Ultrasound carotid intima-media thickness, carotid plaque and cardiac calcium incrementally add to the Framingham Risk Score for the prediction of angiographic coronary artery disease: a multicenter prospective study

Evolution of Stress Echocardiogram in the Era of CT Angiography

The ideal diagnostic modality for acute chest pain is a highly debated topic in the cardiovascular community. With the rapid rise of coronary computed tomography angiography (CTA) and the fall of functional testing, stress echocardiography (SE) is at a delicate crossroads. Though there are many advantages of coronary CTA, it is not without its flaws. The exact realm of SE needs to be clearly defined, as well as which patients need diagnostic testing. The emergence of additional parameters will propel the evolution of modern SE. In this review article, we explore the role of SE, guidelines, comparison of SE versus CTA, and additional parameters in the coronary CTA era.

Composite carotid intima-media thickness as a risk predictor of coronary heart disease in a selected population in Sri Lanka

Background

Segment-specific variations of carotid intima-media thickness (CIMT) have not been assessed in South Asian populations. The purpose of this study was to determine if segment-specific CIMTs or a composite-CIMT score is a better risk predictor of coronary heart disease in South Asian populations.

Methods

A comparative prospective study was conducted from November 2019 to October 2020 in a hospital in Colombo, Sri Lanka. Based on pre-defined inclusion and exclusion criteria, cases (having a diagnosis of Coronary Heart Disease (CHD), n = 338) and controls (non-CHD group, n = 356) were recruited. Ultrasound examination of the common carotid (CCA), the carotid bulb (CB) and the internal carotid segments (ICA) of the carotid vessels was conducted by a radiologist, and CIMTs were measured. A composite-CIMT score defined as the average value of all six segments of the left and right sides was derived.

Results

694 participants were enrolled (male n = 399, 57.5%). The mean (±SD) age of the study sample was 60.2 (±9.86) years. There were variations in segment-specific values between the left and right vessels. The mean composite-CIMT value of the CHD group was significantly higher than that of the non-CHD group. A composite-CIMT score of 0.758 had a sensitivity of 98.4% and a specificity of 64.6% in distinguishing CHD from non-CHD groups (Area under the curve (AUC): 0.926).

Conclusions

Carotid artery segment-specific CIMT variations were present in this population. The composite CIMT score is better than segment-specific CIMTs in predicting CHD and may be used to predict CHD in this population.

Stress-echocardiography or coronary computed tomography in suspected chronic coronary syndrome after the 2019 European Guidelines? A practical guide

Stress-echocardiography can rightly be considered one of the champions of cardiac functional imaging, thanks to its real-time imaging, high temporal resolution, high safety and very low cost. When stress-echocardiography is performed at top technical quality, hence taking advantage of ultrasound contrast media for endocardial border delineation at least for suboptimal cases, subjectivity is minimized, and with the routine use of coronary flow reserve measurement (left anterior descending coronary artery, stress/rest ratio reduced or normal, i.e. <>2.0) diagnostic sensitivity is strengthened. The true competitor of any type of functional imaging, stress-echocardiography included, is nowadays coronary computed tomography angiography, which is instead a diagnostic method directly, noninvasively assessing coronary anatomy, apparently the holy grail for any cardiologist. The new 2019 Guidelines on chronic coronary syndrome of the European Society of Cardiology change the existing landscape and clinical practice, while they probably cannot clarify which type of test, functional or anatomic, should be first chosen in different clinical scenarios of suspected chronic coronary syndrome. We review the existing data and the authors' personal view in order to assess how functional stress-echocardiography compares with coronary computed tomography angiography regarding three main aspects: diagnosis of coronary artery disease, guidance of therapy (coronary revascularization versus medical therapy) and risk stratification.

Carotid Atherosclerosis in Predicting Coronary Artery Disease: A Systematic Review and Meta-Analysis

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Diagnostic Role of Carotid Intima-Media Thickness for Coronary Artery Disease: A Meta-Analysis

Background

The present meta-analysis was conducted to confirm whether carotid intima-media thickness (IMT) could serve as an accurate diagnostic method for coronary artery disease (CAD).

Methods

Databases of PubMed, Google Scholar, and Embase were searched for potential articles. The articles were selected according to inclusion criteria. Pooled sensitivity and specificity with corresponding 95% confidence interval (CI) were used to confirm the diagnostic role of IMT for CAD. I ² and P value were used to assess the existence of heterogeneity. I ² and P value were used to assess the existence of heterogeneity.

