Focused screening for occult carotid artery disease: patients with known heart disease are at high risk

Supermarket/hypermarket opportunistic screening for atrial fibrillation (SHOPS-AF) using sensors embedded in the handles of supermarket trolleys: A feasibility study

BACKGROUND

Atrial fibrillation (AF) increases the risk of death, stroke, heart failure, cognitive decline, and healthcare costs but is often asymptomatic and undiagnosed. There is currently no national screening program for AF. The advent of validated hand-held devices allows AF to be detected in non-healthcare settings, enabling screening to be undertaken within the community.

METHOD AND RESULTS

In this novel observational study, we embedded a MyDiagnostick single lead ECG sensor into the handles of shopping trolleys in four supermarkets in the Northwest of England: 2155 participants were recruited. Of these, 231 participants either activated the sensor or had an irregular pulse, suggesting AF. Some participants agreed to use the sensor but refused to provide their contact details, or consent to pulse assessment. In addition, some data were missing, resulting in 203 participants being included in the final analyses. Fifty-nine participants (mean age 73.6 years, 43% female) were confirmed or suspected of having AF; 20 were known to have AF and 39 were previously undiagnosed. There was no evidence of AF in 115 participants and the remaining 46 recordings were non-diagnostic, mainly due to artefact. Men and older participants were significantly more likely to have newly diagnosed AF. Due to the number of non-diagnostic ECGs (n = 46), we completed three levels of analyses, excluding all non-diagnostic ECGs, assuming all non-diagnostic ECGs were masking AF, and assuming all non-diagnostic ECGs were not AF. Based on the results of the three analyses, the sensor's sensitivity (95% CI) ranged from 0.70 to 0.93; specificity from 0.15 to 0.97; positive predictive values (PPV) and negative predictive values (NPV) ranged from 0.24 to 0.56 and 0.55 to 1.00, respectively. These values should be interpreted with caution, as the ideal reference standard on 1934 participants was imperfect.

CONCLUSION

The study demonstrates that the public will engage with AF screening undertaken as part of their daily routines using hand-held devices. Sensors can play a key role in identifying asymptomatic patients in this way, but the technology must be further developed to reduce the quantity of non-diagnostic ECGs.

The quick carotid scan for prevention of strokes due to carotid artery disease

There are approximately 800,000 strokes in the United States (U.S.) annually. This number has remained the same for decades despite efforts at prevention. The Center for Disease Control (CDC) estimates that 80% of strokes could be prevented. A prime reason for failure of prevention is that the three immediate modifiable causes of strokes, carotid artery disease (CAD), atrial fibrillation (AFib), and hypertension (HTN) are asymptomatic in 80% of cases prior to the stroke. Strokes occur predominantly in seniors and the only possible means of reducing strokes on a large scale is to screen seniors for the asymptomatic disease so that it can be preemptively managed. We present a quick, accurate and cost-effective method of screening the senior population for asymptomatic carotid disease. The technique is a quick carotid scan (QCS). The QCS is a 1-minute long, image only, rapid, color flow ultrasound scan of the cervical carotid arteries that had a sensitivity of 97% when evaluated at New York University (NYU). Once identified by the QCS the approximately 8% of those screened found to have a positive QCS can then be referred for a full carotid duplex ultrasound (DUS). Those patients with a positive DUS can then be referred for further evaluation and appropriate stroke prevention management. The use of a full carotid DUS for screening widely for carotid disease is too time consuming and too costly. Approximately 160,000 or nearly 20% of the 800,000 strokes that occur annually in the U.S. are due to CAD that could in large part be prevented by screening the senior population with the QCS, finding those with CAD, evaluating them, and preemptively managing them prior to the occurrence of the stroke

A Systematic Review Supporting the Society for Vascular Surgery Guidelines on the Management of Carotid Artery Disease

BACKGROUND

To support the development of guidelines on the management of carotid disease, a writing committee from the Society for Vascular Surgery has commissioned this systematic review.

METHODS

We searched multiple data bases for studies addressing 5 questions: medical management vs. carotid revascularization (CEA) in asymptomatic patients, CEA vs. CAS in symptomatic low surgical risk patients, the optimal timing of revascularization after acute stroke, screening high risk patients for carotid disease, and the optimal sequence of interventions in patients with combined coronary and carotid disease. Studies were selected and appraised by pairs of independent reviewers. Meta-analyses were performed when feasible.

