Prevalence of carotid stenosis and silent myocardial ischemia in asymptomatic subjects with a low ankle-brachial index

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.

Risk of undiagnosed coronary artery disease associated with infrapopliteal artery occlusion from a multicenter study

Peripheral artery disease (PAD) is associated with high cardiovascular mortality. Which part of PAD with lower extremities is related to coronary artery disease (CAD) remains unknown. We hypothesized that PAD including infrapopliteal artery (IPA) occlusion was associated with CAD. A total of 260 patients who have no history of CAD or the anginal symptom, complain of the claudication or critical limb ischemia and underwent peripheral angiography were retrospectively analyzed. IPA occlusion was diagnosed with peripheral angiography, and CAD was diagnosed with the coronary angiography. A multivariate logistic regression analysis was performed to determine the predictors of silent CAD. Among them, a total of 146 patients (56.2%) had IPA occlusion. Baseline characteristics were significantly different between two groups as to the proportions of age, male, dyslipidemia (with vs. without IPA occlusion; 72.4 ± 10.8 vs. 69.1 ± 10.2; 62.3% vs. 75.4%; 38.6% vs. 52.6%, respectively, all comparisons P < 0.05). Notably, the prevalence of CAD was significantly higher in patients with IPA occlusion (50.7% vs. 34.2%, P = 0.008). On a multivariate analysis, IPA occlusion was an independent predictor for the presence of silent CAD (OR, 1.94; CI, 1.09-3.44, P = 0.024), but aortoiliac artery occlusion (OR, 1.16; CI, 0.53-2.56, P = 0.71) and femoropopliteal artery occlusion (OR, 1.02; CI, 0.57-1.83, P = 0.96) were not. IPA occlusion was associated with silent CAD. Vascular surgeons, interventional radiologists, as well as interventional cardiologists should recognize IPA occlusion as a risk factor of silent CAD.

Subclinical Peripheral Arterial Disease in Patients with Acute Ischemic Stroke: A Study with Ultrasonography

BACKGROUND

Peripheral arterial disease (PAD) is an advanced form of atherosclerosis defined by an abnormal ankle-brachial index (ABI). However, the ABI provides no information about the location of atherosclerosis. We investigated the clinical implication of PAD confirmed using lower-extremity ultrasonography (LEUS), with consideration of the atherosclerosis location.

METHODS

Patients with acute ischemic stroke who underwent LEUS were enrolled. Patients with PAD were further divided into those with PAD at the proximal (above-popliteal artery, PADP) and distal (below-tibialis artery, PADD) segments. The clinical outcome was compared between patients with and without PAD, and between PADP and PADD. The atherosclerosis location in the cerebral artery was also compared between groups.

RESULTS

Among 289 patients, PAD was observed in 108 (37.4%) patients (43 had PADP and 65 had PADD). Patients with PAD were slightly older (P < .001) and had more significant carotid artery stenosis (30.6% versus 12.7%, P < .001) than those without. Patients with PAD had poor 3-month functional outcome than those without (modified-Rankin Scale score: 3 [interquartile range, 1-4] versus 2 [1-3], respectively, P = .003). Diabetes, high-stroke severity, and the presence of PADP (odds ratio, 3.893; 95% confidence interval, 1.454-10.425; P = .007) were independently associated with poor functional outcome at 3 months. Patients with PADP showed higher prevalence of extracranial stenosis than those with PADD (41.9% versus 23.1%; P = .038).

CONCLUSIONS

Our study suggests that subclinical PAD, especially PADP, is associated with poor functional outcome at 3 months after stroke onset. Interestingly, the location of cerebral atherosclerosis differed according to the location of PAD.

The First Harmonic of Radial Pulse as an Early Predictor of Silent Coronary Artery Disease and Adverse Cardiac Events in Type 2 Diabetic Patients

Background

It has been reported that harmonics of radial pulse is related to coronary artery disease (CAD) in patients with type 2 diabetes mellitus (T2DM). It is still unclear whether or not the first harmonics of the radial pulse spectrum is an early independent predictor of silent coronary artery disease (SCAD) and adverse cardiac events (ACE).

Objectives

To measure the risk of SCAD in patients with T2DM and also to survey whether or not an increment of the first harmonic (C1) of the radial pulse increases ACE.

Methods

1968 asymptomatic individuals with T2DM underwent radial pulse wave measurement. First harmonic of the radial pressure wave, C1, was calculated. Next, the new occurrence of ACE and the new symptoms and signs of coronary artery disease were recorded. The follow-up period lasted for 14.7 ± 3.5 months.

