Evaluation of carotid artery and aortic intima-media thickness measurements for exclusion of significant coronary atherosclerosis in patients scheduled for heart valve surgery

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

[Figure: see text].

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.

Impact of Abdominal Obesity on Proximal and Distal Aorta Wall Thickness in African Americans: The Jackson Heart Study

OBJECTIVE

Abdominal obesity and wall thickness of the central arteries have been associated with higher risk of cardiovascular disease. Despite the higher burden of overweight and cardiovascular disease among African Americans, limited data are available on the association of abdominal obesity with aortic wall thickness in African Americans. We assessed the cross-sectional and the longitudinal associations of abdominal obesity with aortic intima-media thickness (aIMT) in a cohort of African Americans from the Jackson Heart Study.

METHODS

Data on aIMT and repeated measures of waist circumference (WC) and waist to height ratio from 1,572 participants, as well as on abdominal subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT), and aIMT from 1,223 participants, were analyzed. aIMT was measured at proximal ascending aorta (PA-aIMT), proximal descending aorta (PD-aIMT), and distal aorta (bifurcation) using cardiac magnetic resonance. SAT and VAT were measured using computerized tomography.

RESULTS

WC and WHtR were longitudinally associated with PA-aIMT and PD-aIMT; SAT and VAT were associated with PA-aIMT only. Only WC was associated with distal aIMT.

CONCLUSIONS

Abdominal obesity measures are associated with increased proximal aIMT in adult African Americans. Only WC is associated with wall thickness in all three segments of the aorta.

Evaluation of the atherosclerotic burden in hypertensive patients with prediabetes

AIM

To assess the atherosclerotic burden in hypertensive patients with prediabetes without cardiovascular disease.

PATIENTS AND METHODS

We included patients with hypertension and prediabetes (fasting blood glucose: 100-125mg/dL and/or glycohemoglobin A1c: 5.7-6.4%), excluding those with established cardiovascular disease or those at very high risk. We recorded major vascular risk factors. Subclinical arteriosclerosis was measured by the ankle/brachial index (ABI) and carotid intima-medial thickness (IMT). Subclinical arteriosclerosis was mild if IMT was >75p adjusted by age and sex and/or ABI was 0.7-0.9 and was considered moderate-severe when there was plaque and/or ABI<0.7.

RESULTS

We included 53 patients, 63±7 years-old; women: 50,9% (95%CI: 36.8-64.9). Atherosclerotic burden was detected in 66.0% (95%CI: 51.7-78.5) of subjects. 24,5% (95%CI: 13.8-38.3) of patients had mild arteriosclerosis disease and 41.5% (95%CI: 28.1-55.9) had moderate-severe. This allowed us to re-stratified as very high vascular risk the 41.5% (95%CI: 28.1-55.9) of patients. 45.4% (95%CI: 16-74.8) of subjects with moderate initial risk were considered high or very high risk. In multivariate analyses, only smoking was associated with atherosclerotic burden (P=.07).

CONCLUSIONS

Two thirds of hypertensive patients with prediabetes had subclinical arteriosclerotic disease when they were evaluated by the ankle/brachial index and carotid ultrasonography. Approximately forty percent of patients were re-stratified as very high vascular risk. Nearly half of the prediabetic hypertensive patients initially classified as moderate risk were considered high or very high risk.

Usefulness of carotid ultrasonography in the diagnosis of coronary artery disease in patients undergoing exercise echocardiography

BACKGROUND

Relationship between carotid and coronary artery disease (CAD) in patients undergoing invasive and non-invasive test is unclear. The aim of the study is to evaluate whether carotid disease is associated with CAD in patients submitted to exercise echocardiography (EE) and if it improves the EE ability to predict CAD.

METHODS

We retrospectively studied 156 subjects without previous vascular disease who underwent EE, carotid ultrasonography and coronary angiography between 2002 and 2013. Positive EE was defined as exercise induced wall motion abnormalities, carotid disease according to Manheim and American Society of Echocardiography Consensus and significant CAD as stenosis ≥50%.

RESULTS

Eighty-nine (57.1%) subjects had significant CAD. Factors associated with CAD in multivariate analysis were fasting plasma glucose (odds ratio [OR] 1.02, p = 0.031), pre-test probability of CAD > 65% (OR 3.71, p < 0.001), positive EE (OR 10.51, p < 0.001) and carotid plaque (CP) presence (OR 2.95, p = 0.013). There was neither statistical significant difference in area under the curve after addition of CP to EE results (0.77 versus 0.81, p = 0.525) nor sensitivity, specificity, predictive values or efficiency. CP presence reclassified as very high-risk according to Systematic COronary Risk Evaluation 13 patients (34.2%) with negative EE and 22 (33.3%) without CAD.

CONCLUSION

CP is associated with CAD in patients undergoing EE, however its addition to EE does not improve CAD prediction, probably due to insufficient statistical power. CP reclassified one third of patients to very high-risk category despite negative EE or CAD absence, these subjects benefit from aggressive primary prevention interventions.

Increased carotid-femoral pulse wave velocity and common carotid artery intima-media thickness obtained to assess target organ damage in hypertensive patients are closely related

BACKGROUND

Increased carotid-femoral pulse wave velocity (CF-PWV) and increased carotid intima-media thickness (IMT) in hypertension (HT) patients are indicators of asymptomatic organ damage. The relationship between carotid IMT and CF-PWV has been shown; studies comparing CF-PWV and IMT values within different vascular regions are limited. We aimed to investigate the relationship between IMT value measured from different anatomical regions and CF-PWV, and the localization of IMT that determines increased CF-PWV best.

METHODS

This study included 312 patients with HT. CF-PWV measurements with Doppler ultrasonography (USG). Vascular IMTs were measurements of common-internal carotid, brachial, and femoral arteries with B-mode USG (CC-IMT, IC-IMT, B-IMT, and F-IMT, respectively). Patients were divided into two groups according to their CF-PWV value (Increased CF-PWV >10 m/s and normal CF-PWV ≤10m/s).

