A model for predicting occult carotid artery stenosis: screening is justified in a selected population

Derivation of a clinical prediction score for the diagnosis of clinically significant symptomatic carotid artery disease

OBJECTIVES

Emergent vascular imaging identifies a subset of patients requiring immediate specialized care (i.e. carotid stenosis > 50%, dissection or free-floating thrombus). However, most TIA patients do not have these findings, so it is inefficient to image all TIA patients in crowded emergency departments (ED). Our objectives were to derive and internally validate a clinical prediction score for clinically significant carotid artery disease in TIA patients.

METHODS

This was a planned secondary analysis of a prospective cohort study from 14 Canadian EDs. Among 11555 consecutive adult ED patients with TIA/minor stroke symptoms over 12 years, 9882 had vascular imaging and were included in the analysis. Our main outcome was clinically significant carotid artery disease, defined as extracranial internal carotid stenosis ≥ 50%, dissection, or thrombus in the internal carotid artery, with contralateral symptoms.

RESULTS

Of 9882 patients, 888 (9.0%) had clinically significant carotid artery disease. Logistic regression was used to derive a 13-variable reduced model. We simplified the model into a score (Symcard [Symptomatic carotid artery disease] Score), with suggested cut-points for high, medium, and low-risk stratification. A substantial portion (38%) of patients were classified as low-risk, 33.8% as medium risk, and 28.2% as high risk. At the low-risk cut-point, sensitivity was 92.9%, specificity 41.1%, and diagnostic yield 1.7%.

CONCLUSIONS

This simple score can predict carotid artery disease in TIA patients using readily available information. It identifies low-risk patients who can defer vascular imaging to an outpatient or specialty clinic setting. Medium-risk patients may undergo imaging immediately or with slight delay, depending on local resources. High-risk patients should undergo urgent vascular imaging.

Brazilian Angiology and Vascular Surgery Society Guidelines for the treatment of extracranial cerebrovascular disease

Extracranial cerebrovascular disease has been the subject of intense research throughout the world, and is of paramount importance for vascular surgeons. This guideline, written by the Brazilian Society of Angiology and Vascular Surgery (SBACV), supersedes the 2015 guideline. Non-atherosclerotic carotid artery diseases were not included in this document. The purpose of this guideline is to bring together the most robust evidence in this area in order to help specialists in the treatment decision-making process. The AGREE II methodology and the European Society of Cardiology system were used for recommendations and levels of evidence. The recommendations were graded from I to III, and levels of evidence were classified as A, B, or C. This guideline is divided into 11 chapters dealing with the various aspects of extracranial cerebrovascular disease: diagnosis, treatments and complications, based on up-to-date knowledge and the recommendations proposed by SBACV.

Rapid Carotid Screening by Duplex: A Prospective Single Centre Assessment

OBJECTIVE

A novel carotid quick scan (CQS) protocol was developed to rapidly screen for carotid atherosclerosis greater than 50% stenosis in a vascular outpatient setting. This study assessed accuracy and time saved.

MATERIAL & METHODS

The CQS was developed by consensus agreement between vascular surgeons and accredited clinical vascular scientists through a modified Delphi technique. The protocol comprised a rapid B-mode then colour flow transverse sweep of the common and internal carotid arteries, with internal carotid artery velocity assessment. One hundred outpatients attending with peripheral artery disease or abdominal aortic aneurysm were recruited. CQS sensitivity, specificity and accuracy was assessed against a conventional full carotid duplex study, performed to UK and ESVS guidelines.

RESULTS

Twenty four percent of patients (n = 100) had >50% carotid NASCET stenosis. CQS achieved an excellent accuracy of 96.5% in detecting >50% stenosis when compared to full duplex; Cohen's ƙ = .88, (95%CI .79-.97; P < .001), sensitivity 91.4%, specificity 97.6%, positive predictive value (PPV) 88.9% and negative predictive value (NPV) 98.2%. Median (IQR) time to complete the CQS was 13 sec (±12) per side, compared to 151 sec (±78) per side for the full carotid duplex. In the presence of >50% carotid disease, median CQS time was 25 sec (±31) per side compared to 214 (±104) by full scan.

CONCLUSION

CQS as a carotid screening tool is rapid, accurate and acceptable to the population and workforce. It would be simple to roll out in all vascular laboratories to reduce the time and cost burden of excluding significant carotid disease in any group.

Why selective screening for asymptomatic carotid stenosis is currently appropriate: a special report

INTRODUCTION

Two of the main reasons recent guidelines do not recommend routine population-wide screening programs for asymptomatic carotid artery stenosis (AsxCS) is that screening could lead to an increase of carotid revascularization procedures and that such mass screening programs may not be cost-effective. Nevertheless, selective screening for AsxCS could have several benefits. This article presents the rationale for such a program.