RESULTS

Medical management compared to carotid interventions in asymptomatic patients was associated with better early outcome during the first 30 days. However, CEA was associated with significantly lower long-term rate of stroke/death at 5 years. In symptomatic low risk surgical patients, CEA was associated with lower risk of stroke, but a significant increase in MI compared to CAS during the first 30 days. When the long-term outcome of transfemoral CAS vs. CEA in symptomatic patients were examined using pre-planned pooled analysis of individual patient data from four randomized trials, the risk of death or stroke within 120 days of the index procedure was 5.5% for CEA and 8.7% for CAS, which lends support that over the long-term, CEA has superior outcome than transfemoral CAS. When managing acute stroke, the comparison of CEA during the first 48 hours to that between day 2 and day14 did not reveal a statistically significant difference on outcomes during the first 30 days. Registry data show good results with CEA performed in the first week, but not within the first 48 hours. A single risk factor, aside from PAD, was associated with low carotid screening yield. Multiple risk factors greatly increase the yield of screening. Evidence on the timing of interventions in patients with combined carotid and coronary disease was sparse and imprecise. Patients without carotid symptoms, who had the carotid intervention first, compared to a combined carotid intervention and CABG, had better outcomes.

CONCLUSIONS

This updated evidence summary will support the SVS clinical practice guidelines for commonly raised clinical scenarios. CEA was superior to medical therapy in long-term prevention of stroke/death over medical therapy. CEA was also superior to transfemoral CAS in minimizing long-term stroke/death for symptomatic low risk surgical patients. CEA should optimally be performed between 2-14 days from the onset of acute stroke. Having multiple risk factors increases the value of carotid screening.

SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE

Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.

Association Between the Atherosclerotic Disease Risk Score and Carotid Artery Stenosis

BACKGROUND

Carotid artery stenosis (CAS) is the most frequently detected treatable cause of ischemic stroke. However, there are no recommendations to screen asymptomatic patients. The atherosclerotic cardiovascular disease (ASCVD) risk score estimates individuals' 10-year risk for developing cardiovascular disease. The objective of this study is to identify a relationship between the ASCVD risk score and moderate/severe CAS based on ultrasound findings.

MATERIALS AND METHODS

We performed a single-institution retrospective review of patients who underwent a surveillance ultrasound for CAS between 2015 and 2018. We used Strandness velocity criteria to separate patients into two cohorts: none to mild CAS (<50%) and moderate/severe CAS (≥50%). We performed Student's t-test, multivariate analysis, and receiver operator characteristic (ROC) curve analysis to determine a relationship between the ASCVD risk score and degree of CAS. We evaluated a new risk score model based on stepwise logistic regression of significant variables on univariate analysis.

RESULTS

Two thousand eight hundred and fifty-six patients with carotid ultrasounds (1623 with none to mild, 1161 with moderate, and 72 with severe disease) were included in the study. The ASCVD risk score significantly predicted moderate/severe CAS in an adjusted multivariate analysis. Each 10% increase in the ASCVD risk score corresponded to an additional 11% likelihood of moderate/severe stenosis (OR: 1.11 [1.04-1.20], P = 0.004). The ROC area under the curve for predicting moderate/severe CAS based on the ASCVD risk score was 0.59 (Youden index (J) = 0.14); the optimized ASCVD cutoff point was 28.4%. Our new atherosclerotic disease model demonstrated increased odds of moderate/severe CAS with scores greater than zero (ROC area under the curve = 0.57).

CONCLUSIONS

This is the first study to demonstrate an association between atherosclerotic disease risk factors as measured by the ASCVD risk score and moderate/severe CAS. However, this tool is not sensitive or specific for using the ASCVD risk score as a screening mechanism for moderate/severe CAS.

Assesment of Carotid Stenosis with CT Angiography and Color Doppler Ultrasonography

Introduction:

Color Doppler and CT angiography are diagnostic methods commonly used to determine the degree of carotid stenosis.

Aim:

To evaluate how the degree of carotid stenosis determined by the Color Doppler correlates with the degree of stenosis determined by the CT angiography.

Material and Methods:

The study was designed as a retrospective study. It included 42 patients with carotid stenosis. From medical records we collected anamnestic data (gender, age and risk factors - hypertension, hyperlipidemia, diabetes, smoking and obesity) and the results regarding the degree of carotid stenosis determined by Color Doppler and CT angiography.

