Carotid artery intima-media thickness, carotid plaque and coronary heart disease and stroke in Chinese

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Varying Definitions of Carotid Intima-Media Thickness and Future Cardiovascular Disease: A Systematic Review and Meta-Analysis

BACKGROUND

Carotid intima-media thickness (cIMT) has been widely used as a predictor of future cardiovascular disease (CVD); however, various definitions of cIMT exist. This study provides a systematic review and meta-analysis of the associations between different cIMT definitions and CVD.

METHODS AND RESULTS

A systematic review of the different cIMT definitions used in prospective cohort studies was performed. The relationships between cIMT of different definitions (common carotid artery IMT [CCA-IMT], internal carotid artery IMT [ICA-IMT], combined segments [combined-IMT], mean CCA-IMT, and maximum CCA-IMT) with future stroke, myocardial infarction (MI), and CVD events were analyzed using random effects models. Among 2287 articles, 18 articles (14 studies) with >10 different cIMT definitions were identified and included in our meta-analysis. After adjusting for age and sex, a 1-SD increase in CCA-IMT was associated with future stroke (hazard ratio [HR], 1.32 [95% CI, 1.27-1.38]), MI (HR, 1.27 [95% CI, 1.22-1.33]), and CVD events (HR, 1.28 [95% CI, 1.19-1.37]). A 1-SD increase in ICA-IMT was related to future stroke (HR, 1.25 [95% CI, 1.11-1.42]) and CVD events (HR, 1.25 [95% CI, 1.04-1.50]) but not MI (HR, 1.26 [95% CI, 0.98-1.61]). A 1-SD increase in combined-IMT was associated with future stroke (HR, 1.30 [95% CI, 1.08-1.57]) and CVD events (HR, 1.36 [95% CI, 1.23-1.49]). Maximum CCA-IMT was more strongly related than mean CCA-IMT with risk of MI, and both measures were similarly associated with stroke and CVD events.

CONCLUSIONS

Combined-IMT is more strongly associated with CVD events compared with single-segment cIMT definitions. Maximum CCA-IMT shows a stronger association with MI than mean CCA-IMT. Further research is warranted to validate our findings and to standardize the cIMT measurement protocol, as well as to explore underlying mechanisms.

Validity and Reliability of Point-of-Care Ultrasound for Detecting Moderate- or High-Grade Carotid Atherosclerosis in an Outpatient Department

The prevalence of carotid stenosis is considerably higher in asymptomatic individuals with multiple risk factors than in the general population. We investigated the validity and reliability of carotid point-of-care ultrasound (POCUS) for rapid carotid atherosclerosis screening. We prospectively enrolled asymptomatic individuals with carotid risk scores of ≥7 who underwent outpatient carotid POCUS and laboratory carotid sonography. Their simplified carotid plaque scores (sCPSs) and Handa's carotid plaque scores (hCPSs) were compared. Of 60 patients (median age, 81.9 years), 50% were diagnosed as having moderate- or high-grade carotid atherosclerosis. The overestimation and underestimation of outpatient sCPSs were more likely in patients with low and high laboratory-derived sCPSs, respectively. Bland-Altman plots indicated that the mean differences between the participants' outpatients and laboratory sCPSs were within two standard deviations of their laboratory sCPSs. A Spearman's rank correlation coefficient revealed a strong positive linear correlation between outpatient and laboratory sCPSs (r = 0.956, p < 0.001). An intraclass correlation coefficient analysis indicated excellent reliability between the two methods (0.954). Both carotid risk score and sCPS were positively and linearly correlated with laboratory hCPS. Our findings indicate that POCUS has satisfactory agreement, strong correlation, and excellent reliability with laboratory carotid sonography, making it suitable for rapid screening of carotid atherosclerosis in high-risk patients.

Exploring the Risk Factors of Sudden Cardiac Death Using an Electrocardiography and Medical Ultrasonography for the General Population Without a History of Coronary Artery Disease or Left Ventricular Ejection Fraction <35% and Aged >35 Years - A Novel Point-Based Prediction Model Based on the Chin-Shan Community Cardiovascular Cohort

BACKGROUND

Most of the factors and prediction models of sudden cardiac death (SCD) have been developed without considering the Asia population. The purpose of this study is to construct a point-based prediction model for the general population in Asia.

METHODS AND RESULTS

Chin-Shan Community Cardiovascular Cohort (CCCC) is a community-based longitudinal cohort initiated between 1990 and 1991, enrolling participants aged ≥35 years and following them up until 2005. Participants with coronary artery disease (CAD) or a left ventricular ejection fraction (LVEF) of 35% were excluded from this study. The Framingham risk score function was used to derive a simple point-based prediction model. Based on bootstrapping, a novel model (CCCC-SCD-Score) was validated. A total of 2,105 participants were analyzed. The incidence rate of SCD was 0.406 per 1,000 person-years. The CCCC-SCD-Score score was calculated using age groups (maximal points=4), left ventricular hypertrophy, hypertension, left ventricular ejection fraction <40%, aortic flow rate >190 cm/s, and carotid plaque scores ≥5 (point=1 for each risk factor). The C-index of the CCCC-SCD-Score in predicting SCD risks was 0.888 (95% confidence interval: 0.807-0.969).

CONCLUSIONS

For the general Asian population without a history of CAD or a LVEF <35% and who are aged >35 years, the novel model-based scoring system effectively identifies the risk for SCD using the clinical factors, electrocardiographic and echocardiographic data.

