Comparison of Carotid Plaque Score and Coronary Artery Calcium Score for Predicting Cardiovascular Disease Events: The Multi-Ethnic Study of Atherosclerosis

Carotid Plaque-Burden scale and outcomes: A real-life study

BACKGROUND

The value of carotid ultrasound in real-world practice remains controversial. We investigated the outcomes of people with vascular risk factors according to an easy carotid-plaque burden scale (CPB-scale). Predictive yield of the addition CPB-scale to ESC-SCORE2 (CPB-SCORE2 table) was assessed.

METHODS

A cohort of participants without preexisting cardiovascular disease (CVD) was evaluated for clinical outcomes according to the number of plaques by segment. The usefulness of the CPB-SCORE2 table was investigated.

RESULTS

A total of 1004 patients were followed for a mean of 12.5 years for major adverse cardiovascular events (MACEs) and death. The CPB-scale was independently associated with MACEs; compared to those in the low-risk group, the corresponding adjusted hazard ratios (95% confidence intervals) for MACEs among the intermediate and high-risk groups were 13.1 (4.87-35.5) and 19.4 (7.27-51.9), respectively. Similarly, the risk of death was greater for participants stratified as high-risk than for those in the low-risk group (adjusted HR 3.36 [1.58-7.15]). According to our CPB-SCORE2 table, 149 of 178 (84%) CV events were detected in the high-risk group and exhibited greater sensitivity than did the SCORE2 Table, 84%; vs. 62%; but slightly less specificity, 62%; vs. 68%. Our table shows the improved performance of SCORE2; c-statistics: 0.74 vs. 0.68; p<0.001 for net reclassification index and integrated discrimination index.

CONCLUSIONS

A simple prognostic CPB-scale was strongly associated with the long-term risk of developing a first MACE and all-cause death. Adding the CPB-scale to the SCORE2 may improve risk prediction with easy applicability in clinical practice.

Carotid plaque score is associated with 10-year major adverse cardiovascular events in low-intermediate risk patients referred to a general cardiology community clinic

AIMS

Atherosclerotic carotid plaque assessments have not been integrated into routine clinical practice due to the time-consuming nature of both imaging and measurements. Plaque score, Rotterdam method, is simple, quick, and only requires 4-6 B-mode ultrasound images. The aim was to assess the benefit of plaque score in a community cardiology clinic to identify patients at risk for major adverse cardiovascular events (MACE).

METHODS AND RESULTS

Patients ≥ 40 years presenting for risk assessment were given a carotid ultrasound. Exclusions included a history of vascular disease or MACE and being >75 years. Kaplan-Meier curves and hazard ratios were performed. The left and right common carotid artery (CCA), bulb, and internal carotid artery were given 1 point per segment if plaque was present (plaque scores 0-6). Administrative data holdings at ICES were used for 10-year event follow-up. Of 8472 patients, 60% were females (n = 5121). Plaque was more prevalent in males (64% vs. 53.9%; P < 0.0001). The 10-year MACE cumulative incidence estimate was 6.37% with 276 events (males 6.9% vs. females 6.0%; P = 0.004). Having both maximal CCA intima media thickness < 1.00 mm and plaque score = 0 was associated with less events. A plaque score < 2 was associated with a low 10-year event rate (4.1%) compared with 2-4 (8.7%) and 5-6 (20%).

CONCLUSION

A plaque score ≥ 2 can re-stratify low-intermediate risk patients to a higher risk for events. Plaque score may be used as a quick assessment in a cardiology office to guide treatment management of patients.

Quantitative correlation between carotid or lower limb atherosclerosis and coronary heart disease: a retrospective observational study

Background

Early diagnosis and intervention are key for the treatment of coronary heart disease (CHD). Ultrasound is used to assess risk stratification in patients with coronary artery disease. However, few studies quantify the relationship between carotid or lower limb atherosclerosis and coronary revascularization. The purpose of this study is to demonstrate that the semi-quantitative degree of atherosclerosis in the neck or lower extremity vessels can predict the need for coronary revascularization, thereby establishing a predictive model for coronary revascularization based on peripheral vascular disease.

Methods

Patients who underwent coronary angiography and peripheral vascular ultrasound were randomly selected for semi-quantitative analysis of the degree of coronary artery and peripheral vascular stenosis. Data from 306 patients were collected.

Results

The semiquantitative score, grade score and lower limb score from vascular ultrasound were positively correlated with the Gensini score of coronary artery lesions. The semi-quantitative score (score = 2) predicted the sensitivity and specificity for coronary revascularization at 83.74% and 61.72%, respectively. The graded score (score = 2) predicted the sensitivity and specificity for coronary revascularization at 77.24% and 72.13%, respectively. The lower extremity score (score = 3) predicted the sensitivity and specificity for coronary revascularization at 90.24% and 54.55%, respectively.

Conclusions

Carotid semiquantitative scores, grade scores, and lower limb scores are predictive factors for the need for coronary revascularization and can serve as auxiliary examinations for the early diagnosis of coronary artery disease.

Importance of Age and Sex in Carotid Artery Plaque Detection and Cardiovascular Disease Risk

Importance

Carotid artery plaque (CAP) is commonly encountered in clinical practice. Presence of CAP predicts future atherosclerotic cardiovascular disease (ASCVD) events; however, CAP prevalence increases with age, and it is unknown how age and sex affect the association of CAP presence and ASCVD risk.

Objectives

To describe CAP prevalence by age, sex, race, and ethnicity in a multiethnic population and to investigate whether the impact of CAP detection on relative ASCVD risk declines with age and differs by sex.

Design, Setting, and Participants

This cohort study examines participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Adults aged 45 to 84 years who were free of clinical ASCVD at recruitment (2000-2002) were included, and follow-up for ASCVD events was conducted through December 2019. Data analysis was performed from July 2023 to April 2024.

Exposure

Presence of CAP.

Main Outcomes and Measures

The primary outcome was ASCVD events (coronary heart disease events, stroke, and ASCVD death). Prevalence of CAP by age, sex, race, and ethnicity was calculated. Cox proportional hazards models with age interaction terms were used to investigate associations of CAP and incident ASCVD events across sexes.

Results

Among 6814 adults in the MESA cohort, 5689 participants had complete data and were included in this analysis. Among these 5689 participants, mean (SD) age was 62.0 (10.2) years, and 3002 participants (53%) were female. The cohort included 1551 Black participants (27%), 687 Chinese participants (12%), 1276 Hispanic participants (22%), and 2165 White participants (38%). In total, participants experienced 1043 ASCVD events over a median (IQR) period of 17.6 (10.5-18.4) years. Prevalence of CAP differed by age, sex, race, and ethnicity, ranging from 15% in Chinese women younger than 50 years to 95% in non-Hispanic White men aged 80 to 84 years. CAP independently predicted ASCVD events (hazard ratio, 1.38; 95% CI, 1.20-1.58; P < .001). The strength of this association was stronger among younger participants (≤60 years) vs older (>60 years) (P for interaction = .01), especially among women (P for interaction = .005) vs men (P for interaction = .66). CAP detection in younger individuals conferred higher relative ASCVD risk than in older participants, who had higher absolute risk regardless of CAP.

Conclusions and Relevance

CAP becomes very common with increasing age among individuals without clinical ASCVD, and the association of CAP with incident ASCVD events was strongest in younger ages, especially among women. These data can help guide ASCVD risk assessment in younger adults and provide perspective when CAP is detected on clinical imaging studies in older adults.

Assessment of total carotid plaque area progression in patients with chronic kidney disease. Good practices for decision-making

BACKGROUND

Chronic kidney disease (CKD) increases cardiovascular risk, however, traditional cardiovascular risk factors cannot entirely explain it. A real-world investigation examined the concept that renal function decline is linked to carotid total plaque area progression, which strongly confirms cardiovascular risk. We analyzed CKD patients in stages 1-3 to find risk factor relationships before the onset of severe CKD.

METHODS

We monitored 328 patients for 16 ± 5 months. Participants were classified at baseline by estimated glomerular filtration rate (eGFR) stage: G1 (≥ 90), G2 (60-89), and G3 (30-59 ml/min/1.73m2). Ultrasound-guided total plaque area tracked atherosclerosis. Age, sex, blood pressure, lipids, and HbA1c were covariates. Total plaque area and variables were measured on day 1 and at the conclusion of observation. We used a multilevel mixed effects model to assess biological and behavioral factors on total plaque area progression in the general population. For validation, this research was conducted on 73 CKD patients with optimal traditional cardiovascular risk factor management during 15 ± 5 months.

RESULTS

Multiple analyses showed an inverse relationship between eGFR decline and total plaque area progression [β-exponent = 0.99 (95% CI = 0.98-0.99)], regardless of age, lipid profile, blood pressure, smoking, diabetes, or hypertension. The correlation remained significant in the 73-patient sample with optimal traditional cardiovascular risk factor management (β-exponent = 0.99; 95% CI 0.97-0.99). Although traditional cardiovascular risk factor management was excellent, total plaque area increased considerably in G2-G3 patients compared to G1.

CONCLUSIONS

CKD, total plaque area, and eGFR are inversely correlated, independent of traditional cardiovascular risk factors, suggesting that non-traditional mechanisms are responsible for resistant atherosclerosis. The combination of eGFR and total plaque area may be useful in identifying high-risk patients.