Results

Out of 1968 asymptomatic individuals with T2DM, ACE was detected in 239 (12%) of them during the follow-up period. The logrank test demonstrated that the cumulative incidence of ACE in patients with C1 above 0.96 was greater than that in those patients with C1 below 0.89 (P < 0.01). By comparing the data of patients with C1 smaller than the first quartile and the patients with C1 greater than the third quartile, the hazard ratios were listed as follows: ACE (hazard ratio, 2.29; 95% CI, 1.55–3.37), heart failure (hazard ratio, 2.22; 95% CI, 1.21–4.09), myocardial infarction (hazard ratio, 2.44; 95% CI, 1.51–3.93), left ventricular dysfunction (Hazard ratio, 2.01; 95% CI, 0.86–4.70), and new symptoms and signs for coronary artery disease (hazard ratio, 2.03; 95% CI, 1.45–2.84). As C1 increased, the risk for composite ACE (P < 0.001 for trend) and for coronary disease (P < 0.001 for trend) also increased. The hazard ratio and trend for cardiovascular-cause mortality were not significant.

Conclusions

This study showed that C1 of the radial pulse wave is correlated with cardiovascular events. Survival analysis showed that C1 value is an independent predictor of ACE and SCAD in asymptomatic patients with T2DM. Thus, screening for the first harmonic of the radial pulse may improve the risk stratification of cardiac events and SCAD in asymptomatic patients although they had no history of coronary artery disease or angina-related symptom.

Radial Pulse Spectrum Analysis as Risk Markers to Improve the Risk Stratification of Silent Myocardial Ischemia in Type 2 Diabetic Patients

Diabetic patients with silent myocardial ischemia (SMI) have elevated rates of morbidity and mortality and need intensive care and monitoring. An early predictor of SMI may lead to early diagnosis and medical treatment to prevent progression and adverse clinical events. Therefore, this paper was aimed to evaluate the radial pulse spectrum as risk markers to improve the risk stratification of SMI in type-2 diabetic patients; 195 diabetic patients at high-risk of SMI were enrolled. All patients underwent myocardial perfusion imaging and radial pressure wave measurement. The spectrum analysis of the radial pressure wave was calculated and transformed into Fourier series coefficients Cns and Pns. The risk of SMI (odds ratio: 4.46, 95%, C.I. 1.61–12.4, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$P<0.01$ \end{document}) was raised in diabetic patients classified high-risk group by C2. Multivariable regression analysis showed that C2 (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$P<0.05$ \end{document}) and ankle–brachial index [(ABI) \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$P<0.05$ \end{document})] were related to SMI (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$R=0.46$ \end{document} and \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$P<0.05$ \end{document}). The myocardial ischemic score (MIS), combining C2, C3, and P5, the albumin-to-creatinine ratio (ACR), and ABI, presented an excellent risk stratification performance in enrolled patients (odds ratio: 5.78, 95%, C.I. 2.29–14.6, \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$P<0.01$ \end{document}). The area under receiver operating characteristic curves for C2, C3, P5, ABI, ACR, and MIS were 0.66, 0.60, 0.68, 0.51, 0.56, and 0.74, respectively, in identifying SMI. This paper demonstrated that C2 was independently associated with the extent of SMI in multivariable regression analysis. Odds ratio and chi-square tests reflected that C2 could be an important marker for the risk stratification of SMI. Furthermore, MIS, adding radial pulse spectrum analysis to ACR and ABI, could significantly improve the risk stratification of SMI in type-2 diabetic patients compared to any single risk factor.

Actual impact of screening for myocardial ischemia with single-photon emission tomography among patients undergoing peripheral vascular interventions

The present study provides actual data with regard to the prevalence of myocardial ischemia among patients under contemporary cardiovascular prevention strategies undergoing peripheral vascular interventions. We included a total of 200 consecutive patients who underwent gated single-photon emission computed tomography myocardial perfusion study between January 2012 and January 2014 as preoperative evaluation for peripheral vascular interventions at our institution. The baseline medical treatment comprised aspirin (81%), statins (79%), and β-blockers (54%). Thirty-two (16%) patients underwent carotid revascularization; 69 (34.5%) patients underwent lower limb revascularization, and 99 patients underwent aortic interventions. Twenty-six (13%) patients showed evidence of myocardial ischemia, with an extensive ischemic burden identified in seven (3.5%) patients. Within the group of patients with peripheral vasculopathy, those with lower limb arteriopathy had a higher prevalence of ischemia. According to the results of the myocardial perfusion study, the cardiology in charge indicated invasive coronary angiography in 11/26 (42%) patients with evidence of myocardial ischemia. Seven of the 11 (64%) patients who had coronary angiography were revascularized. After a mean follow-up of 24 months, no cardiovascular adverse events were detected.