Nomogram and Carotid Risk Score for Predicting Moderate or High Carotid Atherosclerosis among Asymptomatic Elderly Recycling Volunteers

Carotid atherosclerosis is associated with cardiovascular and cerebrovascular events. We explored an appropriate method for selecting participants without ischemic cerebrovascular disease but with various comorbidities eligible for a carotid ultrasound. This was a retrospective subgroup analysis of the carotid plaque burden from a previous study involving a vascular and cognitive survey of 956 elderly recycling volunteers (778 women and 178 men; mean age: 70.8 years). We used carotid ultrasound to detect the carotid plaque and computed the carotid plaque score (CPS). A moderate or high degree of carotid atherosclerosis (MHCA) was defined as CPS > 5 and was observed in 22% of the participants. The CPS had positive linear correlations with age, systolic blood pressure, and fasting glucose. We stratified the participants into four age groups: 60−69, 70−74, 75−79, and ≥80 years. Multivariable analysis revealed that significant predictors for MHCA were age, male sex, hypertension, diabetes mellitus, hyperlipidemia, coronary artery disease, and a nonvegetarian diet. Coronary artery disease and advanced age were the two strongest predictors. We chose the aforementioned seven significant predictors to establish a nomogram for MHCA prediction. The area under the receiver operating characteristic curve in internal validation with 10-fold cross-validation and the classification accuracy of the nomogram were 0.785 and 0.797, respectively. We presumed people who have a ≥50% probability of MHCA warranted a carotid ultrasound. A flowchart table derived from the nomogram addressing the probabilities of all models of combinations of comorbidities was established to identify participants who had a probability of MHCA ≥ 50% (corresponding to a total nomogram score of ≥15 points). We further established a carotid risk score range from 0 to 17 comprising the seven predictors. A carotid risk score ≥ 7 was the most optimal cutoff value associated with a probability of MHCA ≥ 50%. Both total nomogram score ≥ 15 points and carotid risk score ≥ 7 can help in the rapid identification of individuals without stroke but who have a ≥50% probability of MHCA—these individuals should schedule a carotid ultrasound.

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

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

The Predictive Value of Carotid Ultrasonography With Cardiovascular Risk Factors-A "SPIDER" Promoting Atherosclerosis

Insufficient recommendations do not support the clinical use of carotid ultrasonography for further risk stratification in moderate-to-high risk patients with cardiovascular disease (CVD). A literature review was performed to assess six aspects of the research progress and limitations of carotid ultrasonography and carotid atherosclerosis-related risk factors: (1) structures of the carotid intima and media; (2) plaques; (3) inflammation; (4) dynamics of carotid blood flow; (5) early detection and intervention; and (6) risk factors for CVD. Although carotid intima-media thickness and carotid plaques are well-acknowledged independent predictors of CVD risk, normative and cut-off values are difficult to define due to the heterogeneous measurements reported in previous studies. Plaque properties, including location, number, density, and size, become more important risk predictors for cardiovascular disease, but a better approach for clinical use needs to be further established. Three-dimensional ultrasound and contrast-enhanced ultrasound are promising for promoting risk stratification with more details on plaque morphology. Moreover, inflammatory diseases and biomarkers should be evaluated for a full assessment of the inflammatory burden for atherosclerosis. Carotid flow velocity is not only an indicator for stenosis but also a potential risk predictor. Carotid atherosclerosis should be detected and treated early, and additional clinical trials are needed to determine the efficacy of these measures in reducing CVD risk. Cardiovascular risk factors tend to affect carotid plaques, and early treat-to-target therapy might yield clinical benefits. Based on the aforementioned six aspects, we consider that these six important factors act like a “SPIDER” spinning the web of atherosclerosis; a timely comprehensive assessment and intervention may halt the progression to CVD. Carotid ultrasound results should be combined with other atherosclerotic factors, and a comprehensive risk assessment may help to guide cardiovascular prevention decisions.

Relationship of Neutrophil-to-Lymphocyte Ratio with Carotid Plaque Vulnerability and Occurrence of Vulnerable Carotid Plaque in Patients with Acute Ischemic Stroke

Background

Carotid plaque is an undefined risk factor in ischemic stroke and is driven by inflammation. Mounting evidence suggests that neutrophil-to-lymphocyte ratio (NLR) is crucial not only for cerebrovascular events but also in atherosclerosis progression. Here, we aimed to explore the association between the admission NLR and carotid plaque vulnerability as well as the occurrence of vulnerable carotid plaque detected by carotid ultrasonography in patients with acute ischemic stroke (AIS) among Chinese.

Methods

We conducted a retrospective study composed of 588 patients with AIS and 309 healthy controls free of carotid plaque in the Department of Neurology in The Second Hospital of Lanzhou University from March 2014 to February 2015. All patients were classified as nonplaque, stable plaque, and vulnerable plaque groups on the basis of carotid ultrasonography results. The baseline information was collected and compared among the four different groups. The correlation between variables and carotid plaque vulnerability was tested by Spearman linear correlation analysis. To identify the independent predictors for vulnerable carotid plaque, univariate and multivariate logistic regression analysis was performed.

Results

The comparisons of age, sex proportion, history of hypertension, diabetes, and smoking, the levels of HDL-C, Lp(a), BMI, SBP, DBP, Fib, CRP, leukocyte, and NLR among the four groups showed a statistically significant difference (P < 0.05); in particular, the NLR was significantly higher in the vulnerable plaque group as compared to the control (P = 0.043), nonplaque (P = 0.022), and stable plaque groups (P = 0.015). The Spearman correlation analysis presented a positive correlation between carotid plaque vulnerability and age (r = 0.302; P < 0.001), SBP (r = 0.163; P < 0.001), and NLR (r = 0.087; P = 0.034), while the lymphocyte was negatively related to the carotid plaque vulnerability (r = −0.089; P = 0.030). The multivariate logistic regression analysis adjusted for confounding factors revealed that age (odds ratio [OR], 1.042; 95% confidence interval [CI], 1.025-1.060; P < 0.001), male gender (OR, 2.005; 95% CI, 1.394-2.884; P < 0.001), diabetes (OR, 1.481; 95% CI, 1.021-2.149; P = 0.039), SBP (OR, 1.012; 95% CI, 1.003-1.021; P = 0.010), and NLR (OR, 1.098; 95% CI, 1.018-1.184; P = 0.015) are independent predictors of vulnerable carotid plaque in patients with AIS.