Associations Between Flavonoid Intake and Subclinical Atherosclerosis: The Multi-Ethnic Study of Atherosclerosis

BACKGROUND

Flavonoids may play a role in mitigating atherosclerotic cardiovascular diseases, with evidence suggesting effects may differ between vascular beds. Studies examining associations with subclinical markers of atherosclerosis between subpopulations with different underlying risks of atherosclerosis are lacking.

METHODS

Among 5599 participants from the MESA (Multi-Ethnic Study of Atherosclerosis), associations between dietary flavonoid intakes (estimated from a food frequency questionnaire) and subclinical measures of atherosclerosis (ankle-brachial index, carotid plaques and intima-media thickness, and coronary artery calcification) were examined using repeated measures models. Exposures and outcomes were measured at exam 1 (2000-2002) and exam 5 (2010-2011). Stratified analyses and interaction terms were used to explore effect modification by time, sex, race/ethnicity, and smoking status.

RESULTS

In the analytic population, at baseline, ≈46% were men with a median age of 62 (interquartile range, 53-70) years and total flavonoid intakes of 182 (interquartile range, 98-308) mg/d. After multivariable adjustments, participants with the highest (quartile 4) versus lowest (quartile 1) total flavonoid intakes had 26% lower odds of having an ankle-brachial index <1 (odds ratio, 0.74 [95% CI, 0.60-0.92]) and 18% lower odds of having a carotid plaque (odds ratio, 0.82 [95% CI, 0.69-0.99]), averaged over exams 1 and 5. Moderate (quartile 3) to high (quartile 4) intakes of flavonols, flavanol monomers, and anthocyanins were associated with 19% to 34% lower odds of having an ankle-brachial index <1 and 18% to 20% lower odds of having carotid plaque. Participants with the highest intakes of anthocyanins (quartile 4) at baseline had a marginally slower rate of carotid plaque progression than those with moderate intakes (quartiles 2 and 3). There were no significant associations with intima-media thickness or coronary artery calcification. Observed associations did not differ by sex, race/ethnicity, or smoking status.

CONCLUSIONS

In this multi-ethnic population, higher dietary flavonoid intakes were associated with lower odds of peripheral and carotid artery atherosclerosis. Increasing intakes of healthy, flavonoid-rich foods may protect against atherosclerosis in the peripheral and carotid arteries.

Impact of Preeclampsia and Parity on Sex-based Discrepancies in Subclinical Carotid Atherosclerosis in Type 1 Diabetes

CONTEXT

The excess risk of fatal and nonfatal cardiovascular events is roughly twice as high in women than in men with type 1 diabetes.

OBJECTIVE

To evaluate the impact of preeclampsia and parity on sex-based discrepancies in preclinical atherosclerosis and on the diagnostic performance of a cardiovascular risk scale.

DESIGN

Cross-sectional study.

SETTING

Single tertiary hospital.

PATIENTS

A total of 728 people with type 1 diabetes (48.5% women) without cardiovascular disease and age ≥40 years, nephropathy, and/or ≥10 years of diabetes duration with another risk factor.

INTERVENTION

Standardized carotid ultrasonography.

MAIN OUTCOME MEASURES

Carotid plaque determined by ultrasonography and cardiovascular risk estimated according to the Steno T1 Risk Engine (Steno-Risk).

RESULTS

Nulliparous women and parous women without previous preeclampsia had a lower risk for carotid plaque than men (adjusted odds ratio: .48, 95% confidence interval [.28-.82]; adjusted odds ratio: .51 [.33-.79], respectively), without differences in the preeclampsia group. The prevalence of carotid plaque increased as the estimated cardiovascular risk increased in all subgroups except for preeclampsia group. The area under the curve of the Steno-Risk for identifying ≥2 carotid plaques was lower in the preeclampsia group (men: .7886; nulliparous women: .9026; women without preeclampsia: .8230; preeclampsia group: .7841; P between groups = .042). Neither the addition of parity nor preeclampsia in the Steno-Risk led to a statistically significant increase in the area under the curve.

CONCLUSION

The risk for carotid plaque in women compared with men decreased as exposure to obstetric factors diminished. However, the addition of these factors did not improve the prediction of the Steno-Risk.

The association of carotid plaque burden and composition and the coronary artery calcium score in intermediate cardiovascular risk patients

Both the carotid ultrasound and coronary artery calcium (CAC) score quantify subclinical atherosclerosis and are associated with cardiovascular disease and events. This study investigated the association between CAC score and carotid plaque quantity and composition. Adult participants (n = 43) without history of cardiovascular disease were recruited to undergo a carotid ultrasound. Maximum plaque height (MPH), total plaque area (TPA), carotid intima-media thickness (CIMT), and plaque score were measured. Grayscale pixel distribution analysis of ultrasound images determined plaque tissue composition. Participants then underwent CT to determine CAC score, which were also categorized as absent (0), mild (1-99), moderate (100-399), and severe (400+). Spearman correlation coefficients between carotid variables and CAC scores were computed. The mean age of participants was 63 ± 11 years. CIMT, TPA, MPH, and plaque score were significantly associated with CAC score (ρ = 0.60, p < 0.0001; ρ = 0.54, p = 0.0002; ρ = 0.38, p = 0.01; and ρ = 0.49, p = 0.001). Echogenic composition features %Calcium and %Fibrous tissue were not correlated to a clinically relevant extent. There was a significant difference in the TPA, MPH, and plaque scores of those with a severe CAC score category compared to lesser categories. While carotid plaque burden was associated with CAC score, plaque composition was not. Though CAC score reliably measures calcification, carotid ultrasound gives information on both plaque burden and composition. Carotid ultrasound with assessment of plaque features used in conjunction with traditional risk factors may be an alternative or additive to CAC scoring and could improve the prediction of cardiovascular events in the intermediate risk population.

Association between cardiovascular risk profile and impaired microvascular function in a Swedish middle-aged cohort (the SCAPIS study)

AIMS

The aim was to investigate the relationship between microvascular function, cardiovascular risk profile, and subclinical atherosclerotic burden.

METHODS AND RESULTS

The study enrolled 3809 individuals, 50-65 years old, participating in the population-based observational cross-sectional Swedish CArdioPulmonary bioImage Study. Microvascular function was assessed in forearm skin using an arterial occlusion and release protocol determining peak blood oxygen saturation (OxyP). Cardiovascular risk was calculated using the updated Systematic Coronary Risk Evaluation [SCORE2; 10-year risk of fatal and non-fatal cardiovascular disease (CVD) events]. The OxyP was compared with coronary artery calcification score (CACS) and to plaques in the carotid arteries. Individuals with OxyP values in the lowest quartile (Q1; impaired microvascular function) had a mean SCORE2 of 5.8% compared with 3.8% in those with the highest values of OxyP (Q4), a relative risk increase of 53%. The risk of having a SCORE2 > 10% was five times higher for those in Q1 (odds ratio: 4.96, 95% confidence interval: 2.76-8.93) vs. Q4 when adjusting for body mass index and high-sensitivity C-reactive protein. The OxyP was lower in individuals with CACS > 0 and in those with both carotid plaques and CACS > 0, compared with individuals without subclinical atherosclerotic burdens (87.5 ± 5.6% and 86.9 ± 6.0%, vs. 88.6 ± 5.8%, P < 0.01).

CONCLUSION

In a population without CVD or diabetes mellitus, impaired microvascular function is associated with cardiovascular risk profiles such as higher SCORE2 risk and CACS. We suggest that OxyP may serve as a microcirculatory functional marker of subclinical atherosclerosis and CVD risk that is not detected by structural assessments.

Associations of life's essential 8 with extent of multi-territorial atherosclerotic plaques and stenosis: a cross-sectional study

BACKGROUND

Life's Essential 8 (LE8), the recently updated construct for quantifying cardiovascular health, is related to the risks of cardiovascular events. The present study aimed to evaluate associations of LE8 score with the multi-territorial extent of atherosclerosis in a community-dwelling population.

METHODS

Data were derived from the baseline cross-sectional survey of the PolyvasculaR Evaluation for Cognitive Impairment and vaScular Events (PRECISE) study in Lishui City. The LE8 included overall, medical and behavior LE8 scores, and were categorized as low (< 60), moderate (60-<80), and high (≥ 80) groups. Vascular magnetic resonance imaging was used to evaluate intracranial and extracranial arteries; thoracoabdominal computed tomography angiography to evaluate coronary, subclavian, aorta, renal, ilio-femoral arteries; and ankle-brachial index to evaluate peripheral arteries. The presence of atherosclerotic plaque or stenosis in any territory was defined as plaque or vascular stenosis with 1 territory affected or more in these arteries. The extent of atherosclerotic plaques or stenosis was assessed according to the number of these 8 vascular sites affected, and graded as four grades (none, single territory, 2-3 territories, 4-8 territories).

RESULTS

Of 3065 included participants, the average age was 61.2 ± 6.7 years, and 53.5% were women (n = 1639). The moderate and high overall LE8 groups were associated with lower extent of multi-territorial plaques [common odds ratio (cOR) 0.44, 95% confidence interval (CI), 0.35-0.55; cOR 0.16, 95%CI, 0.12-0.21; respectively] and stenosis (cOR 0.51, 95%CI, 0.42-0.62; cOR 0.16, 95%CI, 0.12-0.21; respectively) after adjustment for potential covariates. Similar results were observed for medical LE8 score with the extent of multi-territorial plaques and stenosis (P < 0.05). We also found the association between behavior LE8 score and the extent of multi-territorial stenosis (P < 0.05).

