significant differences with plaque type (stable versus unstable) and vulnerability plaque parameters, respectively. OPG and OPN co-exist in carotid atherosclerotic plaque demonstrating a modulatory role in inflammatory and calcification processes. OPG is strongly expressed in stable, calcified plaques, while OPN is poorly expressed in calcified plaques and in plaques without hemorrhage, ulceration, inflammation, or necrosis. Starting from the molecular mechanisms, further studies of biomarkers are important to identify new therapeutic resources meant to prevent and treat vascular calcification.

Doppler Ultrasound Monitoring of Echogenicity in Asymptomatic Subcritical Carotid Stenosis and Assessment of Response to Oral Supplementation of Vitamin K2 (PLAK2 Randomized Controlled Trial)

BACKGROUND

Plaque composition may predict the evolution of carotid artery stenosis rather than its sole extent. The grey scale median (GSM) value is a reproducible and standardized value to report plaque echogenicity as an indirect measure of its composition. We monitored plaque composition in asymptomatic subcritical carotid stenosis and evaluated the effect of an oral modulating calcification factor (vitamin K2).

METHODS

Carotid plaque composition was assessed by GSM value. Monitoring the effects of standard therapy (acetylsalicylic acid and low-medium dosage statin) (acetylsalicylic acid (ASA) arm) or standard therapy plus vitamins K2 oral supplementation (ASA + K2 arm) over a 12 months period was conducted using an ultrasound scan in a prospective, open-label, randomized controlled trial (PLAK2).

RESULTS

Sixty patients on low-medium dosage statin therapy were enrolled and randomized (30 per arm) to either ASA + K2 or ASA alone. Thirty-seven patients (61.6%) showed at 12 months a stable plaque with a mean increase in the GSM value in respect to the baseline of 2.6% with no differences between the two study arms (p = 0.66). Fifteen patients (25%) showed an 8% GSM value reduction respect the baseline with no differences between the two study arms (p = 0.99). At multivariable analysis, the adjusted mean (95% confidence interval) GSM change per month from baseline was greater in the ASA + K2 arm (-0.55 points, p = 0.048) compared to ASA alone (-0.18 points, p = 0.529).

CONCLUSIONS

Carotid plaque composition monitoring through GSM value represents a laborious procedure. Although its use may not be applied to everyday practice, a specific application consists in evaluating the effect of pharmacological therapy on plaque composition. This 12 months randomized trial showed that the majority of subcritical asymptomatic carotid plaque on treatment with low-medium dosage statin presented a stable or increased echogenicity. Although vitamin K2 beyond standard therapy did not determine a significant change in plaque composition, for those who presented with GSM reduction it did enhance a GSM monthly decline.

MiR-30c-5p regulates adventitial progenitor cells differentiation to vascular smooth muscle cells through targeting OPG

Background

As the most important component of the vascular wall, vascular smooth muscle cells (VSMCs) participate in the pathological process by phenotype transformation or differentiation from stem/progenitor cells. The main purpose of this study was to reveal the role and related molecular mechanism of microRNA-30c-5p (miR-30c-5p) in VSMC differentiation from adventitial progenitor cells expressing stem cell antigen-1(Sca-1).

Methods

In this study, we detected the expression of miR-30c-5p in human normal peripheral arteries and atherosclerotic arteries. In vitro, a stable differentiation model from adventitial Sca-1⁺ progenitor cells to VSMCs was established using transforming growth factor-β1 (TGF-β1) induction and the expression of miR-30c-5p during the process was observed. Then, we explored the effect of miR-30c-5p overexpression and inhibition on the differentiation from adventitial Sca-1⁺ progenitor cells to VSMCs. The target genes of miR-30c-5p were identified by protein chip and biological analyses and the expression of these genes in the differentiation process were detected. Further, the relationship between the target gene and miR-30c-5p and its effect on differentiation were evaluated. Finally, the co-transfection of miR-30c-5p inhibitor and small interfering RNA (siRNA) of the target gene was implemented to verify the functional target gene of miR-30c-5p during the differentiation from adventitial Sca-1⁺ progenitor cells to VSMCs, and the dual-luciferase reporter gene assay was performed to detect whether the mRNA 3′untranslated region (UTR) of the target gene is the direct binding site of miR-30c-5p.

Results

The expression of miR-30c-5p in the human atherosclerotic arteries was significantly lower than that in the normal arteries. During the differentiation from adventitial Sca-1⁺ progenitor cells to VSMCs, the expression of VSMC special markers including smooth muscle α-actin (SMαA), smooth muscle-22α (SM22α), smooth muscle myosin heavy chain (SMMHC), and h1-caponin increased accompanied with cell morphology changing from elliptic to fusiform. Meanwhile, the expression of miR-30c-5p decreased significantly. In functional experiments, overexpression of miR-30c-5p inhibited SMαA, SM22α, SMMHC, and h1-caponin at the mRNA and protein levels. In contrast, inhibition of miR-30c-5p promoted the expression of SMαA, SM22α, SMMHC, and h1-caponin. The target gene, osteoprotegerin (OPG), was predicted through protein chip and bioinformatics analyses. Overexpression of miR-30c-5p inhibited OPG expression while inhibition of miR-30c-5p had an opposite effect. Co-transfection experiments showed that low expression of OPG could weaken the promotion effect of miR-30c-5p inhibitor on the differentiation from adventitial Sca-1⁺ progenitor cells to VSMCs and the dual-luciferase reporter gene assay demonstrated that miR-30c-5p could target the mRNA 3′UTR of OPG directly.