Conclusion

The admission NLR is a novel and meaningful biomarker that can be used in predicting carotid plaque vulnerability and the presence of vulnerable carotid plaque assessed by carotid ultrasonography in patients with AIS among Chinese.

Impact of carotid atherosclerosis in CHA2DS2-VASc-based risk score on predicting ischemic stroke in patients with atrial fibrillation

BACKGROUND/AIMS

Vascular disease is an established risk factor for stroke in patients with atrial fibrillation (AF), which is included in CHA2DS2-VASc score. However, the role of carotid atherosclerosis remains to be determined.

METHODS

Three hundred-ten patients with AF who underwent carotid sonography were enrolled.

RESULTS

During a median follow-up of 31 months, 18 events (5.8%) of stroke were identified. Patients with stroke had higher carotid intima-media thickness (CIMT) (1.16 ± 0.33 mm vs. 0.98 ± 0.25 mm, p = 0.017). CIMT was significantly increased according to the CHA2DS2-VASc score (p < 0.001) and it was correlated with left ventricular mass index and early diastolic mitral annular velocity (e'), a ratio of early transmitral flow velocity to e' (E/e') and pulmonary artery systolic pressure (all p < 0.05). Cox regression using multivariate models showed that carotid plaque was associated with the risk of stroke (hazard ratio, 3.748; 95% confidence interval [CI], 1.107 to 12.688; p = 0.034). C-statistics increased from 0.648 (95% CI, 0.538 to 0.757) to 0.716 (95% CI, 0.628 to 0.804) in the CHA2DS2-VASc score model after the addition of CIMT and carotid plaque as a vascular component (p = 0.013).

CONCLUSION

Increased CIMT and presence of carotid plaque are associated with a high risk of ischemic stroke, and CIMT is related to myocardial remodeling and diastolic dysfunction, suggesting that carotid atherosclerosis can improve risk prediction of stroke in patients with AF, when included under vascular disease in the CHA2DS2-VASc scoring system.

Urinary heavy metals, DNA methylation, and subclinical atherosclerosis

PURPOSE

Lead (Pb) or cadmium (Cd) exposure has been linked to atherosclerosis. Co-exposure of these two heavy metals often occurs in humans. Recent evidence has indicated a crucial role of DNA methylation in atherosclerosis, while Pb or Cd exposure has also been shown to alter DNA methylation. However, it is still unknown whether DNA methylation plays a role in the pathological mechanism of these two heavy metals in atherosclerosis.

APPROACH AND RESULTS

We enrolled 738 participants (12-30 years) to investigate the association among concentrations of urine Pb or Cd, the 5mdC/dG value (a global DNA methylation marker) and the carotid intima-media thickness (CIMT). When each heavy metal was modeled separately, the results showed urine Pb and Cd concentrations were positively associated with the 5mdC/dG value and CIMT, respectively. When the two heavy metals were analyzed in the same model, urinary Pb concentrations were positively associated with the 5mdC/dG value and CIMT, while urinary Cd concentrations were only positively associated with the CIMT. When Pb and Cd are simultaneously considered in the same logistic regression model, the odds ratios (OR) of thicker CIMT (greater than 75th percentile) with one unit increase in ln-Pb level was 1.67 (95% C.I. = 1.17-2.46, P = 0.005) when levels of 5mdC/dG were above 50th percentile, which is higher than 5mdC/dG bellow the 50th percentile (OR = 1.50 (95% C.I. = 0.96-2.35), P = 0.076). In structural equation model (SEM), Pb or Cd levels are directly associated with CIMT. Moreover, Pb or Cd had an indirect association with CIMT through the 5mdC/dG. When we considered Pb and Cd together, Pb levels had a direct association with CIMT and an indirect association with CIMT through the 5mdC/dG value, while Cd only had a direct association with CIMT.

CONCLUSIONS

Our findings imply that Pb and Cd exposure might be associated with subclinical atherosclerosis, and global DNA methylation might mediate Pb-associated subclinical atherosclerosis in this young population. Future effort is necessary to elucidate the causal relationship.

The association between urine di-(2-ethylhexyl) phthalate metabolites, global DNA methylation, and subclinical atherosclerosis in a young Taiwanese population

Di-(2-ethylhexyl) phthalate (DEHP) has been utilized in many products for years. DEHP exposure has been linked to cardiovascular diseases (CVD) and its risk factors. Recent evidence has found a crucial role for epigenetics, including DNA methylation, in CVD. Moreover, DEHP exposure has proved to alter DNA methylation in epidemiological studies. However, the interplay between DEHP exposure, global DNA methylation, and atherosclerosis has never been reported. In this current study, we enrolled 793 participants (12-30 years) from a Taiwanese population to investigate the association between concentrations of DEHP metabolites, 5mdC/dG (global DNA methylation marker) and the carotid intima-media thickness (CIMT). The results showed urine mono-2-ethylhexyl phthalate (MEHP) level was positively correlated with 5mdC/dG and CIMT, respectively. In logistic regression models, the odds ratios (OR) of thicker CIMT (greater than 75^th percentile) with one unit increase in ln-MEHP level was higher when levels of 5mdC/dG were above 50%. In structural equation model, the result showed urine MEHP levels are directly associated with CIMT. Moreover, MEHP had an indirect association with CIMT through the 5mdC/dG after adjusting other confounding effects. In the current study, urine DEHP metabolite levels were positively correlated with 5mdC/dG, and CIMT. Our results showed DEHP had a direct and indirect association with CIMT through the 5mdC/dG. The finding implies that DNA methylation may mediate the association between DEHP exposures and subclinical atherosclerosis in this young population. Future effort is needed to elucidate the causal relationship between DEHP exposure, DNA methylation and CVD.