CONCLUSIONS

The higher LE8 scores, indicating healthier lifestyle, were associated with lower presence and extent of atherosclerotic plaque and stenosis in southern Chinese adults. Prospective studies are needed to further validate these findings.

Endothelial Dysfunction as a Key Link between Cardiovascular Disease and Frailty: A Systematic Review

Background: Frailty is increasingly recognized as a significant health concern, particularly due to its association with cardiovascular pathologies. This study aims to examine how vascular endothelial dysfunction, a known premorbid stage in the pathophysiology of cardiovascular diseases, contributes to the link between cardiovascular illness and frailty. Methods: The inclusion criteria allowed us to focus on original clinical research articles published in English between January 2014 and January 2024, which reported quantitative assessments of the relationship between frailty and vascular endothelial dysfunction. Excluded from the study were systematic literature reviews, meta-analyses, editorials, conference articles, theses, methodological articles, and studies using animal or cell culture models. Searches were conducted of electronic databases, including Scopus, ScienceDirect, and Medline, up to 22 January 2024. The risk of bias was assessed using the Joanna Briggs Institute's critical appraisal tools. The methods used to present and synthesize the results involved data extraction and categorization based on biomolecular and clinical findings of endothelial dysfunction. Results: Following the application of the inclusion and exclusion criteria, a total of 29 studies were identified. Vascular endothelial dysfunction was associated with increased frailty phenotypes, and we also identified SGLT-2 inhibitors' potential role as an anti-fragility treatment that affects endothelial dysfunction. This study found that the physical and biomolecular markers of endothelial dysfunction are associated with frailty measures and have predictive value for incident frailty. Furthermore, some studies have shown inflammation to have an impact on endothelial dysfunction and frailty, and an innovative age-related chronic inflammation measure has been proven to predict frailty scores. Conclusions: The current evidence suggests an association between endothelial dysfunction and frailty, highlighting the need for further research to elucidate the underlying mechanisms.

Testosterone therapy and the risk of cardiovascular disease in older, hypogonadal men

The debate over the cardiovascular (CV) implications of testosterone therapy (TT) have resulted in diverging safety recommendations and clinical guidelines worldwide. This narrative review synthesizes and critically evaluates long-term studies examining the effects of TT within the context of aging, obesity, and endogenous sex hormones on CV disease (CVD) risk to support informed clinical decision-making. Observational studies have variably linked low endogenous testosterone with increased CVD risk, while randomized controlled trials (RCTs) demonstrate that TT yields cardiometabolic benefits without increasing short-term CV risk. The TRAVERSE trial, as the first RCT powered to assess CVD events, did not show increased major adverse cardiac events (MACE) incidence; however, its limitations - specifically the maintenance of testosterone at low-normal levels, a high participant discontinuation rate, and short follow-up - warrant a careful interpretation of its results. Furthermore, findings from the TTrials cardiovascular sub-study, which showed an increase in non-calcified plaque, indicate the need for ongoing research into the long-term CV impact of TT. The decision to initiate TT should consider the current evidence gaps, particularly for older men with known CVD. The CV effects of maintaining physiological testosterone levels through exogenous means remain to be fully explored. Until more definitive evidence is available, clinical practice should prioritize individualized care and informed discussions on the potential CV implications of TT.

Associations between the retinal/choroidal microvasculature and carotid plaque in patients with CAD: An OCTA study

Background

To investigate the associations between retinal/choroidal microvasculature and carotid plaque in patients with CAD assessed by optical coherence tomography angiography (OCTA).

Methods

This study included 127 CAD patients with and 79 without carotid plaque. Each patient had both OCTA taken and digitized to determine retinal/choroidal thickness, vessel density and flow area and carotid ultrasound for carotid plaque size and stability measurement. The superficial capillary plexus (SCP), deep capillary plexus (DCP), out retina and choriocapillaris vessel density, out retina and choriocapillaris flow area, and full retina thickness were analyzed in the fovea centered 6 × 6 mm area. The association between OCTA measurements and carotid plaque characteristics in patients with CAD were evaluated.

Results

The duration of hypertension and diabetes mellitus (DM) was significantly longer in CAD patients with carotid plaque than that without (p < 0.001). The mean values for vessel density SCP and DCP (except fovea zone), and choriocapillaris nasal zone were significantly lower in plaque group (p < 0.05). Negative correlations between the carotid plaque width and vessel density SCP and DCP (except fovea zone) (p < 0.05) were also found in this study.

Conclusions

In patients with CAD, carotid plaque, a risk factor and marker of atherosclerosis and stenosis, is significantly and independently associated with retinal and choroidal microvascular changes by OCTA.

Glioblastoma and Internal Carotid Artery Calcium Score: A Possible Novel Prognostic Partnership?

Purpose: Clinical evidence suggests an association between comorbidities and outcome in patients with glioblastoma (GBM). We hypothesised that the internal carotid artery (ICA) calcium score could represent a promising prognostic biomarker in a competing risk analysis in patients diagnosed with GBM. Methods: We validated the use of the ICA calcium score as a surrogate marker of the coronary calcium score in 32 patients with lung cancer. Subsequently, we assessed the impact of the ICA calcium score on overall survival in GBM patients treated with radio-chemotherapy. Results: We analysed 50 GBM patients. At the univariate analysis, methyl-guanine-methyltransferase gene (MGMT) promoter methylation (p = 0.048), gross total tumour resection (p = 0.017), and calcium score (p = 0.011) were significant prognostic predictors in patients with GBM. These three variables also maintained statistical significance in the multivariate analysis. Conclusions: the ICA calcium score could be a promising prognostic biomarker in GBM patients.

Discrimination, Smoking, and Cardiovascular Disease Risk: A Moderated Mediation Analysis With MESA

BACKGROUND

Carotid intima-media thickness (cIMT) and carotid plaque are reliable indicators of cardiovascular disease risk, and research highlights that racial and ethnic minority individuals generally exhibit higher cIMT and carotid plaque than White individuals. At present, the mechanisms driving these disparities among different racial and ethnic and biological sex groups are poorly understood.

METHODS AND RESULTS

Data came from the baseline examination of MESA (Multi-Ethnic Study of Atherosclerosis). A total of 6814 participants aged 45 to 84 years free of clinical cardiovascular disease completed assessments on health behavior and perceived discrimination. Four sex-stratified moderated mediation models examined associations between discrimination, cigarette smoking, and mean cIMT and plaque. We hypothesized that cigarette use would mediate the association between discrimination and carotid artery disease features, and that these would differ by race and ethnicity. Indirect effects of discrimination on plaque were observed among Hispanic women such that discrimination was associated with cigarette use and, in turn, higher plaque (β=0.04 [95% CI, 0.01-0.08]). Indirect effects of discrimination on mean cIMT were found among Hispanic (β=0.003 [95% CI, 0.0001-0.007]) and White men (β=0.04 [95% CI, 0.01-0.08]) such that discrimination was associated with cigarette use and, in turn, higher cIMT. Finally, a positive indirect effect of discrimination on plaque was observed among Hispanic men (β=0.03 [95% CI, 0.004-0.07]). No other racial and ethnic differences were observed.

CONCLUSIONS

To understand and address social determinants of cardiovascular disease, researchers must incorporate an intersectional framework that will allow us to understand the complex nature of discrimination and cardiovascular disease risk for individuals of varying intersecting identities and social positions.

Prevalence and Burden of Carotid and Femoral Atherosclerosis in Subjects Without Known Cardiovascular Disease in a Large Community Hospital in South-America

INTRODUCTION

Clinical guidelines recommend measurement of arterial (carotid and femoral) plaque burden by vascular ultrasound (VUS) as a risk modifier in individuals at low or moderate risk without known atherosclerotic cardiovascular disease (ASCVD).

AIM

To evaluate the prevalence of carotid and femoral plaques by age and sex, the burden of subclinical atherosclerosis (SA), and its association with classic CVRF in subjects over 30 years of age without ASCVD.

METHODS

We prospectively enrolled 5775 consecutive subjects referred for cardiovascular evaluation and determined the prevalence and burden of SA using 2D-VUS in carotid and femoral arteries.

RESULTS

Sixty-one percent were men with a mean age of 51.3 (SD 10.6) years. Overall, plaque prevalence was 51% in carotid arteries, 39.3% in femoral arteries, 62.4% in carotid or femoral arteries, and 37.6% in neither. The prevalence of plaques and SA burden showed an increasing trend with age, being higher in men than in women and starting before the age of 40, both in the carotid and femoral sites. There was also an increasing prevalence of plaques according to the number of CVRF, and interestingly we found a high prevalence of plaques in subjects with 0 or 1 classic CVRF.

CONCLUSIONS

We observed an increased prevalence and burden of carotid or femoral SA, higher in men, beginning before the fourth decade of life and increasing with age. Despite a significant association with classic CVRF, a significant number of subjects with low CVRF were diagnosed with SA.