AREAS COVERED

The benefits of selective screening for AsxCS include early recognition of AsxCS allowing timely initiation of preventive measures to reduce future myocardial infarction (MI), stroke, cardiac death and cardiovascular (CV) event rates.

EXPERT OPINION

Mass screening programs for AsxCS are neither clinically effective nor cost-effective. Nevertheless, targeted screening of populations at high risk for AsxCS provides an opportunity to identify these individuals earlier rather than later and to initiate a number of lifestyle measures, risk factor modifications, and intensive medical therapy in order to prevent future strokes and CV events. For patients at 'higher risk of stroke' on best medical treatment, a prophylactic carotid intervention may be considered.

Carotid and Renal Vascular Disease

This article review covers carotid artery disease, abdominal aortic aneurysm, and atherosclerotic renal artery disease. It overviews each condition's clinical presentation, diagnosis, medical management, and interventional approach. Carotid artery disease is characterized by hemispheric and neuropsychological manifestations, which can help detect this condition. Screening for carotid artery stenosis is recommended in high-risk individuals and can be performed using different methods, with carotid duplex ultrasonography being the preferred option. Carotid endarterectomy and carotid artery stenting are indicated based on specific criteria and patient characteristics. An abdominal aortic aneurysm is often asymptomatic, but abdominal, back, or flank pain may sometimes be present. Ultrasonography is an effective method for screening and monitoring abdominal aortic aneurysms, with high sensitivity and specificity. Smoking cessation is a crucial intervention for preventing further enlargement of small aortic aneurysms. Repair of abdominal aortic aneurysm is recommended based on the aneurysm size, growth rate, and the presence of symptoms. Endovascular repair is preferred when suitable anatomy is present. Atherosclerotic renal artery disease is associated with resistant hypertension, renal failure, and occasionally pulmonary edema. Doppler ultrasonography is a valuable diagnostic tool for detecting it, while the renal resistive index provides additional insights into disease severity and treatment response. Revascularization is not routinely recommended for atherosclerotic renal artery disease, but it may be considered in specific cases, such as renal arterial fibromuscular dysplasia or unexplained congestive heart failure.

State-of-the-art CT and MR imaging and assessment of atherosclerotic carotid artery disease: standardization of scanning protocols and measurements-a consensus document by the European Society of Cardiovascular Radiology (ESCR)

The European Society of Cardiovascular Radiology (ESCR) is the European specialist society of cardiac and vascular imaging. This society's highest priority is the continuous improvement, development, and standardization of education, training, and best medical practice, based on experience and evidence. The present intra-society consensus is based on the existing scientific evidence and on the individual experience of the members of the ESCR writing group on carotid diseases, the members of the ESCR guidelines committee, and the members of the executive committee of the ESCR. The recommendations published herein reflect the evidence-based society opinion of ESCR. We have produced a twin-papers consensus, indicated through the documents as respectively "Part I" and "Part II." The first document (Part I) begins with a discussion of features, role, indications, and evidence for CT and MR imaging-based diagnosis of carotid artery disease for risk stratification and prediction of stroke (Section I). It then provides an extensive overview and insight into imaging-derived biomarkers and their potential use in risk stratification (Section II). Finally, detailed recommendations about optimized imaging technique and imaging strategies are summarized (Section III). The second part of this consensus paper (Part II) is focused on structured reporting of carotid imaging studies with CT/MR. KEY POINTS: • CT and MR imaging-based evaluation of carotid artery disease provides essential information for risk stratification and prediction of stroke. • Imaging-derived biomarkers and their potential use in risk stratification are evolving; their correct interpretation and use in clinical practice must be well-understood. • A correct imaging strategy and scan protocol will produce the best possible results for disease evaluation.

Why do guidelines recommend screening for abdominal aortic aneurysms, but not for asymptomatic carotid stenosis? A plea for a randomized controlled trial

BACKGROUND

Current guidelines do not recommend screening for asymptomatic carotid artery stenosis (AsxCS). The rationale behind this recommendation is that detection of AsxCS may lead to an unnecessary carotid intervention. In contrast, screening for abdominal aortic aneurysms is strongly recommended.

METHODS

A critical analysis of the literature was performed to evaluate the implications of detecting AsxCS.

RESULTS

Patients with AsxCS are at high risk for future stroke, myocardial infarction and vascular death. Population-wide screening for AsxCS should not be recommended. Additionally, screening of high-risk individuals for AsxCS with the purpose of identifying candidates for a carotid intervention is inappropriate. Instead, selective screening for AsxCS should be considered and should be viewed as an opportunity to identify individuals at high risk for atherosclerotic cardiovascular disease and future cardiovascular events for the timely initiation of intensive medical therapy and risk factor modification.

CONCLUSIONS

Although mass screening should not be recommended, there are several arguments suggesting that selective screening for AsxCS should be considered. The rationale supporting such selective screening is to optimize risk factor control and to initiate intensive medical therapy for prevention of future cardiovascular events, rather than to identify candidates for an intervention.