The association between urinary levels of 1,3-butadiene metabolites, cardiovascular risk factors, microparticles, and oxidative stress products in adolescents and young adults

1,3-Butadiene (BD) is a synthetic colorless gas used in the production of synthetic rubber and polymers. Exposure to BD has been reported to increase oxidative stress and accelerate atherosclerosis in vitro and in animal studies. In occupational studies, BD exposure has been linked to cardiovascular disease (CVD). However, no previous research has been reported on whether BD exposure is associated with CVD risk factors and oxidative stress in the general population. We recruited 853 young participants to study the correlation between urinary levels of the BD metabolite, N-acetyl-S-(3,4-dihydroxybutyl)-L-cysteine (DHBMA), CVD risk factors, serum levels of endothelial microparticles and platelet microparticles, and the urinary levels of 8-hydroxydeoxyguanosine (8-OHdG). The results showed the DHBMA levels were positively correlated with low-density lipoprotein-C, carotid intima-media thickness (CIMT), CD31+/CD42a - counts (endothelial apoptosis markers), and urinary 8-OHdG levels. Moreover, DHBMA levels were negatively correlated with CD62 P counts (platelet activation marker). The correlation between DHBMA, CIMT, and 8-OHdG was more evident when the levels of CD31+/CD42a - or CD62 P were above 50%. In conclusion, we reported that the urinary levels of DHBMA were associated with the lipid profile, CIMT, microparticles, and marker of oxidative stress in this young population. Future studies on BD exposure and atherosclerosis are needed.

Contemporary Prevalence and risk factors of carotid artery stenosis in asymptomatic low-income Chinese individuals: a population-based study

OBJECTIVES

Carotid artery stenosis (CAS) is an established risk factor for cerebrovascular disease. However, the contemporary prevalence and risk factors of CAS in asymptomatic rural Chinese individuals, especially low-income populations, remains unclear. Therefore, we aimed to explore the present prevalence and risk factors of CAS in a low-income Chinese population.

METHODS

A total of 3126 people aged ≥ 45 years without history of stroke or cardiovascular disease were recruited for this study. B-mode ultrasonography was performed to evaluate the presence of CAS. We used multivariate analysis to determine potential risk factors for CAS.

RESULTS

The overall prevalence of CAS in this population was 6.7%, with a prevalence of 8.8% for men and 5.0% for women. The risk of CAS increased with older age and a higher level of low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), and fasting blood glucose (FBG) (all P < 0.05). Each 1-mmHg increase in SBP increased the risk of CAS by 0.011 times, each 1-mmol/L increase in LDL-C increased the risk of CAS by 0.192 times, and each 1-mmol/L increase in FBG increased the risk of CAS by 0.067 times. In addition, the risk of CAS increased 52.9% in men compared to that in women, increased 100.2% in current drinkers compared to that in never drinkers, and increased 38.9% in patients with diabetes compared to those without diabetes (all P < 0.05).

CONCLUSIONS

These findings suggest that the prevalence of CAS remains high in low-income individuals. Male sex, older age, current drinking, diabetes, and high levels of LDL-C, SBP, and FBG increase the risk of CAS. Thus, to prevent cerebrovascular disease and reduce the severe disease-associated burden for low-income individuals, there is a definitive need to control the risk factors of CAS.

Does the Carotid Bulb Offer a Better 10-Year CVD/Stroke Risk Assessment Compared to the Common Carotid Artery? A 1516 Ultrasound Scan Study

The objectives of this study are to (1) examine the "10-year cardiovascular risk" in the common carotid artery (CCA) versus carotid bulb using an integrated calculator called "AtheroEdge Composite Risk Score 2.0" (AECRS2.0) and (2) evaluate the performance of AECRS2.0 against "conventional cardiovascular risk calculators." These objectives are met by measuring (1) image-based phenotypes and AECRS2.0 score computation and (2) performance evaluation of AECRS2.0 against 12 conventional cardiovascular risk calculators. The Asian-Indian cohort (n = 379) with type 2 diabetes mellitus (T2DM), chronic kidney disease (CKD), or hypertension were retrospectively analyzed by acquiring the 1516 carotid ultrasound scans (mean age: 55 ± 10.1 years, 67% males, ∼92% with T2DM, ∼83% with CKD [stage 1-5], and 87.5% with hypertension [stage 1-2]). The carotid bulb showed a higher 10-year cardiovascular risk compared to the CCA by 18% (P < .0001). Patients with T2DM and/or CKD also followed a similar trend. The carotid bulb demonstrated a superior risk assessment compared to CCA in patients with T2DM and/or CKD by showing: (1) ∼13% better than CCA (0.93 vs 0.82, P = .0001) and (2) ∼29% better compared with 12 types of risk conventional calculators (0.93 vs 0.72, P = .06).

Assessment of the Role of Carotid Atherosclerosis in the Association Between Major Cardiovascular Risk Factors and Ischemic Stroke Subtypes

IMPORTANCE

A better understanding of the role of atherosclerosis in the development of ischemic stroke subtypes could help to improve strategies for prevention of stroke worldwide.

OBJECTIVE

To assess the role of carotid atherosclerosis in the association between major cardiovascular risk factors and ischemic stroke subtypes.