Results:

Out of the total number of patients (n=42), 73.8% were males and 26.2% were females. Average age of examined patients was 65.24±8.61. Most frequent risk factor of atherosclerosis was hypertension, followed by hyperlipidemia and smoking. NASCET grading distinguishes: first (0-29%), second (30-69%) and third (70-99%) degree of carotid stenosis. According to the Color Doppler evaluation findings, the second degree had 8 patients and 34 patients had the third degree of carotid stenosis. CT angiography have shown that 35 patients had third degree carotid stenosis, while 7 patients had the second degree carotid stenosis. In only one case results of evaluated methods differed regarding assessment of carotid stenosis. We have found that there is a significant positive correlation of the degree of carotid stenosis determined by the Color Doppler with the degree of stenosis determined by CT angiography (p=0.0002). Risk factors of atherosclerosis did not have a significant correlation with the degree of carotid stenosis (p>0.05).

Conclusion:

The degree of carotid stenosis estimated by the Color Doppler positively correlates with the degree of stenosis estimated by CT angiography.

Validation of Risk Prediction Models to Detect Asymptomatic Carotid Stenosis

Background Significant asymptomatic carotid stenosis (ACS) is associated with higher risk of strokes. While the prevalence of moderate and severe ACS is low in the general population, prediction models may allow identification of individuals at increased risk, thereby enabling targeted screening. We identified established prediction models for ACS and externally validated them in a large screening population. Methods and Results Prediction models for prevalent cases with ≥50% ACS were identified in a systematic review (975 studies reviewed and 6 prediction models identified [3 for moderate and 3 for severe ACS]) and then validated using data from 596 469 individuals who attended commercial vascular screening clinics in the United States and United Kingdom. We assessed discrimination and calibration. In the validation cohort, 11 178 (1.87%) participants had ≥50% ACS and 2033 (0.34%) had ≥70% ACS. The best model included age, sex, smoking, hypertension, hypercholesterolemia, diabetes mellitus, vascular and cerebrovascular disease, measured blood pressure, and blood lipids. The area under the receiver operating characteristic curve for this model was 0.75 (95% CI, 0.74-0.75) for ≥50% ACS and 0.78 (95% CI, 0.77-0.79) for ≥70% ACS. The prevalence of ≥50% ACS in the highest decile of risk was 6.51%, and 1.42% for ≥70% ACS. Targeted screening of the 10% highest risk identified 35% of cases with ≥50% ACS and 42% of cases with ≥70% ACS. Conclusions Individuals at high risk of significant ACS can be selected reliably using a prediction model. The best-performing prediction models identified over one third of all cases by targeted screening of individuals in the highest decile of risk only.

Management of Asymptomatic Carotid Artery Stenosis

PURPOSE OF REVIEW

The goal of this paper is to provide the reader with a review of the evidence supporting the surgical and medical management of patients with asymptomatic internal carotid artery (ICA) stenosis.

RECENT FINDINGS

Based on the results of earlier clinical trials, surgical intervention with carotid endarterectomy (CEA) has long been the preferred method of management for patients with asymptomatic severe carotid stenosis. Carotid artery stenting (CAS) is another less invasive surgical option that has similar outcomes over the long-term. However, more recent improvements in medical management have reduced the risk of stroke in this population to comparable rates seen with CEA. As a result, medical management alone is advocated as well for patients with asymptomatic carotid stenosis. In addition to stenosis severity, there are a number of features of plaque morphology associated with vulnerable plaque that predict future stroke risk. Rates of stroke in patients with asymptomatic severe carotid stenosis with modern surgical techniques, CEA and CAS, are similar to modern medical therapy alone. Both surgery and medical therapy are good treatment options but it is not known which treatment is superior. The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2), an NIH-sponsored, multicenter, randomized trial that aims to answer this important management decision.

Effectiveness of screening for atrial fibrillation and its determinants. A meta-analysis

Background

Many atrial fibrillation patients eligible for oral anticoagulants are unaware of the presence of AF, and improved detection is necessary to facilitate thromboprophylaxis against stroke.

Objective

To assess the effectiveness of screening for AF compared to no screening and to compare efficacy outcomes of different screening strategies.

Materials and methods

Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE from Jan 1, 2000 –Dec 31, 2015 were searched. Studies employing systematic or opportunistic screening and using ECG or pulse palpation in populations age ≥40 years were included. Data describing study and patient characteristics and number of patients with new AF were extracted. The outcome was the incidence of previously undiagnosed AF.

Results

We identified 25 unique (3 RCTs and 22 observational) studies (n = 88 786) from 14 countries. The incidence of newly detected AF due to screening was 1.5% (95% CI 1.1 to 1.8%). Systematic screening was more effective than opportunistic: 1.8% (95% CI 1.4 to 2.3%) vs. 1.1% (95% CI 0.6 to 1.6%), p<0.05, GP-led screening than community based: 1.9% (95% CI 1.4 to 2.4%) vs. 1.1% (95% CI 0.7 to 1.6%), p<0.05, and repeated heart rhythm measurements than isolated assessments of rhythm: 2.1% (95% CI 1.5–2.8) vs. 1.2% (95% CI 0.8–1.6), p<0.05. Only heart rhythm measurement frequency had statistical significance in a multivariate meta-regression model (p<0.05).