Lessons learned: Implementing and adapting a multimedia campaign to promote heart health to college students

Objective: This one-year pilot study investigated the effectiveness of a multimedia campaign, Heart Healthy U (HHU), to increase awareness about the link between unhealthy behaviors and risk for heart disease among emerging adults on a college campus. This paper describes the implementation of HHU. Participants: The HHU campaign was implemented from the Fall of 2019 through Spring 2020 and during this time there were approximately 15,043 enrolled students at the south eastern U.S. college campus. Methods: The HHU campaign employed print (e.g., banners, posters, and yard signs) and electronic formats (e.g., email, Instagram). We designed the methods across three phases: (1) relationship building and formative research, (2) campaign development, and (3) the Heart Healthy U campaign launch. Results: The HHU encountered challenges when the novel coronavirus (COVID-19 or SARS-co-V2) interrupted campus life, however we relied on the electronic formats to reach students during the state-wide lockdown/quarantine mandates. In addition, there were two changes to the HHU health messages. First, we updated the health messages to illustrate that eating healthy and engaging in physical activity supports immune function. Next, we developed new health messages to address effects of physical isolation and anxiety by promoting psychological well-being during this historic public health crisis. Conclusions: We asked whether a multimedia campaign on a college campus could encourage emerging adults to consume fruits and vegetables and engage in physical activity according to the federally-recommended guidelines. It is essential that interventions intended to reach today's emerging adults be presented in formats that they use (e.g., social media platforms), supported by campus administrators, and endorsed by peer influencers. In conclusion, more intervention studies are needed to counter the unhealthy social norm behaviors common to college campus life that increase heart disease risk, particularly among marginalized populations.

Assessment of Subclinical Atherosclerosis in Asymptomatic People In Vivo: Measurements Suitable for Biomarker and Mendelian Randomization Studies

BACKGROUND

One strategy to reduce the burden of cardiovascular disease is the early detection and treatment of atherosclerosis. This has led to significant interest in studies of subclinical atherosclerosis, using different phenotypes, not all of which are accurate reflections of the presence of asymptomatic atherosclerotic plaques. The aim of part 2 of this series is to provide a review of the existing literature on purported measures of subclinical disease and recommendations concerning which tests may be appropriate in the prevention of incident cardiovascular disease.

METHODS

We conducted a critical review of measurements used to infer the presence of subclinical atherosclerosis in the major conduit arteries and focused on the predictive value of these tests for future cardiovascular events, independent of conventional cardiovascular risk factors, in asymptomatic people. The emphasis was on studies with >10 000 person-years of follow-up, with meta-analysis of results reporting adjusted hazard ratios (HRs) with 95% CIs. The arterial territories were limited to carotid, coronary, aorta, and lower limb arteries.

RESULTS

In the carotid arteries, the presence of plaque (8 studies) was independently associated with future stroke (pooled HR, 1.89 [1.04-3.44]) and cardiac events (7 studies), with a pooled HR, 1.77 (1.19-2.62). Increased coronary artery calcium (5 studies) was associated with the risk of coronary heart disease events, pooled HR, 1.54 (1.07-2.07) and increasing severity of calcification (by Agaston score) was associated with escalation of risk (13 studies). An ankle/brachial index (ABI) of <0.9, the pooled HR for cardiovascular death from 7 studies was 2.01 (1.43-2.81). There were insufficient studies of either, thoracic or aortic calcium, aortic diameter, or femoral plaque to synthesize the data based on consistent reporting of these measures.

CONCLUSIONS

The presence of carotid plaque, coronary artery calcium, or abnormal ankle pressures seems to be a valid indicator of the presence of subclinical atherosclerosis and may be considered for use in biomarker, Mendelian randomization and similar studies.

Serum uric acid predicts the development of atherosclerosis in women but not in men: A ten-year cohort study in China

BACKGROUND AND AIM

Atherosclerosis is becoming a significant health burden. Serum uric acid (SUA) is the final enzymatic product of purine metabolism and can contribute to the development of atherosclerosis. The aim of this study was to explore the possible predictive value of SUA in the development of atherosclerosis in a healthy Chinese population.

METHODS AND RESULTS

In this study, a total of 11,222 healthy subjects with no carotid plaque at baseline were enrolled and divided into sex-specific groups, and then the occurrence of carotid plaque during the follow-up time was documented. The association between carotid plaque and SUA levels was examined using Cox proportional-hazards regression models. The mean SUA level was 5.35 ± 1.41 mg/dL. A total of 2,911 individuals (25.94%) developed carotid plaque during the follow-up time, including 1,071 females and 1,840 males. After adjusting for potential confounding factors, the hazard ratio (HR) and 95% confidence interval (95% CI) in women for the occurrence of carotid plaque associated with SUA levels were 1.163 (1.017-1.330), but no significant correlation was found in men, as the HR was 1.050 (0.965-1.143).

CONCLUSION

Our results indicate that SUA levels predict the development of carotid plaque independent of traditional risk factors only in women.

The clinical value of carotid plaque score in patients with metabolic syndrome and cardiovascular diseases

OBJECTIVE

To investigate the relationship between carotid plaque load score (CPS) and metabolic syndrome (MS) and cardiovascular diseases (CVD), in order to provide theoretical basis for the precaution and control of MS and CVD.

METHODS

A total of 1962 patients were incorporated into the study and divided into MS group and non-MS group, CVD group and non-CVD group. CPS and CIMT were obtained by carotid artery ultrasound, and the data of each group were statistically analyzed.

RESULTS

Age, BMI, basal metabolic rate, body fat rate, gender, and the incidence of central obesity, hypertension, diabetes and dyslipidemia are statistical different between MS group and non-MS group (P < 0.05). CIMT between CVD group and non-CVD group are statistical different (1.040 ± 0.239 VS 0.972 ± 0.297, P < 0.001). CPS was statistically significant between MS group and non-MS group(2.254 ± 2.728 VS 1.548 ± 2.219, P = 0.003) and between CVD group and non-CVD group (2.322 ± 2.760 VS 1.688 ± 2.347, P = 0.004).

CONCLUSION

Patients in MS group and CVD group have higher carotid plaque burden than those in non-MS group and non-CVD group. The higher the CPS was, the higher the incidence of MS and CVD was, and the distribution of CPS in MS and CVD population was consistent.

Female-specific risk factors of parity and menopause age and risk of carotid plaque: the multi-ethnic study of atherosclerosis

BACKGROUND

Female-specific factors of grand multiparity (≥5 births) and early menopause age are associated with an increased risk of cardiovascular disease (CVD). However, mechanisms are incompletely understood. Carotid plaque is a marker of subclinical atherosclerosis and associated with increased CVD risk. We evaluated the association of female-specific factors with plaque burden.

METHODS

We included 2,313 postmenopausal women in the Multi-Ethnic Study of Atherosclerosis, free of clinical CVD, whose parity and menopause age were ascertained by questionnaires and carotid plaque measured by ultrasound at baseline and 10 years later. Parity was categorized as nulliparity (reference), 1-2, 3-4 and ≥5 live births. Menopause age was categorized as <45, 45-49, 50-54 (reference) and ≥55 years. Multivariable regression was performed to evaluate the association of parity and menopause age with carotid plaque presence (yes/no) and extent [carotid plaque score (CPS)].

RESULTS

The mean age was 64±9 years; 52.3% had prevalent carotid plaque at baseline. Compared to nulliparity, grand multiparity was significantly associated with prevalent carotid plaque after adjustment for CVD risk factors (prevalence ratio 1.17 (95% CI 1.03-1.35)) and progression of CPS over 10 years [percent difference 13% (95% CI 3-23)]. There was not any significant association of menopause age with carotid plaque presence or progression in fully-adjusted models.

CONCLUSION

In a multiethnic cohort, grand multiparity was independently associated with carotid plaque presence and progression. Early menopause, a known risk factor for CVD, was not captured by carotid plaque in this study. These findings may have implications for refining CVD risk assessment in women.

Metabolic-associated fatty liver disease in relation to site-specific and multiple-site subclinical atherosclerosis

BACKGROUND & AIMS

Non-alcoholic fatty liver disease (NAFLD) and the newly proposed metabolic-associated fatty liver disease (MAFLD) were each associated with subclinical atherosclerosis. However, there is limited evidence on risk of atherosclerosis in individuals who meet the criteria for one but not the other. We aimed to investigate the associations of MAFLD or NAFLD status with site-specific and multiple-site atherosclerosis.

METHODS

This is a prospective cohort study involving 4524 adults within the MJ health check-up cohort. Logistic regression model was used to estimate odds ratios (ORs) and confidence intervals (CIs) for subclinical atherosclerosis (elevated carotid intima-media thickness [CIMT], carotid plaque [CP], coronary artery calcification [CAC] and retinal atherosclerosis [RA]) associated with MAFLD or NAFLD status, MAFLD subtypes and fibrosis status.

RESULTS

MAFLD was associated with higher risks of elevated CIMT, CP, CAC and RA (OR: 1.41 [95% CI 1.18-1.68], 1.23 [1.02-1.48], 1.60 [1.24-2.08], and 1.79 [1.28-2.52], respectively), whereas NAFLD per se did not increase risk of atherosclerosis except for elevated CIMT. Individuals who met both definitions or the definition for MAFLD but not NAFLD had higher risk of subclinical atherosclerosis. Among MAFLD subtypes, MAFLD with diabetes had the highest risk of subclinical atherosclerosis, but the associations did not differ by fibrosis status. Stronger positive associations were observed of MAFLD with multiple-site than single-site atherosclerosis.

