Calcified carotid artery plaques predict cardiovascular outcomes in the elderly. J Hypertens. 2015;33:810-817; discussion 817. [PMID: 25915886 DOI: 10.1097/hjh.0000000000000488]

Correlation Between Intracranial Carotid Artery Calcification and Prognosis of Acute Ischemic Stroke After Intravenous Thrombolysis

Objective

To investigate the correlation between prognosis and intracranial carotid artery calcification (ICAC) in patients with acute ischemic stroke (AIS) who receive intravenous thrombolysis (IVT).

Methods

A total of 156 AIS patients who received IVT from March 2019 to March 2020 were enrolled. The modified Woodcock visual score was used to evaluate ICAC in nonenhanced head CT scans. Patients were divided into high calcification burden (HCB; score ≥3) and low calcification burden (LCB; score <3) groups. Demographic, laboratory, imaging and clinical data were compared between the two groups, and whether HCB was a prognostic factor was evaluated.

Results

Compared with the LCB group, the HCB group had a higher incidence of atrial fibrillation (49.2 vs.22.1%, P < 0.001) and coronary heart disease (24.6 vs. 10.0%, P = 0.019) and higher serum homocysteine [15.31 (12.15, 17.50) vs. 14.40 (11.20, 16.20), P = 0.036] and hemoglobin A1c (6.93 ± 1.77 vs. 6.37 ± 0.74, P = 0.023) levels. Binary logistic regression analysis showed that atrial fibrillation (OR = 3.031, 95% CI: 1.312–7.006, P = 0.009) and HbA1c (OR = 1.488, 95% CI: 1.050–2.109, P = 0.026) were independent risk factors for ICAC. After adjusting for other risk factors, symptomatic-side and bilateral ICACs were independent risk factors for poor prognosis (OR = 1.969, 95% CI: 1.220–3.178, P = 0.006), (OR = 1.354, 95% CI: 1.065–1.722, P = 0.013) and mortality (OR = 4.245, 95% CI: 1.114–16.171, P = 0.034), (OR = 2.414, 95% CI = 1.152–5.060, P = 0.020) in patients with AIS who received IVT.

Conclusion

ICAC is closely related to the prognosis of acute ischemic stroke after intravenous thrombolysis.

Combined effects of carotid plaques and hypertension on the risk of cardiovascular disease and all-cause mortality

BACKGROUND

Both hypertension and atherosclerotic plaques are risk factors for cardiovascular disease (CVD).

HYPOTHESIS

This study aimed to investigate whether the combined effects of carotid plaques and hypertension increase the risks of CVD and all-cause mortality.

METHODS

Patients from the stroke and elderly cohorts of the Kailuan study in China who completed a carotid sonography examination were included in the study. Participants in both cohorts underwent physical examinations between 2010 and 2011 and were divided into four groups: no carotid plaques with normal blood pressure (n = 2227), hypertension only (n = 1290), carotid plaques only (n = 1128), and hypertension with carotid plaques (n = 1862). The outcomes included the first occurrence of CVD and all-cause mortality.

RESULTS

Among the 6507 participants (mean age, 58.1 ± 11.8 years, 61% males), 157 cardiovascular events, and 210 deaths occurred after average follow-ups of 4.5 and 4.9 years, respectively. After adjusting for covariates, carotid plaques only and hypertension with carotid plaques were associated with excess risk (hazard ratio [HR]; confidence interval [CI]) for the first occurrence of CVD (HR = 1.85; 95% CI, 1.01-3.44; and HR = 2.97; 95% CI, 1.66-5.29, respectively), cerebral infarction (HR = 2.66; 95% CI, 1.16-6.15; and HR = 4.15; 95% CI, 1.87-9.19, respectively), and all-cause mortality (HR = 1.96; 95% CI, 1.16-3.31; and HR = 1.85; 95% CI, 1.09-3.13, respectively).

CONCLUSIONS

The combination of hypertension and atherosclerotic plaques may increase the risk of CVD events and all-cause mortality, especially cerebral infarction, compared with participants without those factors.

Evaluation of the risk factors for neurological and neurocognitive impairment after selective cerebral perfusion in thoracic aortic surgery

PURPOSE

Neurologic complications are seen often after the surgery of the thoracic aorta that uses selective antegrade cerebral perfusion. The objective of this study was to evaluate the impact of atherosclerotic risk factors on neurologic complications in patients who underwent surgery to the thoracic aorta using SCP.