Conclusions

Active screening for AF, whether systematic or opportunistic, is effective beginning from 40 years of age. The organisation of screening process may be more important than technical solutions used for heart rhythm assessment.

Evaluation of the relationship between plaque formation leading to symptomatic carotid artery stenosis and cytomegalovirus by investigating the virus DNA

Introduction

The most common etiologic factor of coronary artery disease (CAD), carotid artery disease, and peripheral artery disease is atherosclerosis. In our study, we aimed to show the effect of cytomegalovirus (CMV), which can occur almost everywhere in the human body, on triggering the chronic inflammatory process in the pathophysiology of atherosclerosis, and its presence and impact in the plaques leading to carotid artery stenosis.

Material and methods

Thirty-six patients, who underwent carotid endarterectomy at the Department of Cardiovascular Surgery, Istanbul University Istanbul Medical Faculty between April 2017 and April 2018, were included in this study upon their consent. Patients with additional immunosuppressive conditions were not included in the study. Unilateral atheromatous plaque was preferred for patients undergoing bilateral carotid endarterectomy and all risk factors (DM, HT, hyperlipidemia, etc.) were evaluated together for all patients.

Results

When the relationship between CMV (DNA) presence in samples taken from patients' plaques and sex, age and comorbidities was examined, CMV (DNA) positivity (45.8%) was significantly higher in DM patients than non-DM patients (8.3%) (p = 0.024). Likewise, CMV(DNA) positivity (40%) was significantly higher in HT patients than in non-HT patients (25%) (p = 0.008). CMV(DNA) positivity (63%) was significantly higher in patients with bilateral carotid artery stenosis than patients without bilateral carotid artery stenosis (0%) (p < 0.001).

Conclusions

It has not yet been clarified whether CMV is a primary trigger for atherosclerosis on the vascular wall, or whether it presents incidentally due to its affinity. When CMV (DNA) positivity was examined according to the presence of bilateral carotid artery stenosis in our study, CMV (DNA) positivity was found to be significantly higher in patients with bilateral carotid artery stenosis (63.16%).

The American Vascular Association Screening Program: Rationale, Method, Guidelines, and Progress

Introduction

The Society of Vascular Surgery, in partnership with the Society for Vascular Ultrasound (SVU), established a National Vascular Screening Program thru the American Vascular Association (AVA). The program screens for the immediate causes of stroke, abdominal aortic aneurysms (AAA), and peripheral vascular disease. Detection of these conditions while the patient still is asymptomatic allows for early management and avoidance of the devastating events they can cause.

Methods

A quick carotid scan is used for detection of carotid artery disease, an EKG rhythm strip for atrial fibrillation, blood pressure determination for hypertension, a quick abdominal scan for AAA, and ankle/brachial indices for peripheral vascular disease. The SVU position on screening, recommending credentialed technologists and accredited laboratories, is used in the AVA screening program, and reporting only the presence or absence of disease has been recommended.

Results

The AVA program, and three other programs reported, screened 6,073 seniors. It is estimated that the carotid screenings alone prevented 30 strokes and saved $12,061,400,000 in stroke costs.

Conclusion

The AVA screening program, with quality ensured by the SVU guidelines, has the potential to prevent a major number of strokes and deaths. Recommendation is for extension of the screening program and for efforts to obtain Medicare funding for the screening.

Risk Focused Screening for Vascular Disease: One University Hospital's Experience

Introduction

Vascular screening programs have been gaining popularity in recent years; however, most programs accept all patients willing to participate. This study was designed to determine the yield of disease when screening examinations are limited to those most at risk, to stratify the amount of disease present in the at-risk population, and to establish which patients might benefit most from vascular screening.

Materials and Methods

Patients enrolled in a community outreach program for seniors 55 years of age and older were asked to participate in a free vascular screening. Screenings consisted of completion of a questionnaire, physical examination, limited carotid artery evaluation for stenosis, aorta evaluation for detection of aneurysm, and ankle/brachial index (ABI) calculation to detect peripheral vascular disease. Findings were grouped into “Normal,” “Mild disease,” and “Significant disease.” Findings were then compared with the following controllable risk factors: hypertension, hyperlipidemia, diabetes, coronary artery disease (CAD), or smoking history.

