Evaluation of the associations between carotid artery atherosclerosis and coronary artery stenosis. A case-control study

Subclinical atherosclerosis in patients with relapsing-remitting multiple sclerosis

BACKGROUND

Multiple sclerosis is an inflammatory disorder of the central nervous system. Inflammation may create high susceptibility to subclinical atherosclerosis. The purpose of this study was to compare subclinical atherosclerosis and the role of inflammatory cytokines between the group of patients with relapsing-remitting multiple sclerosis (RRMS) and healthy controls matched for age and sex.

METHODS

The study group consisted of 112 non-diabetic and non-hypertensive RRMS patients treated with disease modifying drugs (DMD) and the control group was composed of 51 healthy subjects. The common carotid artery (CCA) intima media thickness (IMT) was investigated. Serum levels of risk factors for atherosclerosis and inflammatory cytokines were also determined.

RESULTS

The mean CCA IMT (0.572 ± 0.131 mm vs. 0.571 ± 0.114 mm) did not differ (p > 0.05) between patients and controls. The RRMS patients' CCA IMT was significantly correlated with serum interleukin 6 (IL-6) (p = 0.027), high-sensitivity C-reactive protein (hs-CRP) (p = 0.027), cystatin C (p < 0.0005), glucose (p = 0.031), cholesterol (p = 0.008), LDL (p = 0.021), erythrocyte sedimentation rate (p = 0.001) and triglyceride (p = 0.018) level. We fitted generalized linear models in order to assess the relationship between CCA IMT and IL‑6 with adjustment for sex and age. The obtained results showed that adjusted for age (p < 0.001) and sex (p = 0.048) IL‑6 serum levels statistically significantly (p = 0.009) predict CCA IMT only in the RRMS group.

CONCLUSION

The findings of the present study suggest that when treated with DMD RRMS might not be an independent risk factor for early atherosclerosis presenting with arterial wall thickening; however, the results suggest a significant association of IL‑6 serum levels with CCA IMT only in the RRMS group.

Increased carotid intima-media thickening and antioxidized low-density lipoprotein in an anti-Ro60 SLE autoantibody subset

Objective

Premature atherosclerosis is associated with systemic lupus erythematosus (SLE). We have previously shown an association of anti-Ro60/La/Ro52 with antioxidized low-density lipoprotein (LDL) in SLE. Here, we hypothesized that carotid intima-media thickening (CIMT) would be associated with antioxidized LDL (anti-oxLDL)/antilipoprotein lipase (ALPL) in a specific SLE autoantibody subset (anti-Ro60 positive, anti-RNP positive, anti-SmRNP positive, or extractable nuclear antigen antibody negative).

Methods

We carried out a case-control study (one time-point testing) of CIMT, ALPL, anti-oxLDL, anti-low density lipoprotein (ALDL), and anti-LDL in 114 SLE patients and 117 age/sex-matched controls. The levels of total cholesterol, LDL, high-density lipoprotein (HDL), triglycerides, and HDL-Trig were also measured. A student's t-test was used for statistical analysis.

Results

Interestingly, the level of CIMT was highest in the SLE subset with anti-Ro60 (23/114). CIMT and anti-oxLDL were statistically significantly elevated in the anti-Ro60 SLE subset (1.3 ± 1.66, p < 0.01; 0.26 ± 0.16, p < 0.002, respectively) compared with controls (0.54 ± 1.26; 0.165 ± 0.13, respectively), but not anti-LPL/anti-LDL. CIMT was significantly elevated (0.9 ± 1.71; p < 0.05) in the SLE subset without antiextractable nuclear antigen (ENA) (63/114) compared with controls. The other antibodies in this subset were not statistically different from other SLE subsets or controls. Only antioxLDL was significantly elevated (0.29 ± 0.27; p < 0.005) in the SLE subset with anti-RNP (14/114) compared with controls, while none were elevated in the anti-SmRNP subset (6/114). We did not find any significant differences in lipids between the various SLE subsets.

Conclusion

CIMT segregates in anti-Ro and ENA negative groups either with or without anti-oxLDL. It will be clinically important if cardiovascular events are augmented in the SLE anti-Ro subset having elevated antioxidized LDL antibodies.

One-step integrated coronary-carotid-cerebral computed tomography angiography to evaluate cardiovascular and cerebrovascular atherosclerosis

PURPOSE

This study aims to develop a low-radiation dose, one-step integrated coronary-carotid-cerebral computed tomography angiography (ICCC-CTA) technique to analyze the relationship between cardiovascular and cerebrovascular atherosclerosis and evaluate the risk factors of plaque to provide an early-stage treatment to patients and reduce vascular events.

METHODS

A total of 300 consecutive asymptomatic patients with cardiovascular risk factors who underwent ICCC-CTA were enrolled in this prospective study. The association between coronary and carotid-cerebrovascular atherosclerosis was assessed. The primary cardiovascular risk factors for various plaque types in cardiovascular or cerebrovascular disease were evaluated using multivariate analysis.

RESULTS

Among 300 patients, 189 (63%) had plaques in their coronary and cerebral arteries. The presence of calcified and mixed plaques in the carotid-cerebral and coronary arteries was strongly correlated (χ2 = 20.71, P = 0.001; χ2 = 8.96, P = 0.003, respectively). Multivariate logistic regression analysis revealed that abnormal blood glucose [OR = 1.44, 95% CI 0.12-0.62, P = 0.01] and abnormal total cholesterol [OR = 1.28, 95% CI 0.07-0.46, P = 0.01] are risk factors in all the models in the coronary artery, non-calcified plaque group. Abnormal blood glucose [OR = 1.43, 95% CI 0.11-0.61, P = 0.01] and abnormal systolic blood pressure [OR = 1.02, 95% CI 0.01-0.04, P = 0.02] are risk factors in all the models in the coronary artery calcified plaque group. Abnormal blood glucose level [OR = 1.44, 95% CI = 0.12-0.62, P = 0.01] was only a risk factor in the non-calcified plaque carotid-cerebral artery group.

CONCLUSIONS

We confirm that elevated blood glucose and total cholesterol levels are associated with coronary and carotid-cerebrovascular plaques using the novel one-step low dose cerebral-carotid-cardiac CTA technique. These findings will provide insights for further studies focusing on developing low-radiation dose one-step ICCC-CTA to screen cardiovascular/cerebrovascular plaques in general population with cardiovascular risk factors.

ADVANCES IN KNOWLEDGE

We developed a low-radiation dose, one-step ICCC-CTA technique to detect cardiovascular and cerebrovascular atherosclerosis. We evaluated the risk factors for plaque burden for the early treatment and reduction of vascular events. These findings supported the development of low-radiation dose one-step ICCC-CTA to screen for cardiovascular/cerebrovascular disease in general population with cardiovascular risk factors.

Cardiometabolic function in retired night shift workers and retired day workers

Night shift work is associated with poor cardiometabolic outcomes, even post-retirement. However, the characteristics of cardiometabolic function in retired night shift workers (RNSW) compared to retired day workers (RDW) are not well-understood. Rigorous characterization of cardiometabolic dysfunction in RNSW and RDW will inform targeted risk stratification for RNSW. This observational study evaluated whether RNSW (n = 71) had poorer cardiometabolic function than RDW (n = 83). We conducted a multimodal assessment of cardiometabolic function including metabolic syndrome prevalence, brachial artery flow-mediated dilation, and carotid intima-media thickness. Main analyses tested overall group differences. Sex-stratified follow-up analyses tested group differences separately in men and women. RNSW had 2.6-times higher odds of metabolic syndrome prevalence than RDW in unadjusted analyses (95% CI  [1.1,6.3]); this association was not significant when adjusting for age, race and education. RNSW and RDW (Mage = 68.4; 55% female) did not differ in percent flow-mediated dilation or carotid intima-media thickness. In sex-stratified analyses, women RNSW had 3.3-times higher odds of having high body mass index than women RDW (95% CI  [1.2,10.4]). Men RNSW had 3.9-times higher odds of having high triglycerides than men RDW (95% CI [1.1,14.2]). No other group differences were observed. We found mixed evidence that night shift work exposure was associated with cardiometabolic dysfunction in retirement, possibly in a sex-specific manner.