RESULTS

Increased CF-PWV was detected in 54 (17.3%) of HT patients. The patient group with increased CF-PWV was older, and their CC-IMT, IC-IMT and F-IMT values were found to be higher. The other 3 IMT increases excluding B-IMT were closely related to the CF-PWV increase. Only age and CC-IMT values were found to be most closely related to CF-PWV. CC-IMT and age were found to be independently associated with increased CF-PWV. CC-IMT (each-0.1 mm) and age (each year) were found to augment the development of increased CF-PWV by 50.3% and 14.6%, respectively.

CONCLUSION

There is a close relationship between CC-IMT and CF-PWV increase in HT. It was thought that it would still be more useful to look at the increase of CC-IMT compared to other vascular regions for screening asymptomatic organ damage.

Increased aortic intima-media thickness may be used to detect macrovascular complications in adult type II diabetes mellitus patients

Background

Carotid intima media thickness (C-IMT) and aortic IMT (A-IMT) increase in adult and pediatric patients with diabetes mellitus (DM), respectively. In both age groups IMT is used for early detection of macrovascular complications. In adult DM patients, A-IMT is still not a routine examination and is not used frequently. We aimed to determine whether there is an increase in A-IMT values measured from abdominal aorta besides traditional C-IMT in patients with type II DM and to determine parameters closely related to A-IMT in the same patient group.

Methods

We included 114 type II DM patients and 100 healthy control subjects similar in age and sex in our study. Bilateral C-IMT and A-IMT values were measured by B-mode ultrasonography (USG) in addition to anamnesis, physical examination and routine examinations of all patients.

Results

When the clinical, demographic and laboratory data of patients with and without DM were compared, there was a high level of glucose and HbA1c and low hemoglobin levels in the DM patient group. All other parameters were found to be similar between the two groups. When the B-mode USG findings were examined, it was found that C-IMT and A-IMT were increased in patients with DM, with the A-IMT increase being more prominent. A-IMT values were found to be strongly and positively correlated with age, systolic blood pressure, blood urea nitrogen, DM onset time and HbA1c levels, and a negatively and significantly correlated with hemoglobin levels (p < 0.05, for each). In the regression model, the parameters correlating most closely with A-IMT were DM diagnosis onset time, HbA1c and hemoglobin levels (p = 0.001 and β = 0.353, p = 0.014 and β = 0.247 and p < 0.001 and β = − 0.406).

Conclusions

As in pediatric DM patients also in adult DM patients A-IMT can easily be measured with new model USG devices. A-IMT must be measured during abdominal USG which is routine in adult DM patients. A-IMT is an easy, reproducible and non-invasive parameter that may be used in the diagnosis of macrovascular complications of adult type II DM.

There is a significant relationship between morning blood pressure surge and increased abdominal aortic intima-media thickness in hypertensive patients

PURPOSE

There are limited data about increased aortic intima-media thickness (A-IMT) in the presence of subclinical target organ damage in hypertensive (HT) patients. In this study, we aimed to determine the frequency of increased A-IMT, the parameters determining increased A-IMT, and the relationship between increased A-IMT and other vascular IMT measurements.

MATERIALS AND METHODS

We prospectively included 265 patients (mean age 54.1 ± 10.6 years, male/female 91/174) with essential HT. Physical examination of all patients was performed. Laboratory data and antihypertensive treatments were recorded. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) was performed. Bilateral carotid, brachial, and femoral artery and abdominal A-IMT values were measured by B-mode ultrasonography (USG). Patients were categorized into two main groups: patients with increased A-IMT (≥ 3 mm) or normal A-IMT (< 3 mm).

RESULTS

Increased A-IMT was detected in 55 patients (20.8%). There was a close relationship between increased A-IMT and advanced age, presence of coronary artery disease, high morning blood pressure surge (MBPS), and bilateral carotid and femoral IMT. Parameters associated with increased A-IMT in univariate analysis were assessed by regression analysis. Left femoral IMT and MBPS were independently associated with increased A-IMT. In the regression model, each 5-mmHg elevation in MBPS increased the risk of increased A-IMT by 34.2%. The cutoff value of MBPS obtained by the ROC curve analysis was 32 mmHg for the prediction of increased A-IMT (sensitivity 76.3%, specificity 63.5%). The area under the curve was 0.784 (95% CI 0.720-0.847, p < 0.001).

CONCLUSION

Abdominal A-IMT increased at a significant rate in patients with HT. An independent association was found between MBPS and A-IMT, which can both be easily detected by ABPM and B-mode USG. The high MBPS level was considered to be a simple and inexpensive method for detecting subclinical target organ damage. A-IMT measurement should also be a part of abdominal USG, which is a routine examination in HT patients.

Aortic versus carotid intima-media thickness and impact of aortic valve disease

BACKGROUND AND AIMS

Intima-media thickness is a marker for atherosclerosis but is also influenced by shear stress and flow. We evaluated the relation between intima-media thickness of the descending aorta (AoIMT) and the common carotid artery (CIMT) in patients with and without severe aortic valve disease (sAVD).

METHODS

A total of 310 patients (233 with sAVD, 77 without) were examined with regard to AoIMT and CIMT using transesophageal echocardiography and carotid ultrasound, respectively, before valvular and/or aortic surgery. Digitally stored B-mode images were used for semiautomatic AoIMT and CIMT measurements.

RESULTS

There were no significant differences in patients with or without sAVD with regard to AoIMT (1·35 ± 0·31 vs. 1·35 ± 0·33 mm) or CIMT (0·80 ± 0·15 vs. 0·78 ± 0·16 mm). The correlations between AoIMT and CIMT were r = 0·29 in patients with and r = 0·51 in patients without sAVD, and the difference between these correlations was significant (P<0·05). In multivariate regression, age was the main determinant for AoIMT and CIMT in both groups, further in sAVD, the aortic mean pressure gradient (P_mean ) was a determinant of AoIMT, but not of CIMT.

CONCLUSIONS

The correlation between CIMT and AoIMT is weaker in patients with sAVD compared to those without sAVD. P_mean is also a significant predictor of AoIMT, but not of CIMT. This implies that, in addition to the atherosclerotic process, turbulent aortic flow or altered blood flow helicity created by large stroke volumes and diastolic flow reversal or high-velocity jets, affect the intima-media of the descending aorta and common carotid artery differently.