Results

Between May 16 and October 17, 2007, 357 participants' (75 male, 157 female, mean age 72.9 years) results were analyzed. Overall, 140 participants (43%) had some form of vascular disease (“mild” and “significant” categories combined). Of 324 eligible participants, carotid findings showed 199 normal (61%), 104 mild (32%), and 21 significant (7%) results. Aorta findings showed 296 normal (91%), 25 mild (8%), and 3 significant (1%) results. ABI findings showed 278 normal (86%), 18 mild (6%), and 28 significant (8%) results. In participants with three or more risk factors, there was a greater probability that carotid ( p = 0.0022) and peripheral vascular disease ( p = 0.0003) would be detected; however, there was no predictive value for aortic aneurysm ( p = 0.5).

Conclusion

Vascular screening programs focusing on the at-risk population may reduce unnecessary testing compared with programs evaluating all patients willing to participate.

Type-2 diabetes and carotid stenosis: a proposal for a screening strategy in asymptomatic patients

The objective of this prospective observational study was to establish the prevalence of carotid atherosclerosis in an asymptomatic diabetic population and to determine predictive factors for a screening optimization. A total of 300 consecutive type-2 diabetic subjects (166 males, 134 females) underwent a physical examination and duplex carotid scanning. Patients with a recent cerebrovascular event (±6 weeks) or previous carotid surgery were excluded. The prevalence of carotid stenosis ≥60% or occlusion was 4.7%; the prevalence of carotid atherosclerosis was 68.3%. Risk factors for stenosis ≤60% or occlusion were the presence of diabetic retinopathy (OR: 3.62; 95% CI: 1.12-11.73), ankle-brachial index (ABI) <0.85 (OR: 3.94; 95% CI: 1.21-12.84) and a personal history of neurological disorders (OR: 4.54; 95% CI: 1.16-17.81). Being female was a protective factor (OR: 0.09; 95% CI: 0.01-0.78). The two factors in the analysis limited to the male population were an ABI < 0.85 (OR: 3.66; 95% CI: 1.04-12.84) and a personal history of coronary heart disease (OR: 3.34; 95% CI: 1.01-11.01). If male diabetics without either of these two factors are excluded, the negative predictive value for carotid stenosis is 96.6%. In conclusion, the prevalence of atherosclerotic carotid disease in diabetic patients is high. In these patients, the probability of finding >60% stenosis is highest among men with a history of coronary heart disease or an ABI <0.85.

Vessel Wall Imaging of the Intracranial and Cervical Carotid Arteries

Vessel wall imaging can depict the morphologies of atherosclerotic plaques, arterial walls, and surrounding structures in the intracranial and cervical carotid arteries beyond the simple luminal changes that can be observed with traditional luminal evaluation. Differentiating vulnerable from stable plaques and characterizing atherosclerotic plaques are vital parts of the early diagnosis, prevention, and treatment of stroke and the neurological adverse effects of atherosclerosis. Various techniques for vessel wall imaging have been developed and introduced to differentiate and analyze atherosclerotic plaques in the cervical carotid artery. High-resolution magnetic resonance imaging (HR-MRI) is the most important and popular vessel wall imaging technique for directly evaluating the vascular wall and intracranial artery disease. Intracranial artery atherosclerosis, dissection, moyamoya disease, vasculitis, and reversible cerebral vasoconstriction syndrome can also be diagnosed and differentiated by using HR-MRI. Here, we review the radiologic features of intracranial artery disease and cervical carotid artery atherosclerosis on HR-MRI and various other vessel wall imaging techniques (e.g., ultrasound, computed tomography, magnetic resonance, and positron emission tomography-computed tomography).

Pathophysiology and Medical Treatment of Carotid Artery Stenosis

Stroke is the third leading cause of mortality. Approximately 80 to 85% strokes are ischemic due to carotid artery stenosis (CAS). The prevalence of significant CAS is 7% in women and 9% in men. Severe asymptomatic CAS varies from 0 to 3.1%. Prevalence of symptomatic CAS is high in patients with peripheral arterial disease. CAS is due to atherosclerosis, the major risk factors for which include dyslipidemia, hypertension, diabetes, obesity, cigarette smoking, advanced glycation end products (AGEs) and its receptors (RAGE, soluble RAGE [sRAGE]), lack of exercise and C-reactive protein (CRP). This article discusses the basic mechanism of atherosclerosis and the mechanisms by which these risk factors induce atherosclerosis. The role of AGEs and its receptors in the development and progression of CAS has been discussed in detail. Lifestyle changes and medical treatment of CAS such as lifestyle changes, lipid-lowering agents, antihypertensive agents, antidiabetic drugs, anti-AGE therapy, measures to elevate soluble receptors of AGE (sRAGE, esRAGE). CRP-lowering agents have been discussed in detail. The drugs especially lipid-lowering agents, and antihypertensive and antidiabetic drugs suppress, regress, and slow the progression of CAS. The possible role of lowering the levels of AGEs and raising the levels of sRAGE in the treatment of CAS has been proposed. Lifestyle changes besides medical treatment have been stressed. Lifestyle changes and medical treatment not only would slow the progression of CAS but would also regress the CAS.