CONCLUSIONS

In Chinese adults, MAFLD was associated with subclinical atherosclerosis, with stronger associations for multiple-site atherosclerosis. More attention should be paid to MAFLD with diabetes, and MAFLD might be a better predictor for atherosclerotic disease than NAFLD.

A new score for improving cardiovascular risk prediction and prevention

BACKGROUND AND AIMS

The ultrasonographic detection of subclinical atherosclerosis (scATS) at carotid and femoral vascular sites using the atherosclerosis burden score (ABS) improves the risk stratification for atherosclerotic cardiovascular disease beyond traditional cardiovascular (CV) risk factors. However, its predictive value should be further enhanced. We hypothesize that combining the ABS and the Framingham risk score (FHRS) to create a new score called the FHRABS will improve CV risk prediction and prevention. We aim to investigate if incorporating the ABS into the FHRS improved CV risk prediction in a primary prevention setting.

METHODS AND RESULTS

1024 patients were included in this prospective observational cohort study. Carotid and femoral plaques were ultra-sonographic detected. Major incident cardiovascular events (MACEs) were collected. The receiver operating characteristic curve (ROC-AUC) and Youden's index (Ysi) were used to compare the incremental contributions of each marker to predict MACEs. After a median follow-up of 6.0 ± 3.3 years, 60 primary MACEs (5.8%) occurred. The ROC-AUC for MACEs prediction was significantly higher for the FHRABS (0.74, p < 0.024) and for the ABS (0.71, p < 0.013) compared to the FHRS alone (0.71, p < 0.46). Ysi or the FHRABS (42%, p < 0.001) and ABS (37%, p < 0.001) than for the FHRS (31%). Cox proportional-hazard models showed that the CV predictive performance of FHRS was significantly enhanced by the ABS (10.8 vs. 5.5, p < 0.001) and FHRABS (HR 23.30 vs. 5.50, p < 0.001).

CONCLUSIONS

FHRABS is a useful score for improving CV risk stratification and detecting patients at high risk of future MACEs. FHRABS offers a simple-to-use, and radiation-free score with which to detect scATS in order to promote personalized CV prevention.

Coronary heart disease and ischemic stroke polygenic risk scores and atherosclerotic cardiovascular disease in a diverse, population-based cohort study

The predictive ability of coronary heart disease (CHD) and ischemic stroke (IS) polygenic risk scores (PRS) have been evaluated individually, but whether they predict the combined outcome of atherosclerotic cardiovascular disease (ASCVD) remains insufficiently researched. It is also unclear whether associations of the CHD and IS PRS with ASCVD are independent of subclinical atherosclerosis measures. 7,286 White and 2,016 Black participants from the population-based Atherosclerosis Risk in Communities study who were free of cardiovascular disease and type 2 diabetes at baseline were included. We computed previously validated CHD and IS PRS consisting of 1,745,179 and 3,225,583 genetic variants, respectively. Cox proportional hazards models were used to test the association between each PRS and ASCVD, adjusting for traditional risk factors, ankle-brachial index, carotid intima media thickness, and carotid plaque. The hazard ratios (HR) for the CHD and IS PRS were significant with HR of 1.50 (95% CI: 1.36-1.66) and 1.31 (95% CI: 1.18-1.45) respectively for the risk of incident ASCVD per standard deviation increase in CHD and IS PRS among White participants after adjusting for traditional risk factors. The HR for the CHD PRS was not significant with an HR of 0.95 (95% CI: 0.79-1.13) for the risk of incident ASCVD in Black participants. The HR for the IS PRS was significant with an HR of 1.26 (95%CI: 1.05-1.51) for the risk of incident ASCVD in Black participants. The association of the CHD and IS PRS with ASCVD was not attenuated in White participants after adjustment for ankle-brachial index, carotid intima media thickness, and carotid plaque. The CHD and IS PRS do not cross-predict well, and predict better the outcome for which they were created than the composite ASCVD outcome. Thus, the use of the composite outcome of ASCVD may not be ideal for genetic risk prediction.

Cross-Sectional Association of Dietary Patterns and Supplement Intake with Presence and Gray-Scale Median of Carotid Plaques-A Comparison between Women and Men in the Population-Based Hamburg City Health Study

This population-based cross-sectional cohort study investigated the association of the Mediterranean and DASH (Dietary Approach to Stop Hypertension) diet as well as supplement intake with gray-scale median (GSM) and the presence of carotid plaques comparing women and men. Low GSM is associated with plaque vulnerability. Ten thousand participants of the Hamburg City Health Study aged 45-74 underwent carotid ultrasound examination. We analyzed plaque presence in all participants plus GSM in those having plaques (n = 2163). Dietary patterns and supplement intake were assessed via a food frequency questionnaire. Multiple linear and logistic regression models were used to assess associations between dietary patterns, supplement intake and GSM plus plaque presence. Linear regressions showed an association between higher GSM and folate intake only in men (+9.12, 95% CI (1.37, 16.86), p = 0.021). High compared to intermediate adherence to the DASH diet was associated with higher odds for carotid plaques (OR = 1.18, 95% CI (1.02, 1.36), p = 0.027, adjusted). Odds for plaque presence were higher for men, older age, low education, hypertension, hyperlipidemia and smoking. In this study, the intake of most supplements, as well as DASH or Mediterranean diet, was not significantly associated with GSM for women or men. Future research is needed to clarify the influence, especially of the folate intake and DASH diet, on the presence and vulnerability of plaques.

Asthma as a Systemic Disease: Cardiovascular Effects Associated with Asthma

Asthma and cardiovascular disease (CVD) pose significant public health burdens. Airway inflammation is central to asthma pathophysiology and systemic inflammation, which occurs in asthma, is central to CVD pathophysiology. Numerous robust epidemiological studies have demonstrated deleterious systemic cardiovascular effects associated with the asthma syndrome. The cardiovascular effects associated with asthma include arterial injury, atherosclerotic CVD events, atrial fibrillation, and hypertension. Asthma is a heterogeneous disease, however, and the risk of CVD is not homogeneous across the various clinical phenotypes and molecular endotypes, highlighting prior inconsistent associations of asthma and its subtypes with various forms of CVD. The mechanistic underpinnings of the increased CVD risk in asthma remain multifactorial and undefined. Collectively, this supports the need for a precision approach in the identification of individuals with asthma who remain at elevated risk of development of cardiovascular diseases to guide both diagnostic and preventive interventions to decrease CVD risk among individuals living with asthma.

Predictive Value of Noninvasive Peripheral Atherosclerosis Measurement for Coronary Artery Disease in Patients with Long T2DM Duration

Objective

This study aimed to compare the predictive value of carotid or femoral artery ultrasound for coronary artery disease (CAD) in type 2 Diabetes mellitus (T2DM) patients free from known CAD, and to assess the relationship with the severity of coronary artery stenosis.

Methods

Cross-sectional study in adults with a T2DM duration of at least 5 years and without established CAD. Carotid plaque score (CPS) and Gensini score were used to measure the severity of carotid and coronary artery stenosis, respectively, and patients were divided into no or mild group, moderate group, and severe group according to the tertile of the score. Univariate and multivariate logistic regression analysis was used to explore the possible risk factors for CAD. Receiver operating characteristic (ROC) curves were created to determine the most accurate assessment for detecting significant CAD (≥50% stenosis).

Results

245 patients (137 male) aged 68.21±9.5 years (range: 36-95 years), with T2DM duration 12.04± 6.17 years (range: 5-34 years), and without CVD were included. CAD was diagnosed in 165 patients (67.3%). Multiple regression analysis showed that CPS, femoral plaque, and smoking were independently and positively correlated with CAD. CPS yielded the highest area under the curve for detecting significant coronary disease (AUC=0.7323). In contrast, the area under the curve of femoral artery plaque and carotid intima-media thickness was lower than 0.7, which was at a lower prediction level.

Conclusion

In patients with long T2DM duration, CPS has a higher ability to predict the occurrence and severity of CAD. However, femoral artery plaque has special value in predicting moderate to severe coronary artery disease in patients with long-term T2DM.

Utility of carotid ultrasound on prediction of 1-year mortality in emergency department patients with neurological deficits: A 10-year population-based cohort study

BACKGROUND

This study aimed to investigate the association between the carotid ultrasound results and 1-yr mortality of patients with neurological deficits in the emergency department (ED).

METHODS

This study included patients with neurological symptoms who presented to the ED between January 1, 2009 and December 31, 2018, and underwent sonographic imaging of the bilateral carotid bulb, common carotid artery (CCA), internal carotid artery (ICA), and external carotid arteries. A stenosis degree of >50% was defined as significant carotid stenosis. Carotid plaque score (CPS) was calculated by adding the score of stenosis severity of all segments. The association between carotid ultrasound results and 1-yr mortality was investigated using the Cox regression model.