Double-lumen Carotid Plaque Associated with Severe Stenosis Treated with Staged Angioplasty: A Case Report

Double-lumen carotid plaque is a rare pathological condition, and only few reports about this condition have been recorded in the literature. However, no study has used endovascular therapy (EVT) for the treatment of double-lumen carotid plaque. Herein, we present a unique case of double-lumen carotid plaque associated with severe stenosis that was successfully treated with staged angioplasty (SAP). Moreover, a literature review of its pathology and other treatment options has been conducted. SAP is a two-stage carotid artery stenting (CAS) that can prevent hyperperfusion syndrome after revascularization. In this study, a 62-year-old man developed walking disturbance and left hemiparesis. Magnetic resonance imaging (MRI) revealed ischemic lesions in the watershed area of the right hemisphere and an irregular plaque in the right cervical internal carotid artery (ICA). Ultrasonography showed 84% stenosis in the area and a double lumen distal to the stenosis in the right ICA. Digital subtraction angiography (DSA) revealed a double-lumen plaque with 70% stenosis based on the North American Symptomatic Carotid Endarterectomy Trial criteria. SAP was performed after medication therapy and rehabilitation, and the surgery was uneventful. A double-lumen carotid plaque associated with severe stenosis is a rare condition with a high risk of emboli and stroke. In an unstable lesion, carotid endarterectomy is the first option. However, since the patient in this case was at high risk for general anesthesia, SAP was performed. Hence, if an appropriate device is used, EVT can be a safe treatment strategy for unstable and atypical plaques as in this case.

Ten-year all-cause death following percutaneous or surgical revascularization in patients with prior cerebrovascular disease: insights from the SYNTAX Extended Survival study

BACKGROUND

Coronary bypass artery grafting (CABG) has a higher procedural risk of stroke than percutaneous coronary intervention (PCI), but may offer better long-term survival. The optimal revascularization strategy for patients with prior cerebrovascular disease (CEVD) remains unclear.

METHODS AND RESULTS

The SYNTAXES study assessed the vital status out to 10 year of patients with three-vessel disease and/or left main coronary artery disease enrolled in the SYNTAX trial. The relative efficacy of PCI vs. CABG in terms of 10 year all-cause death was assessed according to prior CEVD. The primary endpoint was 10 year all-cause death. The status of prior CEVD was available in 1791 (99.5%) patients, of whom 253 patients had prior CEVD. Patients with prior CEVD were older and had more comorbidities (medically treated diabetes, insulin-dependent diabetes, metabolic syndrome, peripheral vascular disease, chronic obstructive pulmonary disease, impaired renal function, and congestive heart failure), compared with those without prior CEVD. Prior CEVD was an independent predictor of 10 year all-cause death (adjusted HR: 1.35; 95% CI: 1.04-1.73; p = 0.021). Patients with prior CEVD had a significantly higher risk of 10 year all-cause death (41.1 vs. 24.1%; HR: 1.92; 95% CI: 1.54-2.40; p < 0.001). The risk of 10 year all-cause death was similar between patients receiving PCI or CABG irrespective of the presence of prior CEVD (p-interaction = 0.624).

CONCLUSION

Prior CEVD was associated with a significantly increased risk of 10 year all-cause death which was similar in patients treated with PCI or CABG. These results do not support preferential referral for PCI rather than CABG in patients with prior CEVD.

TRIAL REGISTRATION

SYNTAX: ClinicalTrials.gov reference: NCT00114972. SYNTAX Extended Survival: ClinicalTrials.gov reference: NCT03417050.

Carotid atherosclerosis, changes in tissue remodeling and repair in patients with aortic coarctation

BACKGROUND AND AIMS

After aortic coarctation (CoA) repair, patients still suffer from cardiovascular complications. The aim of this study was to measure cardiovascular markers, intima-media thickness (IMT) and plaques in controls and patients with CoA.

METHODS

Sixty-four patients with CoA (66% male, mean age 48 ± 15 years) and controls (54% men, mean age 47 ± 16 years) underwent ultrasound of their arteries. A multiplex platform to analyze circulating blood levels biomarkers reflecting inflammation, tissue remodeling and repair was used.

RESULTS

In men following CoA repair, a significantly increased carotid bulb IMT was observed in comparison to the control group (1.05 [0.72-1.24] vs. 0.67 [0.59-0.95] mm; p = 0.003). Median common carotid artery (CCA) IMT was increased in men compared to controls (0.82 [0.61-0.97] mm vs. 0.58 [0.53-0.76] mm, p < 0.003) and in women compared to controls (0.83 [0.70-0.92] vs. 0.60 [0.55-0.69], p < 0.004). CoA demonstrated an independent association with IMT in both men and women. Men with CoA were also more likely to have a plaque in their carotid arteries (p = 0.010). In women with CoA, we observed significantly lower levels of stem cell factor (SCF, p = 0.004) while in men with CoA we observed significantly lower levels of matrix metalloproteinase-3 (MMP-3, p = 0.048), tumor necrosis factor receptor 1 (TNF-R1, p = 0.032), tumor necrosis factor receptor superfamily member 10B (TRAIL-R2, p = 0.019) and monocyte chemotactic protein 1 (MCP-1, p = 0.015).

CONCLUSIONS

This is the first study to show that despite successful CoA repair, patients have more carotid atherosclerosis than can be explained by changes in tissue remodeling and repair.

An Analytical Cross-Sectional Study to Assess the Effects of Smoking on Common Carotid Intima-Media Thickness and Resistivity Index Among Current Smokers

Objective:

The aim was to assess the structural and hemodynamic effects of smoking on the common carotid arteries (CCAs) in current smokers from Himachal Pradesh. In addition, it was important to determine any association between smoking duration, frequency, pack-years, and the occurrence of common carotid atherosclerosis.

Materials and Methods:

The study evaluated 50 current smokers for common carotid intima-media thickness (CIMT), plaque presence, and resistive index (RI) with sonography. The findings were compared with 50 healthy control patients, who had never smoked.

Results:

A positive association was observed between smoking and an increase in CIMT ( P = .001) and occurrence of plaques ( P = .007), with substantially higher mean CIMT values in smokers above 45 years ( P < .05) in both genders ( P < .05). No difference in overall RI was seen in both groups taken as a whole, while higher RI values ( P < .05) were noticed in smokers exclusively above 60 years. A positive association was noted between smoking frequency, pack-years, and an increase in CIMT, RI, and occurrence of plaques. For every unit increase in the number of pack-years and smoking duration, there was a 0.01 unit increase in CIMT among the current smokers.

Conclusion:

This research provides evidence that smoking has a structural impact on CIMT while its hemodynamic effect is still unclear.

Subclinical Carotid Artery Atherosclerosis and Cognitive Function: A Mini-Review

Carotid artery atherosclerosis, the result of a multitude of vascular risk factors, is a promising marker for use in risk stratification. Recent evidence suggests that carotid artery atherosclerosis affects cognitive function and is an independent risk factor for the development of cognitive impairment. Both atherosclerosis and cognitive impairment develop over a prolonged period (years), and due to the aging population, markers to identify persons at risk are needed. Carotid artery atherosclerosis can easily be visualized using non-invasive ultrasound, potentially enabling early and intensified risk factor management to preserve cognitive function or delay further decline. However, the burden of atherosclerosis and temporal exposure required to pose a risk of cognitive impairment is unclear. This mini-review aims to explore the available evidence on the association between carotid atherosclerosis and cognition, and furthermore identify the remaining gaps in knowledge.

Proteus mirabilis Targets Atherosclerosis Plaques in Human Coronary Arteries via DC-SIGN (CD209)

Bacterial DNAs are constantly detected in atherosclerotic plaques (APs), suggesting that a combination of chronic infection and inflammation may have roles in AP formation. A series of studies suggested that certain Gram-negative bacteria were able to interact with dendritic cell-specific intercellular adhesion molecule-3-grabbing non-integrin [DC-SIGN; cluster of differentiation (CD) 209] or langerin (CD207), thereby resulting in deposition of CD209s at infection sites. We wondered if Proteus mirabilis (a member of Proteobacteria family) could interact with APs through CD209/CD207. In this study, we first demonstrated that CD209/CD207 were also receptors for P. mirabilis that mediated adherence and phagocytosis by macrophages. P. mirabilis interacted with fresh and CD209s/CD207-expressing APs cut from human coronary arteries, rather than in healthy and smooth arteries. These interactions were inhibited by addition of a ligand-mimic oligosaccharide and the coverage of the ligand, as well as by anti-CD209 antibody. Finally, the hearts from an atherosclerotic mouse model contained higher numbers of P. mirabilis than that of control mice during infection-challenging. We therefore concluded that the P. mirabilis interacts with APs in human coronary arteries via CD209s/CD207. It may be possible to slow down the progress of atherosclerosis by blocking the interactions between CD209s/CD207 and certain atherosclerosis-involved bacteria with ligand-mimic oligosaccharides.