Conclusions

This study demonstrates that miR-30c-5p expression was significantly decreased in atherosclerotic arteries and miR-30c-5p inhibited VSMC differentiation from adventitial Sca-1⁺ progenitor cells through targeting OPG, which may provide a new target for the treatment of VSMCs-associated diseases.

Brachial Artery Echogenicity and Grayscale Texture Changes in HIV-Infected Individuals Receiving Low-Dose Methotrexate

Objective- We evaluated the biological effects of low-dose methotrexate on 3 novel brachial artery grayscale ultrasound measures that may indicate subclinical arterial injury. Approach and Results- Exploratory analysis from a clinical trial of people with HIV infection at increased cardiovascular disease risk who were randomly assigned to low-dose methotrexate (target dose 15 mg/wk) or placebo. Brachial artery ultrasound grayscale median, gray level difference statistic texture-contrast (GLDS-CON), and gray level texture entropy were measured at baseline and after 24 weeks of intervention. Findings from the intention-to-treat (N=148) and adequately-dosed (N=118) populations were consistent, so the adequately-dosed population results are presented. Participants were a median (Q1, Q3) age of 54 (50, 60) years. After 24 weeks, the low-dose methotrexate intervention was associated with a 25.4% (-18.1, 58.6; P=0.007) increase in GLDS-CON compared with 1.3% (-29.1, 44.7; P=0.97) with placebo ( P=0.05) and a 0.10 u (-0.06, 0.23; P=0.026) increase in entropy compared with 0.02 u (-0.11, 0.14; P=0.54) with placebo ( P=0.14). At week 24, changes in CD4+ T cells correlated inversely with changes in GLDS-CON (ρ=-0.20; P=0.031), and entropy (ρ=-0.21; P=0.023). Changes in D-dimer levels, but no other inflammatory biomarkers, also correlated inversely with changes in GLDS-CON (ρ=-0.23; P=0.014) and entropy (ρ=-0.26; P=0.005). Conclusions- Brachial artery GLDS-CON and entropy increased after 24 weeks of low-dose methotrexate, though the latter was not significantly different from placebo. Grayscale changes were associated with decreases in CD4+ T-cell and D-dimer concentrations and may indicate favorable arterial structure changes.

Influence of Ultrasound System and Gain on Grayscale Median Values

OBJECTIVES

The purpose of this study was to determine the reliability of grayscale median (GSM) measurements across different ultrasound (US) systems and effects of gain on GSM values.

METHODS

Two vessels in a grayscale vascular phantom were imaged with 7 US systems at 3 gain settings. Two human participants were imaged at 3 gain settings. Each image was normalized, standardized, and segmented by expert and novice readers using grayscale analysis software. The concordance correlation coefficient (CCC) assessed agreement of GSM values for each system across gain settings and vessels and between readers. The intraclass correlation coefficient (ICC) assessed system-level reader concordance across gain settings and vessels. A general linear mixed model for repeated measures was used to assess within- and between-system mean GSM values.

RESULTS

Grayscale median measurements performed on images from the same US system yielded excellent (CCC) (95% confidence intervals): 0.85 (0.75, 0.92) to 0.96 (0.92, 0.98). ICC per system were 0.94 to 0.98 for the expert reader and 0.85 to 0.95 for the novice reader. Gain adjustments above and below an optimal setting contributed to significantly different intrasystem GSM values on 4 of 7 systems in the near zone and 5 of 7 systems in the far zone (P < .05). Intersystem GSM values differed on 5 of 7 systems (P < .05). Images from the human participants showed differences in GSM values at optimum gain values ± 10 dB/%.

CONCLUSIONS

Grayscale median measurements are highly reproducible when obtained from the same US system with similar gain settings. Grayscale median values differ significantly across gain values and between systems. Researchers should consider the impact of US system and gain settings on GSM values when working to minimize system- and operator-dependent factors.

Brachial artery intima-media thickness and grayscale texture changes in patients with peripheral artery disease receiving supervised exercise training in the PROPEL randomized clinical trial

We performed an exploratory analysis to evaluate the effects of a treadmill exercise program on brachial artery (BA) intima-media thickness (IMT) and three BA grayscale ultrasound measures that may indicate subclinical arterial injury. Data were from a clinical trial in individuals with peripheral artery disease who were randomly assigned to treadmill exercise training or attention control. B-mode ultrasonography was performed at baseline and after 26 weeks. BA IMT, grayscale median (GSM), entropy, and gray-level difference statistic-contrast (GLDS-CON) were measured by a single reader. The 184 participants were (mean (SD)) 66.7 (8.2) years old and had an ankle-brachial index of 0.70 (0.18). Exercise training was associated with a 0.01 (0.06) mm ( p = 0.025) reduction in BA IMT compared to 0.00 (0.05) mm ( p = 0.807) in the control group (between-group p = 0.061). BA GSM, entropy, and GLDS-CON did not change significantly with exercise. Improvements in the 6-minute walk distance correlated with increases in resting BA blood flow ( r = 0.23, p = 0.032), flow-mediated dilation ( r = 0.24, p = 0.022), diameter ( r = 0.29, p = 0.005), entropy ( r = 0.21, p = 0.047), and GLDS-CON ( r = 0.22, p = 0.041). In a post hoc analysis, BA IMT improved significantly with treadmill exercise training but did not change with attention control; however, the between-group difference did not reach statistical significance. With exercise, improvements in the 6-minute walk distance were associated with improved endothelial function, increased resting blood flow, and BA dilation, as well as higher grayscale entropy and GLDS-CON, indicating that lower extremity exercise is associated with salutary changes in upper-extremity arterial wall structure and function. ClinicalTrials.gov Identifier: NCT01408901.