RESULTS

The analysis included 7,961 patients (median age: 69 yr; men: 58.7%). Among them, 247 (3.1%) passed away from cardiovascular (CV)-related causes, and 746 (9.4%) died within a year. The mortality group presented with more significant carotid stenosis of the carotid bulb, CCA, or ICA and had a higher median CPS. A higher CPS was associated with a greater 1-yr all-cause mortality (adjusted hazard ratio [aHR] = 1.08; 95% confidence interval [CI] = 1.03-1.13; p = 0.001; log-rank p < 0.001) and CV-related mortality (aHR = 1.13; 95% CI = 1.04-1.22; p = 0.002, log-rank p < 0.001). Significant stenosis of either carotid artery segment did not result in a higher risk of 1-yr mortality.

CONCLUSIONS

We comprehensively investigated the utility of carotid ultrasound parameters on predicting mortality in this 10-yr population-based cohort, which included over 7,000 patients with acute neurological deficits presented to the ED. The result showed that CPS could be used as risk stratification tools for 1-yr all-cause and CV mortality.

Associations of urinary isoprostanes with measures of subclinical atherosclerosis: The Multi-Ethnic Study of Atherosclerosis (MESA)

Background

Urinary isoprostanes are markers of systemic oxidative stress, which is implicated in the pathogenesis of atherosclerotic cardiovascular disease (ASCVD). Coronary artery calcium (CAC), thoracic aortic calcium (TAC) and carotid plaque are measure subclinical atherosclerosis and prognosticate ASCVD risk. We examined the associations between urinary isoprostane levels and measures of plaque prevalence, burden, incidence and progression across three vascular beds in a cohort from the Multi-Ethnic Study of Atherosclerosis.

Methods

Urinary levels of 8-isoprostane and 2,3-dinor-8-F₂-isoprostane were measured in 1089 participants (mean ± SD 62 ± 8 years, 48% women) at baseline. Participants underwent computed tomography for CAC and TAC, and duplex ultrasound for carotid plaque. TAC and CAC were reassessed at 2.4 and 10 years, respectively. Regression models were adjusted for CVD risk factors.

Results

In adjusted models, there were no significant associations between isoprostane levels with CAC prevalence or progression. Highest versus lowest tertile of 8-isoprostane was associated with 28% lower prevalence of descending TAC at baseline [prevalence ratio (PR) 0.72 95% CI (0.56, 0.94)], while 1-SD higher 2,3-dinor-8-F₂-isoprostane was associated with 96% higher incident ascending TAC at follow-up [Relative Risk 1.96 (1.24, 3.09)]. Highest versus lowest tertile of isoprostane measures were associated with 22% higher prevalence of carotid plaque [(PR 1.22 (1.04, 1.45)] and 14% difference [3,26] in greater extent of carotid plaque at baseline.

Conclusions

Higher urinary isoprostanes were inconsistently associated with some measures of subclinical atherosclerosis by imaging. This suggests a limited role of urinary isoprostane levels as a prognostic marker for the development of ASCVD.

Trial registration

The MESA cohort design is registered at clinicaltrials.gov as follows: https://clinicaltrials.gov/ct2/show/NCT00005487.

Predictive nomogram for coronary heart disease in patients with type 2 diabetes mellitus

Objective

This study aimed to identify risk factors for coronary heart disease (CHD) in patients with type 2 diabetes mellitus (T2DM), build a clinical prediction model, and draw a nomogram.

Study design and methods

Coronary angiography was performed for 1,808 diabetic patients who were recruited at the department of cardiology in The Second Affiliated Hospital of Nanchang University from June 2020 to June 2022. After applying exclusion criteria, 560 patients were finally enrolled in this study and randomly divided into training cohorts (n = 392) and validation cohorts (n = 168). The least absolute shrinkage and selection operator (LASSO) is used to filter features in the training dataset. Finally, we use logical regression to establish a prediction model for the selected features and draw a nomogram.

Results

The discrimination, calibration, and clinical usefulness of the prediction model were evaluated using the c-index, receiver operating characteristic (ROC) curve, calibration chart, and decision curve. The effects of gender, diabetes duration, non-high-density lipoprotein cholesterol, apolipoprotein A1, lipoprotein (a), homocysteine, atherogenic index of plasma (AIP), nerve conduction velocity, and carotid plaque merit further study. The C-index was 0.803 (0.759-0.847) in the training cohort and 0.775 (0.705-0.845) in the validation cohort. In the ROC curve, the Area Under Curve (AUC) of the training set is 0.802, and the AUC of the validation set is 0.753. The calibration curve showed no overfitting of the model. The decision curve analysis (DCA) demonstrated that the nomogram is effective in clinical practice.

Conclusion

Based on clinical information, we established a prediction model for CHD in patients with T2DM.

Longitudinal Associations Between Serum Bilirubin Level and Carotid Atherosclerosis Plaque in a Health Screening Population

This study aimed to determine the relationship between bilirubin levels and carotid atherosclerosis (CAS) in the health screening population. After propensity score matching, this retrospective cohort study included 4360 subjects who underwent health examinations regularly in Hebei General Hospital between January 2010 and December 2019 and had no carotid plaque at baseline. After an average follow-up of 26.76 months, the main endpoint Cox regression analysis of carotid plaques was performed. After adjusting the confounding factors, Cox regression analysis showed that when serum total bilirubin (TBIL) and unconjugated bilirubin (UCB) increased by 1 standard deviation (SD), the risk of carotid plaque decreased by 7.30% (95% confidence interval (CI): 2.80-11.60%) and 15.70% (95% CI: 11.40-19.80%), respectively. When conjugated bilirubin (CB) increased by 1 SD, the risk of carotid plaques increased by 24.3% (95% CI: 19.7-29.0%). TBIL and UCB levels were negatively associated with CAS, and CB levels were positively associated with CAS.

Carotid Siphon Calcification Predicts the Symptomatic Progression in Branch Artery Disease With Intracranial Artery Stenosis

Arterial calcification in the aortic arch, carotid bifurcation, or siphon on computed tomography was associated with cardiovascular disease. The association between arterial calcification prevalence and progression of branch atheromatous disease (BAD) in intracranial artery atherosclerosis was little investigated.

Low serum creatinine to cystatin C ratio is independently associated with sarcopenia and high carotid plaque score in patients with type 2 diabetes

BACKGROUND AND AIMS

Low serum creatinine (Cr) to cystatin C (cysC) ratio has been suggested to be associated with low muscle mass and strength and poor prognosis in various chronic disease. We investigated the associations of CCR with sarcopenia and carotid plaque score (PS) in patients with type 2 diabetes mellitus.

METHODS AND RESULTS

A total of 1577 patients with type 2 diabetes were enrolled. High PS was defined as PS ≥ 3. Sarcopenia was assessed by the measurement of appendicular skeletal muscle mass (ASM) and grip strength (GS). Compared to the highest CCR group, the lowest tertile group was older; had higher C-reactive protein levels, CIMT, and PS, but lower cysC-based estimated glomerular filtration rate (cysC-eGFR), ASM/BMI, and GS. Positive correlations between CCR and ASM/BMI (r = 0.239 in men and 0.303 in women, p < 0.001) and GS (r = 0.282 in men and 0.270 in women, p < 0.001) were observed in both genders. Odds ratios and 95% confidence intervals for high PS after adjusting for age and sex were 1.22 (0.92-1.61, p = 0.18) in the middle and 1.74 (1.31-2.30, p < 0.001) in the lowest tertiles, respectively, with those of the lowest tertile remaining significant after further adjusting for multiple confounders.

CONCLUSIONS

Low CCR was independently associated with sarcopenia and high PS in patients with type 2 diabetes mellitus, especially after adjusting for ASM/BMI and GS.

Prevalence and Vascular Distribution of Multiterritorial Atherosclerosis Among Community-Dwelling Adults in Southeast China

IMPORTANCE

Data are limited on the prevalence and vascular distribution of multiterritorial atherosclerotic plaque and stenosis in community populations.

OBJECTIVE

To investigate the prevalence and vascular distribution of multiterritorial atherosclerotic plaque and stenosis in older, community-dwelling populations in China.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study was based on the baseline survey from the Polyvascular Evaluation for Cognitive Impairment and Vascular Events (PRECISE) study, a population-based prospective cohort study that enrolled community-dwelling adults aged 50 to 75 years based on cluster sampling from 6 villages and 4 living communities of Lishui city in southeast China. Data were collected from May 2017 to September 2019 and analyzed from September to November 2021.

MAIN OUTCOMES AND MEASURES

Atherosclerotic plaque and stenosis at baseline were assessed in multiple vascular territories. Brain vessel wall magnetic resonance imaging (MRI) for intracranial and extracranial arteries; computed tomography angiography (CTA) for coronary, subclavian, aorta, renal, and iliofemoral arteries; and ankle-brachial index for peripheral arteries were performed at baseline survey. The extent of atherosclerosis was assessed according to the number of these 8 vascular sites affected, and polyvascular lesions were defined as at least 2 affected sites.