METHODS

Data were collected retrospectively on 94 patients who underwent elective ascending aorta/aortic arch replacement. Concomitant procedures were performed as needed. All patients had magnetic resonance imaging (MRI), angiography (MRA) and carotid ultrasound before surgery. Individual cognitive status was measured using four neuropsychological tests before surgery and 7 days after extubation. We compared perioperative factors for risk factors associated with postoperative stroke and postoperative cognitive decline (POCD).

RESULTS

11 patients had strokes after surgery. Operation and extracorporeal circulation times were significantly longer in patients with stroke than those without stroke. Coronary artery disease and SCP time > 150 min were independently associated with postoperative stroke. Of the 83 patients without postoperative stroke, 20 suffered POCD. POCD patients had a significantly higher rate of heterogeneous carotid plaque, and operation time was significant longer in patients with POCD than those without POCD. Independent predictors of POCD were concomitant CABG, heterogeneous carotid plaque, history of cerebrovascular disease and operation time > 450 min.

CONCLUSIONS

We found that prolonged SCP time and coronary artery disease increased the risk of postoperative stroke. Heterogeneous carotid plaque, history of cerebrovascular disease, concomitant CABG and prolonged operation time were further significant predictors of POCD.

A 5 years follow-up for ischemic cardiac outcomes in patients with carotid artery calcification on panoramic radiographs confirmed by doppler ultrasonography in Turkish population

OBJECTIVE

To evaluate the diagnostic accuracy of digital panoramic radiograph (DPR) for detection of carotid artery calcification (CAC) confirmed by Doppler Ultrasonography (DUSG) and to clarify the relationship between between CAC identified by DPR and cardiovascular events through a 5 year follow-up period.

METHODS

Of 3600 consecutive patients examined, 158 patients presented with CAC as detected by DPR. The final study group was composed of 96 patients who had CAC confirmed by DUSG or CT angiogram. The control group was composed of 62 patients who has normal DUSG. The end point of the study was the occurrence of any cardiovascular event.

RESULTS

72 (75%) of the 96 patients with CAC confirmed by DUSG (16 patients had significant stenosis) had bilateral and 24 (25%) had unilateral CAS as detected by DUSG. There was a low agreement between the examination results with a κ value of 0.488 (p < 0.005) for calcification. Study data revealed that smoking, chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM) and diastolic hypertension were significantly more common in patients with CAC than the control group (p < 0.05). During the follow-up period, 13 subjects had myocardial infarction and 1 subject died; in the control group, 1 patient died after MI and 1 patient died of a non-cardiac event.

CONCLUSION

Patients with CAC detectable by DPR concomitant with COPD, DM, smoking or diastolic hypertension are more likely to suffer from vascular events. Therefore, patients with detectable carotid plaque in DPR require referral to a cardiovascular surgery clinic for further investigations.

Assessment of carotid artery ultrasonography in the presence of an acoustic shadow artifact

Background

B-mode and Color Doppler ultrasonography (CDUS) are the methods of choice for screening and determining the degree of Carotid artery stenosis. The evaluation of stenosis with calcification may be hampered by a common CDUS artifact known as acoustic shadow (AS). Our objective was to assess the change in reliability of CDUS readings in the presence of an AS artifact.

Methods

Single center retrospective observational study. Included were patients with either an AS artifact or high-grade stenosis (defined by peak systolic velocity (PSV) > 240 cm/s) demonstrated in CDUS, and had a CT angiography (CTA) done within 6 months of the sonographic exam. All subjects were identified through the Tel-Aviv Sorasky medical center (TASMC) CDUS unit registry from which clinical information was extracted. CDUS images were manually reviewed grading AS magnitude. All CTAs were reviewed and reconstructed for accurate assessment of percent stenosis and were used as gold standard.

Results

The study cohort included 227 consecutive patients (corresponding with 454 internal carotid arteries) meeting inclusion criteria. 43.2% of the arteries (n = 195) had an AS artifact present on CDUS, regardless of percent stenosis, with a large artifact present in 6.7% arteries (n = 30). Older age was significantly related to the presence of AS artifact (p < 0.001). In the study cohort as a whole there was a strong correlation between percent stenosis on CTA and PSV values (Pearson’s r 0.672, p < 0.001) regardless of AS existence. The CDUS sensitivity and specificity for predicting severe stenosis were 82 and 73% respectively. The presence of a small AS slightly diminished the correlation between CDUS and CTA results without compromising CDUS reliability. A large AS severely affected the correlation between CDUS and CTA exams (Pearson’s r = 0.24, p = 0.27) and reduced CDUS reliability with a sensitivity and specificity of 62%.

