Early carotid atherosclerosis and cardiac diastolic abnormalities in hypertensive subjects

Carotid Intima-Media Thickness and Its Correlation With Echocardiographic Left Ventricular Function and Geometry in Hypertensive Individuals: A Cross-Sectional Study

Background It is important to consider left ventricular hypertrophy (LVH) and carotid intima-media thickness (CIMT) in assessing hypertensive patients' global cardiovascular risk profile, as LVH and arterial wall changes occur concurrently. This study aimed to assess the relationship between CIMT and left ventricular geometry and function in hypertensive patients. Methodology This cross-sectional study included 200 hypertensive individuals and sought to correlate their CIMT with left ventricular geometry and function in Lagos University Teaching Hospital. Hypertension was defined as blood pressure ≥140/90 mmHg or on treatment for hypertension presenting at the outpatient clinics. Patients who satisfied the inclusion criteria were recruited. Abnormal CIMT was defined as >0.9 mm. Patients' demographic data were obtained in addition to general characteristics, physical examination, transthoracic echocardiography, and CIMT. The statistical relationship between CIMT and left ventricular geometry and function was obtained and analyzed. Results Normal geometry and LVH were observed in 50.5% and 15.5%, respectively. Left ventricular geometry was associated with abnormal CIMT (χ2 = 31.688, p < 0.001). Furthermore, the mean left ventricular mass index was statistically different between abnormal and normal CIMT (97.84 ± 30.5 vs. 80.75 ± 15.6; p < 0.001). Regarding left ventricular function, there was no significant difference in E-point septal separation, left ventricular fractional shortening, and left ventricular ejection fraction in abnormal versus normal CIMT groups. However, there was a significant association of CIMT with grades of diastolic dysfunction (χ2 = 7.069, p = 0.029). Additionally, individual parameters of diastolic dysfunction such as left atrial volume index and septal mitral were significantly different (p < 0.001). Conclusions There was an association between age, left ventricular geometry, diastolic function, and CIMT in hypertensive individuals. Therefore, it is beneficial to evaluate CIMT and for these patients to receive more targeted blood pressure control which may reduce the risk of cardiovascular diseases.

Comorbidities impact and de-prescribing in elderly with HCV-related liver disease: analysis of a prospective cohort

Management for HCV has undergone a notable change using direct-acting antiviral drugs (DAAs), which are safe and effective even in elderly. Here, we define impact of comorbidities, concomitant medication and drug-drug interactions in elder patients with HCV related disease before starting DAAs regimen. We analyzed data of 814 patients prospectively enrolled at our Unit within the web based model HCV Sicily Network. Out of 814, 590 were treated with DAAs and 414 of them were older than 65 years. We divided those 414 in two groups, one including 215 patients, aged between 65 and 74 years, and another with 199 patients, aged of 75 years and over. Charlson Comorbidity Index (CCI) was assessed for each patient; drug-drug interactions (DDI) and de-prescribing process were carried out appropriately. Within 414 patients included, percentage rates of women treated was higher than males, BMI was lower and cirrhosis was frequently reported in patients older than 75 years. Hypertension, diabetes mellitus, dyslipidemia (p < 0.0001), prostatic pathologies, kidney disease, gastrointestinal disease (p < 0.0001), osteoporosis (p < 0.01) and depression were most common co-morbidities. CCI showed lower scores in the first group as compared with the second one (p < 0.0001). Among drugs, statins were frequently suspended and anti-hypertensive often replaced. DAAs are useful and effective regardless of disease severity, comorbidities, medications and age. De-prescribing allows a stable reduction of number of medications taken with real improvement of quality of life.