[A role of carotid endarterectomy in prevention of cerebral ischemic damage]

Authors present a literature review on the prevalence, clinical presentations, diagnosis and outcome of surgical treatment of atherosclerotic stenosis of the internal carotid artery.

Carotid stenosis: what is the high-risk population?

OBJECTIVE

Prevention is the best treatment for cerebrovascular disease, which is why early diagnosis and the immediate treatment of carotid stenosis contribute significantly to reducing the incidence of stroke. Given its silent nature, 80% of stroke cases occur in asymptomatic individuals, emphasizing the importance of screening individuals with carotid stenosis and identifying high-risk groups for the disease. The aim of this study was to determine the prevalence and the most frequent risk factors for carotid stenosis.

METHODS

A transversal study was conducted in the form of a stroke prevention campaign held on three nonconsecutive Saturdays. During the sessions, carotid stenosis diagnostic procedures were performed for 500 individuals aged 60 years or older who had systemic arterial hypertension and/or diabetes mellitus and/or coronary heart disease and/or a family history of stroke.

RESULTS

The prevalence of carotid stenosis in the population studied was 7.4%, and the most frequent risk factors identified were mean age of 70 years, carotid bruit, peripheral obstructive arterial disease, coronary insufficiency and smoking. Independent predictive factors of carotid stenosis include the presence of carotid bruit or peripheral obstructive arterial disease [corrected] and/or coronary insufficiency.

CONCLUSIONS

The population with peripheral obstructive arterial disease [corrected] and/or coronary insufficiency and carotid bruit should undergo routine screening for carotid stenosis.

Carotid endarterectomy: still the standard of care for carotid bifurcation disease

Current treatment guidelines of symptomatic and asymptomatic carotid stenosis are based on studies performed over a decade ago. Since that time, significant advances have been made in medical management, namely high dose statin therapy and improved antiplatelet agents, and in carotid interventions, namely the advent of carotid artery stenting. Especially with carotid stenting, the technology has grown by leaps and bounds and continues to advance at a rapid pace. These advances have necessitated new studies to compare these treatments with the gold standard of carotid endarterectomy. In asymptomatic patients, the current data does not justify medical management alone for severe (>80%) carotid stenosis. Furthermore, in both asymptomatic and symptomatic patients current studies have failed to demonstrate equivalence of CAS to CEA for significant carotid stenosis. Clearly additional studies comparing CAS, CEA, and medical management are needed to further clarify this issue. In the future, advances in CAS technology and techniques may greatly expand the role of CAS beyond its current role in certain high-risk patient subsets. However, for the time being CEA still remains the gold standard for carotid intervention.

Percutaneous versus surgical revascularization for symptomatic carotid artery disease

Stroke is the third leading cause of death worldwide and the number one disease associated with permanent disability. In 2006, the estimated total cost of stroke in the United States was a staggering $60 billion. Significant stenosis of the internal carotid artery is responsible for 10% to 20% of all strokes, and current recommendations suggest that patients with symptomatic carotid artery stenosis undergo revascularization for stroke prevention or risk reduction. Since the 1950s, carotid endarterectomy (CEA) has been the dominant modality of revascularization. However, carotid artery angioplasty, introduced in the 1980s, and subsequent carotid artery stenting (CAS), have greatly improved in recent years and provide a viable alternative to CEA, particularly for certain high-risk patients. Encouraging results from clinical studies of CAS and CEA have played pivotal roles in shaping current practice guidelines. We review the published studies on CAS and discuss appropriate use of this procedure for symptomatic carotid artery disease.

Carotid artery intima-media thickness, carotid plaque and coronary heart disease and stroke in Chinese

Background

Our aim was to prospectively investigate the association between carotid artery intima-media thickness (IMT) as well as carotid plaque and incidence of coronary heart disease (CHD) and stroke in Chinese, among whom data are limited.