Head and Neck Cancer Types and Risks of Cervical-Cranial Vascular Complications within 5 Years after Radiation Therapy

Background and purpose: to investigate the frequency of cervical−cranial vascular complications soon after radiation therapy (RT) and identify differences among patients with various types of head and neck cancer (HNC). Methods: We enrolled 496 patients with HNC who had received their final RT dose in our hospital. These patients underwent carotid duplex ultrasound (CDU) for monitoring significant carotid artery stenosis (CAS). Brain imaging were reviewed to detect vertebral, intracranial artery stenosis, or preexisted CAS before RT. Primary outcome was significant CAS at the internal or common carotid artery within first 5 years after RT. We categorized the patients into nasopharyngeal carcinoma (NPC) and non-NPC groups and compared the cumulative occurrence of significant CAS between the groups using Kaplan−Meier and Cox-regression analyses. Results: Compared to the NPC group, the non-NPC group had a higher frequency of significant CAS (12.7% vs. 2.0%) and were more commonly associated with significant CAS after adjusting the covariates (Adjusted hazard ratio: 0.17, 95% confident interval: 0.05−0.57) during the follow-up period. All the non-NPC subtypes (oral cancer/oropharyngeal, hypopharyngeal, and laryngeal cancers) were associated with higher risks of significant CAS than the NPC group (p < 0.001 respectively). Conclusion: Significant CAS was more frequently noted within 5 years of RT among the patients with non-NPC HNC than among the patients with NPC. Scheduled carotid artery surveillance and vascular risk monitoring should be commenced earlier for patients with non-NPC HNC. By contrast, vascular surveillance could be deferred to 5 years after RT completion in NPC patients.

[A comparative analysis of the clinical and anamnestic status of patients with chronic occlusion of the carotid arteries based on the data of observational registries]

OBJECTIVE

To study the clinical and anamnestic status of patients with chronic carotid artery occlusion (CCAO) based on the analysis of risk factors, demographic and clinical and anatomical characteristics, the dynamics of the disease; to evaluate ongoing drug therapy, the incidence of strokes (MI) and deaths (according to the local registry compared with the results of other observational studies).

MATERIAL AND METHODS

PubMed and eLibrary searches for a systematic review were performed from October 24 to December 10, 2021 independently by two investigators. Out of 870 articles, based on inclusion/exclusion criteria, 8 studies were selected and included in the systematic review.

RESULTS

A comparative analysis of the clinical and anamnestic status of patients with CCAO according to the present review showed the following data on the prevalence of the main risk factors/diseases: hypertension - 79.1%; male gender - 83.7%; smoking - 46%; diabetes mellitus - 30.5%. Of the entire of own Duplex registry group (n=2548), 7 patients were identified with CCAO (0.27%). All patients were male (mean age 71.3±9.4 years). Endpoints were recorded in 5 of 7 participants during the follow-up period (8.9 years): 5 deaths, 2 fatal MI, 1 non-fatal MI, 1 myocardial infarction. A significant impact of the fact of MI on the survival of patients was confirmed using the standard log-rank test (p=0.02 and the Cox-Mendel test (p=0.04). The incidence of MI during the prospective follow-up according to the analyzed studies ranged from 4.3% (within a month of follow-up) to 42.8% (with a follow-up of 8.9 years), and averaged 12%.

CONCLUSIONS

A comparative analysis of the clinical and anamnestic status of patients with CCAO based on data from observational registers showed that the probability of detecting this pathology is associated with age and male gender. Data obtained from prospective observation of patients with CCAO in our own study show that the development of MI is one of the main factors affecting the survival of this category of patients.

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

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.

Development and Internal Validation of a Risk Score to Detect Asymptomatic Carotid Stenosis

OBJECTIVE

Asymptomatic carotid stenosis (ACS) is associated with an increased risk of ischaemic stroke and myocardial infarction. Risk scores have been developed to detect individuals at high risk of ACS, thereby enabling targeted screening, but previous external validation showed scope for refinement of prediction by adding additional predictors. The aim of this study was to develop a novel risk score in a large contemporary screened population.

METHODS

A prediction model was developed for moderate (≥50%) and severe (≥70%) ACS using data from 596 469 individuals who attended screening clinics. Variables that predicted the presence of ≥50% and ≥70% ACS independently were determined using multivariable logistic regression. Internal validation was performed using bootstrapping techniques. Discrimination was assessed using area under the receiver operating characteristic curves (AUROCs) and agreement between predicted and observed cases using calibration plots.