Comparison of the Relation of Carotid Intima-Media Thickness With Incident Heart Failure With Reduced Versus Preserved Ejection Fraction (from the Multi-Ethnic Study of Atherosclerosis [MESA])

Increased carotid intima-media thickness (cIMT) is associated with heart failure (HF) in previous studies, but it is not known whether the association of cIMT differs between HF with reduced (HFrEF) versus preserved ejection fraction (HFpEF). We studied 6699 participants (mean age 62 ± 10 years, 47% male, and 38% white) from the Multi-Ethnic Study of Atherosclerosis (MESA) with baseline cIMT measurements. We classified HF events as HFrEF (EF <50%) or HFpEF (EF ≥ 50%) at the time of diagnosis. Cox proportional hazard regression was used to compute hazard ratios (HR), and 95% confidence intervals (CI) for the association between the IMT Z-score (measured maximum IMT of Internal Carotid (IC) and Common Carotid (CC) sites as the mean of the maximum IMT of the near and far walls of right and left sides), and incident HFrEF or HFpEF. Models were adjusted for covariates and interim coronary artery disease (CAD) events. A total of 191 HFrEF and 167 HFpEF events occurred during follow-up. In multivariable analysis, each 1 standard deviation increase in the measured maximum IMT (Z-score) was associated with both HFrEF and HFpEF in the unadjusted and demographically adjusted models [HR, 95% CI 1.57 (1.43 to 1.73)] and [HR, 95% CI 1.61 (1.47 to 1.77)] but not in the fully adjusted models [HR, 95% CI 1.11 (0.96 to 1.28)] and [HR, 95% CI 1.13 (0.98 to 1.30)]. In conclusion, cIMT was significantly associated with incident HF, but the association is partially attenuated with adjustment for demographic factors and becomes non-significant after adjustment for other traditional heart failure risk factors and interim CAD events. There was no difference in the association of IMT measures with HFrEF versus HFpEF.

Education and hypertension: impact on global cardiovascular risk

BACKGROUND

Improving cardiovascular risk prediction continues to be a major challenge and effective prevention of cardiovascular disease. Accordingly, several studies have recently reported on the role of cardiovascular risk education. This study was designed to evaluate the impact of education on global cardiovascular risk in hypertensive patients.

SUBJECTS AND METHODS

The study population consisted of 223 consecutive hypertensive outpatients. Their educational status was categorized according to the number of years of formal education as follows: (1) low education (less than 10 years) and (2) medium-high education (10-15 years).

RESULTS

In both groups, cardiometabolic comorbidities, global cardiovascular risk and echocardiographic measurements were analysed. Less educated hypertensive subjects were characterized by a significantly higher prevalence of patients with metabolic syndrome (MetS) (p < .01), greater global cardiovascular risk (p < .001), and a higher consumption of antihypertensive drugs (p < .01) rather than medium-high educated hypertensive subjects. In the same subjects, a significant increase in microalbuminuria (MA) (p < .01) and a significant decrease in E/A (p < .001) ratio was found. Univariate analysis indicated that global cardiovascular risk correlated directly with waist-hip ratio, mean blood pressure, MA, left ventricular mass index, MetS and inversely with education (r = -0.45; p < .001). Education was independently (p < .001) associated with global CV risk.

CONCLUSIONS

Our data suggest that education may be considered the best predictor of global cardiovascular risk in hypertensives and thus has to be evaluated in the strategies of hypertension and cardiovascular risk management.

Correlation Between Diastolic Dysfunction and Coronary Artery Disease on Coronary Computed Tomography Angiography

Aims:

We investigated the relationship between coronary artery calcium score (CACS) and coronary artery disease (CAD) on coronary computed tomography angiography (CCTA), and measures of left ventricular diastolic function (DD).

Methods:

We included 429 consecutive patients (39% women; mean age 49 ± 12 years) without known CAD, who underwent CCTA and transthoracic echocardiography (TTE) within 1-month. Evaluation of CCTA was per vessel, and per segment basis for intraluminal diameter stenosis. We also used the 16-segment model to determine overall coronary plaque burden with segment involvement score (SIS). DD on TTE was assessed using mitral inflow E wave-to-A wave ratio (EAR) and tissue Doppler early mitral annual tissue velocity axial excursion.

