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Nyúl-Tóth Á, Patai R, Csiszar A, Ungvari A, Gulej R, Mukli P, Yabluchanskiy A, Benyo Z, Sotonyi P, Prodan CI, Liotta EM, Toth P, Elahi F, Barsi P, Maurovich-Horvat P, Sorond FA, Tarantini S, Ungvari Z. Linking peripheral atherosclerosis to blood-brain barrier disruption: elucidating its role as a manifestation of cerebral small vessel disease in vascular cognitive impairment. GeroScience 2024:10.1007/s11357-024-01194-0. [PMID: 38831182 DOI: 10.1007/s11357-024-01194-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/06/2024] [Indexed: 06/05/2024] Open
Abstract
Aging plays a pivotal role in the pathogenesis of cerebral small vessel disease (CSVD), contributing to the onset and progression of vascular cognitive impairment and dementia (VCID). In older adults, CSVD often leads to significant pathological outcomes, including blood-brain barrier (BBB) disruption, which in turn triggers neuroinflammation and white matter damage. This damage is frequently observed as white matter hyperintensities (WMHs) in neuroimaging studies. There is mounting evidence that older adults with atherosclerotic vascular diseases, such as peripheral artery disease, ischemic heart disease, and carotid artery stenosis, face a heightened risk of developing CSVD and VCID. This review explores the complex relationship between peripheral atherosclerosis, the pathogenesis of CSVD, and BBB disruption. It explores the continuum of vascular aging, emphasizing the shared pathomechanisms that underlie atherosclerosis in large arteries and BBB disruption in the cerebral microcirculation, exacerbating both CSVD and VCID. By reviewing current evidence, this paper discusses the impact of endothelial dysfunction, cellular senescence, inflammation, and oxidative stress on vascular and neurovascular health. This review aims to enhance understanding of these complex interactions and advocate for integrated approaches to manage vascular health, thereby mitigating the risk and progression of CSVD and VCID.
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Affiliation(s)
- Ádám Nyúl-Tóth
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Public Health, Semmelweis University, Semmelweis University, Budapest, Hungary
| | - Roland Patai
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Anna Csiszar
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
| | - Anna Ungvari
- Department of Public Health, Semmelweis University, Semmelweis University, Budapest, Hungary.
| | - Rafal Gulej
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Peter Mukli
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Public Health, Semmelweis University, Semmelweis University, Budapest, Hungary
| | - Andriy Yabluchanskiy
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Doctoral College/Department of Public Health, International Training Program in Geroscience, Semmelweis University, Budapest, Hungary
| | - Zoltan Benyo
- Institute of Translational Medicine, Semmelweis University, 1094, Budapest, Hungary
- Cerebrovascular and Neurocognitive Disorders Research Group, HUN-REN, Semmelweis University, 1094, Budapest, Hungary
| | - Peter Sotonyi
- Department of Vascular and Endovascular Surgery, Heart and Vascular Centre, Semmelweis University, 1122, Budapest, Hungary
| | - Calin I Prodan
- Veterans Affairs Medical Center, Oklahoma City, OK, USA
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Eric M Liotta
- Doctoral College/Department of Public Health, International Training Program in Geroscience, Semmelweis University, Budapest, Hungary
- Department of Neurology, Division of Stroke and Neurocritical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Peter Toth
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Public Health, Semmelweis University, Semmelweis University, Budapest, Hungary
- Department of Neurosurgery, Medical School, University of Pecs, Pecs, Hungary
- Neurotrauma Research Group, Szentagothai Research Centre, University of Pecs, Pecs, Hungary
- ELKH-PTE Clinical Neuroscience MR Research Group, University of Pecs, Pecs, Hungary
| | - Fanny Elahi
- Departments of Neurology and Neuroscience Ronald M. Loeb Center for Alzheimer's Disease Friedman Brain Institute Icahn School of Medicine at Mount Sinai, New York, NY, USA
- James J. Peters VA Medical Center, Bronx, NY, USA
| | - Péter Barsi
- ELKH-SE Cardiovascular Imaging Research Group, Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Pál Maurovich-Horvat
- ELKH-SE Cardiovascular Imaging Research Group, Department of Radiology, Medical Imaging Centre, Semmelweis University, Budapest, Hungary
| | - Farzaneh A Sorond
- Department of Neurology, Division of Stroke and Neurocritical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Stefano Tarantini
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Doctoral College/Department of Public Health, International Training Program in Geroscience, Semmelweis University, Budapest, Hungary
| | - Zoltan Ungvari
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Doctoral College/Department of Public Health, International Training Program in Geroscience, Semmelweis University, Budapest, Hungary
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Csiszar A, Ungvari A, Patai R, Gulej R, Yabluchanskiy A, Benyo Z, Kovacs I, Sotonyi P, Kirkpartrick AC, Prodan CI, Liotta EM, Zhang XA, Toth P, Tarantini S, Sorond FA, Ungvari Z. Atherosclerotic burden and cerebral small vessel disease: exploring the link through microvascular aging and cerebral microhemorrhages. GeroScience 2024:10.1007/s11357-024-01139-7. [PMID: 38639833 DOI: 10.1007/s11357-024-01139-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 03/14/2024] [Indexed: 04/20/2024] Open
Abstract
Cerebral microhemorrhages (CMHs, also known as cerebral microbleeds) are a critical but frequently underestimated aspect of cerebral small vessel disease (CSVD), bearing substantial clinical consequences. Detectable through sensitive neuroimaging techniques, CMHs reveal an extensive pathological landscape. They are prevalent in the aging population, with multiple CMHs often being observed in a given individual. CMHs are closely associated with accelerated cognitive decline and are increasingly recognized as key contributors to the pathogenesis of vascular cognitive impairment and dementia (VCID) and Alzheimer's disease (AD). This review paper delves into the hypothesis that atherosclerosis, a prevalent age-related large vessel disease, extends its pathological influence into the cerebral microcirculation, thereby contributing to the development and progression of CSVD, with a specific focus on CMHs. We explore the concept of vascular aging as a continuum, bridging macrovascular pathologies like atherosclerosis with microvascular abnormalities characteristic of CSVD. We posit that the same risk factors precipitating accelerated aging in large vessels (i.e., atherogenesis), primarily through oxidative stress and inflammatory pathways, similarly instigate accelerated microvascular aging. Accelerated microvascular aging leads to increased microvascular fragility, which in turn predisposes to the formation of CMHs. The presence of hypertension and amyloid pathology further intensifies this process. We comprehensively overview the current body of evidence supporting this interconnected vascular hypothesis. Our review includes an examination of epidemiological data, which provides insights into the prevalence and impact of CMHs in the context of atherosclerosis and CSVD. Furthermore, we explore the shared mechanisms between large vessel aging, atherogenesis, microvascular aging, and CSVD, particularly focusing on how these intertwined processes contribute to the genesis of CMHs. By highlighting the role of vascular aging in the pathophysiology of CMHs, this review seeks to enhance the understanding of CSVD and its links to systemic vascular disorders. Our aim is to provide insights that could inform future therapeutic approaches and research directions in the realm of neurovascular health.
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Affiliation(s)
- Anna Csiszar
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Anna Ungvari
- Department of Public Health, Semmelweis University, Semmelweis University, Budapest, Hungary.
| | - Roland Patai
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Rafal Gulej
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Andriy Yabluchanskiy
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral College/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Zoltan Benyo
- Institute of Translational Medicine, Semmelweis University, 1094, Budapest, Hungary
- Cerebrovascular and Neurocognitive Disorders Research Group, HUN-REN, Semmelweis University, 1094, Budapest, Hungary
| | - Illes Kovacs
- Department of Ophthalmology, Semmelweis University, 1085, Budapest, Hungary
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY, 10021, USA
| | - Peter Sotonyi
- Department of Vascular and Endovascular Surgery, Heart and Vascular Centre, Semmelweis University, 1122, Budapest, Hungary
| | - Angelia C Kirkpartrick
- Veterans Affairs Medical Center, Oklahoma City, OK, USA
- Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Calin I Prodan
- Veterans Affairs Medical Center, Oklahoma City, OK, USA
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Eric M Liotta
- International Training Program in Geroscience, Doctoral College/Department of Public Health, Semmelweis University, Budapest, Hungary
- Department of Neurology, Division of Stroke and Neurocritical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Xin A Zhang
- Department of Physiology, University of Oklahoma Health Science Center, Oklahoma City, OK, USA
| | - Peter Toth
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Public Health, Semmelweis University, Semmelweis University, Budapest, Hungary
- Department of Neurosurgery, Medical School, University of Pecs, Pecs, Hungary
- Neurotrauma Research Group, Szentagothai Research Centre, University of Pecs, Pecs, Hungary
- ELKH-PTE Clinical Neuroscience MR Research Group, University of Pecs, Pecs, Hungary
| | - Stefano Tarantini
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral College/Department of Public Health, Semmelweis University, Budapest, Hungary
| | - Farzaneh A Sorond
- Department of Neurology, Division of Stroke and Neurocritical Care, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Zoltan Ungvari
- Vascular Cognitive Impairment, Neurodegeneration and Healthy Brain Aging Program, Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK, USA
- Oklahoma Center for Geroscience and Healthy Brain Aging, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- Department of Health Promotion Sciences, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
- International Training Program in Geroscience, Doctoral College/Department of Public Health, Semmelweis University, Budapest, Hungary
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Wang Z, Xia K, Li J, Liu Y, Zhou Y, Zhang L, Tang L, Zeng X, Fan D, Yang Q. Essential Nutrients and White Matter Hyperintensities: A Two-Sample Mendelian Randomization Study. Biomedicines 2024; 12:810. [PMID: 38672165 PMCID: PMC11047968 DOI: 10.3390/biomedicines12040810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/24/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Stroke and dementia have been linked to the appearance of white matter hyperintensities (WMHs). Meanwhile, diffusion tensor imaging (DTI) might capture the microstructural change in white matter early. Specific dietary interventions may help to reduce the risk of WMHs. However, research on the relationship between specific nutrients and white matter changes is still lacking. We aimed to investigate the causal effects of essential nutrients (amino acids, fatty acids, mineral elements, and vitamins) on WMHs and DTI measures, including fraction anisotropy (FA) and mean diffusivity (MD), by a Mendelian randomization analysis. We selected single nucleotide polymorphisms (SNPs) associated with each nutrient as instrumental variables to assess the causal effects of nutrient-related exposures on WMHs, FA, and MD. The outcome was from a recently published large-scale European Genome Wide Association Studies pooled dataset, including WMHs (N = 18,381), FA (N = 17,663), and MD (N = 17,467) data. We used the inverse variance weighting (IVW) method as the primary method, and sensitivity analyses were conducted using the simple median, weighted median, and MR-Egger methods. Genetically predicted serum calcium level was positively associated with WMHs risk, with an 8.1% increase in WMHs risk per standard deviation unit increase in calcium concentration (OR = 1.081, 95% CI = 1.006-1.161, p = 0.035). The plasma linoleic acid level was negatively associated with FA (OR = 0.776, 95% CI = 0.616-0.978, p = 0.032). Our study demonstrated that genetically predicted calcium was a potential risk factor for WMHs, and linoleic acid may be negatively associated with FA, providing evidence for interventions from the perspective of gene-environment interactions.