RESULTS

Predictors of ≥50% and ≥70% ACS were age, sex, current smoking, diabetes mellitus, prior stroke/transient ischaemic attack, coronary artery disease, peripheral arterial disease, blood pressure, and blood lipids. Models discriminated between participants with and without ACS reliably, with an AUROC of 0.78 (95% confidence interval [CI] 0.77-0.78) for ≥ 50% ACS and 0.82 (95% CI 0.81-0.82) for ≥ 70% ACS. The number needed to screen in the highest decile of predicted risk to detect one case with ≥50% ACS was 13 and that of ≥70% ACS was 58. Targeted screening of the highest decile identified 41% of cases with ≥50% ACS and 51% with ≥70% ACS.

CONCLUSION

The novel risk model predicted the prevalence of ACS reliably and performed better than previous models. Targeted screening among the highest decile of predicted risk identified around 40% of all cases with ≥50% ACS. Initiation or intensification of cardiovascular risk management in detected cases might help to reduce both carotid related ischaemic strokes and myocardial infarctions.

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.

Unrecognized Cardiovascular Abnormalities Detected Through a Community Cardiovascular Screening Program

Objective:

Self-referral community cardiovascular screening programs (CCSPs) have a potential to reduce outcome events through early detection of disease. This study evaluated the characteristics of a population that could predict a positive test.

Materials and Methods:

Participants who completed a cardiovascular screening protocol were compared. The screening protocol included a blood pressure (BP), Doppler ankle brachial index (ABI) testing, a limited carotid sonogram, a limited aortic sonogram, electrocardiogram (ECG), and limited transthoracic echocardiogram (TTE).

Results:

Screenings were performed on 205 participants (58% female, 68 ± 9 years of age). Sixty-seven (34%) participants were abnormal in at least one of the following screening tests: ABI (2%), carotid sonogram (6%), aortic sonogram (3%), ECG (11%), and TTE (22%). Although 60.5% of the participants reported recent symptoms, there were no differences in normal or abnormal results of participants presenting with or without symptoms ( P = .06). Income was not a predictor of abnormal test results (odds ratio, 0.76; 95% confidence interval, 0.55–0.97; P = .19). Multivariate analysis demonstrated, when controlling for age greater than 75 years, that participants taking BP medication was the only variable that predicted a positive test result.

Conclusion:

One-third of patient results were abnormal, regardless of symptoms or lack thereof, suggestive of subclinical disease. Further large-scale studies would demonstrate the role of CCSPs in risk stratifying participants.

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.

A model to predict unstable carotid plaques in population with high risk of stroke

BACKGROUND

Several models have been developed to predict asymptomatic carotid stenosis (ACS), however these models did not pay much attention to people with lower level of stenosis (<50% or carotid plaques, especially instable carotid plaques) who might benefit from early interventions. Here, we developed a new model to predict unstable carotid plaques through systematic screening in population with high risk of stroke.

METHODS

Community residents who participated the China National Stroke Screening and Prevention Project (CNSSPP) were screened for their stroke risks. A total of 2841 individuals with high risk of stroke were enrolled in this study, 266 (9.4%) of them were found unstable carotid plaques. A total of 19 risk factors were included in this study. Subjects were randomly distributed into Derivation Set group or Validation Set group. According to their carotid ultrasonography records, subjects in derivation set group were further categorized into unstable plaque group or stable plaque group.

RESULTS

174 cases and 1720 cases from Derivation Set group were categorized into unstable plaque group and stable plaque group respectively. The independent risk factors for carotid unstable plaque were: male (OR 1.966, 95%CI 1.406-2.749), older age (50-59, OR 6.012, 95%CI 1.410-25.629; 60-69, OR 13.915, 95%CI 3.381-57.267;≥70, OR 31.267, 95%CI 7.472-130.83), married(OR 1.780, 95%CI 1.186-2.672), LDL-C(OR 2.015, 95%CI 1.443-2.814), and HDL-C(OR 2.130, 95%CI 1.360-3.338). A predictive scoring system was generated, ranging from 0 to 10. The cut-off value of this predictive scoring system is 6.5. The AUC value for derivation and validation set group were 0.738 and 0.737 respectively.

CONCLUSIONS

For those individuals with high risk of stroke, we developed a new model which could identify those who have a higher chance to have unstable carotid plaques. When an individual's predictive model score exceeds 6.5, the probability of having carotid unstable plaques is high, and carotid ultrasonography should be conducted accordingly. This model could be helpful in the primary prevention of stroke.

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.

ECAS progression score: a web-based model to predict progression of extracranial carotid artery stenosis

BACKGROUND AND PURPOSE

To develop and validate a risk model (Extracranial Carotid Artery Stenosis progression score, ECAS-PS) and to predict risk of ECAS progression.

METHODS

The ECAS-PS was developed based on the Renqiu Stroke Screening Study (RSSS), in which eligible participants were randomly divided into derivation (60%) and validation (40%) cohorts. ECAS at baseline and follow-up was diagosed by carotid duplex ultrasound according to the published criteria. ECAS progression was defined as an increase in ECAS to≥50% for those with a baseline of <50% or as an increase to a higher category of stenosis if the baseline stenosis was ≥50%. Independent predictors of ECAS progression were obtained using multivariable logistic regression. The area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow test were used to assess model discrimination and calibration.