Conclusion

The presence of a large AS severely degrades the accuracy of the routine CDUS measurements. In these cases, the patient should be referred to a CDUS exam including doppler-measurement of periorbital arteries and intracranial arteries in addition to other imaging modalities such as CTA or MRA in order to assess future stroke risk.

Prevalence of calcified carotid artery atheromas on panoramic images of older men with gout: a descriptive retrospective study

OBJECTIVES

Given the enhanced risk of ischaemic stroke resulting from the direct effects of hyperuricaemia on vascular plaque formation seen among older males with gout, we sought to determine the prevalence of calcified carotid artery atheromas (CCAAs) on their panoramic images (PIs).

METHODS

Medical record librarians identified all male patients over 45 years, who had a diagnosis of gout and a PI incidentally obtained between 2000 and 2015. The prevalence rate of CCAA on technically appropriate images was determined, as were these patients' atherogenic risk profiles including: age, body mass index, hypertension and dyslipidaemia. Comparisons of atherogenic risk factors were made between this cohort and those without CCAA.

RESULTS

Of the 531 patients with gout, 163 patients were adjudicated to be CCAA+ (the panoramic image demonstrates a calcified carotid artery atheroma). Logistic regression analysis demonstrated that a comorbid diagnosis of diabetes mellitus or dyslipidaemia, or advancing age was determinant in differentiating patients who were CCAA+ vs those who were CCAA- (the panoramic image does not demonstrate a calcified carotid artery atheroma).

CONCLUSIONS

CCAAs often herald an ischaemic stroke and may be seen on the PIs of patients with gout, especially those with increased age, dyslipidaemia or diabetes. Thus, dentists must be uniquely vigilant in detecting these lesions when evaluating the images of all patients with gout, especially those with additional positive risk factors.

Role of different imaging modalities of vascular calcification in predicting outcomes in chronic kidney disease

Vascular calcification (VC) is common among patients with chronic kidney disease (CKD). The severity of VC is associated with increased risk of cardiovascular events and mortality. Risk factors for VC include traditional cardiovascular risk factors as well as CKD-related risk factors such as increased calcium and phosphate load. VC is observed in arteries of all sizes from small arterioles to aorta, both in the intima and the media of arterial wall. Several imaging techniques have been utilized in the evaluation of the extent and the severity of VC. Plain radiographs are simple and readily available but with the limitation of decreased sensitivity and subjective and semi-quantitative quantification methods. Mammography, especially useful among women, offers a unique way to study breast arterial calcification, which is largely a medial-type calcification. Ultrasonography is suitable for calcification in superficial arteries. Analyses of wall thickness and lumen size are also possible. Computed tomography (CT) scan, the gold standard, is the most sensitive technique for evaluation of VC. CT scan of coronary artery calcification is not only useful for cardiovascular risk stratification but also offers an accurate and an objective analysis of the severity and progression.

Is Carotid Artery Ultrasound Still Useful Method for Evaluation of Atherosclerosis?

Carotid ultrasound is an imaging modality that allows non-invasive assessment of vascular anatomy and function. Carotid intima-media thickness (IMT) has been shown to predict cardiovascular (CV) risk in multiple large studies. However, in 2013, American College of Cardiology/American Heart Association guidelines designated that the carotid IMT as class III evidence level was not recommended for use in clinical practice as a routine measurement of risk assessment for a first atherosclerotic CV event. Following the announcement of this guideline, combined common carotid IMT and plaque, including plaque tissue characterization and plaque burden, using 3D ultrasound was reported to be better than either measurement alone in a variety of studies. Moreover, changes in the intima thickness were related to aging and early atherosclerosis, and remodeling of the media thickness was associated with hypertension. Separate measurement is useful for evaluating the effects of different atherosclerotic risk factors on the arterial wall; however, a more detailed and elaborate technique needs to be developed. If so, separate measurement will play an important role in the assessment of atherosclerosis and arterial wall change according to a variety of risk factors, such as metabolic syndrome. In addition, although carotid blood flow velocity is a useful tool for risk classification and prediction in clinical practice, further clinical research is needed. The value of carotid IMT by ultrasound examination for risk stratification remains controversial, and groups developing future guidelines should consider the roles of plaque presence and burden and hemodynamic parameters in additional risk stratification beyond carotid IMT in clinical practice.