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Affiliation(s)
- Zhengrui Wang
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
- Peking University Health Science Center, Beijing 100191, China
| | - Kailin Xia
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
| | - Jiayi Li
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
- Peking University Health Science Center, Beijing 100191, China
| | - Yanru Liu
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
- Peking University Health Science Center, Beijing 100191, China
| | - Yumou Zhou
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
- Peking University Health Science Center, Beijing 100191, China
| | - Linjing Zhang
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
| | - Lu Tang
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
| | - Xiangzhu Zeng
- Department of Radiology, Peking University Third Hospital, Beijing 100191, China
| | - Dongsheng Fan
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
- Beijing Key Laboratory of Biomarker and Translational Research in Neurodegenerative Diseases, Beijing 100191, China
- Key Laboratory for Neuroscience, National Health Commission, Ministry of Education, Peking University, Beijing 100191, China
| | - Qiong Yang
- Department of Neurology, Peking University Third Hospital, Beijing 100191, China
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4
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von Rennenberg R, Nolte CH, Liman TG, Hellwig S, Riegler C, Scheitz JF, Georgakis MK, Fang R, Bode FJ, Petzold GC, Hermann P, Zerr I, Goertler M, Bernkopf K, Wunderlich S, Dichgans M, Endres M. High-Sensitivity Cardiac Troponin T and Cognitive Function Over 12 Months After Stroke-Results of the DEMDAS Study. J Am Heart Assoc 2024; 13:e033439. [PMID: 38456438 PMCID: PMC11010029 DOI: 10.1161/jaha.123.033439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 01/24/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Subclinical myocardial injury in form of hs-cTn (high-sensitivity cardiac troponin) levels has been associated with cognitive impairment and imaging markers of cerebral small vessel disease (SVD) in population-based and cardiovascular cohorts. Whether hs-cTn is associated with domain-specific cognitive decline and SVD burden in patients with stroke remains unknown. METHODS AND RESULTS We analyzed patients with acute stroke without premorbid dementia from the prospective multicenter DEMDAS (DZNE [German Center for Neurodegenerative Disease]-Mechanisms of Dementia after Stroke) study. Patients underwent neuropsychological testing 6 and 12 months after the index event. Test results were classified into 5 cognitive domains (language, memory, executive function, attention, and visuospatial function). SVD markers (lacunes, cerebral microbleeds, white matter hyperintensities, and enlarged perivascular spaces) were assessed on cranial magnetic resonance imaging to constitute a global SVD score. We examined the association between hs-cTnT (hs-cTn T levels) and cognitive domains as well as the global SVD score and individual SVD markers, respectively. Measurement of cognitive and SVD-marker analyses were performed in 385 and 466 patients with available hs-cTnT levels, respectively. In analyses adjusted for demographic characteristics, cardiovascular risk factors, and cognitive status at baseline, higher hs-cTnT was negatively associated with the cognitive domains "attention" up to 12 months of follow-up (beta-coefficient, -0.273 [95% CI, -0.436 to -0.109]) and "executive function" after 12 months. Higher hs-cTnT was associated with the global SVD score (adjusted odds ratio, 1.95 [95% CI, 1.27-3.00]) and the white matter hyperintensities and lacune subscores. CONCLUSIONS In patients with stroke, hs-cTnT is associated with a higher burden of SVD markers and cognitive function in domains linked to vascular cognitive impairment. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT01334749.
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Affiliation(s)
- Regina von Rennenberg
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BerlinBerlinGermany
| | - Christian H. Nolte
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BerlinBerlinGermany
- German Center for Cardiovascular Research (Deutsches Zentrum für Herz‐Kreislaufforschung), partner site Berlin, Charité‐Universitätsmedizin BerlinBerlinGermany
- Berlin Institute of Health at Charité –Universitätsmedizin Berlin, BIH Biomedical Innovation AcademyBerlinGermany
| | - Thomas G. Liman
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BerlinBerlinGermany
- Department of Neurology, School of Medicine and Health SciencesCarl von Ossietzky University of OldenburgOldenburgGermany
| | - Simon Hellwig
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- Berlin Institute of Health at Charité –Universitätsmedizin Berlin, BIH Biomedical Innovation AcademyBerlinGermany
| | - Christoph Riegler
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
| | - Jan F. Scheitz
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- German Center for Cardiovascular Research (Deutsches Zentrum für Herz‐Kreislaufforschung), partner site Berlin, Charité‐Universitätsmedizin BerlinBerlinGermany
- Berlin Institute of Health at Charité –Universitätsmedizin Berlin, BIH Biomedical Innovation AcademyBerlinGermany
| | - Marios K. Georgakis
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU MunichMunichGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site MunichMunichGermany
| | - Rong Fang
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU MunichMunichGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site MunichMunichGermany
| | - Felix J. Bode
- Division of Vascular Neurology, Department of NeurologyUniversity Hospital BonnBonnGermany
| | - Gabor C. Petzold
- Division of Vascular Neurology, Department of NeurologyUniversity Hospital BonnBonnGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BonnBonnGermany
| | - Peter Hermann
- German Center for Neurodegenerative Diseases (DZNE) GöttingenGöttingenGermany
- Clinical Dementia Center, Department of NeurologyUniversity Medical CenterGöttingenGermany
| | - Inga Zerr
- German Center for Neurodegenerative Diseases (DZNE) GöttingenGöttingenGermany
- Clinical Dementia Center, Department of NeurologyUniversity Medical CenterGöttingenGermany
| | - Michael Goertler
- Department of NeurologyMagdeburg University Vascular and Stroke CentreMagdeburgGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site MagdeburgMagdeburgGermany
| | - Kathleen Bernkopf
- Department of Neurology, School of MedicineKlinikum rechts der Isar, Technical University of MunichMunichGermany
| | - Silke Wunderlich
- Department of Neurology, School of MedicineKlinikum rechts der Isar, Technical University of MunichMunichGermany
| | - Martin Dichgans
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU MunichMunichGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site MunichMunichGermany
| | - Matthias Endres
- Department of Neurology (Klinik und Hochschulambulanz für Neurologie)Charité—Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt‐Universität zu BerlinBerlinGermany
- Center for Stroke Research Berlin (CSB)Charité—Universitätsmedizin BerlinBerlinGermany
- German Center for Neurodegenerative Diseases (Deutsches Zentrum für Neurodegenerative Erkrankungen), partner site BerlinBerlinGermany
- German Center for Cardiovascular Research (Deutsches Zentrum für Herz‐Kreislaufforschung), partner site Berlin, Charité‐Universitätsmedizin BerlinBerlinGermany
- Berlin Institute of Health at Charité –Universitätsmedizin Berlin, BIH Biomedical Innovation AcademyBerlinGermany
- German Center for Mental Health (DZPG), partner site BerlinBerlinGermany
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5
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Jian W, Dong Z, Shen X, Zheng Z, Wu Z, Shi Y, Han Y, Du J, Liu J. Machine learning-based coronary artery calcium score predicted from clinical variables as a prognostic indicator in patients referred for invasive coronary angiography. Eur Radiol 2024:10.1007/s00330-024-10629-3. [PMID: 38337067 DOI: 10.1007/s00330-024-10629-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 01/16/2024] [Accepted: 01/18/2024] [Indexed: 02/12/2024]
Abstract
OBJECTIVES Utilising readily available clinical variables, we aimed to develop and validate a novel machine learning (ML) model to predict severe coronary calcification, and further assessed its prognostic significance. METHODS This retrospective study enrolled patients who underwent coronary CT angiography and subsequent invasive coronary angiography. Multiple ML algorithms were used to train the models for predicting severe coronary calcification (cardiac CT-measured coronary artery calcium [CT-CAC] score ≥ 400). The ML-based CAC (ML-CAC) score derived from the ML predictive probability was stratified into quartiles for prognostic analysis. The primary endpoint was a composite of all-cause death, nonfatal myocardial infarction, or nonfatal stroke. RESULTS Overall, 5785 patients were divided into training (80%) and test sets (20%). For clinical practicability, we selected the nine-feature support vector machine model with good and satisfactory performance regarding both discrimination and calibration based on five repetitions of the 10-fold cross-validation in the training set (mean AUC = 0.715, Brier score = 0.202), and based on the test in the test set (AUC = 0.753, Brier score = 0.191). In the test set cohort (n = 1137), the primary endpoint was observed in 50 (4.4%) patients during a median 2.8 years' follow-up. The ML-CAC system was significantly associated with an increased risk of the primary endpoint (adjusted hazard ratio for trend 2.26, 95% CI 1.35-3.79, p = 0.002). There was no significant difference in the prognostic value between the ML-CAC and CT-CAC systems (C-index, 0.67 vs. 0.69; p = 0.618). CONCLUSION ML-CAC score predicted from clinical variables can serve as a novel prognostic indicator in patients referred for invasive coronary angiography. CLINICAL RELEVANCE STATEMENT In patients referred for invasive coronary angiography who have not undergone preoperative CT-measured coronary artery calcium scoring, machine learning-based coronary artery calcium score assessment can serve as an alternative for predicting the prognosis. KEY POINTS • The coronary artery calcium (CAC) score, a solid prognostic indicator, can be predicted using non-CT methods. • We developed a machine learning (ML)-CAC model utilising nine clinical variables to predict severe coronary calcification. • The ML-CAC system offers significant prognostic value in patients referred for invasive coronary angiography.
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Affiliation(s)
- Wen Jian
- Center for Coronary Artery Disease, Beijing Anzhen Hospital of Capital Medical University, Beijing, China
| | - Zhujun Dong
- Beijing Anzhen Hospital of Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Xueqian Shen
- Center for Coronary Artery Disease, Beijing Anzhen Hospital of Capital Medical University, Beijing, China
| | - Ze Zheng
- Center for Coronary Artery Disease, Beijing Anzhen Hospital of Capital Medical University, Beijing, China
| | - Zheng Wu
- Center for Coronary Artery Disease, Beijing Anzhen Hospital of Capital Medical University, Beijing, China
| | - Yuchen Shi
- Center for Coronary Artery Disease, Beijing Anzhen Hospital of Capital Medical University, Beijing, China
| | - Yingchun Han
- Beijing Anzhen Hospital of Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jie Du
- Beijing Anzhen Hospital of Capital Medical University and Beijing Institute of Heart Lung and Blood Vessel Diseases, Beijing, China
| | - Jinghua Liu
- Center for Coronary Artery Disease, Beijing Anzhen Hospital of Capital Medical University, Beijing, China.
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Jin H, Qin X, Zhao F, Yan Y, Meng Y, Shu Z, Gong X. Is coronary artery calcium an independent risk factor for white matter hyperintensity? BMC Neurol 2023; 23:313. [PMID: 37648961 PMCID: PMC10466815 DOI: 10.1186/s12883-023-03364-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 08/17/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Cardiovascular diseases have been considered the primary cause of disability and death worldwide. Coronary artery calcium (CAC) is an important indicator of the severity of coronary atherosclerosis. This study is aimed to investigate the relationship between CAC and white matter hyperintensity (WMH) in the context of diagnostic utility. METHODS A retrospective analysis was conducted on 342 patients with a diagnosis of WMH on magnetic resonance images (MRI) who also underwent chest computed tomography (CT) scans. WMH volumes were automatically measured using a lesion prediction algorithm. Subjects were divided into four groups based on the CAC score obtained from chest CT scans. A multilevel mixed-effects linear regression model considering conventional vascular risk factors assessed the association between total WMH volume and CAC score. RESULTS Overall, participants with coronary artery calcium (CAC score > 0) had larger WMH volumes than those without calcium (CAC score = 0), and WMH volumes were statistically different between the four CAC score groups, with increasing CAC scores, the volume of WMH significantly increased. In the linear regression model 1 of the high CAC score group, for every 1% increase in CAC score, the WMH volume increases by 2.96%. After including other covariates in model 2 and model 3, the β coefficient in the high CAC group remains higher than in the low and medium CAC score groups. CONCLUSION In elderly adults, the presence and severity of CAC is related to an increase in WMH volume. Our findings suggest an association between two different vascular bed diseases in addition to traditional vascular risk factors, possibly indicating a comorbid mechanism.
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Affiliation(s)
- Hui Jin
- Bengbu Medical College, Bengbu, 233030, China
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People's Hospital(Affiliated People's Hospital), Hangzhou Medical College, No. 158 Shangtang Road, Hangzhou City, Zhejiang Province, China
| | - Xue Qin
- Bengbu Medical College, Bengbu, 233030, China
| | - Fanfan Zhao
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People's Hospital(Affiliated People's Hospital), Hangzhou Medical College, No. 158 Shangtang Road, Hangzhou City, Zhejiang Province, China
| | - Yuting Yan
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People's Hospital(Affiliated People's Hospital), Hangzhou Medical College, No. 158 Shangtang Road, Hangzhou City, Zhejiang Province, China
| | - Yu Meng
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People's Hospital(Affiliated People's Hospital), Hangzhou Medical College, No. 158 Shangtang Road, Hangzhou City, Zhejiang Province, China
| | - Zhenyu Shu
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People's Hospital(Affiliated People's Hospital), Hangzhou Medical College, No. 158 Shangtang Road, Hangzhou City, Zhejiang Province, China
| | - Xiangyang Gong
- Center for Rehabilitation Medicine, Department of Radiology, Zhejiang Provincial People's Hospital(Affiliated People's Hospital), Hangzhou Medical College, No. 158 Shangtang Road, Hangzhou City, Zhejiang Province, China.