Results:

A total of 293 (68.4%) patients had DD, 15.4% had more than stage 2 DD. The presence of DD was associated with increasing CACS (P < 0.001). Similarly, there was a statistically significant correlation between EAR and CCS (r = −0.147, P = 0.004) and SIS (r = 0.536, P < 0.001). The prevalence of more than stage 2 DD was associated with higher prevalence of obstructive CAD (26.2% vs. 11.7%, P < 0.0001). In multivariable analyses, the independent predictors of more than stage 1 DD are the age (P < 0.001), and diabetes (P = 0.010), while the CACS and SIS were not independently associated with DD.

Conclusion:

Our analysis suggests that CACS, as well as CAD by CCTA, are not independently associated with measures of DD on echocardiography.

Association between low education and higher global cardiovascular risk

This study was designed to evaluate the impact of educational status on global cardiovascular risk in a southern Italian urban population. The study population consisted of 488 consecutive outpatients aged 18 years and older. Educational status was categorized according to the number of years of formal education as follows: (1) low education group (<10 years) and (2) medium-high education group (10-15 years). In both groups, cardiometabolic comorbidities (obesity, visceral obesity, diabetes, dyslipidemia, metabolic syndrome, microalbuminuria, left ventricular hypertrophy) and global cardiovascular risk, according to international guidelines, were analyzed. Left ventricular mass index and ejection fraction by echocardiography and E/A ratio, by pulsed-wave Doppler, were calculated. The low education group was characterized by a significantly higher prevalence of patients with visceral obesity (P=.021), hypertension (P=.010), metabolic syndrome (P=.000), and microalbuminuria (P=.000) and greater global cardiovascular risk (P=.000). Significantly increased levels of microalbuminuria (P=.000) and significantly decreased values of E/A ratio (P=.000) were also detected in the low education group. Global cardiovascular risk correlated directly with waist-to-hip ratio (P=.010), microalbuminuria (P=.015), and the metabolic syndrome (P>.012) and inversely with educational status (P=.000). Education was independently (P=.000) associated with global cardiovascular risk. These data indicate a strong association between low education and cardiometabolic comorbidities suitable to influence the evolution of chronic degenerative diseases. Preventive strategies need to be more efficient and more effective in this patient population.

Systems pharmacology and molecular docking strategies prioritize natural molecules as cardioprotective agents

Multidimensional prioritization of cardioprotective natural compounds.

Visit-to-visit blood pressure variability is a marker of cardiac diastolic function and carotid atherosclerosis

Background

The associations between visit-to-visit blood pressure (BP) variability and cardiac function and carotid atherosclerosis is not clear.

Methods

Study subjects were 144 subjects (80 were female, aged 73 ± 9 years) who underwent echocardiography and cervical ultrasonography. The ratio of early ventricular filling velocity to early diastolic mitral annular velocity (E/e’), ejection fraction, left ventricular mass index (LVMI), and maximum intima-media thickness (max-IMT) of the carotid artery were compared between the highest (high variability) and lowest (low variability) tertiles of the standard deviation of systolic BP (9.9 ± 3.5 mmHg).

Results

E/e’ and max-IMT were significantly greater in the high variability group than in the low variability group after adjusting for age, sex, baseline systolic BP, and other covariates (high variability vs. low variability; E/e’: 13.03 ± 5.33 vs. 10.66 ± 3.30, multivariate-adjusted difference (β) = 1.82, 95% confidence interval 0.06–3.58; max-IMT: 1.65 ± 0.43 mm vs. 1.42 ± 0.46 mm, β = 0.20 mm, 95% confidence interval 0.03–0.36 mm). There were no significant differences in LVMI or ejection fraction.

Conclusion

These results indicate that high visit-to-visit BP variability is associated with diastolic function and carotid atherosclerosis, and is a possible risk factor for diastolic dysfunction and atherosclerosis.

Carotid intima-media thickness is associated with incident heart failure among middle-aged whites and blacks: the Atherosclerosis Risk in Communities study

Background

Increased carotid intima‐media thickness (IMT) is associated with subclinical left ventricular myocardial dysfunction, suggesting a possible role of carotid IMT in heart failure (HF) risk determination.