Ultrasound carotid plaque features, cardiovascular disease risk factors and events: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND AND AIMS

It is not known if ultrasound carotid plaque features are associated with cardiovascular disease (CVD) risk factors or if they predict future CVD events.

METHODS

We measured total carotid plaque area (TPA) and grayscale plaque features (grayscale median, black areas, and discrete white areas) by B-mode carotid ultrasound among 2205 participants who participated in the first (baseline) visit of the Multi-Ethnic Study of Atherosclerosis. Multivariable linear regression was used to examine relationships between ultrasound plaque features and CVD risk factors at baseline. Cox proportional hazards models were used to assess if TPA, grayscale features, and carotid plaque score (number of arterial segments with a plaque) could predict incident coronary heart disease and cerebrovascular disease events over a mean follow-up of 13.3 years.

RESULTS

Participants were mean (standard deviation [SD]) 65.4 (9.6) years, 49% male, 39% White, 11% Chinese, 28% Black, and 22% Hispanic. Mean TPA 27.7 (24.7) mm2, but no grayscale plaque features, was associated with CVD risk factors. In fully adjusted models, TPA but no grayscale features predicted incident coronary heart disease (CHD) events (HR 1.23; 95%CI 1.11-1.36; p<0.001), however, C-statistics for CHD were similar to carotid plaque score but less than for coronary artery calcium (CAC) scoring. Neither TPA nor grayscale features independently predicted cerebrovascular events.

CONCLUSIONS

In middle-aged adults free of known cardiovascular disease, TPA but not grayscale plaque features was associated with CVD risk factors and predicted incident CHD events. For CHD, prediction indices for TPA were similar to carotid plaque score but less than for CAC.

Osteoprotegerin and Cardiovascular Events in High-Risk Populations: Meta-Analysis of 19 Prospective Studies Involving 27 450 Participants

Background Osteoprotegerin is a cytokine involved in bone metabolism as well as vascular calcification and atherogenesis. Although circulating osteoprotegerin levels are robustly associated with incident cardiovascular disease ( CVD ) in the general population, its relevance as a biomarker among populations at high CVD risk is less clear. Methods and Results Three independent reviewers systematically searched PubMed, EMBASE , and Web of Science to identify prospective studies that had recruited participants on the basis of having conditions related to high CVD risk. A total of 19 studies were eligible for inclusion, reporting on 27 450 patients with diabetes mellitus (2 studies), kidney disease (7 studies), preexisting heart disease (5 studies), or recent acute coronary syndromes (5 studies) at baseline. Over a mean follow-up of 4.2 years, 4066 CVD events were recorded. In a random-effects meta-analysis, the pooled risk ratio for CVD events comparing people in the top versus the bottom tertile of osteoprotegerin concentration was 1.30 (95% confidence interval, 1.12-1.50; P<0.001; I2=68.3%). There was evidence for presence of publication bias ( P value from Egger's test=0.013). Correction for publication bias using the trim-and-fill method reduced the risk ratio to 1.21 (95% confidence interval, 1.03-1.42; P<0.001). The risk ratios did not vary significantly by population type, geographical region, statistical adjustment, sample or assay type, age, sex, or length of follow-up. Conclusions In populations at high CVD risk, elevated circulating osteoprotegerin levels are associated with a higher risk for future CVD events. The magnitude of association appears weaker than in the general population.

NGAL and MMP-9/NGAL as biomarkers of plaque vulnerability and targets of statins in patients with carotid atherosclerosis

BACKGROUND

Neutrophil gelatinase associated lipocalin (NGAL) is expressed in atherosclerotic lesions and was recently implicated in the pathogenesis of cardiovascular pathologies. Statins are known to exert stabilizing effects on atherosclerotic plaque. The aims of our study were (1) to investigate the association of serum NGAL and metalloproteinase (MMP)-9/NGAL complex with the vulnerability of the atherosclerotic plaque, and (2) to reveal the effects of statin treatment on circulating NGAL and MMP-9/NGAL levels in patients with carotid artery stenosis.

METHODS

We examined the levels of NGAL and MMP-9/NGAL in blood samples from 136 patients with carotid artery stenosis by specific enzyme-linked immunosorbent assays.

RESULTS

Patients with vulnerable plaques, as determined by ultrasound (plaques with decreased echogenicity) and histological analysis (type VI according to the classification of American Heart Association [AHA]), displayed the highest levels of NGAL (both p<0.0001) and MMP-9/NGAL complex (p=0.0004 and p=0.004, respectively). Moreover, patients with symptomatic carotid atherosclerosis had significantly higher NGAL levels compared to asymptomatic patients (p=0.0007). The statin-treated group (n=108) demonstrated lower NGAL (73.9 vs. 128.0 μg/L, p<0.0001) and MMP-9/NGAL (28.9 vs. 40.6 μg/L, p=0.046) as compared to the non-statin group (n=28). Furthermore, in multivariate regression analysis NGAL, but not MMP-9/NGAL levels, were independently associated with symptomatic carotid artery stenosis. In addition, statin treatment was independently associated with lower NGAL levels.

CONCLUSIONS

Circulating NGAL and MMP-9/NGAL are associated with plaque vulnerability in patients with carotid artery stenosis. Statin treatment could contribute to plaque stabilization by reducing circulating NGAL and MMP-9/NGAL levels.

Ultrasound assessment of carotid plaque echogenicity response to statin therapy: a systematic review and meta-analysis

OBJECTIVE

To evaluate in a systematic review and meta-analysis model the effect of statin therapy on carotid plaque echogenicity assessed by ultrasound.