Results

22 eligible articles were selected in the present meta-analysis. Pooled sensitivity and specificity of IMT for diagnosing CAD were 0.68 (0.57-0.77) and 0.70 (0.64-0.75), respectively. The corresponding AUC was 0.74 (0.70-0.78). Subgroup analyses based on cutoff value of IMT were performed. A cutoff value of 1 mm was demonstrated to be much more accurate diagnostic criteria for CAD (sensitivity: 0.66; specificity: 0.79; AUC: 0.80). Sensitivity analysis indicated that the pooled results were robust. Deek's funnel plot indicated no significant publication bias (P value were used to assess the existence of heterogeneity.

Conclusion

Carotid IMT may serve as an accurate diagnostic tool. A cutoff value of 1 mm seems to provide much more accurate diagnostic results for CAD.

Cardiovascular morbidity and mortality in patients with aortic valve sclerosis: A systematic review and meta-analysis

AIMS

The association between aortic valve sclerosis (AVSc) and cardiovascular (CV) events is not consistent among different studies. We have performed a meta-analysis evaluating the association between AVSc and fatal and/or non-fatal CV and cerebrovascular events.

METHODS AND RESULTS

A systematic search was performed in the electronic databases (PubMed, Web of Science, Scopus, EMBASE). Studies evaluating coronary artery disease (CAD), stroke and CV mortality in AVSc patients and controls were included. Differences among cases and controls were expressed as Odds Ratio (OR) with pertinent 95% Confidence Intervals (CI). Thirty-one studies on 10,537 AVSc patients and 25,005 controls were included in the final analysis. The absolute risk of CAD was 45.8% (95% CI: 32.9-59.3) in AVSc patients and 29.4% (95% CI: 21.8-38.5) in controls with an OR of 2.02 (95% CI: 1.67-2.44) and an attributable risk of 35.8%. Moreover, stroke was reported in 11.8% (95% CI: 4.4-27.7) of AVSc patients and 7.9% (95% CI: 2.5-22.7) of controls (OR: 1.41, 95% CI: 1.16-1.71) with an attributable risk of 33.0%. CV mortality was 6.2% (95% CI: 2.7-13.5) in AVSc patients and 2.0% (95% CI: 0.5-7.9) in controls (OR: 2.70, 95% CI: 1.45-5.01), with an attributable risk of 67.7%. Results were confirmed when pooling together ORs for CAD, stroke and CV mortality obtained by means of multivariate analysis.

CONCLUSIONS

AVSc is associated with CAD, stroke and CV mortality. Taken together, these data suggest that patients with AVSc may benefit from a stricter CV risk monitoring and that AVSc screening may be included in the frame of CV risk stratification protocols.

Stress Echocardiography: Need to Optimize its Appropriate Use in Suspected Angina and a Review of Available Additional Tools for its Clinical Application in 2018: First do no Harm! Second do it at the Highest Possible Accuracy

There is a need to reassess the most appropriate indications for stress echocardiography in the current era, in patients with suspect or known coronary artery disease (CAD), and also the most helpful additional parameters that can be easily calculated in clinical practice to increase the known suboptimal sensitivity for obstructive CAD of this test. The current review tries to clarify what is and what should be the proper role for functional testing in general, but specifically regarding modern stress echocardiography in the current practice, for suspected CAD and/or atypical chest pain. Few candidate additional parameters beyond wall motion assessment are here suggested to improve diagnostic accuracy of stress echocardiography, and pertinent literature is briefly reviewed, together with a more personal view of the author regarding the characteristics of each parameter, as far as ease of acquisition, cost, and true diagnostic or prognostic clinical usefulness are concerned. The reviewed additional parameters, which can be acquired during stress echocardiography, are Doppler coronary flow reserve in the left anterior descending artery, cardiac calcium score, global longitudinal strain, ventricular elastance, and contrast myocardial perfusion. Each of them finds a potential place in the current practice or may find a place in the future practice of stress echocardiography.

A Noninvasive Sonographic Study of Multisite Atherosclerosis in an Elderly Chinese Population

OBJECTIVES

A sonographic study was conducted to determine the prevalence of atherosclerosis across multiple arterial beds in an elderly Chinese population and to examine relationships between detected atherosclerosis and traditional risk factors.

METHODS

A total of 197 participants underwent sonography of the abdominal aorta and bilateral carotid, femoral, and lower limb arteries. Images were reviewed to determine the presence or absence of plaques in each artery. Plaque thickness was measured as the indicator of plaque burden. Plaque prevalence was estimated per site and correlated with age, sex, and the Framingham Risk Score (FRS). Plaque frequency and thickness were compared between different arterial beds.

RESULTS

Of the 197 participants (54% female; age range, 58-86 years), 90% had plaques present in at least 1 artery, and 55% had plaques present in at least 4 arteries. The most common sites for plaques were the carotid arteries (80%), followed by the lower limb arteries (59%), femoral arteries (57%), and abdominal aorta (37%). Plaque prevalence in each arterial bed except the abdominal aorta was significantly associated with male participants (P < .05), increasing age (P < .003) and FRS (P < .04). Male participants were more likely to have carotid (P = .04), femoral (P = .045), and lower limb (P = .006) plaques than female participants, but there was no significant difference in aortic plaque prevalence between male and female participants (P = .9).