Methods and Results

Mean far wall carotid IMT, measured by B‐mode ultrasound, was available for 13 590 Atherosclerosis Risk in Communities study participants aged 45 to 64 years and free of HF at baseline. HF was defined using ICD‐9 428 and ICD‐10 I‐50 codes from hospitalization records and death certificates. The association between carotid IMT and incident HF was assessed using Cox proportional hazards analysis with models adjusted for demographic variables, major CVD risk factors, and interim CHD. There were 2008 incident HF cases over a median follow‐up of 20.6 years (8.1 cases per 1000 person‐years). Mean IMT was higher in those with HF than in those without (0.81 mm±0.23 versus 0.71 mm±0.17, P<0.001). Unadjusted rate of HF for the fourth compared with the first quartile of IMT was 15.4 versus 3.9 per 1000 person‐years; P<0.001. In multivariable analysis, after adjustment, each standard deviation increase in IMT was associated with incident HF (HR 1.20 [95% CI: 1.16 to 1.25]). After adjustment, the top quartile of IMT was associated with HF (HR 1.60 [95% CI: 1.37 to 1.87]). Results were similar across race and gender groups.

Conclusions

Increasing carotid IMT is associated with incident HF in middle‐aged whites and blacks, beyond risks explained by major CVD risk factors and CHD. This suggests that carotid IMT may be associated with HF through mechanisms different from myocardial ischemia or infarction.

Clinical significance of subclinical carotid atherosclerosis and its relationship with echocardiographic parameters in non-diabetic chronic kidney disease patients

Background

Non-diabetic chronic kidney disease (CKD) patients are a heterogeneous group with a variety of prognosis. We investigated the role of subclinical carotid atherosclerosis for the prediction of adverse cardiovascular (CV) outcomes in these patients, and tried to identify clinical and echocardiographic parameters associated with subclinical carotid atherosclerosis.

Methods

As a prospective design, 182 asymptomatic non-diabetic CKD patients underwent carotid ultrasonography and Doppler echocardiography. Carotid atherosclerosis was defined as a carotid intima-media thickness ≥1.0 mm and/or the presence of plaque.

Results

During the mean follow-up period of 28.8 ± 16.1 months, 23 adverse CV events occurred. Patients with carotid atherosclerosis (99, 54.4%) showed significantly higher rates of annual CV events than those without (8.6 vs. 1.5%, p <0.001). Particularly, the presence of carotid plaque was a powerful predictor of adverse CV outcomes (OR 7.80, 95% CI 1.45-45.97). Clinical parameters associated with the presence of subclinical carotid atherosclerosis were old age, previous history of hypertension, increased pulse pressure, and higher high-sensitivity C-reactive protein (hs-CRP) level. By echocardiography, early diastolic mitral annular velocity (E’) and the ratio of early peak transmitral inflow velocity (E) to E’ (E/E’) were closely related with the presence of carotid atherosclerosis. A multivariate analysis showed that age, hs-CRP, and E/E’ were significant determinants of carotid atherosclerosis.

Conclusions

Carotid plaque, even subclinical, was closely associated with a poor prognosis in non-diabetic CKD patients. Increased age, hs-CRP level, and E/E’ ratio may be useful markers suggesting the presence of carotid atherosclerosis in these patients.

Accumulated brisk walking reduces arterial stiffness in overweight adults: evidence from a randomized control trial

Arterial stiffness is a major contributor to the development of atherosclerosis and consequently cardiovascular disease. This study aimed to examine whether 6 months of accumulated (3 × 10 minutes, 5 days/week) brisk walking was sufficient to reduce arterial stiffness in sedentary, overweight individuals. Seventy-seven individuals (19 men, 58 women; age, 30-55 years) were randomly allocated to one of three groups; two groups completed 30 minutes of accumulated walking with either monthly or weekly telephone support; the third group (control) performed stretching exercises. The walking groups were combined and telephone support included as a covariate. Anthropometry, blood pressure (BP), blood lipids, pulse wave velocity (PWV), and NOx (surrogate marker for nitric oxide) were measured at baseline, post-intervention and 4 months post-intervention. No changes were observed for anthropometry, BP, or lipids. However, at the end of the intervention, there was a decrease in PWV (P < .001) accompanied by an increase in NOx (P < .001), with changes maintained 4 months post-intervention. A strong negative correlation between PWV and NOx was also observed (P < .001; r = -0.65). A lifestyle approach to meeting current physical activity guidelines results in favorable alterations in arterial function in overweight individuals.