RESULTS

A total of 4111 participants were included and the mean age was 64.3. A total number of 29 (0.7%), 24 (0.6%) and 48 (1.2%) patients progressed during 2-year follow-up for left, right and bilateral (either left or right) carotid artery, respectively. The ECAS-PS was developed from a set of predictors of ECAS progression. The ECAS-PS demonstrated good discrimination in both the derivation and validation cohorts (AUROC range: 0.824-0.917). The Hosmer-Lemeshow tests of ECAS progression score were not significant in the derivation and validation cohorts (all P > 0.05).

CONCLUSION

The ECAS progression score is a valid model for predicting the risk of ECAS progression. Further validation of the ECAS-PS in different populations and larger samples is warranted.

Carotid artery flow as determined by real-time phase-contrast flow MRI and neurovascular ultrasound: A comparative study of healthy subjects

BACKGROUND

The assessment of carotid artery flow by neurovascular ultrasound (nvUS) can be complemented by real-time phase-contrast (RT-PC) flow MRI which apart from quantitative flow parameters offers velocity distributions across the entire vessel lumen.

MATERIALS AND METHODS

The feasibility and diagnostic potential of RT-PC flow MRI was evaluated in 20 healthy volunteers in comparison to conventional nvUS. RT-PC flow MRI at 40 ms temporal resolution and 0.8 mm in-plane resolution resulted in velocity maps with low phase noise and high spatiotemporal accuracy by exploiting respective advances of a recent nonlinear inverse model-based reconstruction. Peak-systolic velocities (PSV), end-diastolic velocities (EDV), flow volumes and comprehensive velocity profiles were determined in the common, internal and external carotid artery on both sides.

RESULTS

Flow characteristics such as pulsatility and individual abnormalities shown on nvUS could be reproduced and visualized in detail by RT-PC flow MRI. PSV to EDV differences revealed good agreement between both techniques, mean PSV and EDV were significantly lower and flow volumes were higher for MRI.

CONCLUSION

Our findings suggest that RT-PC flow MRI adds to clinical diagnostics, e.g. by alterations of dynamic velocity distributions in patients with carotid stenosis. Lower PSV and EDV values than for nvUS mainly reflect the longer MRI acquisition time which attenuates short peak velocities, while higher flow volumes benefit from a proper assessment of the true vessel lumen.

Cardiovascular Ultrasound Combined With Non-invasive Screening for the Detection of Undiagnosed Cardiovascular Disease: A Literature Review

Non-invasive screenings have been widely utilized in the United States and worldwide to provide early identification of cardiovascular disease, allowing for earlier diagnosis and treatment. Screening sonography detects valve disease, cardiac dysfunction, and carotid disease in 5% to 20% of the population. This review discusses the current data regarding cardiovascular screening, the methodologies, and the resources required for performance of screenings. Cardiac and carotid sonography is highly accurate and discovers cardiovascular diseases that impact quality of life and risk of future events. Screenings are performed in a variety of settings and accuracy depends on the quality of personnel performing the non-invasive testing, the equipment utilized, and the personnel interpreting the studies. Despite the potential benefit for disease detection, population screening to detect cardiovascular disease is not widely supported by national organizations due to the theoretical cost of further testing and lack of cost versus benefit data. Additional studies are necessary to compare costs and benefits of non-invasive cardiovascular screening in the community setting.

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.

ECAS score: a web-based risk model to predict moderate and severe extracranial carotid artery stenosis

Background and purpose To develop and validate a risk model (Extracranial Carotid Artery Stenosis score, ECAS score) to predict moderate and severe ECAS. Furthermore, we compared discrimination of the ECAS score and three existing models with regard to both moderate and severe ECAS. Methods The ECAS score was developed based on the Renqiu Stroke Screening Study (RSSS), in which eligible patients were randomly divided into derivation (60%) and validation (40%) cohorts. ECAS was diagnosed by carotid duplex ultrasound according to the published criteria. Independent predictors of moderate (≥50%) and severe (≥70%) ECAS were obtained using multivariable logistic regression. The area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow test were used to assess model discrimination and calibration. Results A total of 5010 participants were included and the mean age was 64.3. The proportion of ECAS of < 50%, 50-69%, 70-99% and occlusion was 4.4, 0.5, 0.4, and 0.4%, respectively. The ECAS score was developed from sets of predictors of moderate and severe ECAS. The ECAS score demonstrated good discrimination in the derivation and validation cohorts (AUROC range: 0.785-0.846). The Hosmer-Lemeshow tests of ECAS score for moderate and severe ECAS were not significant in the derivation and validation cohorts (all P > 0.05). When compared to the three existing models, the ECAS score showed significantly better discrimination for both moderate and severe ECAS (all P < 0.001). Conclusion The ECAS score is a valid model for predicting moderate and severe ECAS. Further validation of the ECAS score in different populations and larger samples is warranted.