DESIGN, SETTING, AND PARTICIPANTS

The prospective China Kadoorie Biobank cohort study was conducted in the general population of 5 urban and 5 rural areas in China, with a baseline survey obtained between June 2004 and July 2008. A random sample of 23 973 participants with no history of cardiovascular disease at enrollment who had carotid artery ultrasonographic measurements recorded at a resurvey from September 2013 to June 2014 were included. Data analysis was performed from July 1, 2016, to April 10, 2019.

EXPOSURES

Major cardiovascular risk factors (ie, blood pressure [BP], blood lipid levels, smoking, and diabetes).

MAIN OUTCOMES AND MEASURES

Carotid ultrasonographic measures of plaque burden (derived from number and maximum size of carotid artery plaques at resurvey) and first ischemic stroke during follow-up (n = 952), with subtyping (data release, August 2018) as lacunar (n = 263), probable large artery (n = 193), probable cardioembolic (n = 66), or unconfirmed (n = 430). Associations between cardiovascular risk factors, carotid plaque burden, and ischemic stroke subtypes were adjusted for age, sex, and geographic area.

RESULTS

The 23 973 participants in the study had a mean (SD) age of 50.6 (10.0) years, and 14 833 (61.9%) were women. Systolic BP had a stronger association (odds ratio [OR] per SD, 1.51; 95% CI, 1.42-1.61) than plaque burden (OR per SD, 1.34; 95% CI, 1.26-1.44) with ischemic stroke, and the associations of systolic BP with each subtype of ischemic stroke were modestly attenuated by adjustment for plaque burden. After adjustment for BP, plaque burden had a stronger association with probable large artery stroke (OR, 1.43; 95% CI, 1.24-1.63) than with lacunar stroke (OR, 1.25; 95% CI, 1.10-1.43) but was not associated with probable cardioembolic stroke (OR, 1.06; 95% CI, 0.83-1.36).

CONCLUSIONS AND RELEVANCE

Although BP was an important risk factor for all ischemic stroke subtypes, carotid atherosclerosis was an important risk factor only for large artery and lacunar strokes, suggesting that drug treatments targeting atherosclerosis may reduce the risk of stroke subtypes to different extents.

Common Genetic Variants on Bone Morphogenetic Protein Receptor Type IB (BMPR1B) Gene Are Predictive for Carotid Intima-Media Thickness

BACKGROUND

Bone morphogenetic proteins (BMP) 2 and 4 are implicated in the development of atherosclerosis. However, the relationships between the proteins, their main receptors and carotid intima-media thickness (cIMT), a predictive preclinical phenotype of atherosclerosis, have not been established. Methods and Results: We screened and validated the relationships of single-nucleotide polymorphisms (SNPs) on BMP2, BMP4, BMPR1A, BMPR1B, and BMPR2 with thicker cIMT by 2 independent case-control studies that used different subject selection methods. Among 200 screened SNPs, 12 on BMPR1B were regarded as candidate genetic markers (P-value <5.0×10^-4). After combining the discovery and validation studies and adjusting for traditional cardiovascular risk factors, rs4456963*G, rs4235438*T, rs2522530*T, and rs3796433*C showed significant higher odds ratios (ORs) of having thicker cIMT (adjusted ORs: 1.50-1.56; all P-values <2.5×10^-4). Multivariate analyses showed that rs4456963 and rs3796433 were significantly independent determinants of cIMT thickening. The corresponding multivariate-adjusted ORs for rs4456963*G and rs3796433*C alleles were 1.50 (95% confidence interval (CI): 1.22-1.84) and 1.50 (95% CI: 1.23-1.82), respectively. Interaction between rs4456963 and rs3796433 was evident by the significantly higher OR (8.16, 95% CI: 3.12-21.3) for subjects with the GG-CC genotype. The rs4456963*G and rs3796433*C showed positively linear trends with severity of carotid atherosclerosis.

CONCLUSIONS

We identified 2 SNPs on BMPR1B showing significantly independent correlations with thicker cIMT. The study provides invaluable evidence supporting that BMPR1B is closely related to carotid atherosclerosis and a potential target for the development of therapeutic agents for atherosclerotic disease.

Serum Tumor Marker Carbohydrate Antigen 125 Levels and Carotid Atherosclerosis in Patients with Coronary Artery Disease

Objective

We assessed the correlation between serum carbohydrate antigen 125 (CA125) and carotid intima-media thickness (cIMT) in patients with coronary artery disease (CAD).

Methods

We collected 518 CAD patients from the cardiovascular disease center in our hospital, and all cIMT values were measured in patients with CAD.

Results

The serum CA125 concentrations were found to be increased in CAD patients with early carotid atherosclerosis compared with patients without early carotid atherosclerosis (20.1±7.72 vs. 17.7±6.41 U/mL, p<0.001). The cIMT values were increased in patients with higher serum CA-125 levels than those with lower serum CA-125 concentrations (1.16±0.32 vs. 0.98±0.29 mm, p<0.001). There was a positive correlation between serum CA125 and cIMT in CAD patients (r=0.262, p<0.001). Moreover, the serum CA125 concentrations also were positively correlated with cIMT in subjects with early carotid atherosclerosis and without early carotid atherosclerosis (r=0.255, p<0.001; r=0.189, p=0.002). We found that serum CA-125 concentrations were independently correlated with cIMT (beta = 0.293, p<0.001) in multiple linear regression analysis.

Conclusions

We found that serum CA125 concentrations were positively correlated with cIMT in CAD patients, serum CA125 might be a potential biochemical marker for the estimation of atherosclerosis in patients with CAD.

