Corneal arcus: indicator for severity of coronary atherosclerosis?

Cutaneous manifestations of cardiovascular diseases

Cardiovascular diseases may affect multiple organ systems including the skin. By identification of specific cutaneous findings, dermatologists may be the first physician to diagnose an underlying cardiovascular disease. This article discusses a number of cardiac disorders with prominent skin findings in addition to general dermatologic signs suggestive of cardiovascular disease.

Correlating corneal arcus with atherosclerosis in familial hypercholesterolemia

BACKGROUND

A relationship between corneal arcus and atherosclerosis has long been suspected but is controversial. The homozygous familial hypercholesterolemia patients in this study present a unique opportunity to assess this issue. They have both advanced atherosclerosis and corneal arcus.

METHODS

This is a cross-sectional study of 17 patients homozygous for familial hypercholesterolemia presenting to the Clinical Center of the National Institutes of Health. Plasma lipoproteins, circumferential extent of arcus, thoracic aorta and coronary calcific atherosclerosis score, and Achilles tendon width were measured at the National Institutes of Health.

RESULTS

Patients with corneal arcus had higher scores for calcific atherosclerosis (mean 2865 compared to 412), cholesterol-year score (mean 11830 mg-yr/dl compared to 5707 mg-yr/dl), and Achilles tendon width (mean 2.54 cm compared to 1.41 cm) than those without. Corneal arcus and Achilles tendon width were strongly correlated and predictive of each other. Although corneal arcus was correlated with calcific atherosclerosis (r = 0.67; p = 0.004), it was not as highly correlated as was the Achilles tendon width (r = 0.855; p < 0.001).

CONCLUSION

Corneal arcus reflects widespread tissue lipid deposition and is correlated with both calcific atherosclerosis and xanthomatosis in these patients. Patients with more severe arcus tend to have more severe calcific atherosclerosis. Corneal arcus is not as good an indicator of calcific atherosclerosis as Achilles tendon thickness, but its presence suggests increased atherosclerosis in these hypercholesterolemic patients.

Bedside diagnosis of coronary artery disease: a systematic review

PURPOSE

To assess the accuracy of bedside findings for diagnosing coronary artery disease and acute myocardial infarction.

METHODS

A MEDLINE search was performed to retrieve articles published from January 1966 to January 2003 that were relevant to the bedside diagnosis of coronary disease in adults.

RESULTS

In patients with stable, intermittent chest pain, the most useful bedside predictors for a diagnosis of coronary disease were found to be the presence of typical angina (likelihood ratio [LR]=5.8; 95% confidence interval [CI]: 4.2 to 7.8), serum cholesterol level >300 mg/dL (LR=4.0; 95% CI: 2.5 to 6.3), history of prior myocardial infarction (LR=3.8; 95% CI: 2.1 to 6.8), and age >70 years (LR=2.6; 95% CI: 1.8 to 4.0). Nonanginal chest pain (LR=0.1; 95% CI: 0.1 to 0.2), pain duration >30 minutes (LR=0.1; 95% CI: 0.0 to 0.9), and intermittent dysphagia (LR=0.2; 95% CI: 0.1 to 0.8) argued against a diagnosis of coronary disease. In patients with acute chest pain, the most important bedside predictors for a diagnosis of myocardial infarction were new ST elevation (LR=22; 95% CI: 16 to 30), new Q waves (LR=22; 95% CI: 7.6 to 62), and new ST depression (LR=4.5; 95% CI: 3.6 to 5.6). A normal electrocardiogram (LR=0.2; 95% CI: 0.1 to 0.3), chest wall tenderness (LR=0.3; 95% CI: 0.2 to 0.4), and pain that was pleuritic (LR=0.2; 95% CI: 0.2 to 0.3), sharp (LR=0.3; 95% CI: 0.2 to 0.5), or positional (LR=0.3; 95% CI: 0.2 to 0.5) argued against the diagnosis of myocardial infarction.

CONCLUSION

The accuracy of bedside predictors depends on the clinical setting. In the evaluation of stable, intermittent chest pain, a patient's description of pain was found to be the most important predictor of underlying coronary disease. In the evaluation of acute chest pain, the electrocardiogram was the most useful bedside predictor for a diagnosis of myocardial infarction. Aside from the extremes in cholesterol values, the analysis of traditional risk factors changed the probability of coronary disease or myocardial infarction very little or not at all.