METHODS

We have systematically searched electronic databases (PubMed, MEDLINE, EMBASE and Cochrane Center Register) up to April, 2015, for studies evaluating the effect of statins on plaque echogenicity. Two researchers independently determined the eligibility of studies evaluating the effect of statin therapy on carotid plaque echogenicity that used ultrasound and grey scale median (GSM) or integrated back scatter (IBS).

RESULTS

Nine out of 580 identified studies including 566 patients' carotid artery data were meta-analyzed for a mean follow up of 7.2 months. A consistent increase in the echogenicity of carotid artery plaques, after statin therapy, was reported. Pooled weighted mean difference % (WMD) on plaque echogenicity after statin therapy was 29% (95% CI 22%-36%), p<0.001, I2=92.1%. In a meta-regression analysis using % mean changes of LDL, HDL and hsCRP as moderators, it was shown that the effects of statins on plaque echogenicity were related to changes in hsCRP, but not to LDL and HDL changes from the baseline. The effect of statins on the plaque was progressive; it showed significance after the first month of treatment, and the echogenicity continued to increase in the following six and 12 months.

CONCLUSIONS

Statin therapy is associated with a favorable increase of carotid plaque echogenicity. This effect seems to be dependent on the period of treatment and hsCRP change from the baseline, independent of changes in LDL and HDL.

Ultrasound tissue characterization of vulnerable atherosclerotic plaque

A thrombotic occlusion of the vessel fed by ruptured coronary atherosclerotic plaque may result in unstable angina, myocardial infarction or death, whereas embolization from a plaque in carotid arteries may result in transient ischemic attack or stroke. The atherosclerotic plaque prone to such clinical events is termed high-risk or vulnerable plaque, and its identification in humans before it becomes symptomatic has been elusive to date. Ultrasonic tissue characterization of the atherosclerotic plaque is possible with different techniques--such as vascular, transesophageal, and intravascular ultrasound--on a variety of arterial segments, including carotid, aorta, and coronary districts. The image analysis can be based on visual, video-densitometric or radiofrequency methods and identifies three distinct textural patterns: hypo-echoic (corresponding to lipid- and hemorrhage-rich plaque), iso- or moderately hyper-echoic (fibrotic or fibro-fatty plaque), and markedly hyperechoic with shadowing (calcific plaque). Hypoechoic or dishomogeneous plaques, with spotty microcalcification and large plaque burden, with plaque neovascularization and surface irregularities by contrast-enhanced ultrasound, are more prone to clinical complications than hyperechoic, extensively calcified, homogeneous plaques with limited plaque burden, smooth luminal plaque surface and absence of neovascularization. Plaque ultrasound morphology is important, along with plaque geometry, in determining the atherosclerotic prognostic burden in the individual patient. New quantitative methods beyond backscatter (to include speed of sound, attenuation, strain, temperature, and high order statistics) are under development to evaluate vascular tissues. Although not yet ready for widespread clinical use, tissue characterization is listed by the American Society of Echocardiography roadmap to 2020 as one of the most promising fields of application in cardiovascular ultrasound imaging, offering unique opportunities for the early detection and treatment of atherosclerotic disease.

Atorvastatin treatment and carotid plaque morphology in first-ever atherosclerotic transient ischemic attack/stroke: a case-control study

BACKGROUND

A relationship between echolucency of carotid plaques and the consequent risk of ipsilateral ischemic stroke has been observed. An aggressive lipid-lowering therapy may increase the echogenicity of carotid plaque in patients with elevated low-density lipoprotein cholesterol levels. The aim of this study is to prospectively evaluate the long-term effect of high-dose atorvastatin on carotid plaque morphology in patients with first-ever transient ischemic attack or stroke.

METHODS

All patients with symptomatic first ischemic atherosclerotic cerebrovascular event occurred within the previous 10 days were enrolled. Carotid Doppler ultrasound of the neck vessels with 7-11 MHz probe for the definition of the atherosclerotic carotid framework was performed. The analysis of the gray-scale median (GSM) of each plate was carried out with image processing software.

RESULTS

A total of 240 symptomatic plaques were included and divided into 3 groups: 80 in group A (atorvastatin 80 mg), 80 in group B (atorvastatin 40 mg), and 80 to group C (no atorvastatin). GSM score increases significantly more extensive in group A than in group B (+48.65 vs. +39.46, P < .02) and group C (+48.65 vs. 19.3, P = .0002). An inverse association between reduction of low-density lipoprotein and the increase in the GSM score (r = -.456, P = .007) has been observed. Moreover, the reduction of high-sensitive C-reactive protein correlates inversely with the increase of the GSM (r = -.398, P = .021).

CONCLUSIONS

Dose-dependent effect of atorvastatin on symptomatic carotid plaque morphology may suggest a specific role of this drug in the atherosclerotic stroke prevention.

Treatment with betablockers is associated with higher grey-scale median in carotid plaques

Background

The presence of echolucent carotid plaques as defined by low ultrasound grey-scale median (GSM) is associated with a higher risk of stroke and myocardial infarction. Betablockers have shown possible anti-atherosclerotic effects. The aim of the present study was to determine if there is an association between carotid plaque GSM and treatment with betablockers.

Methods

The GSM of the carotid plaques of 350 patients who underwent carotid endarterectomy (CEA) for asymptomatic (n = 113) or symptomatic (n = 237) carotid disease was measured. Patients were divided in two groups based on the absence/presence of an on-going long-term (i.e. at least 6 months) oral treatment with betablockers at the time of CEA.

Results

The prevalence and type of preoperative neurological symptoms were similar in the two groups. Patients with betablockers had more frequently arterial hypertension (P < .0001), diabetes (P = .035) and a higher BMI (P = .0004), while patients without betablockers were most frequently smokers (P = .017).