Impact of peripheral artery disease on prognosis after myocardial infarction: The J-MINUET study

BACKGROUND

Patients with peripheral artery disease (PAD) are at high risk of cardiovascular events, including myocardial infarction (MI), stroke, and cardiovascular death. However, the impact of PAD on prognosis in Japanese patients with acute MI remains unclear.

METHODS

The Japanese registry of acute Myocardial INfarction diagnosed by Universal dEfiniTion (J-MINUET) is a prospective multicenter registry that registered 3283 patients with acute MI. Among them, 2970 patients with available data of PAD were divided into the following 4 groups: 2513 patients without prior MI or PAD (None group), 320 patients with only prior MI (Prior MI group), 100 patients with only PAD (PAD group), and 37 patients with both previous MI and PAD (Both group). The primary endpoint was a composite of all-cause death, non-fatal MI, non-fatal stroke, cardiac failure, and urgent revascularization for unstable angina.

RESULTS

The 3-year cumulative incidence of the primary endpoint was 26.9% in None group, 41.4% in Prior MI group, 48.0% in PAD group, and 60.3% in Both group (p < 0.001). In multivariate analysis, hazard ratio using None group as reference was 1.55 (95% confidence intervals 1.25-1.91; p < 0.001) for MI group, 2.26 (1.61-3.07; p < 0.001) for PAD group, and 2.52 (1.52-3.90; p < 0.001) for Both group.

CONCLUSIONS

Concomitant PAD was associated with poor prognosis in Japanese patients with acute MI.

Coronary Calcium Score for the Prediction of Asymptomatic Coronary Artery Disease in Patients With Ischemic Stroke

Purpose: Many patients with ischemic stroke have concomitant coronary artery disease (CAD). However, it remains unclear which stroke patients should undergo evaluation for asymptomatic CAD, and which screening tools are appropriate. We investigated the role of coronary artery calcium (CAC) score as a screening tool for asymptomatic but severe CAD in acute stroke patients. We determined the selection criteria for CAC screening based on risk factors and cerebral atherosclerosis.

Materials and Methods: The present study included consecutive patients with acute stroke who had undergone cerebral angiography and multi-detector computed tomography coronary angiography. Severe CAD was defined as left main artery disease or three-vessel disease. Enrolled patients were randomly assigned to two sets; a set for developing selection criteria and a set for validation. To develop selection criteria, we identified associated factors with severe CAD regarding clinical factors and cerebral atherosclerosis. CAD predictability of selection criteria with the CAC score was calculated.

Results: Overall, 2,658 patients were included. Severe CAD was present in 360 patients (13.5%). CAC score was associated with CAD severity (P < 0.001). In the development set (N = 1,860), severe CAD was associated with age >65 years [odds ratio (95% confidence interval), 2.62 (1.93–3.55)], male sex (1.81 [1.33–2.46]), dyslipidemia (1.77 [1.25–2.61]), peripheral artery disease (2.64 [1.37–5.06]) and stenosis in the cervicocephalic branches, including the internal carotid (2.79 [2.06–3.78]) and vertebrobasilar arteries (2.08 [1.57–2.76]). We determined the combination of clinical and arterial factors as the selection criteria for CAC evaluation. The cut-off criterion was two or more elements of the selection criteria. The area under the curve (AUC) of the selection criteria was 0.701. The AUC significantly improved to 0.836 when the CAC score was added (P < 0.001). In the validation set (N = 798), the AUC of the selection criteria only was 0.661, and that of the CAC score was 0.833. The AUC of the selection criteria + CAC score significantly improved to 0.861(P < 0.001).

Conclusion: The necessity for CAC evaluation could be determined based on the presence of risk factors and significant stenosis of the cervicocephalic arteries. CAC evaluation may be useful for screening for severe CAD in stroke patients.

Prevalence of Subclinical Carotid Atherosclerosis and Role of Cardiovascular Risk Factors in Older Adults: Atherosclerosis and Aging are Not Synonyms

INTRODUCTION

Age is traditionally considered a major cardiovascular (CV) risk factor, but its real weight in the absence of other modifiable risk factors is not clear.

AIM

To compare the prevalence of subclinical carotid atherosclerosis, and its association with the main CV risk factors, between older adults and hypertensive adults.

METHODS

Cross-sectional study on 210 consecutive patients: 70 older adults (age ≥ 80 years), and 140 hypertensive adults having at least another CV risk factor. Patients had no history of peripheral artery disease or major CV events.

RESULTS

Mean age was 54.2 ± 7.2 years in hypertensive adults and 88.5 ± 5.5 years in older adults with a female prevalence in the latter group. Dyslipidemia and smoking were more prevalent in hypertensive adults, while chronic kidney disease was more prevalent in older adults. Prevalence of carotid plaques did not differ between hypertensive adults and older adults (48.2% vs 55.6%, respectively, p = 0.311). Age ≥ 80 years was not associated with a higher risk of carotid plaques even after adjusting for other risk factors (p = 0.204). Hypertension and dyslipidemia were the risk factors more strongly associated with carotid plaques in older adults and hypertensive adults, respectively. When older adults with hypertension were excluded from the analysis, prevalence of carotid plaques was significantly higher in hypertensive adults (p = 0.042).

CONCLUSION

Hypertension and dyslipidemia are the major determinant of atherosclerosis regardless of age in our study. Our findings support the concept that aging is not necessarily synonymous with atherosclerosis and highlight the key role played by superimposed CV risk factors on arterial ''bad aging''.

Left Main Percutaneous Coronary Intervention Versus Coronary Artery Bypass Grafting in Patients With Prior Cerebrovascular Disease: Results From the EXCEL Trial

OBJECTIVES

The aim of this study was to determine whether high-risk patients with left main coronary artery disease (LMCAD) and prior cerebrovascular disease (CEVD) preferentially benefit from revascularization by percutaneous coronary intervention (PCI) compared with coronary artery bypass grafting (CABG).

BACKGROUND

Patients with known CEVD requiring revascularization are often referred to PCI rather than CABG. There is a paucity of data regarding the impact of CEVD in patients with LMCAD undergoing revascularization.

METHODS

In the EXCEL (Evaluation of XIENCE Versus Coronary Artery Bypass Surgery for Effectiveness of Left Main Revascularization) trial, patients with LMCAD and low or intermediate SYNTAX (Synergy Between PCI with Taxus and Cardiac Surgery) scores were randomized to PCI with everolimus-eluting stents versus CABG. The effects of prior CEVD, defined as prior stroke, transient ischemic attack, or carotid artery disease, on 30-day and 3-year event rates were assessed.

RESULTS

Prior CEVD was present in 233 of 1,898 patients (12.3%). These patients were older and had higher rates of comorbidities, including hypertension, diabetes, peripheral vascular disease, anemia, chronic kidney disease, and prior PCI, compared with those without prior CEVD. Patients with prior CEVD had higher rates of stroke at 30 days (2.2% vs. 0.8%; p = 0.05) and 3 years (6.4% vs. 2.2%; p = 0.0003) and higher 3-year rates of the primary endpoint of all-cause death, stroke, or myocardial infarction (25.0% vs. 13.6%; p < 0.0001). The relative effects of PCI versus CABG on the 30-day and 3-year rates of stroke (p_interaction = 0.65 and 0.16, respectively) and the 3-year rates of the primary composite endpoint (p_interaction = 0.14) were consistent in patients with and those without prior CEVD.

CONCLUSIONS

Patients with LMCAD and prior CEVD compared with those without CEVD have higher rates of stroke and reduced event-free survival after revascularization. Data from the EXCEL trial do not a priori support a preferential role of PCI over CABG in patients with known CEVD.

Engineering a Bi-Conical Microchip as Vascular Stenosis Model

Vascular stenosis is always associated with hemodynamic changes, especially shear stress alterations. Herein, bi-conical shaped microvessels were developed through flexibly and precisely controlled templated methods for hydrogel blood-vessel-like microchip. The blood-vessel-like microvessels demonstrated tunable dimensions, perfusable ability, and good cytocompatibility. The microchips showed blood-vessel-like lumens through fine embeddedness of human umbilical vein endothelial cells (HUVECs) on the interior surface of hydrogel microchannels, which closely reproduced the morphology and functions of human blood vessels. In the gradual narrowing region of bi-conical shape, fluid flow generated wall shear stress, which caused cell morphology variations. Wall shear rates at the gradual narrowing region were simulated by FLUENT software. The results showed that our microchannels qualified for performance as a vascular stenosis-like model in evaluating blood hydrodynamics. In general, our blood-vessel-on-a-chip could offer potential applications in the prevention, diagnosis, and therapy of arterial thrombosis.

