Distribution of Cervicocephalic Atherosclerotic Lesions and Their Correlation with Cardiovascular Risk Factors in a Population of Amerindians. The Atahualpa Project

Neuroimaging investigation of the intracranial vasculature is warranted in older adults with lacunes of presumed vascular origin

BACKGROUND AND PURPOSE

Lacunes of presumed vascular origin are perceived as biomarkers of cerebral small vessel disease (cSVD), although they may also be related to other pathogenetic mechanisms. We aimed to assess whether lacunes are more often associated with intracranial artery stenosis (IAS) than with white matter hyperintensities (WMH) of presumed vascular origin (a biomarker of cSVD) in older adults.

METHODS

This study included 585 individuals aged ≥60 years living in rural Ecuador. Logistic regression models were fitted to assess the strength of the association between IAS or moderate-to-severe WHM on one side, and lacunes on the other. Mediation analysis was used to estimate the percentage of the effect of IAS on lacunes that was mediated by WMH.

RESULTS

Lacunes were noticed in 62 (11%) individuals, IAS in 39 (7%), and moderate-to-severe WMH in 169 (29%). Fourteen of 39 individuals (36%) with IAS had lacunes, which corresponded to the territory of the stenotic artery in 50% of cases. Lacunes have a larger association with IAS than with moderate-to-severe WMH. The estimated prevalence rate of lacunes independently of any confounder was 10.6% (95% C.I.: 8.3-12.9%), which increased to 22.2% in subjects with IAS, but only to 16.4% among those with moderate-to-severe WMH. Only 24.5% of the effect of IAS on lacunes was mediated by WMH.

CONCLUSION

Lacunes are more often associated with IAS than with WMH at the population level. Neuroimaging investigation of the intracranial vasculature in individuals with lacunes will provide informed-based decisions for secondary stroke prevention.

Arterial stiffness and progression of white matter hyperintensities of presumed vascular origin in community-dwelling older adults of Amerindian ancestry: The Atahualpa Project Cohort

OBJECTIVE

Arterial stiffness - as measured by the aortic pulse wave velocity (aPWV) - has been associated with biomarkers of cerebral small vessel disease (cSVD), in particular with white matter hyperintensities (WMH) of presumed vascular origin. Most studies have been conducted in White and Asian populations, and information on this relationship in other ethnic groups is limited. We designed a longitudinal prospective study to assess the impact of aPWV on WMH progression in individuals of Amerindian ancestry.

PATIENTS AND METHODS

Participants of the Atahualpa Project Cohort were assessed at baseline with aPWV determinations, clinical interviews and brain MRIs. At the end of the study, brain MRIs were repeated in order to ascertain WMH progression. Poisson regression models adjusted for demographics and cardiovascular risk factors were fitted to assess WMH progression incidence rate by baseline levels of aPWV.

RESULTS

The study included 260 individuals aged ≥60 years (mean age: 65.6 ± 6.1 years; 57 % women). The mean aPWV was 9.9 ± 1.5 m/s. Follow-up MRIs revealed WMH progression in 102 (39 %) individuals after a mean follow-up of 6.5 ± 1.4 years. Unadjusted analysis showed a higher baseline aPWV among subjects that developed WMH progression compared with those who did not (p < 0.001). Multivariate Poisson regression models showed an increased WMH progression rate among individuals in the second (IRR: 2.06; 95 % C.I.: 1.09-3.88) and third (IRR: 2.75; 95 % C.I.: 1.29-5.87) tertiles of aPWV compared with those in the first tertile.

CONCLUSIONS

aPWV is associated with WMH progression, suggesting a link between atherosclerosis and cSVD in the study population.

Risk for Subsequent SARS-CoV-2 Infection and Severe COVID-19 Among Community-Dwellers With Pre-Existing Cervicocephalic Atherosclerosis: A Population-Based Study

BACKGROUND

COVID-19 patients may develop atherosclerosis-related complications. Whether a proportion of these patients already had asymptomatic cervicocephalic atherosclerosis before SARS-CoV-2 infection is not known. This study assessed whether pre-existing cervicocephalic atherosclerosis increased the susceptibility to SARS-CoV-2 infection or resulted in more severe or fatal COVID-19.

METHODS

Individuals enrolled in the Atahualpa Project cohort who received head CT (for assessing carotid siphon calcifications) and B-mode ultrasounds (for measurement of the carotid intima-media thickness) prior to the pandemic were eligible for this study. Among this cohort, those who also received serological tests for detection of SARS-CoV-2 antibodies and clinical evaluations for assessment of COVID-19 severity were enrolled. Multivariate logistic regression and exposure-effect models were fitted to assess the association between pre-existing atherosclerosis biomarkers, and SARS-CoV-2 seropositivity and COVID-19 severity.