Patients with betablockers revealed to have higher GSM (37.79 ± 25 vs 32.61 ± 23.50 P = .036). Echogenic plaques (i.e. with GSM > 30) showed to be more frequent in patients with betablockers also after correction for age, gender, the occurrence of preoperative symptoms, diabetes, hypertension, smoking and statins use (P = .024).

Conclusions

These results suggest the use of standardized ultrasound techniques as an important tool in evaluating the effect of anti-atherosclerotic medications and underline the need of.further prospective randomized studies on larger patient cohorts in order to confirm these results.

The relationship of novel adipokines, RBP4 and omentin-1, with carotid atherosclerosis severity and vulnerability

OBJECTIVE

We investigated the relationship of circulating novel adipokines, retinol-binding protein 4 (RBP4) and omentin-1, with advanced carotid atherosclerosis and ultrasound indexes of severity (total plaque area-TPA) and plaque echogenicity and vulnerability (Gray-Scale median - GSM score).

METHODS

We enrolled 225 patients with high-grade carotid stenosis (HGCS) who underwent carotid revascularization (73 Symptomatic patients, 152 asymptomatic patients) and 75 age- and sex-matched, asymptomatic individuals with low-grade (<50%) carotid stenosis (LGCS). Seventy-three individuals without current manifestations of atherosclerotic disease served as control group (COG). All participants underwent carotid ultrasound with TPA and GSM score assessment. Moreover, clinical parameters, metabolic profile, and circulating levels of hsCRP and adipokines were assessed.

RESULTS

RBP4 was significantly elevated in HGCS (51.44 ± 16.23 mg/L) compared to LGCS (38.39 ± 8.85 mg/L), independent of symptoms existence, whereas RBP4 levels in COG were even lower (25.74 ± 10.72 mg/L, p < 0.001 compared to either HGCS or LGCS). Inversely, serum omentin-1 levels were significantly lower across HGCS (490.41 ± 172 ng/ml) and LGCS (603.20 ± 202.43 ng/ml) than COG (815.3 ± 185.32, p < 0.001). Moreover, the considerable difference between HGCS and LGCS (p < 0.001) was exclusively attributed to the excessive suppression of omentin-1 concentrations in symptomatic versus asymptomatic (p = 0.004) patients. HGCS and LGCS did not differ in the rest of clinical and biochemical parameters. In multiple regression analysis, RBP4 (beta = 0.232, p = 0.025) and hsCRP (beta = 0.300, p = 0.004) emerged as independent determinants of TPA in patients with carotid atherosclerosis. Low serum levels of omentin-1 correlated with GSM score and symptoms but that association was lost in multivariate analysis..

CONCLUSION

RBP4 serum levels were significantly elevated in patients with established carotid atherosclerosis and were positively associated with atherosclerosis severity. The association of low serum omentin-1 with carotid plaque echolucency requires further investigation.. ClinicalTrials.gov Identifier: NCT00636766.

Non-invasive vulnerable plaque imaging: how do we know that treatment works?

Atherosclerosis is an inflammatory disorder that can evolve into an acute clinical event by plaque development, rupture, and thrombosis. Plaque vulnerability represents the susceptibility of a plaque to rupture and to result in an acute cardiovascular event. Nevertheless, plaque vulnerability is not an established medical diagnosis, but rather an evolving concept that has gained attention to improve risk prediction. The availability of high-resolution imaging modalities has significantly facilitated the possibility of performing in vivo regression studies and documenting serial changes in plaque stability. This review summarizes the currently available non-invasive methods to identify vulnerable plaques and to evaluate the effects of the current cardiovascular treatments on plaque evolution.

Grayscale median analysis of primary stenosis and restenosis after carotid endarterectomy

BACKGROUND

Several studies have reported that echolucent carotid lesions, as determined by grayscale median (GSM) analysis, are associated with increased perioperative embolic complications during carotid artery stenting (CAS). However, there is limited research of the predictive value of GSM analysis comparing values for primary atherosclerotic lesions in the carotid artery with those for recurrent lesions after carotid endarterectomy (CEA).

METHODS

Retrospective data were collected and analyzed from all patients undergoing CAS from November 2005 to August 2010. Available preoperative images amenable to GSM analysis were processed in Adobe Photoshop (version CS4; San Jose, Calif). Statistical analysis included t-test, Fischer exact test, and generation of a receiver operating characteristic curve.

RESULTS

With at least 29 days of follow-up, 212 patients underwent 228 CAS procedures. There were 189 stents placed for primary lesions (CAS for primary stenosis group) and 39 stents placed for restenosis after CEA (CAS for restenosis group). GSM analysis was feasible for 47 patients, and the mean GSM was 45.6 (n = 34; 95% confidence interval, ± 8.3) for the primary stenosis group and 20.5 (n = 13; 95% confidence interval, ±9.6) for the restenosis group (P < .01). The mean time from CEA to CAS intervention for the restenosis group was 8.6 years. There was no statistical difference in procedural individual and combined complications of ipsilateral stroke, 30-day stroke, or 30-day mortality between the CAS for primary stenosis group and the CAS for restenosis group. In the primary stenosis group, the mean GSM was lower in those with procedural complications compared with those without complications (15 ± 22 vs 49 ± 8; P = .02).

CONCLUSIONS

A low GSM value was associated with increased perioperative risk when CAS was performed for native carotid lesions, but a low GSM value was not associated with higher procedural risk when carotid stenting was performed for carotid stenosis after CEA (restenosis). GSM analysis for restenosis may be altered by the time interval from CEA to restenosis.