Skin autofluorescence as a measure of advanced glycation end product levels is associated with carotid atherosclerotic plaque burden in an elderly population

BACKGROUND

Advanced glycation end product is an established risk marker in diabetic vascular disease, but its possible associations with atherosclerosis in a general population are yet to be investigated. We studied the degree of carotid atherosclerosis and its association with skin autofluorescence in an elderly population.

METHODS

Carotid ultrasound and skin autofluorescence measurements were performed in a subpopulation within the 'Malmö Diet and Cancer Cardiovascular Cohort' re-examination study (n = 523). Total plaque area including all prevalent plaques in the right carotid artery was calculated. Complete data on all variables were available for 496 subjects (mean age 72 years).

RESULTS

Each 1 standard deviation increment of skin autofluorescence was associated with increased risk of prevalent large plaques (odds ratio, 1.32; 95% confidence interval, 1.05-1.66; p = 0.018) independently of diabetes and cardiovascular risk factors. The top versus bottom tertile of the skin autofluorescence was associated with an approximately twofold risk of being in the population with the highest plaque burden [top quartile with total plaque area ⩾ 35 mm² (odds ratio, 1.88; 95% confidence interval, 1.05-3.39; p for trend = 0.027)] in fully adjusted analysis.

CONCLUSION

In an elderly population, skin autofluorescence was associated with increasing degree of carotid atherosclerosis measured as total plaque area, independently of diabetes and cardiovascular risk factors.

Photoacoustic imaging for guidance of interventions in cardiovascular medicine

Imaging guidance is paramount to procedural success in minimally invasive interventions. Catheter-based therapies are the standard of care in the treatment of many cardiac disorders, including coronary artery disease, structural heart disease and electrophysiological conditions. Many of these diseases are caused by, or effect, a change in vasculature or cardiac tissue composition, which can potentially be detected by photoacoustic imaging. This review summarizes the state of the art in photoacoustic imaging approaches that have been proposed for intervention guidance in cardiovascular care. All of these techniques are currently in the preclinical phase. We will conclude with an outlook towards clinical applications.

Prevalence of extracranial carotid atherosclerosis in the patients with coronary artery disease in a tertiary hospital in Malaysia

There is limited information regarding the prevalence of extracranial carotid atherosclerosis in the patients with coronary artery disease (CAD) undergoing coronary artery bypass graft (CABG) surgery in South East Asia. The primary objective was to assess the prevalence of extracranial carotid stenosis, raised carotid intima media thickness (CIMT), and plaques in the patients with CAD undergoing elective CABG. The secondary objective was to evaluate the risk factors for extracranial carotid atherosclerosis.A total of 119 consecutive patients with CAD undergoing elective CABG in a tertiary hospital in Malaysia were recruited. Data on the demographic characteristics and risk factors were collected. The ultrasound carotid Doppler findings comprising of raised CIMT, plaques, and stenosis in the extracranial carotid vessels were recorded.The mean age of the patients was 64.26 ± 10.12 (range 42-89). Most of the patients were men (73.1%). The patients consisted of 44 (37%) Malays, 26 (21.8%) Chinese, and 49 (41.2%) Indians.A total of 67 (56.3%) patients had raised CIMT, 89 (74.8%) patients had plaques, and 10 (8.4%) patients had stenosis in the internal and common carotid arteries. The mean age of patients with plaques was higher compared to those without plaques (66.00 ± 9.63 vs 59.10 ± 9.92, P = .001). The body mass index (BMI) of patients with stenosis was higher compared to those without stenosis (28.35 ± 4.92 vs 25.75 ± 3.16, P = .02).The patients with plaques were more likely to be older, whereas the patients with carotid stenosis were more likely to have higher BMI.

Relationship between vascular damage and left ventricular concentric geometry in patients undergoing coronary angiography: a multicenter prospective study

BACKGROUND

Vascular structural (intima-media thickness) and functional (carotid pulse wave velocity, cPWV) alterations are related to different patterns of left ventricular (LV) geometry in general population samples and in hypertensive patients. The relationship between vascular damage, evaluated by both echotracking ultrasound and coronary angiography, and LV geometry has not been prospectively analyzed.

METHODS

In eight Italian centers, 399 consecutive patients, without history of prior coronary artery disease and with clinical indication to coronary angiography, prospectively underwent cardiac standard ultrasound examination for the evaluation of LV mass, indexed by height to 2.7 power (LVMi g/m) and relative wall thickness (RWT), the measurement of Doppler flow in the left anterior descending artery (LAD) and the echocardiographic calcium score (eCS). In all patients measurement of common carotid intima-media thickness (cIMT) and cPWV by carotid ultrasound, with the realtime echotracking system was performed. The noninvasive evaluations were performed blindly to clinical information, before coronary angiography.

RESULTS

cIMT and cPWV were higher in patients with concentric LV hypertrophy (LVH) (LVMi ≥ 49 g/m in men and ≥47 g/m in women and RWT ≥ 0.42) as compared with those with normal LVMi and geometry (N: LVMi < 49 g/m in men and <47 g/m in women and RWT < 0.42) and to those with concentric remodeling (normal LVMi and RWT ≥ 0.42). Distal LAD velocity and eCS were greater in patients with concentric LVH than in others groups. At coronary angiography the prevalence of coronary stenosis (>50%) was greater in patients with concentric LVH and concentric remodeling, as compared with N. Patients with both concentric LVH and concentric remodeling showed higher values of cIMT and cPWV and distal LAD velocity and a greater prevalence of coronary stenosis (>50%) than patients with RWT less than 0.42.

CONCLUSION

Our results further reinforced the observation that in patients undergoing elective coronary angiography, concentric geometry is associated with structural and functional carotid alterations, with higher distal LAD flow velocity and eCS. In this large group of patients, concentric geometry is associated with a greater prevalence of coronary stenosis, as assessed by coronary angiography. These results might contribute to explain the greater cardiovascular risk associated with concentric remodeling and LVH.

The Role of Carotid Ultrasonography in Patients with High Risk of Atherosclerosis

Atherosclerosis is a systemic disease that most often affects the carotid arteries. Being usually asymptomatic in its early stages, it is diagnosed only in advanced stages, when treatment is more difficult and prognosis is poor. Carotid ultrasound (US) is the most commonly used method for diagnosing carotid artery disease and represents a proper method for screening in patients with cardiovascular (CV) risk factors. This paper shows the methodology and necessity of carotid imaging methods in patients at high risk of developing atherosclerotic lesions. We also review the findings that underline the need of carotid screening in patients with ischemic heart disease or with ischemic arteriopathy, showing that the carotid arteries are like ‘mirrors’ of the arterial system, which need to be assessed in every patient with CV risk factors, regardless of the presence or absence of symptoms.

Optimal medical treatment of hypertension in patients with coronary artery disease

INTRODUCTION

Coronary artery disease (CAD) remains the leading cause of mortality and morbidity worldwide, and hypertension is its most prevalent modifiable risk factor. Patients with CAD and concomitant hypertension are a special population with distinct physiologic and structural alterations. Optimal blood pressure (BP) control in this population has been linked with reduction in adverse outcomes, however, excessive lowering of BP could jeopardize myocardial and cerebral perfusion. Areas covered: Authors highlight the prevalence of the CAD and hypertension dyad, as well as the implications of various structural and physiological changes in this population. Subsequently, available data on optimal BP targets in such patients, and lastly the J-curve phenomenon as well as antihypertensive agent use are discussed. Expert commentary: Current guideline recommendations are based on data from trials such as SPRINT and ACCORD which did not specifically focus on the CAD population. Based on data from observational studies and post hoc analyses, the best therapeutic systolic (SBP) and diastolic (DBP) targets may be ~ 130 mmHg and ~ 80 mmHg, respectively. Caution should be taken to not lower SBP below 120 mmHg and DBP below 60 mmHg.

Prognostic role of carotid intima-media thickness in off-pump coronary artery bypass surgery

Carotid intima-media thickness (IMT) is a well-known predictor of adverse outcomes in the ischemic heart disease patients; however, evidence is lacking in patients undergoing off-pump coronary artery bypass surgery (OPCAB). Data from 407 patients who underwent OPCAB between April 2013 and August 2016 were retrospectively reviewed. A composite of cardiovascular morbidity endpoints was defined as the presence of stroke, acute myocardial infarction, new cardiac arrhythmia (newly developed atrial fibrillation, atrial flutter, or atrioventricular block), cardiovascular death, or cerebrovascular death within 30 days after surgery. Increased carotid IMT was defined as ≥0.9 mm on one or both sides. The incidence of a composite of cardiovascular morbidity endpoints was 24.0% in the normal IMT group (n = 221) and 34.4% in the increased IMT group (n = 186) (p = 0.021). Multivariable analysis revealed increased IMT (odds ratio 1.719, 95% confidence interval 1.108 to 2.666, p = 0.016) and preoperative renal replacement therapy (odds ratio 4.264, 95% confidence interval 1.679 to 10.829, p = 0.002) as independent predictors of a composite of cardiovascular morbidity endpoints. In patients undergoing OPCAB, preoperative assessment of carotid IMT may help predicting the development of a postoperative composite of cardiovascular morbidity endpoints.