Aortic stenosis: insights on pathogenesis and clinical implications

Aortic stenosis (AS) is a common valvular heart disease in the Western populations, with an estimated overall prevalence of 3% in adults over 75 years. To understand its patho-biological processes represents a priority. In elderly patients, AS usually involves trileaflet valves and is referred to as degenerative calcific processes. Scientific evidence suggests the involvement of an active "atherosclerosis-like" pathogenesis in the initiation phase of degenerative AS. To the contrary, the progression could be driven by different forces (such as mechanical stress, genetic factors and interaction between inflammation and calcification). The improved understanding presents potentially new therapeutic targets for preventing and inhibiting the development and progression of the disease. Furthermore, in clinical practice the management of AS patients implies the evaluation of generalized atherosclerotic manifestations (i.e., in the coronary and carotid arteries) even for prognostic reasons. In counselling elderly patients, the risk stratification should address individual frailty beyond the generic risk scores. In these regard, the co-morbidities, and in particular those linked to the global atherosclerotic burden, should be carefully investigated in order to define the risk/benefit ratio for invasive treatment strategies. We present a detailed overview of insights in pathogenesis of AS with possible practical implications.

Abdominal fat distribution and carotid atherosclerosis in a general population: a semi-automated method using magnetic resonance imaging

PURPOSE

Available evidence suggests functional differences in visceral and subcutaneous fat. We investigated the association between quantitative measures of central adiposity with indicators of carotid atherosclerosis including intima-media thickness (IMT) and plaque in a general population using a semi-automated method on magnetic resonance imaging (MRI) data.

METHODS

In this cross-sectional study 200 subjects (52 % female), aged 50-77 years, were randomly selected from Golestan Cohort Study. Participants underwent ultrasound examination of carotid arteries and abdominal MRI. Segmentation and calculation of visceral (VFA) and subcutaneous fat area (SFA) were performed on three levels using semi-automated software. Various conventional anthropometric indices were also measured.

RESULTS

Among 191 enrolled subjects, 77 (40 %) participants had IMT ≥0.8 mm. Carotid plaques were detected in 86 (44 %) subjects. In separate multivariate analysis models, unlike SFA and other anthropometric indices, the last tertile of VFA values was associated with at least threefold excess risk for IMT ≥0.8 mm (OR 3.8, 95 % CI 1.36-6.94, p = 0.02). There was no significant difference between mean values of categorized obesity indices in subjects with and without plaque, while participants in the highest tertile of VFA values were demonstrated to have higher risk of more than one plaque (OR 4.57, 95 % CI 1.03-20.11, p = 0.034).

CONCLUSIONS

A higher amount of visceral fat, measured by a semi-automated technique using MRI, is associated with increased IMT and having more than one carotid plaque in a general population, while subcutaneous fat measures are poor indicators for identifying carotid atherosclerosis.

Association of aortic wall thickness on contrast-enhanced chest CT with major cerebro-cardiac events

BACKGROUND

There is a significant association between aortic atherosclerosis and previous major cardiovascular events. Particularly, thoracic aortic atherosclerosis is closely related to the degree of coronary and carotid artery disease. Thus, there is a rationale for screening the thoracic aorta in patients who undergo a chest computed tomography (CT) for any clinical question, in order to detect patients at increased risk of cerebro-cardiovascular (CCV) events.

PURPOSE

To estimate the association between either thoracic aortic wall thickness (AWT) or aortic total calcium score (ATCS) and CCV events.

MATERIAL AND METHODS

One hundred and forty-eight non-cardiac patients (78 men; 67 ± 12 years) underwent chest contrast-enhanced multidetector CT (MDCT). The AWT was measured at the level of the left atrium (AWTref) and at the maximum AWT (AWTmax). Correlation with clinical CCV patients' history was estimated. The value of AWTmax and of a semi-quantitative ATCS as a marker for CCV events was assessed using receiver-operating characteristic curve (ROC) analysis and multivariate regression analysis.

RESULTS

Out of 148 patients, 59% reported sedentary lifestyle, 44% hypertension, 32% smoking, 23% hypercholesterolemia, 13% family history of cardiac disease, 12% diabetes, and 10% BMI ≥ 30 kg/m(2); 9% reported myocardial infarction, 8% aortic aneurism, 8% myocardial revascularization, and 2% ischemic stroke. Twenty-six percent of patients had a medium-to-high ATCS. Both AWTmax and AWTref correlated with hypertension and age (P < 0.002). At the ROC analysis, a 4.8 mm threshold was associated to a 90% specificity and an odds ratio of 6.3 (AUC = 0.735). Assuming as threshold the AWTmax median value (4.3 mm) of patients who suffered from at least one CCV event in their history, a negative predictive value of 90%, a RR of 3.6 and an OR of 6.3 were found. At the multivariate regression analysis, AWTmax was the only independent variable associated to the frequency of CCV events.

CONCLUSION

Patients with increased thoracic AWTmax on chest MDCT could be considered at risk for CCV disease.

Imaging of atherosclerotic plaques in obesity: excessive fat accumulation, plaque progression and vulnerability

Obesity is becoming a major health issue in the world due to sedentary lifestyles and increasing intake of Western diets. Obesity is associated with metabolic abnormalities and atherosclerotic cardiovascular diseases. Adipose tissue has been increasingly considered to play a critical role in inducing metabolic disturbances and promoting atherogenesis. Arterial wall imaging permits direct visualization of atheroma burden in various vascular beds. In addition, recent advances in imaging technology help characterize components, microstructures and functional features of atherosclerotic plaques. These imaging modalities have contributed to elucidating factors associated with atherosclerosis in obese patients. Also, it provides opportunities to evaluate the effect of novel therapies on plaques in the setting of obesity. The findings of recent imaging studies and the clinical implications will be reviewed.