Intima-media thickness in patients with obstructive sleep apnea without comorbidities

Background

Obstructive sleep apnea (OSA) is associated with elevated risk of cardiovascular events. The early stages of vascular complications can be visualized by means of ultrasound. Intima-media thickness (IMT) correlates with the presence of risk factors of cardiovascular diseases such as hypertension, diabetes, tobacco smoking, or hyperlipidemia. However, little is known whether OSA itself may be the cause of IMT thickening.

Methods

The study group was composed of 28 patients (6 women, 22 men; mean age = 53.8 years, mean BMI = 27.1 kg/m², mean AHI = 22.4/h) with OSA who had no comorbidities. The control group consisted of 28 healthy subjects (6 women, 22 men; mean age = 53.9 years; mean BMI = 27.5 kg/m²). In both groups IMT was assessed in common carotid arteries with the use of ultrasonography. Additionally, in patients with OSA, pulse wave velocity, echocardiography, 24-h automated blood pressure monitoring, clinical signs and symptoms, and blood tests were performed to investigate possible correlations with IMT.

Results

Median IMT was 0.41 mm in OSA patients and 0.46 mm in the control group (p = 0.087). Echocardiography revealed left ventricle hypertrophy in 21 %, systolic disorders in 8 %, and diastolic disorders in 57 % of the patients. In a large majority of patients, pulse wave velocity was found to be normal. IMT correlated with age (r = 0.446, p = 0.017), total cholesterol (r = 0.518, p = 0.005), daytime systolic blood pressure (r = 0.422, p = 0.025), pulse pressure 24 h and daytime (r = 0.424, p = 0.027 and r = 0.449, p = 0.019), early mitral flow/atrial mitral flow (E/A) (r = −0.429, p = 0.023), and posterior wall diameter (PWD) (r = 0.417, p = 0.270).

Conclusion

In a relatively nonobese group of patients, no significant differences were found in the intima-media thickness between OSA patients without concomitant cardiovascular diseases and healthy controls. This may lead to the conclusion that IMT does not reflect increased risk of cardiovascular events in patients with isolated OSA.

Arterial stiffness, carotid atherosclerosis and left ventricular diastolic dysfunction in postmenopausal women

BACKGROUND

Postmenopausal women have an increased cardiovascular morbidity that may be due to the increase in classical cardiovascular risk factors and also to the arterial structure and function alterations. The aim of our study was to evaluate the association of aortic pulse wave velocity (PWV), and carotid intima-media thickness (IMT), with left ventricular diastolic dysfunction (LVDD) in postmenopausal women.

PATIENTS AND METHODS

In 96 women without overt cardiovascular disease (age 62±7.7 years), and with normal left ventricular systolic function, aortic PWV was assessed by using an oscillometric device, intima-media thickness was measured by B-mode ultrasonography and the parameters of left ventricular diastolic function were evaluated by a transthoracic echocardiographic study.

RESULTS

LVDD, defined as an E/A ratio≤1 was found in 50 patients (52%). All of them had mild LVDD. In these patients we found significant increase in age (p<0.001), aortic PWV (p<0.001), carotid IMT (p=0.002) and plaque score (p=0.004) when compared with patients without LVDD. In a logistic regression analyzed, after adjusting for age, only aortic PWV was a significant predictor of LVDD (2.15, 95% CI 1.39-3.31, p=0.0006).

CONCLUSIONS

This study among postmenopausal women provides evidence that increased arterial stiffness as measured by aortic PWV and not carotid IMT may be a marker or a risk factor for LVDD, independent of other classical risk factors.