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Choi J, Kim JY, Kwon HJ, Choi HJ, Kim SH, Kim S, Lee J, Park JE. Association of cerebral white matter hyperintensities with coronary artery calcium in a healthy population: a cross-sectional study. Sci Rep 2022; 12:21562. [PMID: 36513747 PMCID: PMC9747792 DOI: 10.1038/s41598-022-25654-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022] Open
Abstract
In brain magnetic resonance imaging (MRI), white matter hyperintensity (WMH) is a commonly encountered finding and is known to reflect cerebral small vessel disease. The aim of our study was to investigate the association of coronary artery calcium (CAC) with WMH and elucidate the relationship between WMH and atherosclerotic risk factors in a large-scale healthy population. This retrospective study included 1337 individuals who underwent brain MRI and CAC scoring computed tomography at healthcare centers affiliated with a tertiary hospital. Cerebral WMH was defined as Fazekas score greater than 2 on brain MRI. Intracranial artery stenosis (ICAS) was also assessed and determined to be present when stenosis was more than 50% on angiography. The associations of risk factors, CAC score, and ICAS with cerebral WMH were assessed by multivariable regression analysis. In multivariable analysis, categories of higher CAC scores showed increased associations with both periventricular and deep WMHs in a dose-dependent relationship. The presence of ICAS was also significantly related to cerebral WMH, and among the clinical variables, age and hypertension were independent risk factors. In conclusion, CAC showed a significant association with cerebral WMH in a healthy population, which might provide evidence for referring to the CAC score to identify individuals with risk of cerebral WMH.
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Affiliation(s)
- Jinyoung Choi
- grid.264381.a0000 0001 2181 989XDepartment of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, 03181 Republic of Korea
| | - Jung Youn Kim
- grid.410886.30000 0004 0647 3511Department of Radiology, CHA Bundang Medical Center, CHA University, Seongnam, Gyeonggi-Do 13496 Republic of Korea
| | - Heon-Ju Kwon
- grid.264381.a0000 0001 2181 989XDepartment of Radiology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, 03181 Republic of Korea
| | - Hye Jeong Choi
- grid.410886.30000 0004 0647 3511Department of Radiology, CHA Bundang Medical Center, CHA University, Seongnam, Gyeonggi-Do 13496 Republic of Korea
| | - Sang Heum Kim
- grid.410886.30000 0004 0647 3511Department of Radiology, CHA Bundang Medical Center, CHA University, Seongnam, Gyeonggi-Do 13496 Republic of Korea
| | - Sinae Kim
- grid.264381.a0000 0001 2181 989XDivision of Biostatistics, Department of R&D Management, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, 03181 Republic of Korea
| | - Jungbin Lee
- grid.412678.e0000 0004 0634 1623Department of Radiology, Soonchunhyang University Bucheon Hospital, Bucheon, Gyeonggi-Do 14584 Republic of Korea
| | - Ji Eun Park
- grid.413967.e0000 0001 0842 2126Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, 05505 Republic of Korea
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Yokoyama R, Kanzaki Y, Watanabe T, Yamamura K, Komori T, Takeda Y, Nakajima O, Sohmiya K, Hoshiga M. Prevalence and Risk Factors of Silent Cerebral Microbleeds in Patients with Coronary Artery Disease. J Stroke Cerebrovasc Dis 2021; 31:106211. [PMID: 34823092 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 10/20/2021] [Accepted: 10/31/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Cerebral microbleeds (CMBs), which can be detected by gradient-echo T2*-weighted magnetic resonance imaging (MRI), represent small chronic brain hemorrhages caused by structural abnormalities in cerebral small vessels. CMBs are known to be a potential predictor of future stroke, and are associated with age, various cardiovascular risk factors, cognitive impairment, and the use of antithrombotic drugs. Patients with coronary artery disease (CAD) are at potentially high risk of CMBs due to the presence of coexistent conditions. However, little is known about CMBs in patients with CAD. We aimed to identify the factors associated with the presence of CMBs among patients with CAD. METHODS We evaluated 356 consecutive patients [mean age, 72 ± 10 years; men = 276 (78%)] with angiographically proven CAD who underwent T2*-weighted brain MRI. The brain MRI was assessed by researchers blinded to the patients' clinical details. RESULTS CMBs were found in 128 (36%) patients. Among 356 patients, 119 (33%) had previously undergone percutaneous coronary intervention (PCI), and 26 (7%) coronary artery bypass grafting (CABG). There was no significant relationship between CMBs and sex, hypertension, dyslipidemia, diabetes mellitus, anticoagulation therapy, antiplatelet therapy, or prior PCI. CMBs were significantly associated with advanced age, previous CABG, eGFR, non-HDL cholesterol, carotid artery disease, long-term antiplatelet therapy, and long-term dual antiplatelet therapy (DAPT) using univariate logistic regression analysis. The multivariate logistic regression analysis showed that long-term antiplatelet therapy (odds ratio, 1.73; 95% CI, 1.06 - 2.84; P = 0.03) or long-term DAPT (odds ratio, 2.92; 95% CI, 1.39 - 6.17; P = 0.004) was significantly associated with CMBs after adjustment for confounding variables. CONCLUSIONS CMBs were frequently observed in patients with CAD and were significantly associated with long-term antiplatelet therapy, especially long-term DAPT.
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Affiliation(s)
- Ryo Yokoyama
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan; Department of Cardiology, Hirakata City Hospital
| | - Yumiko Kanzaki
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan.
| | - Tomohiko Watanabe
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan
| | - Kenichiro Yamamura
- Departments of Radiology, Osaka Medical and Pharmaceutical University, Japan
| | - Tsuyoshi Komori
- Departments of Radiology, Osaka Medical and Pharmaceutical University, Japan
| | - Yoshihiro Takeda
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan; Department of Cardiology, Hirakata City Hospital
| | | | - Koichi Sohmiya
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan
| | - Masaaki Hoshiga
- Departments of Cardiology, Osaka Medical and Pharmaceutical University, Japan
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Liu Y, Han Y, Guan M, Cai Y, Wang W, Chen H, Zhao X. Added value of femoral artery atherosclerosis for determining severity of white matter lesion by carotid atherosclerosis: a magnetic resonance imaging study. Acta Radiol 2021; 62:1112-1121. [PMID: 32811157 DOI: 10.1177/0284185120950106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Previous studies reported that single vascular atherosclerosis was an effective indicator for white matter lesions (WMLs). PURPOSE To investigate the added value of femoral atherosclerosis for determining severity of WMLs by carotid atherosclerosis using three-dimensional vessel wall magnetic resonance imaging (MRI). MATERIAL AND METHODS Elderly individuals without cardiovascular symptoms within the previous six months were recruited. The plaque features of carotid and femoral arteries were evaluated and compared between individuals with WML score ≤ 3 and those with WML score > 3. Logistic regression and receiver operating characteristic (ROC) analyses were used to determine the value of plaque features in discriminating WMLs with score > 3. RESULTS In total, 112 individuals (49 men, mean age 72.0±5.6 years) were included. Participants with a WML score > 3 showed a significantly greater carotid wall area and femoral artery stenosis and higher incidence of carotid calcification and femoral artery calcification and lipid-rich necrotic cores (LRNC) compared to those with a WML score ≤ 3 (all P < 0.05). Carotid artery calcification and femoral artery calcification, LRNC, and stenosis were found to be significantly associated with severe WMLs before and after adjustment for clinical factors (odds ratio 1.51-3.79, all P < 0.05). ROC analysis showed, in discriminating severe WMLs, the area under the curve increased from 0.615 to 0.754 after combining femoral artery LRNC and stenosis with carotid calcification compared to the carotid calcification alone. CONCLUSION Characteristics of femoral artery atherosclerosis determined by vessel wall MRI have added value for carotid atherosclerosis in determining the severity of WMLs.
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Affiliation(s)
- Yang Liu
- Department of Radiology, The Affiliated Hospital of Yangzhou University, Yangzhou, PR China
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, PR China
| | - Yongjun Han
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, PR China
- Center for Brain Disorders Research, Capital Medical University and Beijing Institute for Brain Disorders, Beijing, PR China
| | - Maobin Guan
- Department of Radiology, The Affiliated Hospital of Yangzhou University, Yangzhou, PR China
| | - Ying Cai
- Department of Radiology, Taizhou People’s Hospital, Taizhou, PR China
| | - Wei Wang
- Department of Radiology, The Affiliated Hospital of Yangzhou University, Yangzhou, PR China
| | - Huijun Chen
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, PR China
| | - Xihai Zhao
- Center for Biomedical Imaging Research, Department of Biomedical Engineering, Tsinghua University School of Medicine, Beijing, PR China
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10
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Suzuki H, Davis-Plourde K, Beiser A, Kunimura A, Miura K, DeCarli C, Maillard P, Mitchell GF, Vasan RS, Seshadri S, Fujiyoshi A. Coronary Artery Calcium Assessed Years Before Was Positively Associated With Subtle White Matter Injury of the Brain in Asymptomatic Middle-Aged Men: The Framingham Heart Study. Circ Cardiovasc Imaging 2021; 14:e011753. [PMID: 34256573 PMCID: PMC8323993 DOI: 10.1161/circimaging.120.011753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Using magnetic resonance diffusion tensor imaging, we previously showed a cross-sectional association between carotid-femoral pulse wave velocity, a measure of aortic stiffness, and subtle white matter injury in clinically asymptomatic middle-age adults. While coronary artery calcium (CAC) is a robust measure of atherosclerosis, and a predictor of stroke and dementia, whether it predicts diffusion tensor imaging-based subtle white matter injury in the brain remains unknown. METHODS In FHS (Framingham Heart Study), an observational study, third-generation participants were assessed for CAC (2002-2005) and brain magnetic resonance imaging (2009-2014). Outcomes were diffusion tensor imaging-based measures; free water, fractional anisotropy, and peak width of mean diffusivity. After excluding the participants with neurological conditions and missing covariates, we categorized participants into 3 groups according to CAC score (0, 0 < to 100, and >100) and calculated a linear trend across the CAC groups. In secondary analyses treating CAC score as continuous, we computed slope of the outcomes per 20 to 80th percentiles higher log-transformed CAC score using linear regression. RESULTS In a total of 1052 individuals analyzed (mean age 45.4 years, 45.4% women), 71.6%, 22.4%, and 6.0% had CAC score of 0, 0 < to 100, and >100, respectively. We observed a significant linear trend of fractional anisotropy, but not other measures, across the CAC groups after multivariable adjustment. In the secondary analyses, CAC was associated with lower fractional anisotropy in men but not in women. CONCLUSIONS CAC may be a promising tool to predict prevalent subtle white matter injury of the brain in asymptomatic middle-aged men.