A Case of Severe Carotid Stenosis in a Patient with Familial Hypercholesterolemia without Significant Coronary Artery Disease

Familial hypercholesterolemia (FH) is an inherited metabolic disorder characterized by elevated low-density lipoprotein cholesterol levels in the blood. In its heterozygous form, it occurs in 1 in 500 individuals in the general population. It is an important contributor to the early onset of coronary artery disease (CAD), accounting for 5–10% of cases of cardiovascular events in people younger than 50 years. Atherogenesis triggered by hypercholesterolemia generally progresses faster in the coronary arteries, followed by the subsequent involvement of other arteries such as the carotids. Thus, symptoms of CAD commonly appear before the onset of significant carotid stenosis. Herein, we report the case of a patient with untreated FH who had severe carotid atherosclerosis at the age of 46 years but had no evidence of significant CAD.

Mean platelet volume is associated with aortic intima-media thickness in patients without clinical manifestation of atherosclerotic cardiovascular disease

Objective:

Mean platelet volume (MPV) plays a pivotal role in the pathophysiology of atherosclerotic disease. Thoracic aortic intima-media thickness (IMT) was reported as an earlier marker of preclinical atherosclerosis than carotid IMT. However, the relationship between MPV and aortic IMT was not investigated. We aimed to assess the relationship between thoracic aortic IMT and MPV in patients undergoing transesophageal echocardiography (TEE) examination for different indications.

Methods:

We studied 190 patients (mean age 37.0±12.5 years) who underwent TEE for different indications. The patients who have known atherosclerotic disease were excluded from study. The patients were divided into 2 groups according to the median thoracic aortic IMT values (IMT_low group <13 mm and IMT_high group ≤13 mm). Platelet count and MPV were analyzed with an automated hematology analyzer. A multiple stepwise linear regression analysis was performed to identify the independent associations of thoracic aortic IMT.

Results:

The highest MPV values were observed in the IMT_high group compared with the IMT_low group (9.5±10 fL vs. 10.9±1.2 fL, p<0.001). Also, the IMT_high group had higher age, hs-CRP and uric acid levels (p<0.05 for all). Multiple linear regression analysis showed that aortic IMT was independently related with age (β=0.340, p<0.001), uric acid (β=0.111, p=0.041), hs-CRP (β=0.200, p<0.001), and MPV (β=0.482, p<0.001).

Conclusion:

MPV is independently related to the extent of subclinical thoracic aortic atherosclerosis. Increases in MPV may be a crucial biochemical marker for initial atherosclerosis.

Serum 25-Hydroxyvitamin D Level and Aortic Intima-Media Thickness in Patients Without Clinical Manifestation of Atherosclerotic Cardiovascular Disease

OBJECTIVES

Existing evidence suggests that impaired vitamin D metabolism contribute to the development of atherosclerosis. Aortic intima-media thickness (IMT) is an earlier marker than carotid IMT of preclinical atherosclerosis. However, there is a lack of researches on direct investigation of relevance between serum 25-hydroxyvitamin D (25(OH)D) and thoracic aortic IMT. In this study, we aimed to assess the relationship between thoracic aortic IMT and 25(OH)D.

METHODS

We studied 117 patients (mean age: 45.5 ± 8.4 years) who underwent transesophageal echocardiography (TEE) for various indications. Serum 25(OH)D was measured using a direct competitive chemiluminescent immunoassay. The patients were divided into three groups according to the their serum 25(OH)D levels (VitDdeficiency , VitDinsufficient and VitDnormal groups). TEE was performed in all subjects. High sensitive C-reactive protein (hsCRP) and other biochemical markers were measured using an automated chemistry analyzer.

RESULTS

Only 24.8% (29 patients) of patients had normal levels of 25(OH)D. The highest aortic IMT values were observed in VitDdeficiency group compared with VitDinsufficient and VitDnormal groups (P < 0.05, for all). Also aortic IMT values of VitDinsufficient group were higher than VitDnormal group (P < 0.05). 25(OH)D was independently associated with hs-CRP (β = -0.442, P < 0.001) and aortic IMT (β = -0.499, P < 0.001).

CONCLUSIONS

The lower 25(OH)D level was independently associated with higher aortic IMT values. Therefore, hypovitaminosis D may have a role on pathogenesis of subclinical thoracic atherosclerosis.

Carotid intima-media thickness: Current evidence, practices, and Indian experience

As the developed and developing nations cope up with increasing predisposition to cardiovascular diseases (CVD) by adopting lifestyle changes the burden of coronary artery disease continues to rise globally. The presence of modifiable risk factors, which account for more than 90% of the cardiovascular (CV) risk, cannot always be interpreted as the presence of atherosclerotic heart disease and absence of modifiable risk factors do not guarantee absence of atherosclerotic changes in the arterial tree. Increasing awareness about primordial prevention and primary prevention of CVD is of vital importance in such scenarios. Ultrasonographic measurement of intima media thickness has been reported as a procedure to detect the early stages of atherosclerosis. Carotid intima media thickness (CIMT) testing is a safe, noninvasive and cost effective method to detect early atherosclerotic vascular diseases. This method of CV risk evaluation drew attention worldwide and of Indian physicians because of its feasibility in Indian population. Hence, detection and management of atherosclerosis in asymptomatic individuals will go a long way in preventing atherosclerotic diseases and prolonging survival and improving quality of life.

Serum Bilirubin Level and Aortic Intima–Media Thickness in Patients Without Clinical Manifestation of Atherosclerotic Cardiovascular Disease

We investigated the association between serum bilirubin level and thoracic aortic intima–media thickness (IMT). The study population consisted of 417 patients without coronary artery disease, who underwent transesophageal echocardiography examination for various indications. The highest aortic IMT values were observed in the bilirubinlow group compared with the bilirubinhigh group ( P < .001). Serum bilirubin level was associated with high-density lipoprotein cholesterol level ( r = .162, P = .001), high-sensitivity C-reactive protein (hsCRP; r = −.265, P < .001), and aortic IMT ( r = −.551, P < .001) in bivariate analysis. Multivariate linear regression analysis showed that serum bilirubin level was independently and negatively associated with hsCRP (β = −.095, P = .028) and aortic IMT (β = −.513, P < .001). Serum bilirubin level may be an independent predictor of the extent of subclinical aortic atherosclerosis assessed by thoracic aortic IMT.