Methods and Findings

We conducted a community-based cohort study composed of 2190 participants free of cardiovascular disease at baseline in one community. During a median 10.5-year follow up, we documented 68 new cases of coronary heart disease and 94 cases of stroke. The multivariate relative risks (RRs) associated with a change of 1 standard deviation of maximal common carotid IMT were 1.38 (95% confidence interval [CI], 1.12–1.70) for CHD and 1.47 (95% CI, 1.28–1.69) for stroke. The corresponding RRs with internal carotid IMT were 1.47 (95% CI, 1.21–1.79) for CHD and 1.52 (95% CI, 1.31–1.76) for stroke. Carotid plaque measured by the degree of diameter stenosis was also significantly associated with increased risk of CHD (p for trend<0.0001) and stroke (p for trend<0.0001). However, these associations were largely attenuated when adjusting for IMT measurements.

Conclusions

This prospective study indicates a significant association between carotid IMT and incidence of CHD and stroke in Chinese adults. These measurements may be useful for cardiovascular risk assessment and stratification in Chinese.

Screening for Significant Carotid Artery Disease among a Cohort of 1,000 Egyptian Patients

The objective of this study was to determine the prevalence of significant carotid artery disease (SCAD) in a cohort of Egyptian patients to compare it with matched groups of patients in published data of Western populations. One thousand consecutive patients referred for color flow duplex scanning of the carotid arteries were included. SCAD was defined as carotid stenosis ≥ 50% or occlusion. There were 567 males (56.7%), and the mean age was 60.4 years. There were 382 (38.2%) patients presenting with and 617 (61.7%) patients without specific carotid territory symptoms. SCAD was significantly more prevalent in patients aged ≥ 60 (13.2%, vs 6.25%; p < .001), in symptomatic patients (16.45% vs 6.32%; p < .001), in diabetics (15.96% vs 7.39%; p < .001), in patients with ischemic heart disease (17.65% vs 7.22%; p < .001), in hypertensive patients (12% vs 7.54%; p = .025), and in patients with dyslipidemia (12.53% vs 6.56%; p < .025). The prevalence of SCAD in this cohort of Egyptian patients was similar to that of matched patients of Western populations. Screening for SCAD in patients with specific carotid territory symptoms is recommended. Screening of asymptomatic subjects could be considered if they are ≥ 60 years of age and have three or more associated risk factors.

Medical Benefits of a Peripheral Vascular Screening Program

We present preliminary results and analysis of a screening program that has been offered at a community-based hospital since July 2004. The program includes a quick carotid ultrasound study, abdominal aortic ultrasound imaging, and measurement of bilateral ankle/brachial indices (ABI). From July 2004 through January 2006, 1,719 patients were screened, including 1,094 (64%) women and 652 (36%) men. The majority of carotid screens were normal; however, 28.9% (497 patients) had 15-40% stenosis, 1.4% (24 patients) had 40-60% stenosis, and 0.3% (six patients) had >60% stenosis. Sixteen patients (1%) had infrarenal aortic dilation (>3 cm), and an abnormal ABI (<0.90) was detected in at least one limb in 100 patients (5.8%). No procedures resulted from carotid screening; however, two patients underwent urgent repair for 9.3 and 7.5 cm diameter abdominal aortic aneurysms. Abnormal ABI in conjunction with symptoms led to arteriography in three patients, one of whom had iliac stent deployment. This nonselective vascular screening program attracted many new patients into the health-care system. The open/endovascular procedure yield was low, but early disease detection was significant, causing numerous patients to be referred for additional testing and risk factor modification programs. These preliminary data suggest that community-based vascular screening programs play a key role in early vascular disease detection and provide the potential for prevention of disease progression while, at the same time, building sustainable business for hospitals and physicians.

Guidelines for Screening of Extracranial Carotid Artery Disease: A Statement for Healthcare Professionals from the Multidisciplinary Practice Guidelines Committee of the American Society of Neuroimaging; Cosponsored by the Society of Vascular and Interventional Neurology

The aim of this new statement is to provide comprehensive and timely evidence-based recommendations on the screening for asymptomatic carotid artery stenosis in the general population and selected subsets of patients. Recommendations are included for high-risk persons in the general population; patients undergoing open heart surgery including coronary artery bypass surgery; patients with peripheral vascular diseases, abdominal aortic aneurysms, and renal artery stenosis; patients after radiotherapy for head and neck malignancies; patients following carotid endarterectomy, or carotid artery stent placement; patients with retinal ischemic syndromes; patients with syncope, dizziness, vertigo or tinnitus; and patients with a family history of vascular diseases and hyperhomocysteinemia. The recommendations are based on prevalence of disease, anticipated benefit, and concurrent guidelines from other professional organizations in selected populations.