Grading of proximal internal carotid artery (ICA) stenosis by Doppler/duplex ultrasound (DUS) and computed tomographic angiography (CTA): correlation and interrater reliability in real-life practice

Doppler/duplex ultrasound (DUS) and computed tomographic angiography (CTA) are frequently applied methods to assess the degree of proximal internal carotid artery (ICA) stenoses in patients with acute ischemic stroke. This study evaluated the agreement and interrater reliability (IR) of both methods using a revised DUS grading system as well as different criteria (ECST/NASCET) under real-life conditions. CTA and DUS data of 281 proximal ICA stenoses [143 patients; 65.7 % male; age (mean (years) ± SD, range) 72.2 ± 11.1, 40-99] were retrospectively analyzed. For both methods, two independent raters estimated the degree of stenosis according to NASCET and ECST criteria. DUS raters applied revised German DUS criteria. For agreement and IR assessment, the linear weighted Kappa statistic was used. Correlation between DUS and CTA was substantial irrespective of the applied classification [weighted Kappa: 0.77 (NASCET)/0.79 (ECST)]. IR for DUS was almost perfect (weighted Kappa: 0.94) and better than for CTA [weighted Kappa: 0.78 (NASCET)/0.78 (ECST)]. In a real-life setting, CTA and DUS assessments of the degree of proximal ICA stenoses agreed substantially irrespective of the criteria applied (ECST/NASCET). For DUS, IR was better than for CTA.

Improving imaging to optimize screening strategies for carotid artery stenosis

Carotid stenosis is a major risk factor for ischemic stroke. Recently, the United States Preventive Services Task Force issued a recommendation against screening for carotid stenosis in the general population. There is the potential for efficient risk-stratifying or staged screening approaches that identify individuals at highest risk for carotid stenosis and stroke, but these tools have yet to be proven effective in external validation studies. In this paper, we review how medical imaging can be used to detect carotid stenosis and highlight several areas that could be improved to identify potentially efficient screening strategies for carotid stenosis.

Utility of carotid duplex ultrasonography in a general inner-city hospital

BACKGROUND

Carotid Duplex Ultrasonography (CDUS) is one of the non-invasive imaging modalities used to evaluate for carotid artery stenosis. However, it is often used in patients with coronary artery disease (CAD), peripheral artery disease (PAD), before heart surgery, syncope and non-specific neurological symptoms although its value is unclear. Our study aimed to further investigate the yield of CDUS in these conditions.

METHODS

A retrospective analysis was conducted on 827 consecutive carotid ultrasounds ordered between March 2013 and August 2013 at Newark Beth Israel Medical Center. Clinical characteristics such as age, sex, smoking status, systemic hypertension, diabetes mellitus, CAD, PAD, carotid bruit and indications for carotid ultrasound were included. Significant cerebrovascular disease (sCBVD) was defined as greater than or equal to 50% diameter reduction in internal carotid arteries (ICA) or any degree of occlusion in vertebrobasilar system.

RESULTS

Only 88 out of 827 (10.6%) patients had sCBVD. Using logistic regression analysis we identified age greater than 65 years (OR 2.1, 95% CI 1.2 to 3.7; P=0.006), carotid bruit (OR 7.8, 95% CI 3.6 to 16.6; P <0.001) and history of prior carotid endarterectomy or carotid artery stenting (OR 5.8, 95% CI 2.3 to 14.8; P <0.001) as significant predictors of sCBVD.

CONCLUSIONS

Significant carotid artery stenosis is more likely in patients 65 years and older, presence of carotid bruit and prior CEA. On the other hand, it has low diagnostic yield in less than 65-year-old individuals, syncope and non-focal neurological symptoms. This highlights the need for better risk prediction models in order to promote optimal utilization.

[Carotid artery screening for stroke prevention]

CLINICAL/METHODICAL ISSUE

The aim was to identify the risk of impending stroke originating from diseases of the carotid artery.

STANDARD RADIOLOGICAL METHODS

Duplex scanning is the standard method for clinical examination of carotid arteries.

METHODICAL INNOVATIONS

By implementing the new standardized German Society for Ultrasound in Medicine (DEGUM) criteria, ultrasound examination enables reliable grading of carotid artery disease and identification of the progression of stenosis.

PERFORMANCE

Current guidelines recommend duplex scanning as the standard method. In consequence of finding atherosclerosis, intensive monitoring and therapy of cardiovascular risk factors is mandatory. In cases showing rapid progression of stenosis or a very high degree of stenosis indicating increased risk of stroke, carotid endarterectomy or stenting is warranted.