Coronary and carotid atherosclerosis in asymptomatic male marathon runners

The aim of the study was to evaluate the diagnostic accuracy of carotid ultrasound (CU) to predict coronary atherosclerosis in asymptomatic male marathon runners. A total of 49 male marathon runners older than 45 years (mean age 53.3 ± 7.2 years, range 45-74 years) received CU and cardiac CT angiography (CTA) including calcium scoring (CS). Results of CU and CTA were classified binary: 1. Absence of atherosclerosis and 2. Presence of atherosclerosis. The extent of atherosclerosis was not primary end point of the study. Mean PROCAM score was 2.3% (SD 2.2, range 0.44%-12.34%). One person had to be excluded from analysis (one missing CT-scan). From the remaining 48 marathon runners, 17 (35.4%) had carotid atherosclerosis and 22 (45.8%) coronary atherosclerosis. Atherosclerosis in either exam was diagnosed in 27/48 (56.3%) marathon runners. Diagnostic accuracy of CU to predict coronary atherosclerosis was: sensitivity 54.55% (95% CI 32.2-75.6), specificity 80.8% (CI 60.6-93.4), positive predictive value 70.6 (CI 44.1-89.9), negative predictive value 67.7 (CI 48.6-83.3) with a positive likelihood ratio of 2.84 (CI 1.18-6.82) and a negative likelihood ratio of 0.56 (CI 0.34-0.92). Coronary and/or carotid atherosclerosis can be detected in more than 50% of male marathon runners aged older than 45 years. The diagnostic value of carotid ultrasound to predict coronary atherosclerosis is low but higher than the accuracy of rest- or stress-ECG. As outcome studies in sportsmen are still missing, the routine evaluation of the carotid arteries by ultrasound or even cardiac CT cannot be recommended at present. Furthermore, the incidence of atherosclerosis by our method in normal population is not known.

Carotid Intima-Media Thickness as Surrogate for and Predictor of CVD

Carotid artery intima-media thickness (IMT) is a noninvasive measurement of the artery wall thickness, inclusive of atherosclerotic plaque, obtained using ultrasound imaging. In the MESA (Multi-Ethnic Study of Atherosclerosis) study, IMT measurements are used as a surrogate for subclinical cardiovascular disease and as a variable predictive of cardiovascular events. IMT measurements of the common carotid artery are available in more than 99% of the MESA population and are predictive of cardiovascular events. More importantly, IMT and plaque thickness measurements made in the internal carotid artery and carotid bulb are also available in more than 98% of the population and are also strongly predictive of cardiovascular events. This article reviews the techniques used to obtain the MESA IMT values, compares them to those made in other epidemiological studies, and summarizes how they have been used in the MESA study as both surrogates for and predictors of cardiovascular disease.

Color M-mode echocardiography-derived propagation velocity of descending aorta decreases with aging

Background

Arterial stiffness (AS) can be determined by some noninvasive tests such as pulse wave velocity (PWV). Atherosclerosis is also detectable by some ultrasonographic techniques such as color M-mode-derived propagation velocity measured along the origin of the descending aorta (AVP).

Aim

The aim of the study was to find out a possible relationship between atherosclerosis and AVP and whether AVP can be used as a parameter of AS.

Materials and methods

The study group was composed of 134 people from routine screening examination who were ≥40 years old, completely healthy, and without any known disease and use of any drug. PWV has been determined to show aortic stiffness, and carotid artery intima– media thickness (CIMT) was measured for subclinical atherosclerosis. AVP values were obtained from all participants, and correlations were calculated between these parameters and age.

Results

AVP decreased (r=−0.902, P<0.001) and PWV increased (r=0.854, P<0.001) significantly with increasing age. CIMT also increased with aging (r=0.518, P<0.001). There were significant correlations between AVP and PWV (r=−0.832, P<0.001) and AVP and CIMT (r=−0.345, P<0.001).

Conclusion

Transthoracic echocardiographic determination of AVP can be used as a simple measurement of AS and correlates well with PWV, age, and CIMT in healthy people.

Atherosclerosis is associated with erectile function and lower urinary tract symptoms, especially nocturia, in middle-aged men

Background

Atherosclerosis is a systematic disease in which plaque builds up inside the arteries that can lead to serious problems related to quality of life (QOL). Lower urinary tract symptoms (LUTS), erectile dysfunction (ED), and late-onset hypogonadism (LOH) are highly prevalent in aging men and are significantly associated with a reduced QOL. However, few questionnaire-based studies have fully examined the relation between atherosclerosis and several urological symptoms.

Materials and methods

The study comprised 303 outpatients who visited our clinic with symptoms of LOH. Several factors influencing atherosclerosis, including serum concentrations of triglyceride, fasting blood sugar, and total testosterone measured by radioimmunoassay, were investigated. We also measured brachial-ankle pulse wave velocity (baPWV) and assessed symptoms by specific questionnaires, including the Sexual Health Inventory for Men (SHIM), Erection Hardness Score (EHS), International Prostate Symptom Score (IPSS), QOL index, and Aging Male Symptoms rating scale (AMS). Stepwise associations between the ratio of measured/age standard baPWV and clinical factors including laboratory data and the scores of the questionnaires were compared using the Jonckheere–Terpstra test for trend. The associations between the ratio of measured/age standard baPWV and each IPSS score were assessed in a multivariate linear regression model after adjustment for serum triglyceride, fasting blood sugar, and total testosterone.

Results

Regarding ED, a higher level of the ratio of measured/age standard baPWV was associated with a lower EHS, whereas no association was found with SHIM. Regarding LUTS, a higher ratio of measured/age standard baPWV was associated with a higher IPSS and QOL index. However, there was no statistically significant difference between the ratio of measured/age standard baPWV and AMS. A multivariate linear regression model showed only nocturia to be associated with the ratio of measured/age standard baPWV for each IPSS score.

Conclusion

Atherosclerosis is associated with erectile function and LUTS, especially nocturia.

Correlation between adipokines and carotid intima media thickness in a group of obese Romanian children: is small for gestational age status an independent factor for cardiovascular risk?

OBJECTIVE

To investigate the relationship between markers of adiposity and common carotid artery (CIMT) in obese children born small for gestational age (SGA) versus appropriate for gestational age (AGA), to establish cut-off values for CIMT in obese pediatric populations.

SUBJECTS AND METHODS

A cross-sectional study was carried out over a 1-year period (Jul 2013 - June 2014). We analyzed 122 obese patients aged 4-20 (mean age 14.9 ± 2.28). Twenty-six patients were born SGA. CIMT was measured in all the patients. Using ROC curve, cut-off values were obtained for both groups.

RESULTS

We demonstrated a correlation between CIMT and adiponectin, leptin and high sensitivity C-reactive protein (hsCRP) (r = -0.25, r = 0.279, r = 0.498) in obese children. CIMT in obese children born SGA were significantly increased as compared with obese children born AGA of similar age, sex and body mass index (BMI) (p = 0.0035). A CIMT cut off value of 0.049 cm has been obtained with a high sensitivity and specificity.

CONCLUSION

CIMT is a well-known marker of subclinical atherosclerosis and its measurement is a noninvasive and inexpensive method of detecting subclinical atherosclerosis. Being born SGA increases the atherogenic risk. Obese children with CIMT above 0.049 cm should be screened for metabolic syndrome (MetS).

Iron and peripheral arterial disease: revisiting the iron hypothesis in a different light

The relationship between iron status and atherosclerosis has long been a topic of debate in the literature. Despite more than 25 years of research, there is no consensus regarding a causal relationship. To date, the vast majority of studies have focused on iron burden with respect to a hypothesized role in the onset and progression of coronary artery disease. However, the effect of iron in the coronary arterial system may differ mechanistically and therefore clinically from its effect in the peripheral arterial system. This review will summarize the biochemical, pathologic, animal, and clinical research data with respect to iron and atherosclerosis. This background will be expanded upon to provide insights into ongoing studies and paths for future investigations into the role of iron and peripheral arterial disease.