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Affiliation(s)
- Harumitsu Suzuki
- Department of Hygiene, Wakayama Medical University, Wakayama, Japan
| | - Kendra Davis-Plourde
- The Framingham Heart Study, Framingham, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Massachusetts
| | - Alexa Beiser
- The Framingham Heart Study, Framingham, Massachusetts
- Department of Biostatistics, Boston University School of Public Health, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | | | - Katsuyuki Miura
- Department of Public Health, Shiga University of Medical Science, Shiga, Japan
- NCD Epidemiology Research Center, Shiga, Japan
| | - Charles DeCarli
- Department of Neurology and Center for Neuroscience, University of California Davis, Davis, California
| | - Pauline Maillard
- Department of Neurology and Center for Neuroscience, University of California Davis, Davis, California
| | | | - Ramachandran S. Vasan
- The Framingham Heart Study, Framingham, Massachusetts
- Section of Cardiovascular Medicine, Boston University School of Medicine, Massachusetts
- Sections of Preventive Medicine and Epidemiology, Boston University School of Medicine, Massachusetts
- Department of Epidemiology, Boston University School of Public Health, Massachusetts
| | - Sudha Seshadri
- The Framingham Heart Study, Framingham, Massachusetts
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
- Glenn Biggs Institute for Alzheimer’s and Neurodegenerative Diseases, University of Texas Health Sciences Center, San Antonio
| | - Akira Fujiyoshi
- Department of Hygiene, Wakayama Medical University, Wakayama, Japan
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Muraoka S, Somiya D, Ebata A, Kumagai Y, Koketsu N. Future stroke risk in the chronic phase of post-percutaneous coronary intervention. PLoS One 2021; 16:e0251253. [PMID: 33956898 PMCID: PMC8101951 DOI: 10.1371/journal.pone.0251253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 04/22/2021] [Indexed: 11/19/2022] Open
Abstract
A percutaneous coronary intervention (PCI) is widely performed for acute coronary syndromes or chronic coronary syndromes. Periprocedural stroke is a clinically significant complication during PCI. The incidence of cerebrovascular events (CVEs) after PCI in the chronic phase is obscure. This study aimed to investigate the prevalence of CVEs after PCI in the chronic phase and evaluate the usefulness of a simple coronary artery calcification (CAC) evaluation method. This prospective observational study included 179 patients who underwent PCI between January 2016 and December 2018. The incidence of cerebral infarction was examined from one month after PCI to December 2019. In total, 171 individuals (134 men; mean age, 69.8 ± 9.8 years) were recruited. During a median follow-up period of 33 months, the onset of cerebral infarction was observed in 20 individuals (11.7%). More CAC sites (p = 0.009) and post-PCI for the chronic coronary syndrome (p = 0.049) showed a significant association with future CVEs. There was no significant cervical internal carotid artery stenosis for patients who occurred CVEs. The cutoff value for the number of CAC sites for predicting future CVEs was 4.5. The new and easy method accurately reflected future CVEs risk and may be clinically applicable.
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Affiliation(s)
- Shinsuke Muraoka
- Department of Neurosurgery, Tosei General Hospital, Aichi, Japan
- * E-mail:
| | - Daiki Somiya
- Department of Neurosurgery, Tosei General Hospital, Aichi, Japan
| | - Aoi Ebata
- Department of Neurosurgery, Tosei General Hospital, Aichi, Japan
| | - Yuki Kumagai
- Department of Neurosurgery, Tosei General Hospital, Aichi, Japan
| | - Naoki Koketsu
- Department of Neurosurgery, Tosei General Hospital, Aichi, Japan
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Nassir CMNCM, Ghazali MM, Hashim S, Idris NS, Yuen LS, Hui WJ, Norman HH, Gau CH, Jayabalan N, Na Y, Feng L, Ong LK, Abdul Hamid H, Ahamed HN, Mustapha M. Diets and Cellular-Derived Microparticles: Weighing a Plausible Link With Cerebral Small Vessel Disease. Front Cardiovasc Med 2021; 8:632131. [PMID: 33718454 PMCID: PMC7943466 DOI: 10.3389/fcvm.2021.632131] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/19/2021] [Indexed: 12/24/2022] Open
Abstract
Cerebral small vessel disease (CSVD) represents a spectrum of pathological processes of various etiologies affecting the brain microcirculation that can trigger neuroinflammation and the subsequent neurodegenerative cascade. Prevalent with aging, CSVD is a recognized risk factor for stroke, vascular dementia, Alzheimer disease, and Parkinson disease. Despite being the most common neurodegenerative condition with cerebrocardiovascular axis, understanding about it remains poor. Interestingly, modifiable risk factors such as unhealthy diet including high intake of processed food, high-fat foods, and animal by-products are known to influence the non-neural peripheral events, such as in the gastrointestinal tract and cardiovascular stress through cellular inflammation and oxidation. One key outcome from such events, among others, includes the cellular activations that lead to elevated levels of endogenous cellular-derived circulating microparticles (MPs). MPs can be produced from various cellular origins including leukocytes, platelets, endothelial cells, microbiota, and microglia. MPs could act as microthrombogenic procoagulant that served as a plausible culprit for the vulnerable end-artery microcirculation in the brain as the end-organ leading to CSVD manifestations. However, little attention has been paid on the potential role of MPs in the onset and progression of CSVD spectrum. Corroboratively, the formation of MPs is known to be influenced by diet-induced cellular stress. Thus, this review aims to appraise the body of evidence on the dietary-related impacts on circulating MPs from non-neural peripheral origins that could serve as a plausible microthrombosis in CSVD manifestation as a precursor of neurodegeneration. Here, we elaborate on the pathomechanical features of MPs in health and disease states; relevance of dietary patterns on MP release; preclinical studies pertaining to diet-based MPs contribution to disease; MP level as putative surrogates for early disease biomarkers; and lastly, the potential of MPs manipulation with diet-based approach as a novel preventive measure for CSVD in an aging society worldwide.
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Affiliation(s)
| | - Mazira Mohamad Ghazali
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Sabarisah Hashim
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Nur Suhaila Idris
- Department of Family Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Lee Si Yuen
- Department of Internal Medicine, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
| | - Wong Jia Hui
- Neurobiology of Aging and Disease Laboratory, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Haziq Hazman Norman
- Anatomy Unit, International Medical School (IMS), Management and Science University (MSU), Shah Alam, Malaysia
| | - Chuang Huei Gau
- Department of Psychology and Counselling, Faculty of Arts and Social Science, Universiti Tunku Abdul Rahman (UTAR), Kampar, Malaysia
| | - Nanthini Jayabalan
- Translational Neuroscience Lab, University of Queensland (UQ), Centre for Clinical Research, The University of Queensland, Herston, QLD, Australia
| | - Yuri Na
- Center for Functional Connectomics, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, South Korea
| | - Linqing Feng
- Center for Functional Connectomics, Brain Science Institute, Korea Institute of Science and Technology (KIST), Seoul, South Korea
| | - Lin Kooi Ong
- School of Pharmacy, Monash University Malaysia, Bandar Sunway, Malaysia
- School of Biomedical Sciences and Pharmacy, Priority Research Centre for Stroke and Brain Injury, University of Newcastle, Callaghan, NSW, Australia
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
- Centre of Research Excellence Stroke Rehabilitation and Brain Recovery, National Health and Medical Research Council (NHMRC), Heidelberg, VIC, Australia
| | - Hafizah Abdul Hamid
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
| | - Haja Nazeer Ahamed
- Crescent School of Pharmacy, B.S. Abdur Rahman Crescent Institute of Science and Technology, Chennai, India
| | - Muzaimi Mustapha
- Department of Neurosciences, School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Malaysia
- Hospital Universiti Sains Malaysia, Jalan Raja Perempuan Zainab II, Kubang Kerian, Malaysia
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Alaa El Din A, Debeaumarche H, Thouant P, Maza M, Ricolfi F, Zeller M, Bichat F, Baudouin N, Bejot Y, Cottin Y. Cerebral microbleeds and acute myocardial infarction: Screening and disease progression. IJC HEART & VASCULATURE 2020; 28:100531. [PMID: 32490144 PMCID: PMC7262454 DOI: 10.1016/j.ijcha.2020.100531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/29/2020] [Accepted: 05/01/2020] [Indexed: 11/24/2022]
Abstract
Introduction Cerebral microbleeds (CMB) are associated with intracerebral haemorrhage. Therefore they may represent a concern if anticoagulant and/or antiplatelet therapy is needed. The aim of this study was to determine the prevalence of CMB in patients with acute myocardial infarction (AMI), and to follow their progression at 3 months under dual antiplatelet therapy (DAPT). Methods This prospective study included patients aged over 60 hospitalized in intensive cardiac care unit in our city for AMI. These patients underwent a first brain Magnetic resonance imaging (MRI) within 72 h of admission, that was repeated 3 months. Results 108 patients were included between November 2016 and December 2018. The prevalence of CMB was 21.3%, with a female predominance of 65.2% vs 32.1% (p = 0.004). Diabetes is significantly associated with the presence of CMB, 45.5% vs 21.2% (p = 0.021). Patients with at least one acute CMB had higher haemorrhagic risk as evaluated with CRUSADE score (40.5 ± 13.6 vs 31.2 ± 14.8 (p = 0.004). Multivariate analysis showed that only female sex was associated with the presence of a CMB on the initial MRI. On repeated MRI, an increase in CMB was observed in 6% of patients. Our results suggest that discharge treatment with anticoagulant in combination with antiplatelet therapy may be an independent predictor of early progression of CMB. Conclusion Our study confirms the high prevalence of CMB in patients over 60 years with AMI. The association of anticoagulant with DAPT, 3 months after stenting, may be an independent factor of CMB progression.
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Affiliation(s)
- Abbass Alaa El Din
- University Hospital Center Dijon Bourgogne, Cardiology Department, Dijon, France
| | - Hugo Debeaumarche
- University Hospital Center Dijon Bourgogne, Cardiology Department, Dijon, France
| | - Pierre Thouant
- University Hospital Center Dijon Bourgogne, Neuroradiology Department, Dijon, France
| | - Maud Maza
- University Hospital Center Dijon Bourgogne, Cardiology Department, Dijon, France
| | - Frédéric Ricolfi
- University Hospital Center Dijon Bourgogne, Neuroradiology Department, Dijon, France
| | - Marianne Zeller
- University of Bourgogne Franche-Comté, PEC2, EA 7460 Dijon, France
| | - Florence Bichat
- University Hospital Center Dijon Bourgogne, Cardiology Department, Dijon, France
| | - Nathalie Baudouin
- University Hospital Center Dijon Bourgogne, Neuroradiology Department, Dijon, France
| | - Yannick Bejot
- University Hospital Center Dijon Bourgogne, Neurology Department, Dijon, France
| | - Yves Cottin
- University Hospital Center Dijon Bourgogne, Cardiology Department, Dijon, France
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14
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Del Brutto OH, Mera RM, Del Brutto VJ, Hill JP, Torpey AP, Peralta LD, Generale LM, Matcha G, Costa AF, Recalde BY, Sedler MJ. Cerebral small vessel disease score and atherosclerosis burden - A population study in community-dwelling older adults. Clin Neurol Neurosurg 2020; 194:105795. [PMID: 32220695 DOI: 10.1016/j.clineuro.2020.105795] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/24/2020] [Accepted: 03/17/2020] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Cerebral small vessel disease (cSVD) and large artery atherosclerosis (LAA) are related to different pathogenetic mechanisms. However, relationships between single biomarkers of cSVD and LAA affecting isolated vascular beds have been reported. Using the Atahualpa Project cohort, we aimed to assess the association between cSVD score categories and LAA burden in community-dwelling older adults. PATIENTS AND METHODS Atahualpa individuals aged ≥60 years undergoing assessment of the cSVD score and LAA in the peripheral, carotid extracranial, and intracranial vascular beds (n = 333) were included. Multivariate models were fitted to assess independent associations between the cSVD score and LAA burden. RESULTS The cSVD score was 0 points in 62 % individuals, 1 point in 19 %, 2 points in 13 %, and 3-4 points in 7 %. LAA involved the extracranial carotid bed in 43 % individuals, the intracranial bed in 36 %, and the peripheral bed in 20 %. One vascular bed was involved in 111 (33 %) individuals, two beds in 75 (23 %), and three beds in 23 (7 %). The remaining 124 (37 %) had no atherosclerosis. Ordinal logistic regression models showed progressively greater associations between higher categories of cSVD score and the odds of having more beds involved with LAA. Multinomial logistic regression models showed associations between categories of cSVD score and LAA burden, but only when two or three vascular beds were involved. CONCLUSION This study demonstrates robust associations between the cSVD score and LAA, which become evident at the upper end of the spectrum of cSVD score (3-4 points) and LAA burden (2-3 vascular beds involved).