Correlation between Aortic Wall Thickness and Coronary Artery Disease by 64 Slice Multidetector Computed Tomography

INTRODUCTION

Atherosclerotic cardiovascular disease is a dispersed pathology involving the coronary arteries, carotid arteries, aorta and peripheral arteries. It has been previously suggested that coronary and aortic atherosclerosis may be associated. Imaging of the aorta and the aortic wall can be performed by various imaging modalities including state-of-the-art multidetector computer tomography (MDCT). This study aimed to investigate a possible association between the MDCT-measured thickness of the thoracic aorta and the presence of coronary artery disease (CAD) as well as its severity.

METHODS

Three hundred and fifty candidates of coronary computer tomography angiography (CTA) with signs and symptoms suggestive of CAD were recruited in Tabriz Parsian and Iran CTA Centers. Contrast-enhanced MDCT examinations were performed using a 64 detector scanner. Maximum aortic wall thickness in the mid-portion of descending thoracic aorta (region of pulmonary trunk to diaphragm) was measured perpendicular to the center of the vessel.

RESULTS

CAD was confirmed in 189 cases (54%) and the remaining 161 cases served as controls. The mean age of the cases, as well as the percentage of male subjects was significantly higher in the CAD group. The mean aortic wall thickness was also significantly higher in the patient group (2.21±0.63 mm vs. 1.88±0.58 mm; P<0.001). In multivariate analysis, however, the two groups turned up comparable as to the aortic wall thickness (P=0.31). The optimal cut-off point of aortic wall thickness was ≥2 mm in discriminating between CAD+ and CAD- groups, with a corresponding sensitivity and specificity of 65% and 57%, respectively. There was no significant association between aortic wall thickness and the severity of CAD (the number of significantly occluded coronary arteries).

CONCLUSION

Aortic wall thickness is apparently neither an independent predictor of CAD nor is it associated with the severity of CAD in candidates of CTA.

Gamma glutamyl transferase activity: relationship with thoracic aortic intima media thickness and inflammation

OBJECTIVE

Increased serum gamma-glutamyl transferase (GGT) activity is known to be associated with atherosclerotic diseases. Thoracic aortic intima-media thickness (IMT) was reported as a marker of preclinical atherosclerosis. However, there is a lack of research directly examining the relationship between serum GGT activity and thoracic aortic IMT. Therefore, we aimed to investigate the association between serum GGT activity and thoracic aortic IMT.

PATIENTS AND METHODS

The study population consisted of 329 patients without coronary artery disease, who underwent transesophageal echocardiography (TEE) examination for various indications from January 2011 to April 2013. GGT, high-sensitivity C-reactive protein (hs-CRP) and other biochemical markers were measured in all patients. The patients were classified into tertiles according to their GGT activities (GGTlow < 19 U/l, GGTmid ≥ 19 U/l < 29 U/l, and GGThigh ≥ 29).

RESULTS

The highest aortic IMT values were observed in the GGThigh group compared with the GGTmid and GGTlow groups (p < 0.05, for all). Also, aortic IMT values in the GGTmid group were higher than in the GGTlow group (p < 0.05). Multivariate regression analysis showed that GGT activity was independently associated with aortic IMT (β = 0.487, p < 0.001) hs-CRP (β = 0.282, p < 0.001), and triglyceride level (β = 0.161, p = 0.007).

CONCLUSION

The higher serum GGT concentrations within the "normal" range were associated with a greater IMT of the thoracic aorta. GGT activity may be a predictor of the extent of subclinical aortic atherosclerosis assessed with thoracic aortic IMT.

Aortic distensibility and aortic intima-media thickness in patients without clinical manifestation of atherosclerotic cardiovascular disease

BACKGROUND

There is growing evidence that aortic distensibility (AD) is a subclinical marker of early atherosclerosis. Aortic intima-media thickness (IMT) was an earlier marker than carotid IMT of preclinical atherosclerosis. In this study, we aimed to assess the relationship between thoracic aortic IMT and AD.

METHODS

We studied 192 patients (mean age: 45.5 ± 8.4 years) who underwent transesophageal echocardiography (TEE) for various indications. Four different grades were determined according to IMT of thoracic aorta (Grade 1 < 1 mm; 1 mm ≤ Grade 2 < 3 mm; 3 mm ≤ Grade 3 < 5 mm; 5 mm ≤ Grade 4). AD was calculated from the echocardiographically derived ascending aorta diameters and hemodynamic pressure measurements in all patients. High sensitive C-reactive protein (hsCRP) and other biochemical markers were measured using an automated chemistry analyzer.

RESULTS

TEE evaluation characterized thoracic aortic intimal morphology as grade 1 in 71 patients (37%), grade 2 in 57 patients (29.7%), grade 3 in 34 patients (17.7%), and grade 4 in 30 (15.6%) patients. The lowest AD level was observed in grade 4 group compared with grade 1 and grade 2 groups (P < 0.001, P = 0.009, respectively). AD level of grade 3 group was lower than grade 1 and grade 2 group (P < 0.001, P = 0.021, respectively). In multiple linear regression analysis, AD was independently associated with age (β = -0.138, P = 0.029), hsCRP (β = -0.209, P = 0.001), and aortic IMT (β = -0.432, P < 0.001).

CONCLUSION

AD is independently associated with age, thoracic aortic IMT, and hsCRP. Impaired elasticity index of the aorta might be an independent predictor for the severity of thoracic atherosclerosis.

Uric acid and high sensitive C-reactive protein are associated with subclinical thoracic aortic atherosclerosis

BACKGROUND AND PURPOSE

The detection of atherosclerotic lesions in the aorta by transesophageal echocardiography (TEE) is a marker of diffuse atherosclerotic disease. Hyperuricemia is a well-recognized risk factor for cardiovascular diseases. However, no data are available concerning the relationship between serum uric acid (UA) and subclinical thoracic aortic atherosclerosis. We aimed to investigate the association between thoracic aortic atherosclerosis and serum UA level.

METHODS

We studied 181 patients (mean age 46.3 ± 8 years) who underwent TEE for various indications. Four different grades were determined according to intima-media thickness (IMT) of thoracic aorta. UA and other biochemical markers were measured with an automated chemistry analyzer.