The Association between Ideal Cardiovascular Health Metrics and Extracranial Carotid Artery Stenosis in a Northern Chinese Population: A Cross-Sectional Study

Past epidemiologic studies have indicated that the ideal cardiovascular health (CVH) metrics are associated with a lower risk of cardiovascular diseases (CVDs) and stroke. Carotid artery stenosis (CAS) causes approximately 10% of ischemic strokes. The association between ideal CVH and extracranial CAS has not yet been assessed. In the current study, extracranial CAS was assessed by carotid duplex ultrasonography. Logistic regression was used to analyze the association between ideal CVH metrics and extracranial CAS. A total of 3297 participants (52.2% women) aged 40 years and older were selected from the Jidong community in China. After adjusting for sex, age and other potential confounds, the odds ratios (95% confidence intervals) for extracranial CAS were 0.57 (0.39–0.84), 0.46 (0.26–0.80) and 0.29 (0.15–0.54), and for those quartiles, quartile 2 (9–10), quartile 3 (11) and quartile 4 (12–14), respectively, compared with quartile 1 (≤8). This negative correlation was particularly evident in women and the elderly (≥60 years). This cross-sectional study showed a negative correlation between the ideal CVH metrics and the prevalence of extracranial CAS in northern Chinese adults.

Clinical Characteristics of Young Type 2 Diabetes Patients with Atherosclerosis

Objective

The prevalence of type 2 diabetes is increasing rapidly in the young population. The clinical characteristics and risk factors for young type 2 diabetes patients with atherosclerosis are not fully explicated. The aim of the present study was to investigate various clinical and biochemical characteristics of young type 2 diabetic patients with atherosclerosis.

Design and Methods

This was a cross-sectional study. The study involved 2199 hospitalized patients with type 2 diabetes. The young patients were classified into the atherosclerotic group or the non-atherosclerotic group, and we also enrolled an older group with peripheral atherosclerosis disease and an age of at least 45 years. Comparisons were made between the different groups to investigate the cardiovascular and metabolic risk profiles of young type 2 diabetes patients with atherosclerosis. We also used logistic regression models to assess the atherosclerosis risk factors for young patients.

Results

Compared to older type 2 diabetes patients with atherosclerosis, young patients with atherosclerosis had more deleterious profiles of weight and hyperlipidemia. Only age and diabetes duration were found to be significant independent risk factors for atherosclerosis in young patients. The ratio of the presence of atherosclerosis in the lower extremity arteries alone was significantly higher in young patients than older patients (26.4% vs. 14.0%, P = 0.000).

Conclusion

Young type 2 diabetes patients with atherosclerosis have more adverse cardiovascular risk profiles and inadequate control of these risk factors. Lower extremity examination is of high importance in young patients.

American Society of Echocardiography Report

Noninvasive measures of atherosclerosis have emerged as adjuncts to standard cardiovascular disease (CVD) risk factors in an attempt to refine risk stratification and the need for more aggressive preventive strategies. Two such approaches, carotid artery imaging and brachial artery reactivity testing (BART), are ultrasound based. Numerous carotid artery imaging protocols have been used, and methodologic aspects are described in detail in this review. The panel recommends that protocols: (1) use end-diastolic (minimum dimension) images for intimal-medial thickness (IMT) measurements; (2) provide separate categorization of plaque presence and IMT; (3) avoid use of a single upper limit of normal for IMT because the measure varies with age, sex, and race; and (4) incorporate lumen measurement, particularly when serial measurements are performed to account for changes in distending pressure. Protocols may vary in the number of segments wherein IMT is measured, whether near wall is measured in addition to far wall, and whether IMT measurements are derived from B-mode or M-mode images, depending on the application. BART is a technique that requires meticulous attention to patient preparation and methodologic detail. Its application is substantially more challenging than is carotid imaging and remains largely a research technique that is not readily translated into routine clinical practice.

Rationale and design of a multicenter randomized study for evaluating vascular function under uric acid control using the xanthine oxidase inhibitor, febuxostat: the PRIZE study

BACKGROUND

Xanthine oxidase inhibitors are anti-hyperuricemic drugs that decrease serum uric acid levels by inhibiting its synthesis. Xanthine oxidase is also recognized as a pivotal enzyme in the production of oxidative stress. Excess oxidative stress induces endothelial dysfunction and inflammatory reactions in vascular systems, leading to atherosclerosis. Many experimental studies have suggested that xanthine oxidase inhibitors have anti-atherosclerotic effects by decreasing in vitro and in vivo oxidative stress. However, there is only limited evidence on the clinical implications of xanthine oxidase inhibitors on atherosclerotic cardiovascular disease in patients with hyperuricemia. We designed the PRIZE study to evaluate the effects of febuxostat on a surrogate marker of cardiovascular disease risk, ultrasonography-based intima-media thickness of the carotid artery in patients with hyperuricemia.

METHODS

The study is a multicenter, prospective, randomized, open-label and blinded-endpoint evaluation (PROBE) design. A total of 500 patients with asymptomatic hyperuricemia (uric acid >7.0 mg/dL) and carotid intima-media thickness ≥1.1 mm will be randomized centrally to receive either febuxostat (10-60 mg/day) or non-pharmacological treatment. Randomization is carried out using the dynamic allocation method stratified according to age (<65, ≥65 year), gender, presence or absence of diabetes mellitus, serum uric acid (<8.0, ≥8.0 mg/dL), and carotid intima-media thickness (<1.3, ≥1.3 mm). In addition to administering the study drug, we will also direct lifestyle modification in all participants, including advice on control of body weight, sleep, exercise and healthy diet. Carotid intima-media thickness will be evaluated using ultrasonography performed by skilled technicians at a central laboratory. Follow-up will be continued for 24 months. The primary endpoint is percentage change in mean intima-media thickness of the common carotid artery 24 months after baseline, measured by carotid ultrasound imaging.

CONCLUSIONS

PRIZE will be the first study to provide important data on the effects of febuxostat on atherosclerosis in patients with asymptomatic hyperuricemia. Trial Registration Unique trial Number, UMIN000012911 ( https://upload.umin.ac.jp/cgi-open-bin/ctr/ctr.cgi?function=brows&action=brows&type=summary&recptno=R000015081&language=E ).

The Effect of Sitagliptin on Carotid Artery Atherosclerosis in Type 2 Diabetes: The PROLOGUE Randomized Controlled Trial

BACKGROUND

Experimental studies have suggested that dipeptidyl peptidase-4 (DPP-4) inhibitors provide cardiovascular protective effects. We performed a randomized study to evaluate the effects of sitagliptin added on to the conventional therapy compared with conventional therapy alone (diet, exercise, and/or drugs, except for incretin-related agents) on the intima-media thickness (IMT) of the carotid artery, a surrogate marker for the evaluation of atherosclerotic cardiovascular disease, in people with type 2 diabetes mellitus (T2DM).

METHODS AND FINDINGS

We used a multicenter PROBE (prospective, randomized, open label, blinded endpoint) design. Individuals aged ≥30 y with T2DM (6.2% ≤ HbA1c < 9.4%) were randomly allocated to receive either sitagliptin (25 to 100 mg/d) or conventional therapy. Carotid ultrasound was performed at participating medical centers, and all parameters were measured in a core laboratory. Of the 463 enrolled participants with T2DM, 442 were included in the primary analysis (sitagliptin group, 222; conventional therapy group, 220). Estimated mean (± standard error) common carotid artery IMT at 24 mo of follow-up in the sitagliptin and conventional therapy groups was 0.827 ± 0.007 mm and 0.837 ± 0.007 mm, respectively, with a mean difference of -0.009 mm (97.2% CI -0.028 to 0.011, p = 0.309). HbA1c level at 24 mo was significantly lower with sitagliptin than with conventional therapy (6.56% ± 0.05% versus 6.72% ± 0.05%, p = 0.008; group mean difference -0.159, 95% CI -0.278 to -0.041). Episodes of serious hypoglycemia were recorded only in the conventional therapy group, and the rate of other adverse events was not different between the two groups. As it was not a placebo-controlled trial and carotid IMT was measured as a surrogate marker of atherosclerosis, there were some limitations of interpretation.

CONCLUSIONS

In the PROLOGUE study, there was no evidence that treatment with sitagliptin had an additional effect on the progression of carotid IMT in participants with T2DM beyond that achieved with conventional treatment.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry UMIN000004490.

Evaluation of the relationship between periodontal risk and carotid artery calcifications on panoramic radiographs

Objective:

To evaluate if there is a relationship between findings of carotid artery calcification (CAC) and periodontal risk in nonsmoker subjects by using panoramic radiographs (DPR).

Materials and Methods:

A total of 1146 DPRs were investigated. Gender, age, severity of bone loss, tooth loss, periodontal risk, and findings of carotid calcification were recorded. The periodontal risk was evaluated and classified according to the degree of alveolar bone loss.