RESULTS

A total of 3433 of 4202 invited individuals consented to participate in the study. After excluding 366 participants with contraindications for MRI or CTA scanning, with life expectancies of 4 years of fewer, or with mental disease, a total of 3067 community-dwelling adults were enrolled. The mean (SD) age was 61.2 (6.7) years; 1640 (53.5%) were women, and 74 (2.4%) had prevalent ASCVD. Most participants (2870 [93.6%]) had atherosclerotic plaques in at least 1 vascular territory. Atherosclerotic plaques were mostly detected in the aorta (2419 [79.6%]) and iliofemoral arteries (2312 [75.8%]), followed by subclavian (1500 [49.8%]), coronary (1366 [44.9%]), extracranial (1110 [36.4%]), renal (873 [28.7%]), and intracranial (542 [17.7%]) arteries. A substantial proportion of participants (1180 [38.5%]) had arterial stenosis of 50% or greater, predominantly affecting the coronary (542 [17.8%]) and iliofemoral (527 [17.3%]) arteries. Polyvascular atherosclerotic plaque was observed in 2541 participants (82.8%), with 1436 (46.8%) with plaque affecting 4 or more vascular territories, and polyvascular stenosis was observed in 412 patients (13.4%).

CONCLUSIONS AND RELEVANCE

In this study, atherosclerotic plaque was highly prevalent in the older community population in China, and a substantial proportion of individuals reach stenosis of 50% or greater.

Association of traditional risk factors with carotid intima-media thickness and carotid plaque in asymptomatic individuals with a family history of premature cardiovascular disease

The use of imaging to detect subclinical atherosclerosis helps to inform decision-making in people classified as having intermediate risk for cardiovascular disease (CVD). This study sought to use carotid plaque as an alternative to carotid intima media thickness (cIMT). Carotid ultrasound for assessment of cIMT and plaque was obtained in 1031 people (53 years, 61% female) with a family history of atherosclerotic CVD. The association of baseline characteristics and standard atherosclerotic risk factors (RFs) were sought with abnormal cIMT and plaque. The strongest association of plaque was a history of hypertension (odds ratio [OR] 1.87 (1.02-3.42), followed by age (OR 1.08 [95% CI 1.02-1.13]). For cIMT, the strongest association was smoking history (OR 1.57 [1.13-2.19]). The area under the receiver operator curve for the presence of plaque was 0.74 (95% CI 0.68-0.81, p < 0.001) and 0.65 (95% CI 0.61-0.70, p < 0.001) for cIMT elevation. Isolated elevation of cIMT (n = 178) was associated with increased total cholesterol, body mass index (BMI) and systolic blood pressure (SBP). Plaque only (n = 29) was associated with hypertension, male sex and older age. The presence of both markers abnormal (n = 22) was associated with a history of smoking. The absence of either abnormal cIMT or plaque (n = 773), was inversely associated with current or past smoking, SBP and BMI. Abnormalities in carotid vessels are present in a minority of intermediate risk patients with familial premature disease. The associations with RFs differ and are more closely associated with plaque.

Association between insomnia and subclinical atherosclerosis among Chinese steelworkers: a cross-sectional survey

Background

Insomnia is a common prevalent sleep disorder. Difficulty maintaining sleep or poor in quality in insomnia caused by disrupted or misaligned circadian rhythms may play an important role in the development of atherosclerosis. This study aimed to examine the association between insomnia and subclinical atherosclerosis in Chinese steelworkers.

Methods

A total of 3240 subjects from a large enterprise located in northern China were included in this study. The Athens Insomnia Scale (AIS) was used to assess the status of insomnia. Subclinical atherosclerosis was evaluated using ultrasonographic measurements of carotid plaque. Multivariable logistic regression was used to identify association between insomnia and carotid atherosclerosis.

Results

The overall prevalence of insomnia and carotid plaque were 35.3 and 31.7% in the study population. Compared with non-insomnia workers, significantly increased odds of carotid plaque were observed among insomnia workers after adjusting for potential confounders, odds ratio (OR) = 1.38, 95% confidence interval (CI): 1.17 to 1.63. Exposure to current shift work and insomnia simultaneously can significantly elevated the odds of carotid plaque.

Conclusion

Insomnia is associated with elevated odds of carotid atherosclerosis in male steelworkers. Insomnia problems of workers should receive further attention in occupational worker health interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13690-022-00834-1.

Association between rotating night shift work and carotid atherosclerosis among Chinese steelworkers: a cross-sectional survey

This study aimed to examine the association between rotating night shift work and carotid atherosclerosis in Chinese steelworkers. A total of 3582 subjects were included in this study. Different exposure metrics of night shifts, including current shift status, duration of night shifts (years), the cumulative number of night shifts (nights), cumulative length of night shifts (hours) and average frequency of night shifts (nights/month), were used to examine the relationship between night shift work and carotid atherosclerosis, including carotid plaque and carotid plaque scores. The prevalence of carotid plaque was 29.9% in the study population. Compared with day workers, significantly increased odds of carotid plaque were observed among shift workers in each quartile of the duration of night shifts after adjusting for potential confounders, especially in the third and fourth quartiles: odds ratio (OR) = 1.91, 95% confidence interval (CI): 1.46 to 2.49, in the third quartiles; OR = 1.69, 95% CI: 1.30 to 2.20, in the fourth quartiles. Positive associations of different exposure metrics of night shifts (continuous) with the odds of carotid plaque and the carotid plaque score were observed in the restricted cubic spline (RCS) models. No significant association was found in female workers between night shift work and carotid plaque. Rotating night shift work is associated with elevated odds of carotid atherosclerosis in male steelworkers.

Excess comorbidities in gout: the causal paradigm and pleiotropic approaches to care

Gout is a common hyperuricaemic metabolic condition that leads to painful inflammatory arthritis and a high comorbidity burden, especially cardiometabolic-renal (CMR) conditions, including hypertension, myocardial infarction, stroke, obesity, hyperlipidaemia, type 2 diabetes mellitus and chronic kidney disease. Substantial advances have been made in our understanding of the excess CMR burden in gout, ranging from pathogenesis underlying excess CMR comorbidities, inferring causal relationships from Mendelian randomization studies, and potentially discovering urate crystals in coronary arteries using advanced imaging, to clinical trials and observational studies. Despite many studies finding an independent association between blood urate levels and risk of incident CMR events, Mendelian randomization studies have largely found that serum urate is not causal for CMR end points or intermediate risk factors or outcomes (such as kidney function, adiposity, metabolic syndrome, glycaemic traits or blood lipid concentrations). Although limited, randomized controlled trials to date in adults without gout support this conclusion. If imaging studies suggesting that monosodium urate crystals are deposited in coronary plaques in patients with gout are confirmed, it is possible that these crystals might have a role in the inflammatory pathogenesis of increased cardiovascular risk in patients with gout; removing monosodium urate crystals or blocking the inflammatory pathway could reduce this excess risk. Accordingly, data for CMR outcomes with these urate-lowering or anti-inflammatory therapies in patients with gout are needed. In the meantime, highly pleiotropic CMR and urate-lowering benefits of sodium-glucose cotransporter 2 (SGLT2) inhibitors and key lifestyle measures could play an important role in comorbidity care, in conjunction with effective gout care based on target serum urate concentrations according to the latest guidelines.

Subclinical Atherosclerosis Measure by Carotid Ultrasound and Inflammatory Activity in Patients with Rheumatoid Arthritis and Spondylarthritis

Objective: To compare the effect of inflammation on subclinical atherosclerosis using carotid ultrasound in patients with rheumatoid arthritis (RA) and spondyloarthritis (SpA). Methods: Cross-sectional study including 347 participants (148 RA, 159 SpA, and 40 controls). We measured the carotid intima media thickness (cIMT) and detection of atheromatous plaques using carotid ultrasound. We recorded disease activity (DAS28-CRP/ASDAS-CRP) and traditional cardiovascular risk factors. We performed descriptive, bivariate, and linear multivariate analyses (dependent variable: cIMT) to evaluate the influence of diagnosis on cIMT in all patients. Two additional multivariate analyses were performed by stratifying patients according to their inflammatory activity. Results: cIMT correlated with the mean CRP during the previous 5 years in RA, but not with CRP at the cut-off date. We did not find such differences in patients with SpA. The first multivariate model revealed that increased cIMT was more common in patients with RA than in those with SpA (β coefficient, 0.045; 95% confidence interval (95% CI), 0.0002–0.09; p = 0.048) after adjusting for age, sex, disease course, and differential cardiovascular risk factors (arterial hypertension, smoking, statins, and corticosteroids). The second model revealed no differences in cIMT between the 2 groups of patients classified as remission–low activity (β coefficient, 0.020; 95% CI, −0.03 to 0.080; p = 0.500). However, when only patients with moderate–high disease activity were analysed, the cIMT was 0.112 mm greater in those with RA (95% CI, 0.013–0.212; p = 0.026) than in those with SpA after adjusting for the same variables. Conclusions: Subclinical atherosclerosis measured by carotid ultrasound in patients with RA and SpA is comparable when the disease is well controlled. However, when patients have moderate–high disease activity, cIMT is greater in patients with RA than in those with SpA after adjusting for age, sex, disease course, and cardiovascular risk factors. Our results point to greater involvement of disease activity in subclinical atherosclerosis in patients with RA than in those with SpA.

Epigenetics of single-site and multi-site atherosclerosis in African Americans from the Genetic Epidemiology Network of Arteriopathy (GENOA)

BACKGROUND

DNA methylation, an epigenetic mechanism modulated by lifestyle and environmental factors, may be an important biomarker of complex diseases including cardiovascular diseases (CVD) and subclinical atherosclerosis.