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Affiliation(s)
- Oscar H Del Brutto
- School of Medicine, Universidad Espíritu Santo - Ecuador, Samborondón, Ecuador.
| | - Robertino M Mera
- Department of Epidemiology, Gilead Sciences, Inc., Foster City, CA, USA
| | - Victor J Del Brutto
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, Fl, USA
| | - John P Hill
- School of Medicine, Stony Brook University, New York, NY, USA
| | - Andrew P Torpey
- School of Medicine, Stony Brook University, New York, NY, USA
| | | | | | - Gautam Matcha
- Internal Medicine Department, Mayo Clinic School of Medicine, Jacksonville, Fl, USA
| | - Aldo F Costa
- Community Center, The Atahualpa Project, Atahualpa, Ecuador
| | | | - Mark J Sedler
- School of Medicine, Stony Brook University, New York, NY, USA
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15
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Khan MMH, Fujiyoshi A, Shiino A, Hisamatsu T, Torii S, Suzuki S, Kunimura A, Segawa H, Kadota A, Ohkubo T, Nozaki K, Miura K, Ueshima H. The Association Between Coronary Artery Calcification and Subclinical Cerebrovascular Diseases in Men: An Observational Study. J Atheroscler Thromb 2020; 27:995-1009. [PMID: 31969522 PMCID: PMC7508726 DOI: 10.5551/jat.51284] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Aim: Coronary artery calcification (CAC) is an independent predictor of stroke and dementia, in which subclinical cerebrovascular diseases (SCVDs) play a vital pathogenetic role. However, few studies have described the association between CAC and SCVDs. Therefore, the aim of this study was to assess the clinical relationship between CAC and SCVDs in a healthy Japanese male population. Methods: In this observational study, 709 men, free of stroke, were sampled from a city in Japan from 2010 to 2014. CAC was scored using the Agatston method. The following SCVDs were assessed using magnetic resonance imaging: intracranial arterial stenosis (ICAS), lacunar infarction, deep and subcortical white matter hyperintensity (DSWMH), periventricular hyperintensity (PVH), and microbleeds. The participants were categorized according to CAC scores as follows: no CAC (0), mild CAC (1–100), and moderate-to-severe CAC (> 100). The adjusted odds ratios of prevalent SCVDs were computed in reference to the no-CAC group using logistic regression. Results: The mean (standard deviation) age of the participants was 68 (8.4) years. Participants in the moderate-to-severe CAC category showed significantly higher odds of prevalent lacunar infarction, DSWMH, and ICAS in age-adjusted and risk-factor-adjusted models. Microbleeds and PVH, in contrast, did not show any significant associations. The trends for CAC with lacunar infarction, DSWMH, and ICAS were also significant (all P-values for trend ≤ 0.02). Conclusions: Higher CAC scores were associated with higher odds of lacunar infarction, DSWMH, and ICAS. The presence and degree of CAC may be a useful indicator for SCVDs involving small and large vessels.
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Affiliation(s)
- Md Maruf Haque Khan
- Department of Public Health, Shiga University of Medical Science.,Center for Epidemiologic Research in Asia, Shiga University of Medical Science.,Department of Public Health and Informatics, Bangabandhu Sheikh Mujib Medical University
| | - Akira Fujiyoshi
- Department of Public Health, Shiga University of Medical Science.,Department of Hygiene, Wakayama Medical University
| | - Akihiko Shiino
- Molecular Neuroscience Research Center, Shiga University of Medical Science
| | - Takashi Hisamatsu
- Department of Environmental Medicine and Public Health, Shimane University
| | - Sayuki Torii
- Department of Public Health, Shiga University of Medical Science
| | - Sentaro Suzuki
- Department of Public Health, Shiga University of Medical Science
| | - Ayako Kunimura
- Department of Public Health, Shiga University of Medical Science
| | - Hiroyoshi Segawa
- Center for Epidemiologic Research in Asia, Shiga University of Medical Science
| | - Aya Kadota
- Department of Public Health, Shiga University of Medical Science
| | - Takayoshi Ohkubo
- Department of Hygiene and Public Health, Teikyo University School of Medicine
| | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science
| | - Katsuyuki Miura
- Department of Public Health, Shiga University of Medical Science.,Center for Epidemiologic Research in Asia, Shiga University of Medical Science
| | - Hirotsugu Ueshima
- Department of Public Health, Shiga University of Medical Science.,Center for Epidemiologic Research in Asia, Shiga University of Medical Science
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16
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Abstract
Small vessel disease (SVD) refers to conditions where damage to arterioles and capillaries is predominant, leading to reduced, or interrupted perfusion of the affected organ. Data suggest that when this condition is evident in any organ, it is already systemic in its occurrence and consequences. SVD affects primarily organs that receive significant portions of cardiac output such as the brain, the kidney, and the retina. Thus, SVD is a major etiologic cause in debilitating conditions such as renal failure, blindness, lacunar infarcts, and dementia. The factors that lead to this devastating condition include all the known vascular risk factors when they are not strictly controlled, but lifestyles that include sedentary existence, obesity, and poor sleep patterns are also recognized drivers of SVD. In addition, depression is now recognized as a vascular risk factor. Inflammation is a mediator of SVD, but it is not known which factor(s) predominate in its etiology. This article emphasizes the need for more investigations to define this link further and suggests clinical and societal responses that might reduce the major impacts of this condition on populations.
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Affiliation(s)
- Antoine M Hakim
- Ottawa Hospital Research Institute, Ottawa, ON, Canada.,Faculty of Medicine, Brain and Mind Research Institute, University of Ottawa, Ottawa, ON, Canada.,Division of Neurology, University of Ottawa, Ottawa, ON, Canada
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17
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Hori S, Hori E, Shibata T, Umemura K, Okamoto S, Kubo M, Horie Y, Kuroda S. Correlation Between Cerebral Microbleeds and Vulnerable Plaque in Patients with Severe Carotid Artery Stenosis; Comparative Magnetic Resonance Imaging Study. J Stroke Cerebrovasc Dis 2019; 28:104300. [PMID: 31358356 DOI: 10.1016/j.jstrokecerebrovasdis.2019.07.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/08/2019] [Accepted: 07/13/2019] [Indexed: 02/05/2023] Open
Abstract
GOAL There are an increasing idea that the inflammation contributes to vascular diseases in various organs. The pathogenesis of both cerebral small vessel disease such as cerebral microbleeds and carotid plaque may be associated with chronic inflammation. This study was aimed to evaluate the correlation between microbleeds and carotid plaque characteristics. MATERIALS AND METHODS This study enrolled 85 patients who underwent surgical/endovascular treatments for carotid artery stenosis between January 2009 and July 2016. Their clinical data were precisely analyzed. T2*-weighted magnetic resonance (MR) imaging was performed to detect the cerebral microbleeds. The carotid plaque with high signal intensity on T1-weighted MR imaging was categorized into vulnerable plaque. FINDINGS The microbleeds was detected in 17 of 85 (20%). The prevalence of vulnerable carotid plaque and previous symptomatic lacunar infarction was significantly greater in the patients with microbleeds than in those without (P = .001 and P = .03, respectively). Multiple logistic regression analysis showed that the vulnerable plaque was significantly associated with the presence of microbleeds when adjusted for age, alcohol intake, antiplatelet drug use, the presence of previous symptomatic lacunar infarction, and coronary artery disease (P = .009, OR = 5.38, 95% CI = 1.51-21.0). CONCLUSIONS These findings suggest the correlation between microbleeds and vulnerable plaque in patients with severe (>70%) carotid artery stenosis. Systemic, chronic inflammation may play a key role in both small and large arteries' disease of the brain. The knowledge may be valuable to fully understand the entity of cerebrovascular diseases as one of systemic, chronic inflammation.
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Affiliation(s)
- Satoshi Hori
- Department of Neurosurgery, Stroke Center, Saiseikai Toyama Hospital, Toyama, Japan.
| | - Emiko Hori
- Department of Neurosurgery, Stroke Center, Saiseikai Toyama Hospital, Toyama, Japan
| | - Takashi Shibata
- Department of Neurosurgery, Stroke Center, Saiseikai Toyama Hospital, Toyama, Japan
| | - Kimiko Umemura
- Department of Neurosurgery, Stroke Center, Saiseikai Toyama Hospital, Toyama, Japan
| | - Soushi Okamoto
- Department of Neurosurgery, Stroke Center, Saiseikai Toyama Hospital, Toyama, Japan
| | - Michiya Kubo
- Department of Neurosurgery, Stroke Center, Saiseikai Toyama Hospital, Toyama, Japan
| | - Yukio Horie
- Department of Neurosurgery, Stroke Center, Saiseikai Toyama Hospital, Toyama, Japan
| | - Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan
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18
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Prognostic impact of body mass index and culprit lesion calcification in patients with acute myocardial infarction. Heart Vessels 2019; 34:1909-1916. [PMID: 31144097 DOI: 10.1007/s00380-019-01439-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 05/24/2019] [Indexed: 01/17/2023]
Abstract
Patients with acute myocardial infarction (AMI) with low body mass index (BMI) have worse outcomes than obese patients, and this phenomenon is recognized as "obesity paradox." Coronary calcification is associated with cardiac events. However, the association between BMI and calcification and their involvement in the mortality of AMI patients remain unknown. This study consecutively enrolled 517 patients with AMI who underwent emergent coronary intervention within 24 h after onset. Patients were divided into four groups according to the baseline BMI interquartile ranges: Q1 (BMI < 21.9 kg/m2), Q2 (21.9 ≤ BMI < 24.0 kg/m2), Q3 (24.0 ≤ BMI < 26.0 kg/m2), and Q4 (BMI ≥ 26.0 kg/m2). Calcification in the culprit lesion was also evaluated. The Q1 group was older and had a lower frequency of coronary risk factors. Moderate/severe calcification was most frequently observed in Q1, followed by Q2, Q3, and Q4. The Q1 group had the highest all-cause mortality, and patients with moderate/severe calcification had a higher all-cause mortality than that in patients without calcification. The highest all-cause mortality was observed in Q1with calcification, and the lowest was in Q4 without calcification. Q1 and the presence of moderate/severe calcification were independently associated with all-cause mortality. Although low-BMI patients with AMI had a lower frequency of coronary risk factors, they had a worse all-cause mortality than that in high-BMI patients. Our findings suggest that lesion calcification and its possible association with low BMI are involved in the higher mortality rate in these patients.
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19
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Association of Genetic Variation at AQP4 Locus with Vascular Depression. Biomolecules 2018; 8:biom8040164. [PMID: 30563176 PMCID: PMC6316852 DOI: 10.3390/biom8040164] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Revised: 11/27/2018] [Accepted: 11/27/2018] [Indexed: 02/07/2023] Open
Abstract
Despite its substantial clinical importance, specific genetic variants associated with depression have not yet been identified. We sought to identify genetic variants associated with depression by (a) focusing on a more homogenous subsample (vascular depression) and (b) applying a three-stage approach. First, we contacted 730 participants with a confirmed atherosclerotic disease (coronary artery disease) from a population-based study population (German Myocardial Infarction Family Study IV) for psychiatric assessment with the Mini International Neuropsychiatric Interview. Second, we genotyped these patients using genome-wide single nucleotide polymorphism (SNP) arrays. Third, we characterized the SNP via in-silico analysis. The final sample consisted of 342 patients (78.3% male, age = 63.2 ± 9.9 years), 22.8% with a severe depressive disorder. Variant rs528732638 on chromosome 18q11.2 was a genome-wide significant variant and was associated with 3.6-fold increase in the odds of lifetime depression. The locus belongs to a linkage disequilibrium block showing expression quantitative trait loci effects on three putative cis-regulated genes, including the aquaporin 4 (AQP4) locus. AQP4 is already known to mediate the formation of ischemic edema in the brain and heart, increasing the size and extent of resulting lesions. Our findings indicate that AQP4 may also play a role in the etiopathology of vascular depression.