Genetic profiling of young and aged endothelial progenitor cells in hypoxia

Age is a major risk factor for diseases caused by ischemic hypoxia, such as stroke and coronary artery disease. Endothelial progenitor cells (EPCs) are the major cells respond to ischemic hypoxia through angiogenesis and vascular remodeling. However, the effect of aging on EPCs and their responses to hypoxia are not well understood. CD34⁺ EPCs were isolated from healthy volunteers and aged by replicative senescence, which was to passage cells until their doubling time was twice as long as the original cells. Young and aged CD34⁺ EPCs were exposed to a hypoxic environment (1% oxygen for 48hrs) and their gene expression profiles were evaluated using gene expression array. Gene array results were confirmed using quantitative polymerase chain reaction, Western blotting, and BALB/c female athymic nude mice hindlimb ischemia model. We identified 115 differentially expressed genes in young CD34⁺ EPCs, 54 differentially expressed genes in aged CD34⁺ EPCs, and 25 common genes between normoxia and hypoxia groups. Among them, the expression of solute carrier family 2 (facilitated glucose transporter), member 1 (SLC2A1) increased the most by hypoxia in young cells. Gene set enrichment analysis indicated the pathways affected by aging and hypoxia most, including genes “response to oxygen levels” in young EPCs and genes involved “chondroitin sulfate metabolic process” in aged cells. Our study results indicate the key factors that contribute to the effects of aging on response to hypoxia in CD34⁺ EPCs. With the potential applications of EPCs in cardiovascular and other diseases, our study also provides insight on the impact of ex vivo expansion might have on EPCs.

Identification of key genes and miRNAs associated with carotid atherosclerosis based on mRNA-seq data

This study was aimed to explore the crucial genes and microRNAs (miRNAs) associated with the carotid atherosclerosis (CA).Two public datasets GSE28829 and GSE43292 were obtained from Gene Expression Omnibus databases to analyze the differentially expressed genes (DEGs) between primary and advanced atherosclerotic plaque tissues. The Gene Ontology (GO) terms, pathways, and protein-protein interactions (PPIs) of these DEGs were analyzed. miRNAs and transcription factor (TF) were predicted.A total of 112 upregulated and 179 downregulated intersection DEGs were identified between 2 datasets. In the PPI network, HSP90AB1 (degree = 19), RAP1A (degree = 14), and integrin subunit beta 1 (ITGB1) had higher degrees. A total of 23 miRNAs were predicted, such as miR-126, miR-155, miR-19A, and miR-19B. Four TFs were associated with upregulated DEGs, while 10 TFs were identified to be associated with downregulated genes.Our study suggests the important roles of HSP90AB1, RAP1A, and integrins proteins of ITGB1, ITGA11, ITGA9, and ITGB2 in the progression of CA plaque. Additionally, miR-126, miR-155, miR-19B, and miR-19A may be considered as biomarkers of CA.

Segment-specific prevalence of carotid artery plaque and stenosis in middle-aged adults and elders in Taiwan: A community-based study

BACKGROUND

Plaque in carotid arteries (CAs) is a major factor of systemic atherosclerosis and cardiovascular disease (CVD). The left and right CAs have different anatomic and geometric features and may influence the predictability of CVD. However, the site- and segment-specific prevalence of carotid plaques (CP) and study on severity of carotid atherosclerosis with CVD risks was very limited.

METHODS

We enrolled 1539 healthy residents aged 40-to-74 years from two northern districts in Taiwan. All volunteers received high resolution B-mode carotid ultrasound scans and CVD risk factors evaluations.

RESULTS

The prevalence rate of extracranial CP was 21.9% in females and 33.8% in males. Carotid bifurcation is the most affected segment. As compared with the right CAs, the age-sex-adjusted matched odds ratio of having plaques in the left CAs was 1.32 (95% confidence interval = 1.02-1.73). The proportions of subjects had a total plaque number≥2, maximum stenosis≥30%, and plaque score≥3 were 8.9, 10.3, and 7.2%, respectively, in females and were 17.7, 17.2, and 15.1%, respectively, in males. Among subjects with moderate and severe carotid atherosclerosis, the mean ± SD of estimated 10-year CVD risk was 19.1 ± 14.6% and more than 65% of them need intensive blood pressure, lipids, or sugar controls.

CONCLUSION

We found that bifurcation was the most prevalent segment, and left CAs was more likely to form plaque than right CAs. The major CVD risk factors were highly prevalent and the estimated CVD risks were high in subjects with more advanced carotid atherosclerosis. The study provides further direction for CVD prevention and treatment.

Gender-specific associations between serum isomers of perfluoroalkyl substances and blood pressure among Chinese: Isomers of C8 Health Project in China

Previous studies have demonstrated associations of perfluoroalkyl substances (PFASs), a group of highly persistent chemicals ubiquitous in wildlife and humans, with hypertension, but the relationships are mixed. Furthermore, academic literature on the relationship between isomers of PFASs and blood pressure (BP) and hypertension in populations from a higher pollution area is scant. We studied 1612 Chinese adults, ages 22-96years old, from Shenyang, China, utilizing high performance liquid chromatography-mass spectrometry to analyze isomers of perfluorooctanesulfonate (PFOS), perfluorooctanoate (PFOA), and other PFASs in blood serum. We used a mercury sphygmomanometer to measure BP. Hypertension was defined as a mean systolic BP (SBP) of at least 140mmHg, and/or diastolic BP (DBP) of at least 90mmHg, and/or use of antihypertensive medications. The results showed that increased serum concentrations of all (both branched and linear) isomers of PFASs were associated with higher prevalence of hypertension. Adjusted odds ratios for hypertension per ln-unit (ng/mL) increase in PFASs ranged from 1.10 (95%CI: 1.04, 1.17) for perfluorobutanoic acid (PFBA) to 1.26 (95%CI: 1.12, 1.42) for 3+4+5m PFOS, and the estimated increases in mean SBP and DBP ranged from 0.80mmHg (95%CI: 0.25, 1.34) for PFBA to 4.51mmHg (95%CI: 3.52, 5.51) for 3+4+5m PFOS, and from 0.51mmHg (95%CI: 0.01, 1.01) for perfluorodecanesulfonate (PFDS) to 2.48 (1.80, 3.16) for perfluorononanoic acid (PFNA), respectively. Compared with linear PFASs isomers, we identified more and stronger associations among branched PFASs isomers and blood pressure. Furthermore, females exhibited consistently stronger effects than males. In conclusion, this study is the first of its kind to show that not only PFASs positively associated with elevated blood pressure, but also that branched PFAS isomers are more frequently associated with blood pressure than linear PFAS isomers.