Ultrasonography of carotid plaque for the prevention of stroke

A carotid ultrasonography is a non-invasive technique that provides an accurate and reliable characterization of the broad spectrum of carotid arteriosclerosis, from the intima-media thickness to the atherosclerotic plaque. Carotid ultrasonography has become a useful tool for identifying patients at high risk of stroke and selecting those who can benefit most from revascularization therapies such as carotid endarterectomy and stenting. In addition to the degree of stenosis, plaque echomorphology has emerged in recent years as an important contributory factor to stroke risk. Changes in plaque echogenicity, as measured by the quantitative computer-assisted ultrasonography index, could be a marker of plaque instability as well as an indicator of plaque remodeling, thereby providing the means for monitoring anti-atherosclerosis drugs such as statins.

The role of osteoprotegerin in cardiovascular disease

Osteoprotegerin (OPG) is a 401 amino acid N-glycosylated protein, which is highly expressed in a large number of tissues. OPG mainly binds to two ligands, i.e. RANKL (receptor activator of nuclear factor κB ligand) and TRAIL (tumor necrosis factor- related apoptosis-inducing ligand). Upon binding to the former ligand, OPG inhibits the activation of osteoclasts and promotes apoptosis of osteoclasts, whereas the binding of OPG with TRAIL prevents apoptosis of tumor cells. There is now emerging evidence that OPG participates in the pathogenesis of atherosclerosis and cardiovascular diseases by amplifying the adverse effects of inflammation and several traditional risk factors such as hyperlipidemia, endothelial dysfunction, diabetes mellitus, and hypertension. Some epidemiological studies also showed a positive association between OPG levels and cardiovascular morbidity and mortality. The aim of this article is to provide an overview of the main biochemical, physiological, and pathological aspects of OPG biology in cardiovascular disease.

The statin-iron nexus: anti-inflammatory intervention for arterial disease prevention

OBJECTIVES

We postulated the existence of a statin-iron nexus by which statins improve cardiovascular disease outcomes at least partially by countering proinflammatory effects of excess iron stores.

METHODS

Using data from a clinical trial of iron (ferritin) reduction in advanced peripheral arterial disease, the Iron and Atherosclerosis Study, we compared effects of ferritin levels versus high-density lipoprotein to low-density lipoprotein ratios (both were randomization variables) on clinical outcomes in participants receiving and not receiving statins.

RESULTS

Statins increased high-density lipoprotein to low-density lipoprotein ratios and reduced ferritin levels by noninteracting mechanisms. Improved clinical outcomes were associated with lower ferritin levels but not with improved lipid status.

CONCLUSIONS

There are commonalities between the clinical benefits of statins and the maintenance of physiologic iron levels. Iron reduction may be a safe and low-cost alternative to statins.

Adipokines: a novel link between adiposity and carotid plaque vulnerability

BACKGROUND

In patients with carotid stenosis, we prospectively investigated the association of novel adipokines, apelin and visfatin, with gray-scale median (GSM) score, a valid index of carotid plaque vulnerability. We also assessed the impact of atorvastatin therapy on the above biochemical and imaging markers.

MATERIALS AND METHODS

Seventy-four overweight [body-mass index (BMI) > 25 kg/m(2) , fat-mass > 30%], statin-free patients, with carotid stenosis, but without indications for intervention were enrolled. Thirty-eight age-, sex- and BMI-matched healthy subjects served as healthy controls (HC). All patients received gradual titrated (10-80 mg) atorvastatin therapy to target LDL-C < 100 mg/dL. GSM score, blood pressure (BP), fat-mass, lipid profile, and serum high-sensitivity C-reactive protein (hsCRP), apelin and visfatin levels were obtained at baseline and after 24 months.

RESULTS

At baseline, patients with carotid atherosclerosis had worse lipid profile, lower apelin and higher systolic BP, hsCRP, visfatin levels compared with HC (P < 0·05). Notably, decreased apelin (P < 0·001) and GSM score (P = 0·010), while increased visfatin (P = 0·019) and hsCRP (P = 0·039) levels were found in symptomatic rather than asymptomatic patients. At baseline, GSM score correlated with fat-mass, BMI, LDL-C, visfatin and apelin (P < 0·05). Apelin, visfatin and fat-mass remained independent determinants of baseline GSM score (R(2) = 0·391, P = 0·007). In parallel, we found that apelin increment and LDL-C reduction were independently associated with the atorvastatin-induced GSM increase (R(2) = 0·411, P = 0·011).

CONCLUSION

Increased fat-mass, low apelin and high visfatin serum levels seem to correlate with carotid plaque vulnerability in patients with carotid stenosis. The atorvastatin-induced modification of apelin and LDL-C may beneficially affect carotid plaque stability.

Rosuvastatin inhibits spontaneous and IL-1β-induced interleukin-6 production from human cultured osteoblastic cells

OBJECTIVE

Experimental and clinical data suggest that statins may protect bone by inhibiting bone resorption and/or stimulating bone formation. Interleukin-6 (IL-6) is produced by osteoblasts, and potently stimulates osteoclast activation playing a key role in normal bone resorption as well as in post-menopausal and inflammation-driven osteoporosis. Although statins inhibit IL-6 production from different cell types, currently no data exist on osteoblasts. The aim of the study was to evaluate the effect of rosuvastatin on IL-6 production by human osteoblasts.

METHODS

Osteoblasts from osteoarthritic patients were incubated with rosuvastatin (0.1-10 μmol/L)±IL-1β, and IL-6 production was evaluated as cytokine concentration in the culture medium (ELISA), as well as mRNA expression in the cells (qPCR). Putative intracellular mechanisms of the drug, such as blocking HMG-CoA-reductase, and interference in the prenylation process were investigated by the addition of mevalonate and isoprenoids. The effect of rosuvastatin±IL-1β on the anti-resorptive molecule osteoprotegerin (OPG) was also assessed (ELISA).