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20
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High-sensitivity cardiac troponin T and severity of cerebral white matter lesions in patients with acute ischemic stroke. J Neurol 2018; 266:37-45. [PMID: 30311052 DOI: 10.1007/s00415-018-9085-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Cardiac troponin (hs-cTnT) is a sensitive marker of myocardial injury and has been linked to incident dementia. The underlying mechanism of that observation is still unknown. Given that severity of cerebral small vessel disease is a predictor of cognitive decline, we aimed to explore whether there is an association between hs-cTnT and severity of white matter lesions (WML) as a marker of cerebral small vessel disease in patients with ischemic stroke. METHODS We analyzed consecutive acute ischemic stroke patients admitted to Charité-University Hospital, Berlin from 2011 to 2013. Severity of WML was graded on 3T-MRI using the age-related white matter severity score (ARWMS). Patients with hs-cTnT elevation suggestive of acute coronary syndrome (ACS) were excluded (hs-cTnT > 52 ng/l or dynamic change of hs-cTnT > 50%, ESC guideline). We performed unadjusted and adjusted quantile regression models to assess the association between increased hs-cTnT (dichotomized at the 99th percentile, 14 ng/l) and severity of WML. RESULTS A total of 860 patients was analyzed (median age 73 years, 44.8% female, median ARWMS 6). Patients with elevated hs-cTnT had more extensive WML than those without (median ARWMS 8 vs. 5, adjusted beta for 50th percentile 1.12, 95% CI 0.41-1.84). The association between WML and hs-cTnT elevation was strongest in patients with severe WML (adjusted beta 1.77, 95% CI 0.26-3.27 for 80th WML percentile). CONCLUSION Elevated hs-cTnT levels were associated with extent of WML in acute stroke patients. Further studies are needed to assess whether hs-cTnT can be used to identify stroke patients at risk for cognitive decline.
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21
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Wei C, Zhang S, Liu J, Yuan R, Liu M. Relationship of cardiac biomarkers with white matter hyperintensities in cardioembolic stroke due to atrial fibrillation and/or rheumatic heart disease. Medicine (Baltimore) 2018; 97:e11892. [PMID: 30113487 PMCID: PMC6112985 DOI: 10.1097/md.0000000000011892] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
White matter hyperintensities (WMHs), which are common in elderly people and contribute to age-related disability, can coexist with cardiac injury. It remains unclear whether cardiac biomarkers are associated with WMHs.To investigate this question, we prospectively recruited patients with cardioembolic stroke due to atrial fibrillation (AF) and/or rheumatic heart disease (RHD). Four cardiac biomarkers were measured: myoglobin, high-sensitivity cardiac troponin T (hs-cTnT), creatine kinase-MB, and terminal pro-brain natriuretic peptide. WMHs in periventricular and deep white matter were assessed separately.In the entire sample of 171 patients, 120 (70.2%) presented with WMHs, of whom 18 (10.5%) presented with moderate to severe deep white matter hyperintensities (DWMH) and 55 (32.2%) presented with moderate to severe periventricular hyperintensities (PVH). Risk of moderate to severe PVH, after adjusting for confounders, was 2.460-fold higher in patients with high myoglobin levels than in those with low levels, and the risk was 2.608-fold higher in patients with high hs-cTnT levels than in those with low levels. There were no significant associations between any of the 4 cardiac biomarkers and moderate to severe DWMH.This prospective observational study provides new evidence of the potential relationship of cardiac biomarkers with WMHs in patients with cardioembolic stroke due to AF and/or RHD. We found that elevated myoglobin levels and high hs-TnT levels were independently associated with the presence of moderate to severe PVH. Further studies are required to test our findings and explore whether cardiac biomarkers contribute directly to WMHs pathogenesis.
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22
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Saleem M, Herrmann N, Dinoff A, Mielke MM, Oh PI, Shammi P, Cao X, Venkata SLV, Haughey NJ, Lanctôt KL. A Lipidomics Approach to Assess the Association Between Plasma Sphingolipids and Verbal Memory Performance in Coronary Artery Disease Patients Undertaking Cardiac Rehabilitation: A C18:0 Signature for Cognitive Response to Exercise. J Alzheimers Dis 2018; 60:829-841. [PMID: 28598843 DOI: 10.3233/jad-161292] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Early subtle deficits in verbal memory, which may indicate early neural risk, are common in patients with coronary artery disease (CAD). While exercise can improve cognition, cognitive response to exercise is heterogeneous. Sphingolipids have been associated with the development and progression of CAD, and impairments in sphingolipid metabolism may play roles in neurodegeneration and in the neural adaptation response to exercise. OBJECTIVE In this study, change in plasma concentrations of sphingolipids was assessed in relation to change in verbal memory performance and in other cognitive domains among CAD subjects undertaking a 6-month cardiac rehabilitation (CR) program. METHODS Patients with CAD (n = 120, mean age = 64±6 y, 84% male, years of education = 16±3) underwent CR with neuropsychological assessments and blood collected at baseline, 3-, and 6-months. Z-scores based on age, gender, and education were combined for verbal memory, visuospatial memory, processing speed, executive function, and global cognition tasks to calculate cognitive domain Z-scores. Plasma sphingolipid concentrations were measured from fasting blood samples using high performance liquid chromatography coupled electrospray ionization tandem mass spectrometry (LC/MS/MS). Mixed models were used to identify sphingolipids significantly associated with performance in verbal memory and other cognitive domains, adjusting for potential confounders. RESULTS A decrease in ceramide C18:0 concentration was significantly associated with improvement in verbal memory performance (b[SE] = -0.51 [0.25], p = 0.04), visuospatial memory (b[SE] = -0.44 [0.22], p = 0.05), processing speed (b[SE] = -0.89 [0.32], p = 0.007), and global cognition (b[SE] = -1.47 [0.59], p = 0.01) over 6 months of CR. CONCLUSIONS Plasma ceramide C18:0 concentrations may be a sensitive marker of cognitive response to exercise in patients with CAD.
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Affiliation(s)
- Mahwesh Saleem
- Neuropsychopharmacology Research Group, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Nathan Herrmann
- Neuropsychopharmacology Research Group, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Adam Dinoff
- Neuropsychopharmacology Research Group, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada
| | - Michelle M Mielke
- Departments of Neurology and Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Paul I Oh
- Division of Clinical Pharmacology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Toronto Rehabilitation Institute, Toronto, ON, Canada
| | - Prathiba Shammi
- Neuropsychology, Sunnybrook HealthSciences Centre, Toronto, ON, Canada
| | - Xingshan Cao
- Evaluative Clinical Sciences, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | | | - Norman J Haughey
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Psychiatry, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Krista L Lanctôt
- Neuropsychopharmacology Research Group, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Pharmacology and Toxicology, University of Toronto, Toronto, ON, Canada.,Department of Psychiatry, University of Toronto, Toronto, ON, Canada.,Toronto Rehabilitation Institute, Toronto, ON, Canada
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23
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Ramezankhani A, Azizi F, Hadaegh F, Momenan AA. Diabetes and number of years of life lost with and without cardiovascular disease: a multi-state homogeneous semi-Markov model. Acta Diabetol 2018; 55:253-262. [PMID: 29299678 DOI: 10.1007/s00592-017-1083-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2017] [Accepted: 11/20/2017] [Indexed: 12/14/2022]
Abstract
AIMS We quantified the impact of type 2 diabetes on incidence of non-fatal cardiovascular disease (CVD) and mortality, considering CVD as a continuum from occurrence of diabetes to the end point, and estimated the 15-year life expectancy with and without CVD. METHODS A total of 7239 Iranian adults (3246 men), aged ≥ 30 years, were followed from 1999 to 2014. We applied a multi-state semi-Markov model with three transitions including CVD-free to non-fatal CVD, CVD-free to death and non-fatal CVD to death, and studied the influence of diabetes on each transition rate, stratifying by sex and adjusting for confounders. RESULTS Diabetes was significantly associated with increased risk of non-fatal CVD in men [hazard ratio, 1.70 (1.36-3.53)] and women [2.19 (1.74-2.77)], and of all-cause death [2.72 (2.03-3.63) and 1.92 (1.37-2.67) in men and women, respectively]. An increased risk of mortality was found only among diabetic men, when non-fatal CVD was occurred [2.19 (1.36-3.53)]. Men with diabetes experienced first non-fatal CVD and death without CVD 1.7 and 1.4 years, respectively, earlier than those without diabetes; the corresponding values were 1.4 and 0.7 years for women. Moreover, diabetic men lived 1.3 years less than non-diabetic counterparts when non-fatal CVD was occurred. CONCLUSIONS Diabetes increased the risk of non-fatal CVD events and all-cause mortality and consequently decreased the number of years lived without CVD. A decrease in LE was found only among diabetic men compared to non-diabetics after non-fatal CVD occurred.
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Affiliation(s)
- Azra Ramezankhani
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Floor 3th, Number 24, Yemen Street, Shahid Chamran Highway, P.O. Box: 19395-4763, Tehran, Iran
| | - Fereidoun Azizi
- Endocrine Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Farzad Hadaegh
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Floor 3th, Number 24, Yemen Street, Shahid Chamran Highway, P.O. Box: 19395-4763, Tehran, Iran.
| | - Amir Abbas Momenan
- Prevention of Metabolic Disorders Research Center, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Floor 3th, Number 24, Yemen Street, Shahid Chamran Highway, P.O. Box: 19395-4763, Tehran, Iran
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24
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Suemoto CK, Bittencourt MS, Santos IS, Benseñor IM, Lotufo PA. Coronary artery calcification and cognitive function: cross-sectional results from the ELSA-Brasil study. Int J Geriatr Psychiatry 2017; 32:e188-e194. [PMID: 28240378 DOI: 10.1002/gps.4698] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 02/03/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVES We examined the relationship between coronary artery calcification (CAC) score and performance in cognitive tests in a large Brazilian sample. METHODS In this cross-sectional study, 4104 participants (mean age = 50.9 ± 8.8 years old, 54% female) from the Brazilian Longitudinal Study of Adult Health had complete information for CAC and cognitive tests. We used linear regression models adjusted for sociodemographics, cardiovascular risk factors (hypertension, diabetes, smoking, alcohol use, physical activity, and body mass index), depression, and thyroid function. To investigate potential different associations for middle-aged and older adults, we stratified the analysis by age groups. RESULTS Participants with CAC ≥ 100 Agatston score had poorer performance in the trail making test compared to those with CAC < 100 Agatston score (β = -0.101, 95% CI = -0.194; -0.010, p = 0.03). We did not find any other association between CAC and cognitive tests. When we investigated the effect modification between CAC and age on cognitive tests, only the effect modification on global cognition (p = 0.02) and trail making test was significant (p = 0.0003). CONCLUSIONS Higher CAC was weakly associated with poorer performance in an executive function test in a large sample from the Brazilian Longitudinal Study of Adult Health. Copyright © 2017 John Wiley & Sons, Ltd.