RESULTS

TEE evaluation characterized thoracic aortic intimal morphology as Grade 1 in 69 patients, Grade 2 in 52 patients, Grade 3 in 31 patients, and Grade 4 in 29 patients. The highest UA level was observed in patients with Grade 4 IMT when compared with Grade 1 and 2 IMT groups (p<0.001 and p=0.014, respectively). UA levels in patients with Grade 3 and Grade 2 IMT were also higher than patients with Grade 1 IMT group (p<0.001, for all). In multiple linear regression analysis, IMT was independently associated with UA level (β=0.350, p<0.001), age (β=0.219, p=0.001), total cholesterol (β=-0.212, p=0.031), low-density lipoprotein cholesterol (β=0.350, p=0.001), and high sensitivity C-reactive protein (hsCRP) levels (β=0.148, p=0.014).

CONCLUSION

Uric acid and hsCRP levels are independently and positively associated with subclinical thoracic atherosclerosis.

Current imaging modalities for atherosclerosis

Atherosclerotic disease is responsible for nearly half of all deaths in the western world. During the past three decades, considerable efforts have been made towards detection and assessment of atherosclerosis plaques in various vascular beds using different imaging techniques. Recently, both noninvasive and invasive modalities have frequently been used to refine cardiovascular risk assessment in high-risk individuals, to evaluate the natural history of atheroma burden and to reveal the impact of anti-atherosclerotic medical therapies on disease progression. In this review, we provide an overview of the currently available imaging modalities. This article will underscore arterial wall imaging to assess the impact of medical therapies on atherosclerosis and to develop the effective therapeutic strategies, resulting in the prevention of cardiovascular complications.

Diagnosis of atherosclerosis by imaging

New and experimental imaging techniques are being developed that will permit better visualization and compositional characterization of atheromatous plaques. This review provides discussion of techniques that are currently used in clinical practice, as well as techniques that are investigational only, including coronary angiography, intravascular ultrasound, computed tomography, magnetic resonance imaging, positron emission tomography, and single-photon emission computed tomography. Types of atheromatous plaque are reviewed, and the value of examining vascular calcification in risk assessment is discussed. Experimental use of these imaging techniques in animal models and in clinical studies will enhance our understanding of the development of plaque and will determine whether these techniques would be useful and practical for predicting disease course. Early detection and identification of the type of plaque that is present may generate novel opportunities for primary prevention through changes in lifestyle or even through drug therapy, especially in patients at high cardiovascular risk.

Association of breast arterial calcification and carotid intima-media thickness

Breast arterial calcification (BAC) on mammography has been identified as calcific medial sclerosis of medium-sized breast arteries, and has been reported to be associated with cardiovascular risk factors, coronary artery disease, and cardiovascular mortality. Carotid intima-media thickness (C-IMT) is a well-known surrogate marker of atherosclerosis and predictor of cardiovascular morbidity and mortality. Consequently, the present study was designed to investigate the association between the presence of BAC on mammography and C-IMT. Twenty-five postmenopausal cases with BAC and 29 subjects without BAC on mammography were included in the study. Cardiovascular risk factors, number of childbirths, postmenopausal duration, and age at menopause were all noted besides detailed physical and laboratory examination. In the whole study population C-IMT was measured with B-mode ultrasound. The women with BAC had significantly increased number of childbirths, postmenopausal duration, frequency of diabetes mellitus, systolic blood pressure, fasting glucose, and CIMT (0.87 +/- 0.17 mm versus 0.60 +/- 0.19 mm) in comparison with the women without BAC (P < 0.05 for all). The C-IMT was correlated with age, number of childbirths, postmenopausal duration, presence of BAC, and serum triglyceride level (P < 0.05 for all). Independent predictors of C-IMT were the presence of BAC on mammography (beta = 0.463, P < 0.001) and serum triglyceride level (beta = 0.222, P = 0.042), whereas the only independent predictor of BAC was CIMT (chi(2) = 23.41, beta = 7.56, P = 0.004). Findings of the present study suggest that the BAC on mammography is independently associated with C-IMT. Screening mammographies merit to be evaluated for the presence of BAC, which might benefit cardiovascular preventive medicine in women by predicting atherosclerosis.

Thoracic aorta atherosclerosis burden index predicts coronary artery disease in patients undergoing transesophageal echocardiography

AIMS

The severity of thoracic aortic atherosclerosis (TAA) is associated with the extent of coronary artery disease (CAD). The aim of this study is to quantitative this relationship by developing a novel atherosclerotic index.

METHODS AND RESULTS

Two hundred and forty six consecutive patients underwent transesophageal echocardiography (TEE) and coronary angiography. A grading system was used to define the extent of TAA for individual segment of the thoracic aorta. TAA burden index (TAABI) was defined as the sum of the grading for each segment. Of the derived values TAABI had the greatest specificity and sensitivity in predicting CAD. A TAABI of greater than 6 was associated with 16-fold increase in the probability of CAD with a specificity of 88% and a sensitivity of 81%. The positive predictive value was 77% and the negative predictive value 90%.

CONCLUSION

A TAABI value of greater than 6 accurately predicts the presence of CAD. Patients with no or mild TAA are at low risk of having angiographically significant CAD.

An Abbreviated Carotid Intima-Media Thickness Scanning Protocol to Facilitate Clinical Screening for Subclinical Atherosclerosis

BACKGROUND

Carotid intima-media thickness (CIMT) testing can assist with cardiovascular risk prediction; however, the requirement for rigorous, time-consuming protocols has limited it use in clinical practice.

METHODS

Bilateral images of the common carotid artery (CCA), bulb, and internal carotid artery segments were obtained using a comprehensive scanning protocol. Three abbreviated scanning protocols were evaluated for their ability to identify patients with increased CIMT (> or = 75th percentile).

RESULTS

Of 261 subjects, 134 (51.3%) had increased left or right CCA CIMT (CCA protocol), 136 (52.1%) had carotid plaque (plaque protocol), and 190 (72.7%) had plaque or at least one increased CCA CIMT (combination protocol). The area under the receiver-operator characteristic curves for the CCA (0.738) and combination protocols (0.692) were higher than the plaque protocol (0.625, P < .05). The combination protocol was 100% sensitive.

CONCLUSIONS

Compared with a comprehensive scanning protocol, plaque screening with measurement of far wall CCA CIMT identifies all patients with increased CIMT.