Carotid atherosclerosis and its relationship to coronary heart disease and stroke risk in patients with type 2 diabetes mellitus

Carotid atherosclerosis (CA) and carotid plaque (CP) are highly correlated with cardiovascular disease. We aimed to determine the prevalence of CA and CP and their relationship with 10-year risks of stroke and coronary heart disease (CHD) in type 2 diabetes mellitus (T2DM).We studied 1584 T2DM patients aged 20 years and older. CA and CP were detected using ultrasonography. Ten-year stroke and CHD risk were determined using the United Kingdom Prospective Diabetes Study (UKPDS) risk engine.The prevalence of CA and CP increased gradually with age. Men had a higher prevalence of CA than women (CA: 58.18% vs 51.54%, P < .01). The 10-year CHD risk (27.9% vs 15.4%, P < .001) and stroke risk (15.2% vs 5.70%, P < .001) were higher in patients with CA than that of those without CA. Compared with patients without CA, the odds ratios (ORs) of CHD in CA and CP group were 4.47 and 10.78 for men, and 4.19 and 5.20 for women, respectively; in the case of stroke, the OR in CA and CP group were 8.83 and 12.07 for men, and 4.35 and 4.90 for women, respectively (P < .001 for all). Multivariate binary logistic regression analysis showed that CA was an independent risk factor for CHD [OR = 2.66, 95% confidence interval (95% CI), 2.05-3.46, P < .001] and stroke (OR = 3.11, 95% CI, 2.38-4.07, P < .001).CA and CP were prevalent in patients with T2DM and positively correlated with 10-year CHD and stroke risk. CA was an independent risk factor for 10-year CHD risk.

Mini-Review of the Chin-Shan Community Cardiovascular Cohort Study in Population Health Research in Taiwan

Preventing and controlling non-communicable diseases (NCDs) is a growing global public health concern, and evidence-based data from population-based health studies are needed in order to develop appropriate public health policies for controlling NCDs. The Chin-Shan Community Cardiovascular Cohort (CCCC) study is a prospective cohort consisting of participants from one community in China in 1990-1991, and has provided substantial evidence-based data on domestic and global health issues in preventive cardiology fields. The present study is a mini-review of the CCCC study. In this review, we have described the historical background of the cardiovascular disease burden and related risk factors, especially lifestyle factors, subclinical disease markers, biomarkers and prediction models, and related international collaborative projects. In addition, this mini-review study provides a measure of insight into future plans for 21st century epidemiological research in cardiovascular diseases, suggesting possible areas of focus for future research.

Sex Differences in Prevalence of and Risk Factors for Carotid Plaque among Adults: A Population-based Cross-Sectional Study in Rural China

Although the associations between carotid plaque and cardiovascular disease risk factors have been identified in previous studies, there is limited information on sex-related differences in factors associated with the development of carotid plaque. We aimed to determine sex differences in the prevalence of carotid plaque and associated risk factors in rural China. A total of 3,789 subjects aged ≥45 years without history of stroke or cardiovascular disease were recruited to the study. B-mode ultrasonography was performed to determine the presence of carotid plaque. The mean age of male subjects was greater than that of female subjects. In addition, there was a higher prevalence of carotid plaque in men than in women (50.1% vs. 35.5%; P < 0.001) irrespective of age group, education level, and presence of risk factors. Older age, hypertension, diabetes mellitus, and high concentrations of low-density lipoprotein cholesterol were pronouncedly associated with the risk of carotid plaque in both men and women. These findings suggest that it is vital for physicians to be aware that conventional risk factors and other related factors are of equal importance among rural residents in China; patients should thus be treated accordingly so that reduce the burden of stroke and cardiovascular disease.

Serum gamma-glutamyltransferase is not associated with subclinical atherosclerosis in patients with type 2 diabetes

BACKGROUND

This study investigated the association between serum gamma-glutamyltransferase (GGT) level and subclinical atherosclerosis in patients with type 2 diabetes.

METHODS

This cross-sectional study involved 1024 patients with type 2 diabetes mellitus. Measurement of brachial-ankle pulse wave velocity (baPWV; as a marker of arterial stiffness) and an ultrasound assessment of carotid atherosclerosis were performed. Subclinical atherosclerosis was defined by the presence of a high baPWV (≥1720 cm/s), carotid atherosclerosis (intima-media thickness >0.8 mm or the presence of plaques), and carotid stenosis (≥50 % of luminal narrowing). The subjects were stratified into quartiles according to GGT level, and the relationship between GGT level and subclinical atherosclerosis was analysed.

RESULTS

Serum GGT levels were closely associated with obesity, atherogenic dyslipidemia, and metabolic syndrome. However, serum GGT levels did not show a linear association with baPWV, carotid intima-media thickness, or plaque grade. The prevalence of high baPWV, carotid atherosclerosis, and carotid stenosis did not differ between the quartiles in men and women. Multivariate logistic regression analyses revealed no association between GGT level and high baPWV, carotid atherosclerosis, and carotid stenosis, either as continuous variables or quartiles.