Importance of plasma N-terminal pro B-type natriuretic peptide, epicardial adipose tissue, and carotid intima-media thicknesses in asymptomatic obese children

This study aimed to analyze the variations of N-terminal pro B-type natriuretic peptide, epicardial adipose tissue thickness, and carotid intima-media thickness in childhood obesity. The study participants consisted of 50 obese children in the study group and 20 nonobese children referred for evaluation of murmurs who proved to have an innocent murmur and were used as control subjects. All the subjects underwent transthoracic echocardiographic examination for determination of left ventricular systolic function and mass index, myocardial tissue rates, and myocardial performance index. Epicardial adipose tissue thickness and carotid intima-media thickness also were measured during echocardiography. Serum N-terminal pro B-type natriuretic peptide levels were measured at the time of evaluation. The left ventricle mass index was 40.21 + or - 10.42 g/m(2) in the obese group and 34.44 + or - 4.51 g/m(2) in the control group (p > 0.05). The serum N-terminal pro B-type natriuretic peptide level was 109.25 + or - 48.53 pg/ml in the study group and 51.96 + or - 22.36 pg/ml and in the control group (p = 0.001). The epicardial adipose tissue thickness was 5.57 + or - 1.45 mm in the study group and 2.98 + or - 0.41 mm in the control group (p = 0.001), and the respective carotid intima-media thicknesses were 0.079 + or - 0.019 cm and 0.049 + or - 0.012 cm (p = 0.001). The left ventricular systolic and diastolic functions showed no statistically significant correlations with N-terminal pro B-type natriuretic peptide levels, carotid intima-media thickness, or epicardial adipose tissue thickness values. The results show that measurement of serum N-terminal pro B-type natriuretic peptide level, carotid intima-media thickness, and epicardial adipose tissue thickness in asymptomatic obese children is not needed.

Early markers of cardiovascular dysfunction in young girls affected by Cushing's syndrome before and after successful cure

BACKGROUND

even after successful surgical cure, Cushing's Syndrome (CS) may induce cardiovascular (CV) diseases including hypertension, or elicit onset of CV risk factors, such as obesity.

OBJECTIVES

to evaluate some early markers of CV dysfunction in adolescent girls before and after successful surgical cure of CS; to compare after surgery data with those of a control group (C) of healthy young girls.

METHODS

23 girls affected by CS were enrolled (range: 11-17 years; mean: 14.3 +/- 1.7 years). Epicardial fat thickness (EFT), intima-media thickness (IMT), N-terminal pro B-type natriuretic peptide (NT-proBNP) were assessed; transthoracic echocardiogram coupled with Tissue Doppler imaging (TDI) was performed. RESULTS (CS before surgery vs. CS after surgery): EFT (p < 0.05). (CS after surgery vs. C): EFT (p = 0.0001); IMT (p = 0.0001); NT-proBNP (p = 0.0001). TDI: isovolumetric relaxation time (p = 0.001); isovolumetric contraction time (p = 0.001); myocardial performance index (p = 0.001). Significant correlations: NT-proBNP with IRT (r = 0.45, p = 0.026 ), ICT (r = 0.47, p = 0.028), and myocardial performance index (r = 0.51, p = 0.0032).

CONCLUSIONS

important structural and functional modifications of heart and vessels are present in young female CS despite successful surgical cure, even in paediatric age. It underlines their significantly higher cardiovascular risk. Our findings confirm that EFT, IMT, NT-proBNP and TDI diastolic parameters, not previously tested in paediatric CS, are early markers of cardiovascular dysfunction. Because of its relationship with TDI, the assessment of NT-proBNP proves to be the best marker in detecting a cardiovascular dysfunction in this specific population.