RESULTS

Rosuvastatin significantly reduced IL-6 levels in the osteoblast culture medium, both in unstimulated and IL-1β-stimulated cells. This effect was reversed by mevalonate or geranylgeraniol, but not farnesol. Moreover, the drug decreased both spontaneous and IL-1β-induced IL-6 mRNA expression in osteoblasts. Conversely, rosuvastatin did not affect OPG levels in the culture medium.

CONCLUSION

Our results show that rosuvastatin decreases IL-6 production by osteoblasts, thereby suggesting a possible inhibiting activity on osteoclast function in an indirect way. These data may provide further rationale for employing rosuvastatin to beneficially affect bone metabolism in post-menopausal women and possibly in inflammation-driven osteoporosis.

Advances in noninvasive imaging for evaluating clinical risk and guiding therapy in carotid atherosclerosis

Managing asymptomatic carotid atherosclerosis with a view to preventing ischemic stroke is a challenging task. As the annual risk of stroke in untreated asymptomatic patients on average is less than the risk of surgical intervention, the key question is how to identify those asymptomatic individuals whose risk of stroke is elevated and who would benefit from surgery, while sparing low-risk asymptomatic patients from the risks of surgical intervention. The advent of a multitude of noninvasive carotid imaging techniques offers an opportunity to improve risk stratification in patients and to monitor the response to medical therapies; assessing efficacy at individual and population levels. As part of this, plaque measurement techniques (using ultrasound, computed tomography or MRI) may be employed in monitoring plaque/component regression and progression. Novel imaging applications targeted to plaque characteristics, inflammation and neovascularization, including contrast-enhanced ultrasound and MRI, dynamic contrast-enhanced MRI, and fluorodeoxyglucose-PET, are also being explored. Ultimately, noninvasive imaging and other advances in risk stratification aim to improve and individualize the management of patients with carotid atherosclerosis.

The short-term effect of atorvastatin on carotid plaque morphology assessed by computer-assisted gray-scale densitometry: a pilot study

Soft, lipid-containing carotid plaques, which appear echolucent on ultrasound imaging, have been associated with increased risk of ischemic stroke. We sought to investigate the effect of short-term treatment with atorvastatin on the change of carotid plaque echodensity. We treated 40 stroke-free and statin-naive subjects with 80 mg atorvastatin daily for 30 days. Computer assisted gray-scale densitometry (GSD) index was calculated at baseline and 30 days after treatment from the normalized plaque images. A multiple logistic regression was used to assess the effect modification of low-density lipoprotein (LDL) cholesterol on plaque stabilization after adjusting for age, sex, and smoking. The average number of carotid plaques at baseline was 2 (range: 0-5; 27 subjects with carotid plaque) and did not change 30 days following atorvastatin treatment. The mean GSD index significantly increased from 73±16 (range: 1-125) at baseline to 89±15 (range: 1-137) at 30 days after treatment (P<0.05). The adjusted odds ratio for the positive GSD plaque index change (vs. no change or decreased gray-scale median (GSM) index) was 1.71 (95% confidence interval: 1.1-7.6, P<0.01). In conclusion, we observed decreased echolucency (increased echodensity) of carotid artery plaques after short-term treatment with atorvastatin.

Changes in carotid plaque echogenicity with time since the stroke onset: an early marker of plaque remodeling?

Carotid plaques undergo histologic changes early after an ischemic stroke. However, the evolution of carotid plaques echolucency after a recent brain ischemia is not well known. A prospective observational study that included consecutive stroke patients and asymptomatic individuals with plaques showing ≥50% stenosis on duplex ultrasound was conducted. Plaque echogenicity was measured with the standardized gray-scale median (GSM) and compared with respect to symptoms presence and time from stroke onset. One hundred twenty-six carotid plaques in 124 patients were studied and four groups of plaques were analyzed: (1) plaques seen within 24 h of stroke onset (32); (2) between 1-7 days (50); (3) more than 7 days after stroke onset (22) and; (4) plaques without associated symptoms (22). Plaques of group 1 had less echogenicity than those of groups 2-4: median GSM (interquartile range) 14 (16), 19.5 (19), 22.5 (21), 26.5 (16) respectively (p = 0.001). In conclusion, carotid plaque echogenicity is increased with time from stroke onset and could be an early marker of plaque remodeling.

Current role of biomarkers in carotid disease: a systematic review

BACKGROUND AND PURPOSE

Accumulating evidence suggests that carotid plaque vulnerability can be used as a determinant of ischemic stroke risk stratification and carotid intervention. Novel markers of high-risk carotid plaque in patients are needed.

SUMMARY OF REVIEW

Advances in cellular and molecular pathophysiology, the demand for accurately predicting carotid risk, and choosing the optimal prevention strategy are stimulating great interest in the development of novel surrogate markers. Biomarkers in cardiovascular disease are expected to predict the natural history, clinical outcomes, and the efficacy of disease-modifying interventions. We aimed to review the literature regarding clinical data on novel serum biomarkers related to ischemic cerebrovascular events associated with carotid artery disease. We provide background information on the biomarkers related to all aspects of carotid disease: natural history, carotid intervention strategies for symptomatic and asymptomatic patients, perioperative risk prediction, and their therapeutic implications.

CONCLUSION

At present, heterogeneous data support evidence that biological markers can help existing practices to more accurately assess patients at risk for stroke. Randomized-controlled trials for carotid artery disease and carotid intervention, incorporating biomarkers, are needed.