ACHIEVEMENTS

Detection of carotid artery atherosclerosis is uncomplicated and the method is not demanding; however, identification of high-risk carotid disease by exact grading of carotid stenosis requires investigation by an experienced examiner.

PRACTICAL RECOMMENDATIONS

Screening is recommended for patients exhibiting cardiovascular risk factors but is not recommended for the general population. On detection of carotid stenosis an exact grading of stenosis by an experienced examiner is absolutely essential.

Carotid artery atherosclerosis among 65-year-old Swedish men - a population-based screening study

OBJECTIVE

There are limited contemporary epidemiological data on the prevalence of carotid atherosclerosis in the general population. The aim was to determine the prevalence of and risk factors associated with carotid artery atherosclerosis among 65-year-old men.

METHODS

This was a population-based screening study. All 65-year-old men in the County of Uppsala, Sweden, who attended screening for abdominal aortic aneurysm (AAA) 2007-2009, were invited for duplex scanning of the carotid arteries.

RESULTS

Of 4801 men invited, 4657 (97%) accepted. Carotid plaques (>2 × 6 mm) were observed in 1169 (25%) men, 94 (2.0%) had carotid stenoses (50-99%), and 15 (0.3%) had occluded carotid arteries. In a multivariate logistic regression model, smoking (OR 1.7, 95% CI 1.5-1.9), hypertension (1.5, 95% CI 1.3-1.7), diabetes mellitus (1.2, 95% CI 1.0-1.5), and coronary artery disease (1.5, 95% CI 1.3-1.8) were associated with prevalence of carotid atherosclerosis (plaque and/or stenosis). The use of antiplatelet agents and statins in participants with a carotid plaque was 20% and 29%, respectively. The corresponding figures in participants with a stenosis were 42% and 41%.

CONCLUSIONS

This study offers contemporary data on the prevalence of carotid atherosclerosis in a population-based cohort of 65-year-old men. Most of those at risk had no other clinical manifestation of atherosclerosis, and therefore had no secondary prevention.

Carotid stenosis management: a review for the internist

Stroke is one of the most important causes of mortality and morbidity worldwide and, for a long time, was the leading cause of death in developed countries. Atherothrombotic carotid stenosis is one of the most important etiologies behind this event. If properly recognized and treated, lives can be saved, as well as long-term disabilities prevented. With population aging and improvements in surgical and clinical care, patients with several comorbidities will be referred for revascularization procedures more frequently, posing a challenge for physicians. The purpose of this review is to provide internists and clinicians with information based on several studies so they can offer to their patients, the best evidence-based care, indicating appropriate medical therapy, as well as referral to a vascular surgeon, or what contraindicates endarterectomy or angioplasty, depending on individual characteristics.

[Screening of carotid arteries before surgery: when does preoperative duplex ultrasound make sense?]

Carotid artery stenosis is a marker for generalized atherosclerosis with high cerebrovascular and cardiovascular morbidity and mortality rates. There is an estimated increase in prevalence of moderate stenosis for older age and male sex. Asymptomatic carotid artery stenosis is a risk factor for perioperative neurological events during general surgery. Planning of effective preoperative screening of populations at risk for asymptomatic carotid artery stenosis is best evaluated for cardiac surgery. General screening is not recommended; however, preoperative screening for asymptomatic carotid artery stenosis should be performed in high-risk patients with options for surgical or interventional treatment. These are patients with clinical signs of peripheral arterial disease and patients over 65 years old with at least one of the risk factors coronary artery disease, smoking and hypercholesterinemia. Preoperative screening in patients with carotid bruits may also be useful. Preoperative carotid artery screening may be beneficial in detecting occult carotid artery stenosis and thereby reducing perioperative neurological events.

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.

Centers for Medicare and Medicaid Services conducts a medical evidence development and coverage advisory committee meeting on carotid atherosclerosis

Publication of the eagerly anticipated Carotid Revascularization Endarterectomy Versus Stenting Trial in May 2010 was anticipated to engender much activity in the realm of interventions for carotid stenosis. Specifically, a variety of professional societies, including the Society for Vascular Surgery (SVS), published updated practice guidelines in the calendar year 2011, timed to include data from large-scale well-conducted clinical trials comparing carotid endarterectomy with carotid artery stenting (CAS). In anticipation of a renewed application to the Centers for Medicare and Medicaid Services (CMS) to reconsider the national coverage determination for CAS, the SVS Board of Directors voted in June 2011 against any change in the national coverage determination for CAS. CMS convened a Medicare evidence development and coverage advisory committee (MEDCAC) meeting to consider fundamental aspects of the treatment of carotid atherosclerosis on January 25, 2012, to allow an unbiased and current deliberation of the state-of-the-art technology and science referable to the management of carotid atherosclerosis. The MEDCAC differs substantially from a reconsideration of coverage determination and, in this case, was built around seven research questions. The MEDCAC consists of a panel of experts who, after reviewing the literature and submitted comments by interested stakeholders, and after hearing testimony from invited speakers and at-large presentations, held a panel vote on the research questions. Given that management of carotid atherosclerosis is a core element of vascular surgical practice, the SVS had a major presence at the MEDCAC in the form of a comprehensive written document individually considering the research questions and a variety of presentations addressing various aspects in carotid disease management. The purpose of this report is to detail the SVS's position on the MEDCAC research questions referable to the management of carotid atherosclerosis and to otherwise detail the proceedings of the MEDCAC.