Study of carotid disease in patients with peripheral artery disease

OBJECTIVE

To study the stenosis of the carotid arteries in patients with symptomatic peripheral arterial disease.

METHODS

we assessed 100 consecutive patients with symptomatic peripheral arterial disease in stages of intermittent claudication, rest pain or ulceration. Carotid stenosis was studied by echo-color-doppler, and considered significant when greater than or equal to 50%. We used univariate analysis to select potential predictors of carotid stenosis, later taken to multivariate analysis.

RESULTS

The prevalence of carotid stenosis was 84%, being significant in 40% and severe in 17%. The age range was 43-89 years (mean 69.78). Regarding gender, 61% were male and 39% female. Half of the patients had claudication and half had critical ischemia. Regarding risk factors, 86% of patients had hypertension, 66% exposure to smoke, 47% diabetes, 65% dyslipidemia, 24% coronary artery disease, 16% renal failure and 60% had family history of cardiovascular disease. In seven patients, there was a history of ischemic cerebrovascular symptoms in the carotid territory. The presence of cerebrovascular symptoms was statistically significant in influencing the degree of stenosis in the carotid arteries (p = 0.02 at overall assessment and p = 0.05 in the subgroups of significant and non-significant stenoses).

CONCLUSION

the study of the carotid arteries by duplex scan examination is of paramount importance in the evaluation of patients with symptomatic peripheral arterial disease, and should be systematically conducted in the study of such patients.

The Ankle-Brachial Index is Associated With Cardiovascular Complications After Noncardiac Surgery

Background:

This study evaluated the association of the ankle-brachial index (ABI) and cardiovascular complications after noncardiac surgery.

Methods:

We prospectively evaluated patients referred for noncardiac surgery. The ABI was performed before surgery. Patients with abnormal ABI (≤0.9) were included in the peripheral artery disease (PAD) group and the remaining constituted the control group. Cardiac troponin and electrocardiogram were obtained 72 hours after surgery. Patients were followed up to 30 days, and primary end point was the occurrence of any cardiovascular event: cardiovascular death, acute coronary syndrome, isolated troponin elevation (ITE), decompensated heart failure, cardiogenic shock, unstable arrhythmias, nonfatal cardiac arrest, pulmonary edema, stroke, or PAD symptoms increase.

Results:

We evaluated 124 patients (61.3% male; mean age 65.4 years). During the study, 57.9% of patients in the PAD group had an event versus 25.7% in the control group ( P = .011). The ITE was the most observed event (24.2%). After logistic regression, the odds ratio for ITE was 7.4 (95% confidence interval 2.2-25.0, P = .001).

Conclusions:

In patients submitted to noncardiac surgery, abnormal ABI is associated with a higher occurrence of a cardiovascular event.

The ARTICO study: identification of patients at high risk of vascular recurrence after a first non-cardioembolic stroke

BACKGROUND

About 20% of patients with a first ischaemic stroke will experience a new vascular event within the first year. The atherosclerotic burden, an indicator of the extension of atherosclerosis in a patient, has been associated with the risk of new cardiovascular events in the general population. However, no predictive models reliably identify groups at a high risk of recurrence. The ARTICO study prospectively analysed the predictive value for the risk of recurrence of specific atherosclerotic markers.

METHODS

The multicentre ARTICO study included 620 consecutive independent patients older than 60 years suffering from a first non-cardioembolic stroke. We analysed classical stroke risk factors; duplex study of supraaortic trunk including intima-media thickness (IMT) measurement; quantification of internal carotid (ICA) stenosis; number, morphology and surface characteristics of carotid plaques; ankle brachial index (ABI); and the presence of microalbuminuria. Patients were followed up at 6 and 12 months after inclusion. The primary end-point was death or major cardiovascular events.