Results:

CAC was diagnosed in %13.6 (n: 156) of DPRs. Of 1146 patients, 338 (29.5%) had low, 668 (60%) had moderate, and 120 (10.5%) had high periodontal risk. A statistically significant relation was observed between carotid calcification and periodontal risk.

Conclusion:

Positive findings of carotid calcification may be related with periodontal problems. Clinicians must be careful about diagnosing CACs on DPRs during routine examinations. In the case of positive findings of CAC and periodontitis together, the patient may be consulted to a specialist for further investigation.

Prevalence of carotid artery stenosis in Chinese patients with angina pectoris

BACKGROUND

The prevalence of carotid artery stenosis (CAS) in Chinese patients with angina pectoris is unknown.

METHODS

The study population consisted of 989 consecutive patients who were scheduled to undergo nonemergent coronary angiography for suspicion of coronary artery disease (CAD) because of angina pectoris between January 2013 and December 2014. All patients underwent carotid ultrasonography to screen for CAS within one month before or after coronary angiography. We defined cases with 0-50%, 50%-70%, and >70% stenosis as mild, moderate, and severe stenosis, respectively.

RESULTS

CAD was presented in 853 patients (86.2%) of whom 191 patients (19.3%) had 1-vessel disease, 246 patients (24.9%) had 2-vessel disease and 416 patients (42.1%) had 3-vessel disease; left main trunk stenosis present in 137 patients (13.9%). In carotid ultrasonography, the prevalence of mild, moderate, and severe stenosis as well as that of total occlusion of the carotid artery was 54.5%, 13%, 4.7% and 0.8%, respectively. Significant CAS (>50% stenosis and total occlusion) was present in 10.3%, 13.9%, 19.9% and 22.8% of patients with 0-vessel, 1-vessel, 2-vessel and 3-vessel CAD. The severity of CAS was directly correlated (r=0.194, P<0.001) with the extent of CAD. The independent predictors of severe CAS and total carotid artery occlusion were increased age, male sex, hypertension, diabetes mellitus, hyperhomocysteinemia, a previous history of stroke and 3-vessel CAD.

CONCLUSIONS

The prevalence of CAS was not rare in China when compared with that in western countries, and the presence of CAS was weakly correlated with the extent of CAD. Screening for CAS should be recommended in Chinese patients with CAD, especially in those with one or more CAS-associated risk factors.

Long-term prognostic role of cerebrovascular disease and peripheral arterial disease across the spectrum of acute coronary syndromes

BACKGROUND

In acute coronary syndromes (ACS), the influence of cerebro-vascular disease (CVD) and/or peripheral artery disease (PAD) on short-midterm outcome has been well established. Data on long-term outcome however, are limited. Our study aimed to explore the effect of CVD and PAD on long-term outcome in a cohort of unselected ACS patients, including ST-elevation (STE-ACS) and non-ST-elevation (NSTE-ACS).

METHODS AND RESULTS

The population consisted of 2046 consecutive patients with a confirmed final diagnosis of ACS; 896 (44%) had STE-ACS and 1150 (66%) NSTE-ACS. CVD alone was present in 98 patients (5%), 282 (14%) had PAD alone, and 30 (1.5%) had both. All cause mortality at 5 years was lowest in patients without CVD/PAD (33%), intermediate in patients with either CVD or PAD (62% and 63%, respectively) reaching 80% in those with both CVD and PAD. These findings were confirmed in the STE-ACS and NSTE-ACS subgroups. CVD and PAD remained independent predictors of mortality after multivariable analysis, the combined presence of both carrying the highest risk within each ACS type (HR 4.15, 95% CI 1.83-9.44 for STE-ACS; HR 2.14, 1.29-3.54 for NSTE-ACS). Patients with CVD and/or PAD were less likely to be treated invasively and received less evidence-based treatment at discharge.

CONCLUSIONS

Across the spectrum of ACS, extracardiac vascular disease harbors a negative long-term prognosis that worsens progressively with the number of affected arterial beds.

SYNTAX Score II predicts carotid disease in a multivessel coronary disease population

BACKGROUND

The SYNTAX Score (SxScore) is an angiographic tool that evaluates CAD complexity, which we previously reported lacking correlation with the presence of carotid disease. Recently, SxScore II has been developed including both angiographic and clinical variables, which could increase the prognostic accuracy for detection of carotid disease.

METHODS AND RESULTS

From January 2013 to June 2014, 244 patients with multivessel CAD (mean age 65.37 years, 84% males) underwent carotid ultrasound scan. At least one carotid lesion (CL) was found in 77% of patients with significant carotid disease (SCD) in 23.4% of cases. Logistic regression analysis revealed no relation between SxScore and CL/SCD (p=0.781 and p=0.368) while SxScore II well correlated with CL (SxScore II-PCI: odds ratio [OR] 1.036; 95% confidence interval [CI]:1.006-1.067; p=0.019; SxScore II-CABG: OR 1.045; 95% CI: 1.015-1.076, p=0.003) and SCD (SxScore II-PCI: OR 1.042; 95% CI: 1.012-1.073, p=0.006; SxScore-CABG: OR 1.054; 95% CI: 1.029-1.080, p<0.0001). The areas under the receiver-operating characteristic curves were: for SxScore 0.512 (95% CI: 0.448-0.577; p=0.77), for SxScore II-PCI and SxScore II-CABG 0.600 (95% CI: 0.536-0.662; p=0.01) and 0.645 (95% CI: 0.581-0.705; p=0.0008), respectively, and 0.527 (95% CI 0.462-0.591; p=0.56), 0.619 (95% CI: 0.555-0.681; p=0.01) and 0.681 (95% CI: 0.619-0.739; p=0.0001), respectively, for the identification of SCD.

CONCLUSIONS

The SxScore II, with inclusion of clinical variables over angiographic complexity, seems more suited to predict the presence of carotid disease than the SxScore.

Preoperative Coronary Stenosis Is a Determinant of Early Vascular Outcome after Carotid Endarterectomy

BACKGROUND AND PURPOSE

The benefit of carotid endarterectomy (CEA) is directly influenced by the risk of perioperative adverse outcomes. However, patient-level risks and predictors including coronary stenosis are rarely evaluated, especially in Asian patients. The aim of this study was to determine the relationship between the vascular risk factors underlying CEA, including coronary stenosis, and postoperative outcome.

METHODS

One hundred and fifty-three consecutive CEAs from our hospital records were included in this analysis. All patients underwent coronary computed tomography angiography before CEA. Data were analyzed to determine the vascular outcomes in patients with mild-to-moderate vs. severe coronary stenosis and high vs. standard operative risk, based on the criteria for high operative risk defined in the Stenting and Angioplasty with Protection in Patients at High Risk for Endarterectomy (SAPPHIRE) trial. The vascular outcome was defined as the occurrence of postoperative (≤30 days) stroke, myocardial infarction (MI), or death.

RESULTS

An adverse vascular outcome occurred in 8 of the 153 CEAs, with 6 strokes, 2 MIs, and 3 deaths. The vascular outcome differed significantly between the groups with mild-to-moderate and severe coronary stenosis (p=0.024), but not between the high- and standard-operative-risk groups (stratified according to operative risk as defined in the SAPPHIRE trial). Multivariable analysis adjusting for potent predictors revealed that severe coronary stenosis (odds ratio, 6.87; 95% confidence interval, 1.20-39.22) was a significant predictor of the early vascular outcome.

CONCLUSIONS

Severe coronary stenosis was identified herein as an independent predictor of an adverse early vascular outcome.

Differential incremental value of ultrasound carotid intima-media thickness, carotid plaque, and cardiac calcium to predict angiographic coronary artery disease across Framingham risk score strata in the APRES multicentre study

AIMS

According to recent data, more accurate selection of patients undergoing coronary angiography for suspected coronary artery disease (CAD) is needed. From the Active PREvention Study multicentre prospective study, we further analyse whether carotid intima-media thickness (cIMT), carotid plaques (cPL), and echocardiographic cardiac calcium score (eCS) have incremental discriminatory and reclassification predictive value for CAD over clinical risk score in subjects undergoing coronary angiography, specifically depending on their low, intermediate, or high class of clinical risk.

METHODS AND RESULTS

In eight centres, 445 subjects without history of prior CAD but with chest pain of recent onset and/or a positive/inconclusive stress test for ischaemia prospectively underwent clinically indicated elective coronary angiography after cardiac and carotid ultrasound assessments with measurements of cIMT, cPL, and eCS. The study population was divided into subjects at low (10%), intermediate (10-20%), and high (>20%) Framingham risk score (FRS). Ultrasound parameters were tested for their incremental value to predict CAD over FRS, in each pre-test risk category. No significant difference could be appreciated between the discrimination value of FRS and Diagnostic Imaging for Coronary Artery Disease score for the presence of CAD. eCS or cPL demonstrated significant incremental prediction over FRS, consistently in the three FRS categories (P < 0.01); this applied to both discrimination and reclassification, with the exception of high-risk subjects, in whom cPL was apparently not incremental over FRS, and eCS was only of borderline significance for better discrimination.