Usefulness of 40-slice multidetector row computed tomography to detect coronary disease in patients prior to cardiac valve surgery

Preoperative identification of significant coronary artery disease (CAD) in patients prior to valve surgery requires systematic invasive coronary angiography. The purpose of this current prospective study was to evaluate whether exclusion of CAD by multi-detector CT (MDCT) might potentially avoid systematic cardiac catheterization in these patients. Eighty-two patients (53 males, 62 +/- 13 years) scheduled to undergo valve surgery underwent 40-slice MDCT before invasive quantitative coronary angiography (QCA). According to QCA, 15 patients had CAD (5 one-vessel, 6 two-vessel and 4 three-vessel disease). The remaining 67 patients had no CAD. On a per-vessel basis, MDCT correctly identified 27/29 (sensitivity 93%) vessels with and excluded 277/299 vessels (specificity 93%) without CAD. On a per-patient basis, MDCT correctly identified 14/15 patients with (sensitivity 93%) and 60/67 patients without CAD (specificity 90%). Positive and negative predictive values of MDCT were 67% and 98%. Performing invasive angiography only in patients with abnormal MDCT might have avoided QCA in 60/82 (73%). MDCT could be potentially useful in the preoperative evaluation of patients with valve disease. By selecting only those patients with coronary lesions to undergo invasive coronary angiography, it could avoid cardiac catheterization in a large number of patients without CAD.

16-Detector row computed tomographic coronary angiography in patients undergoing evaluation for aortic valve replacement: comparison with catheter angiography

AIM

To evaluate the diagnostic accuracy of 16-detector row computed tomography (CT) in assessing haemodynamically significant coronary artery stenoses in patients under evaluation for aortic stenosis pre-aortic valve replacement.

SUBJECTS AND METHODS

Forty consecutive patients under evaluation for severe aortic stenosis and listed for cardiac catheterization before potential aortic valve replacement underwent coronary artery calcium (CAC) scoring and retrospective electrocardiogram (ECG)-gated multi-detector row computed tomographic coronary angiography (MDCTA) using a GE Lightspeed 16-detector row CT within 1 month of invasive coronary angiography (ICA) for comparative purposes. All 13 major coronary artery segments of the American Heart Association model were evaluated for the presence of > or =50% stenosis and compared to the reference standard. Data were analysed on a segment-by-segment basis and also in "whole patient" terms.

RESULTS

A total of 412/450 segments from 35 patients were suitable for analysis. The overall accuracy of MDCTA for detection of segments with > or =50% stenosis was high, with a sensitivity of 81.3%, specificity 95.0%, positive predictive value (PPV) 57.8%, and negative predictive value (NPV) 98.4%. On a "whole-patient" basis, 100% (19/19) of patients with significant coronary disease were correctly identified and there were no false-negatives. Excluding patients with CAC >1000 from the analysis improved the accuracy of MDCTA to: sensitivity 90%, specificity 98.1%, PPV 60%, NPV 99.7%.

CONCLUSION

Non-invasive 16-detector row MDCTA accurately excludes significant coronary disease in patients with severe aortic stenosis undergoing evaluation before aortic valve replacement and in whom ICA can therefore be avoided. Its segment-by-segment accuracy is improved further if CAC>1000 is used as a gatekeeper to MDCTA.

Prediction of coronary artery disease by transesophageal echocardiographic detection of thoracic aortic plaque in patients with chronic kidney disease

BACKGROUND/AIMS

Our aim was to examine the significance of thoracic aortic plaque detected by transesophageal echocardiography (TEE) in the prediction of coronary artery disease (CAD) in patients with chronic kidney disease (CKD).

METHODS

We examined 118 patients (mean age 52 +/- 12 years) with CKD and followed them for a mean of 3.4 +/- 0.8 years. The study group included 52 predialysis patients with moderate to severe CKD (plasma creatinine > or = 200 micromol/l), 32 patients on dialysis treatment, and 34 renal transplant recipients. At baseline, TEE was performed to evaluate thoracic aortic atherosclerosis. CAD was defined by a history of a documented myocardial infarction, a coronary angiogram or a post-mortem autopsy finding showing significant occlusive CAD by the end of the follow-up period.

RESULTS

CAD was documented in 31 (26%) of the 118 study patients. The presence of thoracic aortic plaque had a sensitivity of 100% and a specificity of 37% for CAD and the positive and negative predictive values were 36 and 100%, respectively. In the subset of 36 patients with morphological findings of coronary arteries by angiogram or autopsy, the presence of large thoracic aortic plaques (> or = 3 mm in diameter) had a 73% sensitivity and 90% specificity for significant coronary artery stenosis. The positive and negative predictive values were 95 and 56%, respectively.

CONCLUSION

TEE may be used for detecting high-risk patients with CKD; the absence of thoracic aortic plaque predicted the absence of CAD, and the presence of large aortic plaques predicted significant coronary artery stenosis.

Relationship Between Plasma Total Antioxidant Capacity and Thoracic Aortic Intima-Media Thickness

It is known that antioxidants have an important role in the prevention of coronary artery disease (CAD). Low total antioxidant capacity (TAC) is a risk factor for ischemic heart disease. However, no data are available concerning the relationship between TAC and severity of thoracic aortic atherosclerosis. This study using multiplane transesophageal echocardiography (TEE) examined the relationship between atherosclerotic thoracic aortic intima-media thickness (TAIMT) and TAC. Twenty-nine patients (17 male, 12 female; mean age 36 +/- 8 years) without a history of atherosclerotic cardiovascular disease referred for TEE were included. The patients with obesity, hypertension, diabetes, and CAD were excluded. The TAC was measured for each patient using a more recently developed method. TAIMT and grade of thoracic aortic atherosclerosis were evaluated in each patient by using TEE. Mean TAC level was 1.91 +/- 0.53 mmol Trolox equiv/l. There was a negative and significant correlation between the TAC levels and TAIMT and grade of thoracic aortic atherosclerosis (r = -0.799, P < 0.001 versus r = -0.827, P < 0.001, respectively). Multiple linear regression analysis showed that TAIMT was independently associated with TAC (beta = -0.734, P < 0.001). The mean values of TAC in grade I, II, and III were 2.23 +/- 0.31, 1.58 +/- 0.31, and 1.04 +/- 0.27 mmol Trolox equiv/l, respectively (ANOVA P < 0.001). This study indicates that the TAC is an independent variable for TAIMT and it has a potential for an independent variable for atherosclerotic lesions in the major arterial locations.