Long-term treatment with low-dose metoprolol CR/XL is associated with increased plaque echogenicity: the Beta-blocker Cholesterol-lowering Asymptomatic Plaque Study (BCAPS)

OBJECTIVES

To examine whether the decrease in IMT progression rate in the carotid bulb induced by metoprolol CR/XL treatment (25mg once daily) observed in the β-blocker Cholesterol-lowering Asymptomatic Plaque Study (BCAPS) was accompanied by an effect on carotid plaque echogenicity.

METHODS

Gray scale median (GSM) in carotid plaques, used as a score of echogenicity, was measured at baseline and after 36 months in those 341 subjects (aged 49-69 years) with an asymptomatic moderate- to large-sized carotid plaque present at baseline and at follow-up. Participants were in a factorial design assigned to treatment with metoprolol CR/XL (25mg once daily), fluvastatin (40 mg once daily) or corresponding placebo.

RESULTS

After 36 months plaques were more echogenic in participants treated compared to those not treated with metoprolol CR/XL (57.3 ± 16.8 versus 51.8 ± 20.0, p=0.006). GSM had increased more from baseline in the metoprolol CR/XL treated subjects (25 ± 15 versus 18 ± 20, p<0.001), and plaques that had become more echolucent were less frequent in the metoprolol CR/XL treated subjects (3.6% versus 17.0%, p<0.001).

CONCLUSIONS

Long-term treatment with low dose metoprolol CR/XL in clinically healthy subjects with moderate-sized carotid plaques was associated with increase in plaque echogenicity, suggesting a potential beneficial effect of the β-blocker treatment on plaque stability.

Asymptomatic carotid artery stenosis--medical therapy alone versus medical therapy plus carotid endarterectomy or stenting

Vascular surgery has matured to the point that there exists robust bodies of literature exploring many of our therapies. However, this evidence is but one of the factors that dictate medical practice. Others include local patient demographics, the practical implications of healthcare delivery, and an individual surgeon's interpretation of this evidence, which can be somewhat subjective. As a result, there are numerous examples of vascular specialists' practice patterns differing depending on their geographic location. Recognizing this, the Editors of the Journal of Vascular Surgery and the European Journal of Vascular and Endovascular Surgery have developed a series of Trans-Atlantic Debates to explore these instances. The inaugural debate explores the controversial question of how best to manage asymptomatic carotid artery stenoses. Our debators, Peter Schneider and Ross Naylor, offer reasoned and passionate arguments to defend their differing approaches. We trust that this addition to our journals will prove enlightening and, perhaps, entertaining.

Slightly Elevated High-Sensitivity C-Reactive Protein (hsCRP) Concentrations Are Associated With Carotid Atherosclerosis in Women With Varying Degrees of Glucose Tolerance

We examined whether high-sensitivity C-reactive protein (hsCRP) ≥2.0 mg/L was associated with increased intima-media thickness (IMT), plaque burden, and plaque echolucency in carotid arteries. Women (n = 635) from a population sample of 64-year-old females with varying degrees of glucose tolerance underwent risk factor assessment, measurement of hsCRP, and ultrasound examinations of the carotid arteries. Participants with hsCRP levels ≥2.0 mg/L had elevated carotid bulb IMT independently of other cardiovascular risk factors compared with those with hsCRP <2.0 mg/L. The participants with plaques in the highhsCRP group had larger total plaque area compared to those with plaque in the lower hsCRP group. Plaque echolucency did not differ between groups. High-sensitivity CRP levels ≥2.0 mg/L were accompanied by elevated IMT in the carotid bulbs independently of other cardiovascular risk factors. Total plaque area was larger among women with plaques in the high hsCRP group versus the lower hsCRP group.

Serum levels of apelin and ghrelin in patients with acute coronary syndromes and established coronary artery disease--KOZANI STUDY

Apelin and ghrelin have emerged as novel adipokines, but their role in coronary artery disease (CAD) remains obscure. In the present study, we analyzed their serum levels in patients with acute coronary syndromes (ACS) or established asymptomatic CAD. A total of 355 participants were enrolled. Among them were 80 patients with unstable angina (UA) and 115 patients with acute myocardial infarction (AMI) hospitalized in the coronary care unit. We also included 88 asymptomatic patients with established CAD (asymptomatic CAD) and 72 age-and sex-matched healthy controls (HCs). All groups with CAD underwent coronary angiography, and the Gensini score was determined. Clinical parameters, glycemic and lipid profile, high-sensitivity CRP (hsCRP), insulin resistance (HOMA-IR), as well as apelin and ghrelin were assayed. Patients with ACS (UA or AMI) were sampled at hospital admission. All 3 groups with CAD (UA, AMI, or asymptomatic CAD) showed significantly higher levels of hsCRP, HOMA-IR, and white blood cells than controls (P < 0.01). Conversely, apelin and ghrelin concentrations were considerably (P < 0.05) lower in CAD patients with respect to the control group. Most importantly, UA (6.72 +/- 3.51 ng/mL) and AMI (6.02 +/- 4.07 ng/mL) groups had even lower apelin levels on admission compared with the asymptomatic CAD group (13.53 +/- 5.2 ng/mL) (P < 0.05). Logistic regression analysis showed an independent association of low apelin and ghrelin levels with CAD presence. Besides this result, apelin showed an inverse relationship with ACS incidence and a Gensini score independent of other cardiovascular risk factors (P < 0.05). In conclusion, CAD seemed to correlate with low serum apelin and ghrelin levels. Moreover, apelin concentrations inversely were associated with the severity and the acute phase of CAD, which suggests its involvement in the progression and destabilization of coronary atherosclerotic plaques.