Symptomatic and asymptomatic carotid artery plaque

Carotid atherosclerotic plaques represent both stable and unstable atheromatous lesions. Atherosclerotic plaques that are prone to rupture owing to their intrinsic composition such as a large lipid core, thin fibrous cap and intraplaque hemorrhage are associated with subsequent thromboembolic ischemic events. At least 15-20% of all ischemic strokes are attributable to carotid artery atherosclerosis. Characterization of plaques may enhance the understanding of natural history and ultimately the treatment of atherosclerotic disease. MRI of carotid plaque and embolic signals during transcranial Doppler have identified features beyond luminal stenosis that are predictive of future transient ischemic attacks and stroke. The value of specific therapies to prevent stroke in symptomatic and asymptomatic patients with severe carotid artery stenosis are the subject of current research and analysis of recently published clinical trials that are discussed in this article.

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.

Role of carotid duplex imaging in carotid screening programmes - an overview

Background

Stroke is the third most common cause of death in the UK and the largest single cause of severe disability. Each year more than 110,000 people in England suffer from a stroke which costs the National Health Service (NHS) over GBP2.8 billion. Thus, it is imperative that patients at risk be screened for underlying carotid artery atherosclerosis.

Aim

To assess the role of carotid ultrasound in different carotid screening programmes.

Methods

A literature overview was carried out by using PubMed search engine, to identify different carotid screening programmes that had used ultrasound scan as a screening tool.

Results

It appears that the carotid ultrasound is an effective method for screening carotid artery disease in community as it effectively predicts the presence of stenosis with high accuracy. There is a need for primary care to recommend high risk patients for regular screening, to reduce stroke and transient ischemic attack (TIA) related morbidity and mortality.

Conclusion

Screening programmes using carotid ultrasonography contribute to public health awareness and promotion which in long term could potentially benefit in disease prevention and essentially promote better standards of healthcare.

Validation of two different grading schemes to identify patients with asymptomatic carotid artery stenosis in general population

BACKGROUND

Identification of significant asymptomatic carotid artery stenosis (ACAS) is important because of potential stroke-risk reduction offered by carotid endarterectomy. We present an external validation of two previously developed scoring schemes designed to identify patients with ACAS.

METHODS

We used the data from the Cardiovascular Health Study (CHS)-a cohort study of cardiovascular risk factors, for external validation. Carotid Doppler ultrasound was performed in study participants. Two grading schemes, which used age more than 65 years, current smoking, and history of coronary artery disease and hyperlipidemia as predictors for ACAS, were validated using this dataset.

RESULTS

A total of 5,449 persons (mean age 72 +/- 5 years; 42% men; and 84% white) were screened. The overall prevalence of ACAS of > or =50% was 4.2%. The prevalence of ACAS in the highest risk category was 19% in both stratification schemes. The stratification remained effective in the white sub-population (P < .001), but was not significant in the African American population (P > .05).

CONCLUSION

Both schemes were effective in identifying persons with ACAS among general population aged 65 years or greater. A subset with a prevalence of ACAS of greater than 20% can be identified using these schemes making screening cost-effective among white population.

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.

[Current status of vascular surgery : in vascular medicine and general surgery]

BACKGROUND

The proportion of arterial and venous diseases is increasing due to shifts in population. Therapy is based on conventional vascular surgery and conservative endovascular methods.

MATERIAL AND METHODS

Based on data from the Federal German Statistics Office and the Federal Chamber of Physicians, information was gathered on primary vascular diseases, active special vascular groups, surgical qualifications, and surgical clinics. Additionally, the status of vascular surgery at university clinics and non-university clinics with more than 900 beds was assessed.

RESULTS

In 2004, 413,763 patients with primary vascular disease were treated in 1,846 German general hospitals. More than 70% of these patients were handled in vascular surgical or general surgical clinics, and operations were performed in 50% of cases. There exist independent vascular surgical departments in 213 hospitals. Thirty-three university clinics at 38 locations showed a total of six independent vascular surgery clinics (16%) and seven partially independent sections (18%). Vascular surgery is done within cardiac surgical departments in ten clinics and in general surgery department in 15 clinics. In contrast, there are independent vascular surgical departments in 39% and 53% of non-university clinics with more than 900 and 600-899 beds respectively.

CONCLUSIONS

Vascular surgery has been established in hospitals as an independent speciality. This development must continue in general surgical and university clinics.