RESULTS

Overall, 154 of 519 study participants (30%) had evidence of cervicocephalic atherosclerosis. A total of 325 (63%) individuals became SARS-CoV-2 positive, and 65 (23.5%) of seropositive individuals had severe or fatal COVID-19. The risk of SARS-CoV-2 seropositive status did not differ across individuals with and without atherosclerosis biomarkers (P = .360). Likewise, seropositive individuals with pre-existing atherosclerosis were not more prone to develop severe or fatal COVID-19 than those without evidence of atherosclerosis (P = .274). Average estimated exposure effects of pre-existing cervicocephalic atherosclerosis versus no atherosclerosis over SARS-CoV-2 seropositivity and COVID-19 severity were not significant.

CONCLUSIONS

Pre-existing cervicocephalic atherosclerosis does not increase the risk of acquiring SARS-CoV-2 infection nor the severity of COVID-19 among seropositive individuals.

Height is Inversely Associated with Biomarkers of Intracranial Atherosclerotic Disease in Older Adults of Amerindian Ancestry: Exploring the Obesity Paradox

BACKGROUND

Various anthropometric measurements have been inversely associated with atherosclerosis, giving rise to the concept of an "obesity paradox" However, inconsistent study results make it difficult to determine the best anthropometric measurement with which to assess such inverse relationship. Height has been inversely associated with atherosclerosis and it is unlikely to be associated with unexpected biases. In this study, we aimed to assess the association between height and other anthropometric measurements and intracranial atherosclerotic disease (ICAD).

METHODS

Community-dwelling older adults enrolled in the Three Villages Study received anthropometric measurements, high-resolution head CT (to evaluate calcium content in carotid siphons) and time-of-flight MRA (to assess stenosis of large intracranial arteries). Logistic regression models were fitted to assess the independent association between each anthropometric measurements and the presence of ICAD, after adjusting for relevant confounders. Estimated adjusted proportions were used to show how increases of different anthropometric measurements impacted ICAD log odds and corresponding odds ratios.

RESULTS

A total of 581 individuals were enrolled. Height was the single variable inversely associated with ICAD at the mean of other anthropometric measurements (OR: 0.954; 95% C.I.: 0.918 - 0.991; p=0.016). Every additional cm of height reduced by 4.6% the probability of having ICAD. The significance of other anthropometric measurements vanished in multivariate models with height as an independent variable.

CONCLUSIONS

This study demonstrates a robust inverse association between height and ICAD in Amerindians and opens new avenues of research for a better understanding of the obesity paradox in diverse ethnic groups.

Risk factors for calcification of the vertebrobasilar arteries in cardiovascular patients referred for a head CT, the SMART study

BACKGROUND AND PURPOSE

Vertebrobasilar artery calcification (VBAC) has been associated with increased stroke occurrence. Little is known on VBAC risk factors, especially for patients with cardiovascular disease. We aimed to assess risk factors associated with VBAC in a cohort of cardiovascular patients referred for a head computed tomography (CT) scan.

MATERIALS AND METHODS

All patients who underwent a clinically indicated, unenhanced, thin slice head CT 6 months before or after inclusion in the SMART study were included. CTs were assessed for presence of VBAC (dichotomously). Relative risks of the associations of age, sex, diabetes mellitus (DM), obesity, body mass index, estimated glomerular filtration rate, hypertension, hyperlipidemia, use of lipid lowering medication, smoking status, high sensitivity C-reactive protein, ankle-brachial index (ABI; ≤0.90, ≥1.30, continuous), internal carotid artery stenosis ≥70%, and carotid intima-media thickness (IMT) with VBAC were estimated using Poisson regression analysis with robust standard errors, adjusted for age and sex.

RESULTS

Of the 471 patients included (57% male, median age 58 [interquartile range 47-63]), 117 (24.8%) showed VBAC. Presence of VBAC was associated with older age (RR per 10 years=1.70 [95%CI 1.46-1.99]), DM (RR=1.45 [95%CI 1.03-2.06]), obesity (RR=1.53 [95%CI 1.10-2.12]), ABI ≤0.90 (RR=1.57 [95%CI 1.02-2.41]), and an increased carotid IMT (RR=2.60 per mm [95%CI 1.20-5.62]). Other measurements were not associated with VBAC.

CONCLUSIONS

We identified several markers associated with VBAC in patients with cardiovascular disease referred for a head CT. Future investigation into the relationship between VBAC and stroke is warranted to determine the potential of VBAC in stroke prevention.