Whole-body MR vascular screening detects unsuspected concomitant vascular disease in coronary heart disease patients

Coronary heart disease (CHD) patients often show atherosclerotic vascular disease in other vascular territories. We evaluated how often whole-body MR imaging detects concomitant arterial pathologies in CHD patients, and how often these pathologies were not known to the patients previously. Of 4,814 participants in the population-based Heinz Nixdorf Recall Study, 327 reported CHD (i.e., previous coronary bypass surgery, angioplasty); of those, 160 patients (mean age 66.4 years) were examined using MR of the brain, the heart (excluding the coronary arteries), and whole-body MR angiography. The prevalence of each vascular pathology was assessed, correlated to the others and compared to patients' histories. Of the 160 CHD patients, 16 (10%) showed MR signs of stroke, and 77 (48.1%) had a stenosis >50% in at least one extracerebral peripheral artery (other than the coronaries), including 28 (17.5%) with relevant renal artery stenoses, and 20 (12.5%) with relevant extracerebral internal carotid artery stenoses. False negative histories were reported in 12 of 81 cases with myocardial infarctions, and in 11 of 16 cases with cerebrovascular infarctions. This whole-body atherosclerosis MR screening program allows previously unknown concomitant vascular disease to be detected in coronary heart disease patients. Its prospective value should be assessed in further studies.

Detection of carotid stenosis in African Americans with ischemic heart disease

OBJECTIVES

This study was conducted to define the frequency of internal carotid stenosis in African American patients with ischemic heart disease (IHD).

METHODS

We recruited 101 African American patients with IHD from a university medical center for carotid duplex examination.

RESULTS

The frequency of >30%, >50%, and >70% stenosis was 21%, 11%, and 5%, respectively. Age >60 years (21% vs 3%, P < .01) and diabetes mellitus (22% vs 5%, P < .01) were predictors of unilateral stenosis of >50% and remained significant on multivariate testing.

CONCLUSION

African American patients with established IHD have higher rates of extracranial carotid stenosis than community dwelling African American subjects and comparable rates with other populations.

Noninvasive vascular testing--a 35-year reflection

Noninvasive vascular testing has made a major contribution to the care of vascular surgery patients. This article a reflection on a 35-year corroborative association with Doctor Norman Rich, during which many of the advances in noninvasive vascular testing have been witnessed and effected. I served my vascular surgery fellowship under Doctor Rich in 1967-68 at Walter Reed Army Hospital. The only noninvasive vascular equipment then was a pencil probe Doppler. The value of the Doppler in the management of peripheral vascular disease that year and in determining limb viability in combat surgery in Vietnam the following year was established, and both experiences were published. Later, Doctor Rich established the annual Military Vascular Surgery Meeting and was appointed as the first Chair of the Department of Surgery at the Uniformed Services University for Health Sciences (USU). I entered private practice in Central California in 1976, and ultrasonic imaging was developed which allowed noninvasive examination of the carotid arteries. I then developed a protocol to screen for the three silent, immediate causes of stroke, employing a "a quick carotid scan" for carotid artery disease, a lead II rhythm strip for atrial fibrillation, and blood pressure determination for hypertension so that these common causes of strokes could be recognized and treated, and potentially prevent the majority of strokes. My association with USU, Doctor Rich, and others involved proved instrumental in initiating implementation of stroke prevention screening. The structure established at USU provides a means of establishing the protocol nationally. Noninvasive vascular testing is an addition to Medical Science that has led to significant improvements in individual patient care and that has the potential of allowing a major reduction in death and disability from stroke and other vascular diseases. Throughout a 35-year collaborative association with Doctor Norman M. Rich, I have witnessed and developed many of these advances. These contributions to noninvasive vascular testing reflect the value of our collaboration.

Development and implementation of a rapid, accurate, and cost-effective protocol for national stroke prevention screening

BACKGROUND

Three medical conditions--cervical carotid artery disease, atrial fibrillation, and hypertension--cause the majority of strokes. Discovering these silent, immediate causes of stroke through screening, so they can be treated before stroke occurs, can potentially prevent strokes on an epidemiologic scale.

METHODS

A rapid, accurate, and cost-effective stroke prevention screening (SPS) protocol was developed.

RESULTS

The SPS protocol was used to screen 6,073 seniors residing in the central valley of California, at Madigan Army Medical Center, at New York University, and by the American Vascular Association at 68 leading institutions. The screening was estimated to have prevented 30 strokes and to have saved the health care system >$2 million.

CONCLUSIONS

Implementation of a national SPS for seniors can discover the silent, immediate causes of strokes so they can be managed before stroke occurs and can potentially prevent the majority of strokes that we are currently not preventing.