Arterial stiffness and left-ventricular diastolic dysfunction: Guangzhou Biobank Cohort Study-CVD

Brachial-ankle pulse wave velocity (baPWV), a marker of arterial stiffness, is an established cardiovascular risk factor of ventricular stiffening. We studied the association of baPWV with left-ventricular (LV) diastolic function in a sub-study of the Guangzhou Biobank Cohort Study. In all, 378 Chinese subjects with a normal ejection fraction (>50%) had baPWV measurement by a noninvasive automatic waveform analyser, carotid intima-medial thickness (IMT) measurement by B-mode ultrasonography and cardiac diastolic function assessment by echocardiography. After adjusting for age, both baPWV and IMT were associated with LV mass index, posterior wall end-diastolic thickness and inter-ventricular end-diastolic thickness, but only baPWV was associated with deceleration time, atrial flow velocity and E/A ratio. Multivariable linear regression model showed that baPWV and mean arterial pressure, but not IMT, were significantly associated with E/A ratio (β=-0.02, P=0.03 and β=-0.36, P=0.02, respectively). The receiver operator characteristic curve showed that baPWV was better than pulse pressure or mean arterial pressure to detect LV diastolic dysfunction (E/A<1.0). Our study suggested that increased baPWV might be an independent risk factor or marker for diastolic dysfunction. Early detection of an intervention on increased baPWV may be important for prevention of cardiac diastolic dysfunction.

Use of carotid intima-media thickness to identify patients with ischemic stroke and transient ischemic attack with low yield of cardiovascular sources of embolus on transesophageal echocardiography

BACKGROUND AND PURPOSE

Carotid intima-media thickness (CIMT) is associated with systemic atherosclerosis and cardioembolic conditions and predicts the risk of recurrent strokes. We sought to establish the relationship between CIMT and cardiovascular sources of embolus (CSE) on transesophageal echocardiography (TEE) and hypothesized that a noninvasive strategy of CIMT assessment and transthoracic echocardiography bubble study would identify patients with ischemic stroke or transient ischemic attack in whom TEE would provide little incremental diagnostic yield.

METHODS

In 180 patients with ischemic stroke or transient ischemic attack of undetermined origin referred for TEE, we prospectively performed CIMT measurement/plaque screen (Phase 1, n=96) or CIMT measurement/plaque screen and transthoracic echocardiography bubble study (Phase 2, n=84) before TEE. Phase 1 results were used to construct receiver operating characteristic curves to demonstrate the ability of CIMT to detect CSE on TEE and to identify the optimal CIMT cutoff value for prospective strategy testing (Phase 2).

RESULTS

In Phase 1, CIMT was found to correlate with TEE markers of aortic atherosclerosis, including complex aortic plaques, and combined CSE. The optimal CIMT cutoff for detection of CSE on TEE was 0.78 mm. In Phase 2, a positive noninvasive strategy test (CIMT >or=0.78 mm, +carotid plaque, and/or a positive transthoracic echocardiography bubble study) was present in 61%. The prevalence of CSE on TEE was significantly higher among those with a positive compared with a negative noninvasive strategy test (65% versus 9%, P<0.001), and this strategy had a sensitivity of 92% and a negative predictive value of 91% for the detection of any CSE on TEE.

CONCLUSIONS

In patients with stroke or transient ischemic attack of undetermined origin, a noninvasive strategy of CIMT assessment/plaque screen and transthoracic echocardiography bubble study can identify patients in whom further invasive evaluation with TEE will be of low diagnostic yield.

Vascular failure: A new clinical entity for vascular disease

Atherosclerosis is characterized by the response of the vessel wall to chronic multifactorial injury leading to the formation of atheromatous or fibrous plaques. Endothelial dysfunction represents an initial stage of atherosclerosis. In addition to endothelial dysfunction, smooth muscle dysfunction, metabolic abnormalities of the vessel wall including inflammation, oxidative stress and alterations of neurohormonal balance occur in various stages of atherosclerosis. We now propose a new clinical entity 'vascular failure', defined as the integration of all of these vascular abnormalities. Vascular failure is not an anatomical disease, but rather a comprehensive syndrome of abnormal vascular function. Vascular failure extends from risk factors to established atherosclerotic disease with arterial stenosis, and further to calcification of the vessel wall or serious vascular events that may be caused by plaque rupture and thromboembolic occlusion. We propose aggressive intervention to modify various risk factors, applying to this integrated new entity, vascular failure.