CONCLUSIONS

Plaque prevalence increased significantly in the carotid and peripheral arteries with increasing FRS. These findings should be considered for designing screening programs for stroke and heart attack prevention.

Differential incremental value of ultrasound carotid intima-media thickness, carotid plaque, and cardiac calcium to predict angiographic coronary artery disease across Framingham risk score strata in the APRES multicentre study

AIMS

According to recent data, more accurate selection of patients undergoing coronary angiography for suspected coronary artery disease (CAD) is needed. From the Active PREvention Study multicentre prospective study, we further analyse whether carotid intima-media thickness (cIMT), carotid plaques (cPL), and echocardiographic cardiac calcium score (eCS) have incremental discriminatory and reclassification predictive value for CAD over clinical risk score in subjects undergoing coronary angiography, specifically depending on their low, intermediate, or high class of clinical risk.

METHODS AND RESULTS

In eight centres, 445 subjects without history of prior CAD but with chest pain of recent onset and/or a positive/inconclusive stress test for ischaemia prospectively underwent clinically indicated elective coronary angiography after cardiac and carotid ultrasound assessments with measurements of cIMT, cPL, and eCS. The study population was divided into subjects at low (10%), intermediate (10-20%), and high (>20%) Framingham risk score (FRS). Ultrasound parameters were tested for their incremental value to predict CAD over FRS, in each pre-test risk category. No significant difference could be appreciated between the discrimination value of FRS and Diagnostic Imaging for Coronary Artery Disease score for the presence of CAD. eCS or cPL demonstrated significant incremental prediction over FRS, consistently in the three FRS categories (P < 0.01); this applied to both discrimination and reclassification, with the exception of high-risk subjects, in whom cPL was apparently not incremental over FRS, and eCS was only of borderline significance for better discrimination.

CONCLUSIONS

Ultrasound eCS and cPL assessments were significant predictors of angiographic CAD in patients without prior CAD but with signs or symptoms suspect for CAD, independently and incrementally to FRS, across all pre-test risk probability strata, although in high-risk subjects, only eCS maintained an incremental value. The use of cIMT was not significantly incrementally useful in any FRS risk category.

Structural and Functional Abnormalities of Carotid Artery and Their Relation with EVA Phenomenon

Early vascular aging is a process characterized by a reduction in arterial elastin with an increase in collagen that has been related to cardiovascular risk factor and can determine an increased arterial stiffness and central blood pressure. It can be measured by several non invasive methods and in different arterial segment. The present paper will focus on functional (local stiffness parameter) and structural (intima media thickness) carotid arteries alterations typically evaluated by ultrasound methods. Methodological, research and clinical issue has been reviewed.

Cardiac calcium score on 2D echo: correlations with cardiac and coronary calcium at multi-detector computed tomography

Background

To test the hypothesis that a semi-quantitative echocardiographic calcium score (eCS) significantly correlates with cardiac calcium measured by coronary computed tomography angiography (CCTA) and, secondarily, severe coronary artery calcifications and stenosis.

Methods

This is a retrospective, observational study, conducted in a tertiary centre. eCS was compared with CCTA scores of non-coronary cardiac calcium (nCACS), coronary cardiac calcium (CACS) and number of diseased coronary vessels, in 141 subjects without known coronary artery disease (CAD), who underwent both echocardiography and CCTA for clinical reasons.

Results

Age, prevalence of hypertension and all measures of calcium (eCS, nCACS and CACS) differed significantly between the no-CAD and CAD subgroups. eCS was positively correlated with nCACS (Spearman rho = 0.64, p < 0.0001), CACS (rho = 0.46, p < 0.01) and weakly with the number of diseased coronary vessels (rho = 0.28, p < 0.05). eCS and nCACS had similar area under the curve (AUC) for the prediction of severe CACS (≥400) (0.77, 95% CI 0.68-0.86 and 0.79, 95% CI 0.72-0.88) or obstructive CAD (0.63, 95% CI 0.54-0.72 and 0.63, 95% CI 0.55-0.73).

Conclusions

eCS, a calcium score easily obtainable during standard echocardiography, is moderately to strongly correlated with nCACS by CCTA. The full eCS score correlates with nCACS better than its single components. It correlates with CACS and predicts severe coronary calcification (CACS > 400), a known predictor of cardiovascular morbidity and mortality. The eCS also predicts obstructive CAD, incrementally to age and clinical variables, although for this purpose CACS remains the most accurate score.