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Affiliation(s)
- Claudia K Suemoto
- Division of Geriatrics, University of São Paulo Medical School, São Paulo, Brazil.,Center for Clinical and Epidemiological Research, Hospital Universitário, University of São Paulo, São Paulo, Brazil
| | - Marcio S Bittencourt
- Center for Clinical and Epidemiological Research, Hospital Universitário, University of São Paulo, São Paulo, Brazil
| | - Itamar S Santos
- Center for Clinical and Epidemiological Research, Hospital Universitário, University of São Paulo, São Paulo, Brazil.,Department of Internal Medicine, University of São Paulo Medical School, São Paulo, Brazil
| | - Isabela M Benseñor
- Center for Clinical and Epidemiological Research, Hospital Universitário, University of São Paulo, São Paulo, Brazil.,Department of Internal Medicine, University of São Paulo Medical School, São Paulo, Brazil
| | - Paulo A Lotufo
- Center for Clinical and Epidemiological Research, Hospital Universitário, University of São Paulo, São Paulo, Brazil.,Department of Internal Medicine, University of São Paulo Medical School, São Paulo, Brazil
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25
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Chaikriangkrai K, Jhun HY, Palamaner Subash Shantha G, Bin Abdulhak A, Sigurdsson G, Nabi F, Mahmarian JJ, Chang SM. Coronary artery calcium score as a predictor for incident stroke: Systematic review and meta-analysis. Int J Cardiol 2017; 236:473-477. [DOI: 10.1016/j.ijcard.2017.01.132] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 01/30/2017] [Indexed: 11/26/2022]
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26
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Is there a role for coronary artery calcification scoring in primary prevention of cerebrovascular disease? Atherosclerosis 2017; 257:279-287. [DOI: 10.1016/j.atherosclerosis.2017.01.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 11/29/2016] [Accepted: 01/12/2017] [Indexed: 12/20/2022]
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27
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Nicoll R, Henein M. Arterial calcification: A new perspective? Int J Cardiol 2017; 228:11-22. [DOI: 10.1016/j.ijcard.2016.11.099] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 11/06/2016] [Indexed: 12/19/2022]
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28
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Won HY, Park MH, Im DG, Park SS, Ahn JY, Heo JH. Bilateral Striatopallidodentate Calcinosis and Severe White Matter Lesions in Hypoparathyroidism. Ann Geriatr Med Res 2016. [DOI: 10.4235/agmr.2016.20.3.160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Hye-Yeon Won
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Min-Ho Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Dong-Gyu Im
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Jin-Young Ahn
- Department of Neurology, Seoul Medical Center, Seoul, Korea
| | - Jae-Hyeok Heo
- Department of Neurology, Seoul Medical Center, Seoul, Korea
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29
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Oh HG, Chung PW, Rhee EJ. Increased risk for intracranial arterial stenosis in subjects with coronary artery calcification. Stroke 2014; 46:151-6. [PMID: 25388414 DOI: 10.1161/strokeaha.114.006996] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Intracranial arterial stenosis (ICAS) is considered an important cause of stroke in Asians. Coronary artery calcification (CAC) is a surrogate marker for subclinical atherosclerosis. We aimed to analyze the association of ICAS assessed by transcranial Doppler ultrasonography and CAC in middle-aged Korean population. METHODS This study included 10 550 participants (81.3% men, mean age 43 years) from a health screening program, in whom transcranial Doppler ultrasonography was used to detect >50% intracranial stenosis based on criteria modified from the stroke outcomes and neuroimaging of intracranial atherosclerosis trial. Multidetector computed tomography was used to assess coronary artery calcium score (CACS). CAC grade (0, 1-100, and >100) was defined by CACS. RESULTS The subjects with CAC showed significantly higher proportion of subjects with ICAS compared with those without CAC (4.4% versus 2.8%; P<0.01). Conversely, the subjects with ICAS showed significantly higher proportion of subjects with CAC (24.8% versus 17.1%; P<0.01). When logistic regression analysis was performed with ICAS as the dependent variable, the presence of CAC showed significantly increased risk for ICAS after adjustment for confounding variables (odds ratio, 1.439; 95% confidence interval, 1.095-1.891). When CACS grade was included in the model, the odds ratio for ICAS was the highest in subjects with CACS >400 compared with those with CACS=0 (odds ratio, 2.754; 95% confidence interval, 1.205-2.936). CONCLUSIONS The risk for ICAS was significantly increased in middle-aged Korean subjects with CAC compared with that in those without CAC. These findings suggest the possibility of a separate undetected atherosclerotic focus in subjects with 1 atherosclerotic event.
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Affiliation(s)
- Hyung-Geun Oh
- From the Department of Neurology, Soonchunhyang University College of Medicine, Cheonan, Korea (H.-G.O.); and Departments of Neurology (P.-W.C.) and Endocrinology and Metabolism (E.-J.R.), Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Pil-Wook Chung
- From the Department of Neurology, Soonchunhyang University College of Medicine, Cheonan, Korea (H.-G.O.); and Departments of Neurology (P.-W.C.) and Endocrinology and Metabolism (E.-J.R.), Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Eun-Jung Rhee
- From the Department of Neurology, Soonchunhyang University College of Medicine, Cheonan, Korea (H.-G.O.); and Departments of Neurology (P.-W.C.) and Endocrinology and Metabolism (E.-J.R.), Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Intracranial Vascular Calcification is Protective from Vasospasm after Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2014; 23:2687-2693. [DOI: 10.1016/j.jstrokecerebrovasdis.2014.06.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 06/13/2014] [Indexed: 11/22/2022] Open
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Elevated brain lesion volumes in older adults who use calcium supplements: a cross-sectional clinical observational study. Br J Nutr 2014; 112:220-7. [PMID: 24787048 DOI: 10.1017/s0007114514000828] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Recent studies have implicated Ca supplements in vascular risk elevation, and therefore these supplements may also be associated with the occurrence of brain lesions (or hyperintensities) in older adults. These lesions represent damage to brain tissue that is caused by ischaemia. In the present cross-sectional clinical observational study, the association between Ca-containing dietary supplement use and lesion volumes was investigated in a sample of 227 older adults (60 years and above). Food and supplemental Ca intakes were assessed with the Block 1998 FFQ; participants with supplemental Ca intake above zero were categorised as supplement users. Lesion volumes were determined from cranial MRI (1.5 tesla) scans using a semi-automated technique; volumes were log-transformed because they were non-normal. ANCOVA models revealed that supplement users had greater lesion volumes than non-users, even after controlling for food Ca intake, age, sex, race, years of education, energy intake, depression and hypertension (Ca supplement use: β = 0.34, SE 0.10, F(1,217)= 10.98, P= 0.0011). The influence of supplemental Ca use on lesion volume was of a magnitude similar to that of the influence of hypertension, a well-established risk factor for lesions. Among the supplement users, the amount of supplemental Ca was not associated with lesion volume (β = - 0.000035, SE 0.00 015, F(1,139)= 0.06, P= 0.81). The present study demonstrates that the use of Ca-containing dietary supplements, even low-dose supplements, by older adults may be associated with greater lesion volumes. Evaluation of randomised controlled trials is warranted to determine whether this relationship is a causal one.
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Ueno Y, Okuzumi A, Watanabe M, Tanaka Y, Shimada Y, Yamashiro K, Tanaka R, Hattori N, Urabe T. Cerebral Small Artery Diseases may be Associated with Aortic Arch Calcification in Stroke Patients. J Atheroscler Thromb 2014; 21:1011-21. [DOI: 10.5551/jat.22483] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Lin TC, Chao TH, Shieh Y, Lee TH, Chang YJ, Lee JD, Peng TI, Chang KC, Liou CW, Chang TY, Hung KL, Chang CH. The Impact of Intracranial Carotid Artery Calcification on the Development of Thrombolysis-Induced Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2013; 22:e455-62. [DOI: 10.1016/j.jstrokecerebrovasdis.2013.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2013] [Revised: 04/15/2013] [Accepted: 05/05/2013] [Indexed: 10/26/2022] Open
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Kral BG, Nyquist P, Vaidya D, Yousem D, Yanek LR, Fishman EK, Becker LC, Becker DM. Relation of subclinical coronary artery atherosclerosis to cerebral white matter disease in healthy subjects from families with early-onset coronary artery disease. Am J Cardiol 2013; 112:747-52. [PMID: 23742943 DOI: 10.1016/j.amjcard.2013.05.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 05/02/2013] [Accepted: 05/02/2013] [Indexed: 01/12/2023]
Abstract
White matter disease (WMD) of the brain is associated with incident stroke. Similarly, subclinical calcified coronary artery plaque has been associated with incident coronary artery disease (CAD) events. Although atherogenesis in both vascular beds may share some common mechanisms, the extent to which subclinical CAD is associated with WMD across age ranges in subjects with a family history of early-onset CAD remains unknown. We screened 405 apparently healthy participants in the Genetic Study of Atherosclerotic Risk for CAD risk factors and for the presence of noncalcified and calcified coronary plaque using dual-source multidetector cardiac computed tomographic angiography. The presence and volumes of WMD were assessed by 3-Tesla brain magnetic resonance imaging. Participants were 60% women, 36% African-American, mean age 51.6 ± 10.6 years. The overall prevalence of coronary plaque was 43.0%. Subjects with coronary plaque had significantly greater WMD volumes (median 1,222 mm³, interquartile range 448 to 3,871) compared with those without coronary plaque (median 551 mm³, interquartile range 105 to 1,523, p <0.001). In multivariate regression analysis, adjusting for age, gender, race, traditional risk factors, total brain volume, and intrafamilial correlations, the presence of coronary plaque was independently associated with WMD volume (p = 0.05). This study shows a significant association between WMD and noncalcified and calcified coronary plaque in healthy subjects, independent of age and risk factors. In conclusion, these findings support the premise of possible shared causal pathways in 2 vascular beds in families at increased risk for early-onset vascular disease.
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Affiliation(s)
- Brian G Kral
- Division of Cardiology, Department of Medicine, Johns Hopkins GeneSTAR Research Program, The Johns Hopkins Medical Institutions, Baltimore, MD, USA.
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Dadu RT, Fornage M, Virani SS, Nambi V, Hoogeveen RC, Boerwinkle E, Alonso A, Gottesman RF, Mosley TH, Ballantyne CM. Cardiovascular biomarkers and subclinical brain disease in the atherosclerosis risk in communities study. Stroke 2013; 44:1803-8. [PMID: 23660848 PMCID: PMC4334904 DOI: 10.1161/strokeaha.113.001128] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Accepted: 04/10/2013] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Cerebrovascular and cardiovascular disease share common risk factors. Our goal was to determine whether levels of N-terminal brain natriuretic peptide (NT-proBNP) and cardiac troponin T measured with a highly sensitive assay (hs-cTnT) are associated with silent brain infarcts (BIs) and white matter lesions (WMLs) on MRI in the Atherosclerosis Risk in Communities (ARIC) study. METHODS At ARIC visit 3 (1993-1995), 1920 participants had brain MRI. NT-proBNP and hs-cTnT were measured in all individuals at ARIC visit 4 (1996-1998). Of 1920 individuals, 1112 had a follow-up MRI [2004-2006]). We analyzed the association of NT-proBNP and hs-cTnT with MRI-defined BI and WML on the initial MRI and incident BI and WML progression on the follow-up MRI in participants without heart failure, coronary heart disease, or stroke. RESULTS In the adjusted model, individuals in the highest NT-proBNP quartile had significantly more BI (odds ratio, 3.50; 95% confidence interval, 2.03-6.20), and WML (β-coefficient, 0.09; SE, 0.03) on the baseline MRI and more incident BI (odds ratio, 2.18; 95% confidence interval, 1.38-3.47) and WML progression (β-coefficient, 0.22; SE, 0.10) on the follow-up MRI. Individuals in the highest hs-cTnT category had more BI (odds ratio, 3.03; 95% confidence interval, 1.57-5.82) and WML (β-coefficient, 0.11; SE, 0.04) on the initial MRI and more WML progression (β-coefficient, 0.43; SE, 0.17) on the follow-up MRI. CONCLUSIONS NT-proBNP and hs-cTnT are independently associated with silent MRI-defined BI and WML, suggesting that cardiovascular biomarkers may be useful to identify individuals with subclinical cerebral injury.
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Affiliation(s)
- Razvan T Dadu
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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Serum ionized calcium may be related to white matter lesion volumes in older adults: a pilot study. Nutrients 2013; 5:2192-205. [PMID: 23778149 PMCID: PMC3725500 DOI: 10.3390/nu5062192] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2013] [Revised: 06/05/2013] [Accepted: 06/06/2013] [Indexed: 12/03/2022] Open
Abstract
White matter lesions have detrimental effects upon older adults, while serum calcium levels have been associated with elevated vascular risk and may be associated with these lesions. Depression, a serious mental disorder characterized by disturbances in calcium metabolism, may be an important contributor to any calcium-lesion relationship. This cross-sectional pilot study examined the association between serum ionized calcium (the physiologically active form of calcium) and white matter lesion volumes in a sample of depressed and non-depressed older adults (N = 42; 60 years and older). Serum ionized calcium was determined using an ion-selective electrode technique, while lesion volumes were estimated from magnetic resonance imaging using an automated expectation-maximization segmentation. A linear regression model, controlling for age and group (depression vs. comparison), showed a trend for a positive relationship between serum ionized calcium and white matter lesion volume (β = 4.34, SE = 2.27, t = 1.91, p = 0.063). Subsample analyses with depressed participants showed a significant positive relationship between higher ionic calcium and greater lesion volume (β = 6.41, SE = 2.53, t = 2.53, p = 0.018), but no association was found for non-depressed participants. Sex-specific subsample analyses showed a significant positive relationship between higher calcium and greater lesion volume in men only (β = 7.49, SE = 3.42, t = 2.19, p = 0.041). These preliminary results indicate that serum ionized calcium may be associated with white matter lesions in older adults, particularly among men and individuals with depression. Larger studies are needed to confirm these findings.