RESULTS

Any vascular event or death at 12 months occurred in 78 (13.8%) patients. In 40 (7.1%) of these the vascular event was a stroke recurrence. Weight, history of diabetes mellitus, history of symptomatic PAD, ABI <0.9 and significant ICA stenosis (>50%) were associated with a higher risk of vascular events on follow-up in the bivariate analysis. In the final Cox regression analysis, body mass index (BMI), systolic blood pressure, history of diabetes mellitus, symptomatic PAD (HR, 2.76; 95% CI, 1.10-6.95; p=0.03), and particularly patients with both ICA stenosis >50% and PAD (HR 4.52; 95% CI, 2.14-9.53; p<0.001) were independently associated with an increased risk of vascular events. Neither isolated ICA stenosis >50% nor isolated abnormal ABI remained associated with an increased risk of recurrence in comparison with the whole population.

CONCLUSIONS

Symptomatic PAD identifies a high risk group of vascular recurrence after a first non-cardioembolic stroke. The associated increased risk was particularly high in patients with both ICA stenosis and either symptomatic or asymptomatic PAD. Neither asymptomatic PAD alone nor isolated ICA stenosis >50% were associated with an increased risk of recurrence in this particularly high-risk group of non-cardioembolic stroke.

Cardiovascular risk evaluation and prevalence of silent myocardial ischemia in subjects with asymptomatic carotid artery disease

Introduction:

Silent ischemia is an asymptomatic form of myocardial ischemia, not associated with angina or anginal equivalent symptoms, which can be demonstrated by changes in ECG, left ventricular function, myocardial perfusion, and metabolism. The aim of this study was to evaluate the prevalence of silent myocardial ischemia in a group of patients with asymptomatic carotid stenosis.

Methods:

A total of 37 patients with asymptomatic carotid plaques, without chest pain or dyspnea, was investigated. These patients were studied for age, sex, hypertension, diabetes, dyslipidemia, smoking, and family history of cardiac disease, and underwent technetium-99 m sestamibi myocardial stress-rest scintigraphy and echo-color Doppler examination of carotid arteries.

Results:

A statistically significant relationship (P = 0.023) was shown between positive responders and negative responders to scintigraphy test when both were tested for degree of stenosis. This relationship is surprising in view of the small number of patients in our sample. Individuals who had a positive scintigraphy test had a mean stenosis degree of 35% ± 7% compared with a mean of 44% ± 13% for those with a negative test. Specificity of our detection was 81%, with positive and negative predictive values of 60% and 63%, respectively.

Conclusion:

The present study confirms that carotid atherosclerosis is associated with coronary atherosclerosis and highlights the importance of screening for ischemic heart disease in patients with asymptomatic carotid plaques, considering eventually plaque morphology (symmetry, composition, eccentricity or concentricity of the plaque, etc) for patient stratification.

The role of postexercise measurements in the diagnosis of peripheral arterial disease in HIV-infected patients

Peripheral arterial disease (PAD) is a marker of atherosclerosis, which is not well studied in the population with human immunodeficiency virus (HIV). We prospectively enrolled HIV-infected patients who had normal resting ankle-brachial index (rABI) readings. All participants performed either a treadmill walking test (TT) or pedal plantar flexion test (PFT). Patients were divided into 2 groups according to postexercise changes; PAD and No-PAD group. The 2 groups were compared with regard to established cardiovascular disease risk factors and other HIV infection parameters. Peripheral arterial disease was present in 30 (26.5%) of 113 consecutive HIV-infected patients included in the study. Mean age was 47 ± 10 years. The risk factors studied did not differ significantly among the 2 groups except for male gender, which was significantly associated with PAD (RR: 4.15; CI: 1.6 to 11.1: P < .0008). The prevalence of PAD, diagnosed by significant drop in postexercise ABI and ankle pressure in patients with HIV is high.

Associations between peripheral artery disease and ischemic stroke: implications for primary and secondary prevention

BACKGROUND AND PURPOSE

Although peripheral artery disease (PAD) has a particularly poor prognosis compared with vascular disease in other territories, little attention is paid to its epidemiology, treatment, and prevention. Despite the high prevalence of PAD in patients with stroke, and of stroke in patients with PAD, PAD is omitted from all guidelines for treatment, prevention, and rehabilitation of stroke, although coronary artery disease risk is considered. Therefore, routine PAD screening is seldom undertaken and so disease is probably often missed. Summary of Review- This review evaluates epidemiology of PAD in patients with stroke and of stroke in patients with PAD. The role of the ankle-brachial pressure index; imaging and novel markers in risk prediction of PAD in patients with stroke; and treatment and prevention of PAD are reviewed.

CONCLUSIONS

In both primary and secondary prevention settings, PAD indicates a high risk of future events. Data on which additional preventive measures are beneficial in this patient group are lacking, but the presence of PAD does have implications for current management in both primary and secondary prevention of stroke.