On the association between earlobe crease and the carotid intima-media thickness: A population-based study

The earlobe crease (ELC) has been linked to coronary artery disease, but there is limited information on the association between ELC and extracranial atherosclerosis. Using the Atahualpa Project cohort, we aimed to assess the association between ELC and increased carotid intima-media thickness (cIMT). Atahualpa residents aged ≥40 years underwent visual inspection of both earlobes to evaluate ELC presence, and ultrasound examinations of carotid arteries to calculate the cIMT. The association between both variables was assessed by logistic regression and predictive models, after adjusting for relevant confounders. Mean age of 570 enrolled individuals was 61.5 ± 12.4 years (58% women). ELC was present in 221 (39%) participants. The mean cIMT was 0.85 ± 0.19 mm, with 81 individuals (14%) having an increased cIMT (>1 mm). Univariate logistic regression showed a significant association between ELC presence and increased cIMT (OR: 1.67; 95% C.I.: 1.04-2.69), which disappeared when age (OR: 1.09; 95% C.I.: 0.65-1.85) and other covariables (OR: 1.06; 95% C.I.: 0.62-1.84) were added to the model. Predictive cIMT margins did not differ according to ELC presence or absence, with participants stratified in quartiles of age. This study shows that the effect of the increase in cIMT in subjects with ELC is related to aging.

Sleep quality correlates with the carotid intima-media thickness in stroke-free community-dwelling adults living in rural Ecuador. The Atahualpa Project

BACKGROUND/OBJECTIVES

Evidence of an association between sleep disorders and extracranial atherosclerosis is limited and has not been studied in remote rural settings, where living conditions and cardiovascular risk factors are different than in urban centers. We assessed the relationship between the carotid intima-media thickness (cIMT) and sleep quality in stroke-free individuals aged ≥40 years living in rural Ecuador.

METHODS

Applying a population-based study design, participants underwent face-to-face interviews using the Pittsburgh Sleep Quality Index (PSQI) to assess sleep quality, and sonographic examinations for measurement of the carotid intima-media thickness (cIMT). The association between the cIMT and sleep quality (as the dependent variable) was assessed by means of generalized linear models, adjusted for relevant confounders.

RESULTS

The mean age of 561 participants was 60.4 ± 12.6 years (58% women). The mean PSQI was 4.6 ± 2.2 points. Of those, 79 (14%) individuals had an increased cIMT (>1 mm). A model adjusted for demographics showed a significant association between increased cIMT and the PSQI score (β: 0.602; 95% C.I.: 0.027-1.177; p = 0.040). This relationship was reduced when cardiovascular risk factors were added to the model (β: 0.514; 95% C.I.: -0.072 - 1.101; p = 0.086). When the model was adjusted for demographics and psychological distress, the association between increased cIMT and the PSQI score became significant (β: 0.573; 95% C.I.: 0.013-1.133; p = 0.045). In addition, both symptoms of depression (p = 0.032) and anxiety (p < 0.001) remained independently significant.

CONCLUSIONS

This study shows an association between increased cIMT and the PSQI score, which is, at least, partly mediated by manifestations of psychological distress.

No association between the abdominal aorta diameter and cervicocephalic atherosclerosis-Potential non-atherosclerotic origins of abdominal aorta aneurysms?

The atherosclerotic origin of abdominal aorta (AA) aneurysms is controversial. Using the Atahualpa Project Cohort, we aimed to assess the relationship between the AA diameter and two surrogates of cervicocephalic atherosclerosis, including the carotid intima-media thickness (cIMT) and the presence of carotid siphon calcifications (CSC). Atahualpa residents aged ≥60 years undergoing ultrasound examinations of the abdominal aorta and the carotid arteries (to calculate the AA diameter and the cIMT), and head CT (to assess CSC severity) were included. Associations between AA diameter and cIMT and CSC severity were assessed by generalized linear models, after adjusting for relevant confounders. Of 256 participants, 64 (25%) had an increased cIMT and 85 (33%) had high calcium content in the carotid siphons. In univariate analysis, being male (p < 0.001) and having total cholesterol blood levels <240 mg/dL (p = 0.022) were associated with a higher AA diameter. Also in univariate analysis, the mean AA diameter was higher in individuals with an increased cIMT (p = 0.021), but such association disappeared in adjusted models. The AA diameter was not associated with high calcium content in the carotid siphons in either univariate or multivariate analyses. This population study shows no association between the AA diameter and cervicocephalic atherosclerosis in community-dwelling older adults, suggesting a non-atherosclerotic origin of AA aneurysms.