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Kim D, Lee SH, Joon Kim B, Jung KH, Yu KH, Lee BC, Roh JK. Secondary prevention by stroke subtype: a nationwide follow-up study in 46 108 patients after acute ischaemic stroke. Eur Heart J 2013; 34:2760-7. [PMID: 23729692 DOI: 10.1093/eurheartj/eht185] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AIMS Although use of antithrombotic agents is recommended after ischaemic stroke or transient ischaemic attack (TIA), long-term outcome of secondary prevention between stroke subtypes has not yet been explored. METHODS AND RESULTS We used data from the Korean Stroke Registry (KSR), a nationwide, multicentre, prospective registry for acute stroke patients. Patients with acute ischaemic stroke or TIA within 7 days of onset were consecutively enrolled between January 2002 and September 2010. A total of 46 108 patients with ischaemic stroke and TIA were included in this study. Among the major stroke subtypes, stroke due to small vessel occlusion (SVO) showed the lowest mortality, whereas cardioembolic stroke (CE) was associated with the fatal prognosis during the follow-up [for SVO: hazard ratio (HR) 0.66, 95% CI 0.62-0.71; for CE: HR 1.41, 95% CI 1.30-1.53; large artery atherosclerosis (LAA) group as a reference]. Regarding secondary prevention, antiplatelet polytherapy was better than monotherapy in the patients with LAA-related stroke in prognosis [HR 0.89, 95% CI 0.80-0.98]. Anticoagulant therapy was associated with better outcome than antiplatelet monotherapy in CE-related stroke [HR 0.66, 95% CI 0.59-0.74]. In SVO-related stroke group, antiplatelet polytherapy failed to show benefits over monotherapy. Additionally, the risk of death was higher with anticoagulant therapy in the patients with SVO-related stroke [HR 1.44, CI 95% 1.06-1.97]. CONCLUSIONS Our study demonstrated that stroke subtype affects prognosis and also determines the effectiveness of secondary prevention.
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Affiliation(s)
- Dohoung Kim
- Department of Neurology, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul 110-744, Republic of Korea
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Ahn SS, Nam HS, Heo JH, Kim YD, Lee SK, Han KH, Choi BW, Kim EY. Ischemic stroke: measurement of intracranial artery calcifications can improve prediction of asymptomatic coronary artery disease. Radiology 2013; 268:842-9. [PMID: 23674788 DOI: 10.1148/radiol.13122417] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To examine the associations between intracranial artery calcifications (IACs) and coronary artery calcifications (CACs) in patients with ischemic stroke and to assess the predictive value of IAC for asymptomatic coronary artery disease (CAD). MATERIALS AND METHODS This retrospective study, approved by an institutional review board that waived the need for informed consent, included 314 consecutive patients who had acute ischemic stroke and who underwent both brain and coronary computed tomography (CT) within 1 month of stroke. IAC was quantified semiautomatically by calculating both Agatston scores (area of calcification multiplied by a weighted value assigned to its highest Hounsfield unit) and volumes on thin-section unenhanced images and was correlated with coronary calcium scores and volumes. Quartiles were created for IAC scores and were used for logistic regression analysis. An optimal IAC score cutoff value was determined and used to predict the presence of asymptomatic CAD. Independent factors for asymptomatic CAD were assessed by using multiple logistic regression analysis. Receiver operating characteristic curve analysis was performed to evaluate the added value of IAC scores for prediction of asymptomatic CAD. RESULTS IAC and CAC were significantly correlated for both Agatston scores and volumes (R = 0.665 and 0.663, respectively; P < .001). A graded association was found between IAC scores and presence of asymptomatic CAD. Both IAC scores of 120.11 or greater (odds ratio [OR], 2.57; 95% confidence interval [CI]: 1.45, 4.55) and diabetes mellitus (OR, 4.23; 95% CI: 2.42, 7.4) were independent predictors for asymptomatic CAD. Adding the IAC score to analytic models significantly improved the ability to predict asymptomatic CAD. CONCLUSION The IAC scores quantified by using unenhanced CT correlate significantly with coronary calcium scores and may serve as an independent predictor of asymptomatic CAD in patients with ischemic stroke.
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Affiliation(s)
- Sung Soo Ahn
- Department of Radiology, Research Institute of Radiological Science, Yonsei University College of Medicine, Seoul, Korea
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Hermann DM, Gronewold J, Lehmann N, Moebus S, Jöckel KH, Bauer M, Erbel R. Coronary artery calcification is an independent stroke predictor in the general population. Stroke 2013; 44:1008-13. [PMID: 23449263 DOI: 10.1161/strokeaha.111.678078] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Coronary artery calcification (CAC) is a noninvasive marker of plaque load that predicts myocardial infarcts in the general population. Herein, we investigated whether CAC predicts stroke events in addition to established risk factors that are part of the Framingham risk score. METHODS A total of 4180 subjects from the population-based Heinz Nixdorf Recall study (45-75 years of age; 47.1% men) without previous stroke, coronary heart disease, or myocardial infarction were evaluated for stroke events over 94.9 ± 19.4 months. Cox proportional hazards regressions were used to examine CAC as stroke predictor in addition to established vascular risk factors (age, sex, systolic blood pressure, low-density lipoprotein, high-density lipoprotein, diabetes mellitus, smoking, and atrial fibrillation). RESULTS Ninety-two incident strokes occurred (82 ischemic, 10 hemorrhagic). Subjects suffering a stroke had significantly higher CAC values at baseline than the remaining subjects (median, 104.8[Q1;Q3, 14.0;482.2] vs 11.2[0;106.2]; P<0.001). In a multivariable Cox regression, log10(CAC+1) was an independent stroke predictor (hazards ratio, 1.52 [95% confidence interval, 1.19-1.92]; P=0.001) in addition to age (1.35 per 5 years [1.15-1.59]; P<0.001), systolic blood pressure (1.25 per 10 mm Hg [1.14-1.37]; P<0.001), and smoking (1.75 [1.07-2.87]; P=0.025). CAC predicted stroke in men and women, particularly in subjects <65 years of age and independent of atrial fibrillation. CAC discriminated stroke risk specifically in participants belonging to the low (<10%) and intermediate (10%-20%) Framingham risk score categories. CONCLUSIONS CAC is an independent stroke predictor in addition to classical risk factors in subjects at low or intermediate vascular risk.
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Affiliation(s)
- Dirk M Hermann
- Department of Neurology, University Hospital Essen, Essen, Germany.
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Silent brain infarct is independently associated with arterial stiffness indicated by cardio-ankle vascular index (CAVI). Hypertens Res 2012; 35:756-60. [PMID: 22378472 DOI: 10.1038/hr.2012.20] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
It is still unclear whether silent brain infarct (SBI) and white-matter hyperintensities (WMHs) on magnetic resonance imaging (MRI) scans are associated with cardio-ankle vascular index (CAVI), a novel parameter of arterial stiffness. We studied 220 consecutive patients (mean age, 69 years) without a history of stroke or transient ischemic attack. Patients were assessed for the presence of SBI, WMHs and risk factors. Arterial stiffness was evaluated using CAVI. Patients were categorized into one of two groups according to the presence or absence of SBI and WMHs, and clinical characteristics were compared between the two groups. CAVI was significantly higher in patients with SBI or in patients with WMHs than in those without those respective findings. The CAVI cutoff values for detection of SBI and WMHs were 9.2 and 8.9, respectively. On multivariable analyses, CAVI, a one point increase in CAVI: odds ratio (OR), 1.25; 95% confidence interval (CI), 1.01-1.56; CAVI ≥9.2: OR, 2.34; 95% CI, 1.16-5.02, was independently associated with SBI, however, CAVI was not independently associated with WMHs. Patients with CAVI ≥9.2 had higher OR for the presence of both SBI and WMHs (OR, 2.57; 95% CI, 1.15-5.98) when compared with patients with CAVI <9.2 after adjustment for age and sex. SBI is independently associated with arterial stiffness indicated by CAVI.
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Ryu WS, Lee SH, Kim CK, Kim BJ, Yoon BW. The Relation between Chronic Kidney Disease and Cerebral Microbleeds: Difference between Patients with and without Diabetes. Int J Stroke 2012; 7:551-7. [DOI: 10.1111/j.1747-4949.2011.00732.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Cerebral microbleeds are an important radiologic marker of bleeding-prone brain and have been reported to be associated with the increased risk of intracerebral haemorrhage. Aims We sought to examine the association of chronic kidney disease with cerebral microbleeds, and determine whether the association differs between patients with and without diabetes. Methods A total of 909 patients with ischemic stroke who were consecutively admitted to our hospital were included in this study. We collected demographic, clinical, and laboratory data (including serum creatinine levels) and documented the presence and numbers of microbleeds. Kidney function was estimated by using the Modification of Diet in Renal Disease formula. We categorized estimated glomerular filtration rates into moderate to severe, mild, and normal (<60, 60–90, and >90 ml/min/1.73 m2, respectively). Results Cerebral microbleeds is most frequent in the moderate-to-severe chronic kidney disease group (45.6%). In patients without diabetes, mild and moderate-to-severe chronic kidney disease was found to be independently associated with the presence of cerebral microbleeds (adjusted odds ratio, 1.68; 95% confidence interval, 1.04–2.71 and adjusted odds ratio, 3.74; 95% confidence interval, 1.87–7.47) compared with normal kidney function. In patients with diabetes, however, this relationship was not found. Furthermore, ordinal logistic regression analysis revealed that an increased serum creatinine level and a reduced kidney function were associated with the number of cerebral microbleeds. Conclusion We found that chronic kidney disease is independently associated with cerebral microbleeds in patients without diabetes but not in patients with diabetes.
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Affiliation(s)
- Wi-Sun Ryu
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Clinical Research Center for Stroke, Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Seung-Hoon Lee
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Clinical Research Center for Stroke, Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Chi Kyung Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Clinical Research Center for Stroke, Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Beom Joon Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Clinical Research Center for Stroke, Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
| | - Byung-Woo Yoon
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
- Clinical Research Center for Stroke, Clinical Research Institute, Seoul National University Hospital, Seoul, Korea
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Fujimoto H, Nakamura M, Yokoi H. Impact of Calcification on the Long-Term Outcomes of Sirolimus-Eluting Stent Implantation - Subanalysis of the Cypher Post-Marketing Surveillance Registry -. Circ J 2012; 76:57-64. [DOI: 10.1253/circj.cj-11-0738] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
| | - Masato Nakamura
- Department of Cardiology, Toho University Ohashi Medical Center
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Mogi M, Horiuchi M. Neurovascular coupling in cognitive impairment associated with diabetes mellitus. Circ J 2011; 75:1042-8. [PMID: 21441696 DOI: 10.1253/circj.cj-11-0121] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Although it is feared that diabetes-induced cognitive decline will become a major clinical problem worldwide in the future, the detailed pathological mechanism is not well known. Because patients with diabetes have various complications of vascular disease, with not only macrovascular but also microvascular disorders, vascular disorders in the brain are considered to be one of the mechanisms in diabetes-induced cognitive impairment. Indeed, disruption of the blood-brain barrier (BBB) has been observed in some diabetic patients and experimental diabetes models. Moreover, white matter lesions, part of the evidence of BBB dysfunction, are reported to be observed more frequently in patients with diabetes. Animal studies demonstrate that diabetes enhances BBB permeability through a decrease in the level of tight junction proteins and an increase in matrix metalloproteinase activity. However, there are several reports indicating that BBB disruption does not occur with diabetes. Therefore, the association of BBB breakdown with diabetes-induced cognitive impairment is not conclusive. Recently, neuronal diseases involving dementia have been induced experimentally through dysfunction of neurovascular coupling, which involves blood vessels, astrocytes and neutrons. Diabetes-induced cognitive decline may be induced via disruption of neurovascular coupling, with not only vascular disorder but also impairment of astrocytic trafficking. Here, the relation between vascular disorder and cognitive impairment in diabetes is discussed.
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Affiliation(s)
- Masaki Mogi
- Department of Molecular Cardiovascular Biology and Pharmacology, Ehime University, Graduate School of Medicine, Tohon, Japan.
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Iijima K, Akishita M, Ouchi Y. Coronary artery calcification and cerebral small vessel disease. Association of systemic atherosclerosis. Circ J 2010; 75:272-3. [PMID: 21178293 DOI: 10.1253/circj.cj-10-1192] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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