METHODS

DNA methylation in peripheral blood samples from 391 African-Americans from the Genetic Epidemiology Network of Arteriopathy (GENOA) was assessed at baseline, and atherosclerosis was assessed 5 and 12 years later. Using linear mixed models, we examined the association between previously identified CpGs for coronary artery calcification (CAC) and carotid plaque, both individually and aggregated into methylation risk scores (MRSCAC and MRScarotid), and four measures of atherosclerosis (CAC, abdominal aorta calcification (AAC), ankle-brachial index (ABI), and multi-site atherosclerosis based on gender-specific quartiles of the single-site measures). We also examined the association between four epigenetic age acceleration measures (IEAA, EEAA, PhenoAge acceleration, and GrimAge acceleration) and the four atherosclerosis measures. Finally, we characterized the temporal stability of the epigenetic measures using repeated DNA methylation measured 5 years after baseline (N = 193).

RESULTS

After adjusting for CVD risk factors, four CpGs (cg05575921(AHRR), cg09935388 (GFI1), cg21161138 (AHRR), and cg18168448 (LRRC52)) were associated with multi-site atherosclerosis (FDR < 0.1). cg05575921 was also associated with AAC and cg09935388 with ABI. MRSCAC was associated with ABI (Beta = 0.016, P = 0.006), and MRScarotid was associated with both AAC (Beta = 0.605, equivalent to approximately 1.8-fold increase in the Agatston score of AAC, P = 0.004) and multi-site atherosclerosis (Beta = 0.691, P = 0.002). A 5-year increase in GrimAge acceleration (~ 1 SD) was associated with a 1.6-fold (P = 0.012) increase in the Agatston score of AAC and 0.7 units (P = 0.0003) increase in multi-site atherosclerosis, all after adjusting for CVD risk factors. All epigenetic measures were relatively stable over 5 years, with the highest intraclass correlation coefficients observed for MRScarotid and GrimAge acceleration (0.87 and 0.89, respectively).

CONCLUSIONS

We found evidence of an association between DNA methylation and atherosclerosis at multiple vascular sites in a sample of African-Americans. Further evaluation of these potential biomarkers is warranted to deepen our understanding of the relationship between epigenetics and atherosclerosis.

Association between Carotid Intima-Media Thickness and the Use of Biological or Small Molecule Therapies in Patients with Rheumatoid Arthritis

Objective: The objective of this study was to assess the association of carotid intima-media thickness (CIMT), and also the presence of atheromatous plaque, with biological and targeted synthetic disease-modifying antirheumatic drugs, in an established cohort of patients with rheumatoid arthritis (RA). Patients and Methods: We conducted a cross-sectional observational study based on a cohort of patients with RA and a registry of healthy controls, in whom the CIMT and presence of atheromatous plaque were assessed by ultrasound. Data were collected on disease activity, lab results and treatments. Descriptive and bivariate analyses were performed and two multivariate linear regression models (with CIMT as the dependent variable) were constructed to identify variables independently associated with CIMT in our sample of patients with RA. Results: A total of 176 individuals (146 patients with RA and 30 controls) were included. A higher percentage of patients than controls had atheromatous plaque (33.8% vs. 12.5%, p = 0.036), but no differences were found in terms of CIMT (0.64 vs. 0.61, p = 0.444). Compared to values in patients on other therapies, the CIMT was smaller among patients on tumour necrosis factor alpha (TNFα) inhibitors (mean [SD]: 0.58 [0.10] vs. 0.65 [0.19]; p = 0.013) and among those on Janus kinase inhibitors (mean [SD]: 0.52 [0.02] vs. 0.64 [0.18]; p < 0.001), while no differences were found as a function of the use of the other therapies considered. The multivariate linear regression analysis to identify factors associated with CIMT in our patients, adjusting for traditional cardiovascular risk factors such as hypertension, high levels of low-density lipoproteins, diabetes mellitus and smoking, showed that male sex, older age and having a greater cumulative erythrocyte sedimentation rate were independently associated with a larger CIMT, while patients on TNFα inhibitors had a CIMT 0.075 mm smaller than those on other treatments. Conclusions: The use of TNFα inhibitors may protect against subclinical atherosclerosis in patients with RA, patients on this biologic having smaller CIMTs than patients on other disease-modifying antirheumatic drugs. Nonetheless, these results should be confirmed in prospective studies with larger sample sizes.

Associations of Occupational Heat Stress and Noise Exposure with Carotid Atherosclerosis among Chinese Steelworkers: A Cross-Sectional Survey

Occupational exposure to heat stress and noise at the workplace are widespread physical hazards and have been associated with an increase in both morbidity and mortality. This study aims to examine the association between occupational heat stress and noise exposure and carotid atherosclerosis in Chinese steelworkers. A total of 3471 subjects were included in this study. Carotid plaque was measured using ultrasonography. The occupational information was collected by face-to-face personal interviews and all of the reported information was verified with the company's records. Workers were divided into non-exposure and exposure groups according to the company's records regarding previous and/or current heat stress and noise exposure status in the workplace. The prevalence of carotid plaque was 30.1% in the study population and workers exposed to both occupational heat stress and noise had the highest prevalence of carotid plaque at 37.2%. The odds of carotid plaque in individuals of different exposure status were significantly elevated after adjustment for potential confounders, especially in the heat stress and noise exposure combination group: OR = 1.32, 95% CI: 1.06 to 1.65, in individuals who had experienced heat stress exposure; OR = 1.49, 95% CI: 1.18 to 1.88, in individuals who had experienced noise exposure; OR = 2.02, 95% CI: 1.60 to 2.56, in the combination group. No significant association in female workers and no significant multiplicative or additive interactions were found between occupational heat stress and noise exposure and carotid plaque. Exposure to occupational heat stress and noise are statistically associated with carotid atherosclerosis among male steelworkers.

Carotid Plaque Composition Assessed by CT Predicts Subsequent Cardiovascular Events among Subjects with Carotid Stenosis

BACKGROUND AND PURPOSE

Currently, the characteristics of carotid plaques are considered important factors for identifying subjects at high risk of stroke. This study aimed to test the hypothesis that carotid plaque composition assessed by CTA is associated with an increased risk of future major adverse cardiovascular events among asymptomatic subjects with moderate-to-severe carotid artery stenosis.

MATERIALS AND METHODS

This single-center, retrospective cohort study included 194 carotid plaques from 176 asymptomatic subjects with moderate-to-severe carotid artery stenosis. The association of CTA-determined plaque composition with the risk of subsequent adverse cardiovascular events was analyzed.

RESULTS

During a median follow-up of 41 months, the adverse cardiovascular event incidence among 194 carotid plaques was 19.6%. There were significant differences in plaque Hounsfield units (P < .001) and spotty calcium presence (P < .001) between carotid plaques from subjects with and without subsequent adverse cardiovascular events. Multivariable analysis revealed carotid plaque Hounsfield unit density (P < .001) and spotty calcium (P < .001) as independent predictors of subsequent adverse cardiovascular events. In association with moderate carotid artery stenosis, the plaque Hounsfield unit values were significantly lower among carotid plaques from subjects who experienced subsequent adverse cardiovascular events (P = .002), strokes (P = .01), and cardiovascular deaths (P = .04); the presence of spotty calcium was significantly associated with the occurrence of adverse cardiovascular events (P = .001), acute coronary syndrome (P = .01), and cardiovascular death (P = .04).

CONCLUSIONS

Carotid plaque Hounsfield unit density and spotty calcium were independent predictors of a greater risk of adverse cardiovascular event occurrence.

Imaging-guided evaluation of subclinical atherosclerosis to enhance cardiovascular risk prediction in asymptomatic low-to-intermediate risk individuals: A systematic review

Carotid intima-media thickness (cIMT), plaque quantification and coronary artery calcium (CAC) scoring have been suggested to improve risk prediction of cardiovascular disease (CVD), particularly for asymptomatic individuals classified as low-to-intermediate risk. We aimed to compare the predictive value of cIMT, carotid plaque identification, and CAC scoring for identifying sub-clinical atherosclerosis and assessing future risk of CVD in asymptomatic, low-to-intermediate risk individuals. We conducted a comprehensive search of Ovid (Embase and Medline), Cochrane Central Register of Controlled Trials (CENTRAL) and Medline complete (EBSCO health). A total of 30 papers were selected and data were extracted. Comparisons were made according to the cIMT measurement (mean, maximum), carotid plaque evaluation (presence or area), and CAC scoring. CVD event rates, hazard ratios (HR), net reclassification index (NRI), and c-statistic of the markers were compared. There were 27 studies that reported cIMT, 24 reported carotid plaque, and 6 reported CAC scoring. Inclusion of CAC scores yielded the highest HR ranging from 1.45 (95% CI, 1.11-1.88, p = 0.006) to 3.95 (95% CI, 2.97-5.27, p < 0.001), followed by maximum cIMT (HR 1.08; 95% CI, 1.06-1.11, p < 0.001 to 2.58; 95% CI, 1.83-3.62, p < 0.001) and carotid plaque presence (HR 1.21; 95% CI, 0.5-1.2, p = 0.39 to 2.43; 95% CI, 1.7-3.47, p < 0.001). The c-statistic enhanced predictive value by a minimum increase of 0.7. Finally, the NRI ranked higher with CAC (≥11.2%), followed by carotid plaque (≥2%) and cIMT (3%). CAC scoring was superior compared to carotid plaque and cIMT measurements in asymptomatic individuals classified as being at low-to-intermediate risk.