Subclinical Atherosclerosis and Incipient Regional Myocardial Dysfunction in Asymptomatic Individuals

OBJECTIVES

This study sought to determine whether increased carotid intima-media thickness (IMT) is related to reduced regional myocardial function in participants of the Multi-Ethnic Study of Atherosclerosis (MESA).

BACKGROUND

Carotid artery IMT is an established index of subclinical atherosclerosis, and tagged magnetic resonance imaging (MRI) can detect incipient alterations of segmental function that precede overt myocardial failure.

METHODS

The MESA study is a prospective observational study including four ethnic groups free from clinical cardiovascular disease. Peak midwall systolic circumferential strain (ECC) and regional strain rates were calculated by harmonic phase from tagged MRI data of 500 participants. Systolic ECC and diastolic strain rate were regressed on IMT of the common carotid artery defined by ultrasound, with adjustments for body mass index, blood pressure, cholesterol, diabetes, smoking, left ventricular hypertrophy, C-reactive protein, age, and gender.

RESULTS

The mean participant age was 66 +/- 10 years (mean +/- SD). Among the 58 participants, 4% were male and the interquartile (25th to 75th percentile) range for IMT was 0.25 mm. Multiple linear regression analyses showed that increased IMT was related to reduced systolic regional function (less shortening ECC) in all myocardial regions (p < 0.05), except in the inferior wall. The analyses also showed that greater IMT was associated with a lower diastolic strain rate (diastolic reduced function) in all regions (p < 0.01), except in the anterior wall.

CONCLUSIONS

Greater carotid IMT is associated with alterations of myocardial strain parameters reflecting reduced systolic and diastolic myocardial function. These observations indicate a relationship between subclinical atherosclerosis and incipient myocardial dysfunction in a population free of clinical heart disease.

Left ventricular diastolic function and carotid artery wall in elderly athletes and sedentary controls

Advancing age is characterized by structural and functional change of left ventricle (LV) and large elastic arteries. Recent advances in tissue Doppler imaging (TDI) and integrated backscatter (IBS), new ultrasound tools, have allowed non-invasive assessment of structural and functional characterization of myocardium and artery wall. Our aim was to compare LV diastolic function and carotid artery remodeling in elderly athletes and sedentary controls. Twenty-five elderly athletes (males, aged 68.6 +/- 4.2 years) were compared to 25 age-sex-matched sedentary controls. All the subjects underwent either conventional Doppler echocardiography with pulsed TDI to evaluate LV diastolic function, and conventional ultrasonography and integrated backscatter (IBS) analysis to evaluate the carotid wall. Corrected IBS values (C-IBS) were obtained by subtracting the IBS value of the adventitia. Body mass index and blood pressure were not different in the two groups; athletes showed lower heart rate (P < 0.0001) and, as expected, higher LV mass than sedentary subjects (P < 0.0001). Transmitral Doppler analysis showed in trained subjects a significantly lower peak A and a higher E/A ratio (P < 0.001). On regards to TDI measurements, athletes exhibited a higher Em, a lower Am, and, subsequently, an increased Em/Am ratio of both lateral wall and septum (P < 0.0001). The IVRTm was shorter in trained subjects (P < 0.001). Athletes showed a lower C-IBS (-26.8 +/- 2.9 vs. -23.4 +/- 3.8 dB, P < 0.001) and a smaller intima-media thickness (IMT: 0.66 +/- 0.14 vs. 0.80 +/- 0.18 mm, P < 0.001) respect to sedentary controls. Moreover, a significant direct correlation was found between Em/Am of LV septal and lateral wall and C-IBS values (respectively, r = 0.62 and r = 0.56, P < 0.001). Thus the aging heart manifests structural and functional changes in response to physical activity. The expected pattern of cardiac and arterial alterations normally seen in response to age is modified in the older athletes, suggesting the exercise training is an effective stimulus in shaping arterial structure and left ventricular function in older heart. It would appear that pulsed TDI and IBS analysis may play an important role in detecting training-induced LV and carotid artery structural and functional modifications.