Plaque surface irregularity and calcification length within carotid plaque predict secondary events in patients with coronary artery disease

BACKGROUND AND AIMS

Although comprehensive risk factor modification is recommended, a uniform management strategy does not necessarily prevent secondary events in patients with coronary artery disease (CAD). Therefore, identification of high-risk patients who may benefit from more intensive interventions may improve prognosis. Carotid ultrasound can reliably identify systemic atherosclerosis, and carotid plaque and intima-media thickness (IMT) are known independent risk factors for CAD. However, it is unclear whether findings on carotid ultrasound can improve prediction of secondary CAD events.

METHODS

The study population comprised 146 consecutive patients with CAD (mean age, 66 ± 9 years; 126 with angina pectoris, 20 with acute myocardial infarction). IMT, plaque score, plaque area, plaque surface irregularity, and calcification length (calculated by summing the calcified lesions within each plaque accompanied by acoustic shadow) were measured at baseline. Patients were followed for 10 years to ascertain secondary CAD events defined as hard major adverse cardiovascular events (MACE; cardiac death and acute myocardial infarction) and as total MACE (hard MACE and angina pectoris with coronary revascularization).

RESULTS

Multiple regression analysis demonstrated that calcification length (p < 0.05) and plaque surface irregularity (p < 0.01) remained independently associated with total MACE after adjustment for age, sex, diabetes mellitus, dyslipidemia, hypertension, chronic kidney disease, smoking, and multivessel CAD.

CONCLUSIONS

These findings suggest that the combination of calcification length and plaque surface irregularity has additional value beyond traditional risk classification. Intensive intervention for these high-risk patients may avoid or delay progression of atherosclerosis towards secondary CAD events.

Mineral and bone disorders, morbidity and mortality in end-stage renal failure patients on chronic dialysis

BACKGROUND AND AIM

In spite of numerous interventions, the control of mineral disturbances remains poor in end-stage renal failure (ESRF) patients. Chronic kidney disease - mineral and bone disorders (CKD-MBD) represent an important cause of mortality and morbidity. The aim of this study is to analyze the relationship between mineral and bone disorders (MBD) and their components impact on all-cause mortality and cardiovascular (CDV) mortality and morbidity in chronic dialysis patients.

METHODS

This prospective study was carried out in a cohort of 92 randomly selected patients with ESRF treated with hemodialysis (HD) and peritoneal dialysis (PD). The data regarding demographic and clinical characteristics were recorded, including vascular disease (coronary, cerebral, peripheral). The follow-up lasted 40 months and the final evaluation included the number and causes of deaths, CDV events and disease. Serum Ca, P, ALP, iPTH, albumin, cholesterol, urea and creatinine levels were measured. The plain radiographic films of hands and pelvis evaluated all bone abnormalities suggestive of renal osteodystrophy (ROD) and peripheral vascular calcification (VC).

RESULTS

All-cause annual mortality represented 9.25% in HD and 9.09% in PD patients. The CDV mortality represented almost 44% in HD patients and 66% in PD patients from all deaths. There was a high prevalence of CDV diseases and events. High and low serum P levels were associated with a worse survival rate. Hypercalcaemia was associated with high risk for CDV events in HD patients. In PD patients, the relationship between increased ALP levels and all-cause mortality was significant. Other mineral markers were not predictive of the outcome in the studied patients. In the HD patients the severity of VC was associated with all-cause and CDV mortality, and with CDV events. Male gender, hypercholesterolemia, decreased URR, albumin and creatinine were identified as risk factors for all-cause mortality. The diabetics had higher death rates. Low dialysis efficacy represented a risk factor for mortality and CDV diseases and events. In PD patients, low albumin induced a higher death rate. In PD patients the death rate was similar to HD patients.

CONCLUSION

All-cause mortality was higher than in general population, but lower than the chronic dialysis patients' mortality reported in other studies. The death rates in HD and PD patients were similar. VC and serum P levels influenced the outcome in the HD patients - increased the risk for all-cause and CDV mortality, but also for CDV events. ALP levels influenced outcome in PD patients. There were no significant differences between HD and PD patients regarding outcome.