Prognostic value of carotid intima-media thickness in detection of coronary atherosclerosis in patients with calcified aortic valve stenosis

OBJECTIVE

Aortic stenosis (AS) coexists with coronary artery disease (CAD) in at least 30% of patients. Patients with concomitant CAD may benefit from simultaneous coronary bypass grafting. This study aimed to evaluate the prognostic value of carotid intima-media thickness (IMT) in patients with AS in assessing concomitant CAD.

METHODS

Group I consisted of 33 patients (mean age +/- SD, 61.0 +/- 8.2 years; 18 men and 15 women) with AS but without CAD on angiograms. Group II consisted of 34 patients (64.4 +/- 8.0 years; 25 men and 9 women) with AS and CAD confirmed angiographically. A control group included 36 patients (61.2 +/- 4.9 years; 18 men and 18 women) with normal coronary arteries and no AS. Maximal IMT was assessed in all patients at the common carotid artery, bulb, and internal carotid artery and expressed as a mean value.

RESULTS

There were no differences among the respective groups with regard to age, sex, frequency of hypertension, diabetes, and smoking habit, although patients with CAD were more often hyperlipemic (P = .038). The IMT of the common carotid artery, bulb, and internal carotid artery was significantly higher in patients with AS and CAD compared with both the control group and patients with AS only. The multivariable regression model revealed that CAD (P < .001), AS (P = .006), male sex (P = .034), age (P < .001), and diabetes mellitus (P = .047) were independent risk factors for IMT thickening. A mean IMT value of greater than 1.2 mm was predictive (sensitivity, 73.5%; specificity, 72.7%) of concomitant CAD in patients with AS.

CONCLUSIONS

Intima-media thickness increases in patients with AS. The greatest IMT values are observed in patients with both AS and CAD. Patients with AS might be suspected of having CAD when the IMT value exceeds 1.2 mm.

The inverse relationship between thoracic aortic intima media thickness and testosterone level

BACKGROUND

It is known that testosterone prevents coronary artery disease, and lower testosterone level is a risk factor for ischemic heart disease in men. However, there is no report showing the relationship between testosterone level and severity of thoracic aortic atherosclerosis.

AIM

To investigate whether a relationship exists between atherosclerotic thoracic aortic intima media thickness (TAIT) and testosterone level.

METHOD

Forty-two male patients (mean age 56 +/- 12 years) without a history of atherosclerotic cardiovascular disease referred for transesophageal echocardiography (TEE) were included. Intima media thickness of aorta was evaluated in each patient by using TEE. Testosterone levels were measured using a commercial kit. Blood chemistry parameters were measured by automated analyzers. The data obtained was evaluated by using correlation analyses and linear regression analysis tests.

RESULTS

Mean testosterone values were 507 +/- 209 ng/dl. Testosterone levels showed a negative significant correlation with TAIT (r = -765, p < 0.001). In addition, testosterone levels showed positive correlations with albumin (r = 0.690, p = 0.019) and negative correlations with uric acid (r = -0.630, p < 0.001), HsCRP (r = -0.449, p = 0.003), fibrinogen (r = -0.508, p = 0.001), and white blood cells (r = -0.433, p = 0.005). On the other hand, multiple linear regression analysis showed that TAIT was independently associated with testosterone and uric acid (beta = -0.610, p = 0.002 versus beta = 0.409, p = 0.026 respectively).

CONCLUSION

This study indicates that there is an independent relationship between testosterone and TAIT.

Acoustic radiation force impulse imaging of the mechanical properties of arteries: in vivo and ex vivo results

We present results of a pilot study of ex vivo and in vivo acoustic radiation force impulse (ARFI) imaging demonstrating measurements of the mechanical properties of the carotid and popliteal arteries. The results were obtained on a modified commercial scanner, providing coregistered B-mode and color Doppler images. 2D and 1D through time images are formed from the measurements of tissues' response to very brief and localized applications of radiation force. The images show good correlation with B-mode and, in ex vivo studies, pathology-based characterizations of vessel geometry and plaque stiffness. In vivo measurements of arterial response during both systole and diastole are presented. We address implementation issues and discuss potential applications of this new vascular imaging method.

Aortic atherosclerosis detected with electron-beam CT as a predictor of obstructive coronary artery disease

RATIONALE AND OBJECTIVES

Several studies have demonstrated an association between coronary and aortic atherosclerosis. Aortic atherosclerosis is easily quantified by means of electron-beam computed tomography (CT). The aim of this study was to evaluate the usefulness of measurement of aortic atherosclerosis with electron-beam CT as an independent predictor of obstructive coronary artery disease (CAD).

MATERIALS AND METHODS

Ninety-seven patients (67 men, 30 women; mean age, 61 years +/- 12) were enrolled and underwent electron-beam CT with and without contrast material. Coronary artery calcification was quantified with nonenhanced electron-beam CT by means of Agatston score. CAD was defined as luminal narrowing of the coronary artery by at least 70%, as measured with electron-beam angiography. Aortic atherosclerosis was quantified by measuring raised lesions of the aortic wall (plaque) and wall thickening (volume and thickness) in the midportion of the descending thoracic aorta (10 contiguous sections), as depicted at contrast material-enhanced CT angiography.

RESULTS

Aortic plaque and calcification were detected only in patients who were at least 58 years old. The presence of aortic plaque was predictive of obstructive CAD, independent of coronary artery calcification. The sensitivity of aortic plaque (raised lesions) for obstructive CAD was 89% in patients at least 58 years old, and the specificity was 63%. Aortic calcification had a sensitivity of 56% and a specificity of 72% for diagnosis of obstructive CAD.

CONCLUSION

This study demonstrated that aortic plaque detected with contrast-enhanced electron-beam CT was a more consistent predictor of obstructive CAD than other independent aortic variables. Aortic calcification depicted on nonenhanced CT images was highly specific for obstructive CAD.