CONCLUSIONS

Ultrasound eCS and cPL assessments were significant predictors of angiographic CAD in patients without prior CAD but with signs or symptoms suspect for CAD, independently and incrementally to FRS, across all pre-test risk probability strata, although in high-risk subjects, only eCS maintained an incremental value. The use of cIMT was not significantly incrementally useful in any FRS risk category.

HIV vasculopathy: role of mononuclear cell-associated Krüppel-like factors 2 and 4

OBJECTIVE

To determine the relationships between Krüppel-like factors (KLF) 2 and 4, immune-activation, and subclinical vascular disease in HIV-infected patients on antiretroviral therapy (ART).

DESIGN

Double-blind, randomized, placebo-controlled trial.

METHODS

We studied 74 HIV-infected adults on ART enrolled in a randomized clinical trial of statin therapy. KLF2 and KLF4 gene expression was measured by quantitative PCR from peripheral blood mononuclear cells (PBMCs) at baseline and after 24 weeks of 10 mg daily rosuvastatin or placebo. At the same time points, T-cell and monocyte activation were assessed by flow cytometry and vascular health was assessed by cardiac computed tomography and carotid ultrasound.

RESULTS

KLF4 expression was negatively correlated with duration of ART (r = -0.351, P = 0.004) and positively correlated with measures of immune activation: proinflammatory monocytes [CD14CD16 (r = 0.343, P = 0.003)], patrolling monocytes [CD14CD16 (r = 0.276, P = 0.017)], and activated CD8 T-lymphocytes [CD8DRCD38 (r = 0.264, P = 0.023)]. KLF2 expression was negatively correlated with subclinical atherosclerosis: mean-mean common carotid artery intima-media thickness (r = -0.231, P = 0.048), mean-max carotid artery intima-media thickness (r = -0.271, P = 0.020), and coronary artery calcium score (r = -0.254, P = 0.029). There were no statistically significant changes in KLF2/4 expression in PBMCs after 24 weeks of rosuvastatin.

CONCLUSION

Expression of KLF4 in PBMCs positively correlates with cellular markers of immune activation, whereas KLF2 expression negatively correlates with markers of subclinical atherosclerosis in this HIV-infected population on ART. Additional studies are needed to determine if targeted interventions might alter KLF2/4 expression to reduce inflammation and vascular risk in humans.

Can and should carotid ultrasound be used in cardiovascular risk assessment?: the internist's perspective

Cardiovascular risk management is a major and challenging task for internists. Risk scores using algorithms based on traditional risk factors are helpful in identifying patients in whom intensive prevention strategies are warranted. However there remains a need for more accurate screening tools to allow clinicians to individualize the primary prevention programs to their patients. Approximately 40-80% of apparently healthy, asymptomatic subjects exhibit increased thickness of the lamina intima-media of the carotid artery or have atherosclerotic carotid plaques. These abnormalities can be measured safely and at low cost by ultrasound. Subclinical carotid lesions are strongly associated with generalized atherosclerotic burden and the risk of future cardiovascular events. Although many cardiovascular risk management guidelines recommend the use of these parameters incorporation in clinical practice is still not commonplace. Based on the current literature it can be stated that in high risk patients there is no additional value of carotid ultrasound because even in the absence of carotid lesions these patients should receive an intensive risk reduction regime. In the large low-intermediate risk group however carotid ultrasound findings carry subtle but possibly clinically relevant information about cardiovascular risk profile. The effect of treatment decisions based on carotid ultrasound parameters has not been studied. Sequential measurements to monitor progression and evaluate treatment response on an individual basis are not sufficiently reproducible. We therefore recommend the use of carotid ultrasound in low to intermediate risk patients but emphasize the importance of interpreting the results in conjunction with all cardiovascular risk factors and avoid follow-up measurements.

Shape-based approach for coronary calcium lesion volume measurement on intravascular ultrasound imaging and its association with carotid intima-media thickness

OBJECTIVES

Coronary calcification plays an important role in diagnostic classification of lesion subsets. According to histopathologic studies, vulnerable atherosclerotic plaque contains calcified deposits, and there can be considerable variation in the extent and degree of calcification. Intravascular ultrasound (IVUS) has demonstrated its role in imaging coronary arteries, thereby displaying calcium lesions. The aim of this work was to develop a fully automated system for detection, area and volume measurement, and characterization of the largest calcium deposits in coronary arteries. Furthermore, we demonstrate the correlation between the coronary calcium IVUS volume and the neurologic risk biomarker B-mode carotid intima-media thickness (IMT).

METHODS

Our system automatically detects the frames with calcium, identifies the largest calcium region, and performs shape-based volume measurements. The carotid IMT is measured by using AtheroEdge software (AtheroPoint, LLC) on B-mode ultrasound imaging.

RESULTS

Our database consists of low-contrast IVUS videos and corresponding B-mode images from 100 patients. Our experiments showed that the correlation between calcium volumes and carotid IMT was higher for the left carotid artery compared to the right carotid artery (r = 0.066 for the left carotid artery and 0.121 for the right carotid artery). We obtained 97% accuracy for automated calcium detection compared against the scoring given by our expert radiologists. Furthermore, we benchmarked shape-based volume measurement against the conventional method, which used integration of regions and showed a correlation of 84%.

CONCLUSIONS

Since carotid IMT is an independent prognostic factor for myocardial infarction, and calcium lesions are correlated with stroke risk, we believe that this automated system for calcium volume measurement could be useful for assessing patients' cardiovascular risk.

Predictors of subclinical atherosclerosis in women with spinal cord injury

BACKGROUND

Chronic spinal cord injury (SCI) is associated with an increase in risk factors for cardiovascular disease (CVD). In the general population, atherosclerosis in women occurs later than in men and usually presents differently. Associations between risk factors and incidence of CVD have not been studied in women with SCI.

OBJECTIVE

To determine which risk factors for CVD are associated with increased carotid intima-media thickness (CIMT), a common indicator of atherosclerosis, in women with SCI.

METHODS

One hundred and twenty-two females older than 18 years with traumatic SCI at least 2 years prior to entering the study were evaluated. Participants were asymptomatic and without evidence of CVD. Exclusion criteria were acute illness, overt heart disease, diabetes, and treatment with cardiac drugs, lipid-lowering medication, or antidiabetic agents. Measures for all participants were age, race, smoking status, level and completeness of injury, duration of injury, body mass index, serum lipids, fasting glucose, hemoglobin A1c, and ultrasonographic measurements of CIMT. Hierarchical multiple linear regression was conducted to predict CIMT from demographic and physiologic variables.

RESULTS

Several variables were significantly correlated with CIMT during univariate analyses, including glucose, hemoglobin A1c, age, and race/ethnicity; but only age was significant in the hierarchical regression analysis.

CONCLUSIONS

Our data indicate the importance of CVD in women with SCI.

A numerical study of the effect of varied blood pressure on the stability of carotid atherosclerotic plaque

Background

Blood pressure (BP) is associated with early atherosclerosis and plaque rupture because the BP variability can significantly affect the blood flow velocity and shear stress over the plaque. However, the mechanical response of BP variability to the plaque remains unclear. Therefore, we investigated the correlation between different maximum systolic blood pressure (SBP) and the stress distribution on plaque, as well as the stress over the plaque and blood velocity around the plaque using different BP variations, which are the BP variability in different phases during one cardiac cycle and beat-to-beat BP variability.

Method

We established a two-dimensional artery model with stenosis at the degree of 62.5%. Eight combinations of pulsatile pressure gradients between the inflow and outflow were implemented at the model. Three levels of fibrous cap thickness were taken into consideration to investigate the additional effect on the BP variability. Wall shear stress and stress/strain distribution over the plaque were derived as well as the oscillation shear index (OSI) to analyze the impact of the changing rate of BP.

Result

The stresses at diastole were 2.5% ± 1.8% lower than that at systole under the same pressure drop during one cycle. It was also found that elevated SBP might cause the immediate increment of stress in the present cycle (292% ± 72.3%), but slight reduction in the successive cycle (0.48% ± 0.4%).

Conclusion

The stress/strain distribution over the plaque is sensitive to the BP variability during one cardiac cycle, and the beat-to-beat BP variability could cause considerable impact on the progression of atherosclerosis in long-term.