CONCLUSIONS

Serum GGT levels were significantly associated with obesity, atherogenic dyslipidaemia, and metabolic syndrome, but not with the early and late stages of atherosclerotic vascular changes, in patients with type 2 diabetes. Serum GGT level may not be a reliable marker of subclinical atherosclerosis in type 2 diabetes.

Increased serum visfatin as a risk factor for atherosclerosis in patients with ischaemic cerebrovascular disease

INTRODUCTION

The present study aimed to investigate the possible associations between serum levels of visfatin, an adipokine, and atherosclerosis in patients with ischaemic cerebrovascular disease.

METHODS

A total of 95 participants were recruited for this study. Group A comprised 35 individuals with no history of cerebrovascular disease (control group) and Group B comprised 60 patients with ischaemic cerebrovascular disease. Group B was further categorised into two subgroups based on the ultrasonographic findings of the common carotid artery intima‑media thickness (CCA‑IMT) - Group B1 consisted of 21 patients with no atherosclerosis (i.e. CCA‑IMT ≤ 0.9 mm) and Group B2 consisted of 39 patients with atherosclerosis (i.e. CCA‑IMT > 0.9 mm). The body mass index, fasting blood total cholesterol, triglycerides, high‑density lipoprotein cholesterol, low‑density lipoprotein cholesterol and glucose levels of each patient were measured. Serum visfatin levels were determined using enzyme‑linked immunosorbent assays. Visfatin levels were compared between groups, and stepwise logistic regression analysis was used to identify risk factors for atherosclerosis, including visfatin levels.

RESULTS

The mean serum visfatin level of the patients in Group B was higher than that in Group A (75.5 ± 77.80 ng/mL vs. 8.6 ± 4.69 ng/mL; p < 0.05) and the level was higher in patients from Group B2 than those from Group B1 (89.0 ± 80.68 ng/mL vs. 50.4 ± 72.44 ng/mL; p < 0.05). Multivariate regression analysis showed that CCA‑IMT values were not significantly associated with visfatin levels. However, logistic regression analysis showed that serum visfatin was an independent risk factor for atherosclerosis (odds ratio 37.80; p = 0.004).

CONCLUSION

Serum visfatin may be an independent risk factor for cerebral infarction, as high serum visfatin levels are positively associated with the underlying pathogenic mechanisms of ischaemic cerebrovascular disease.

Cardiovascular Imaging for the Primary Prevention of Atherosclerotic Cardiovascular Disease Events

Traditional cardiovascular risk factors have well-known limitations for the accurate assessment of individual cardiovascular risk. Unlike risk factor-based scores which rely on probabilistic calculations derived from population-based studies, coronary artery calcium (CAC) scoring, and carotid ultrasound allow for the direct visualization and quantification of subclinical atherosclerosis with the potential for a more accurate, personalized risk assessment and treatment approach. Among strategies used to guide preventive management, CAC scoring has consistently and convincingly outperformed traditional risk factors for the prediction of adverse cardiovascular events. Moreover, several studies have demonstrated the potential of CAC testing to improve precision for the use of more intensive pharmacologic therapies, such as aspirin and statins, in patients most likely to derive benefit, as compared to atherosclerotic cardiovascular disease risk calculators. By comparison to CAC, the role of carotid ultrasound for the measurement of carotid intima-media thickness (CIMT) remains less well-elucidated but may be significantly improved with the inclusion of plaque screening and novel three-dimensional measurements of plaque volume and morphology. Despite significant evidence supporting the ability of non-invasive atherosclerosis imaging (particularly CAC) to guide preventive management, imaging remains an under-utilized strategy among current guidelines and clinical practice. Herein, we review evidence regarding CAC and carotid ultrasound for patient risk classification, with a comparison of these techniques to currently advocated traditional risk factor-based scores.

Carotid Intima-Media Thickness and Long-Term Exposure to Traffic-Related Air Pollution in Middle-Aged Residents of Taiwan: A Cross-Sectional Study

BACKGROUND

Associations between long-term exposure to air pollution and carotid intima-media thickness (CIMT) have inconsistent findings.

OBJECTIVES

In this study we aimed to evaluate association between 1-year average exposure to traffic-related air pollution and CIMT in middle-aged adults in Asia.

METHODS

CIMT was measured in Taipei, Taiwan, between 2009 and 2011 in 689 volunteers 35-65 years of age who were recruited as the control subjects of an acute coronary heart disease cohort study. We applied land-use regression models developed by the European Study of Cohorts for Air Pollution Effects (ESCAPE) to estimate each subject's 1-year average exposure to traffic-related air pollutants with particulate matter diameters ≤ 10 μm (PM10) and ≤ 2.5 μm (PM2.5) and the absorbance levels of PM2.5 (PM2.5abs), nitrogen dioxide (NO2), and nitrogen oxides (NOx) in the urban environment.

RESULTS

One-year average air pollution exposures were 44.21 ± 4.19 μg/m3 for PM10, 27.34 ± 5.12 μg/m3 for PM2.5, and (1.97 ± 0.36) × 10-5/m for PM2.5abs. Multivariate regression analyses showed average percentage increases in maximum left CIMT of 4.23% (95% CI: 0.32, 8.13) per 1.0 × 10-5/m increase in PM2.5abs; 3.72% (95% CI: 0.32, 7.11) per 10-μg/m3 increase in PM10; 2.81% (95% CI: 0.32, 5.31) per 20-μg/m3 increase in NO2; and 0.74% (95% CI: 0.08, 1.41) per 10-μg/m3 increase in NOx. The associations were not evident for right CIMT, and PM2.5 mass concentration was not associated with the outcomes.

CONCLUSIONS

Long-term exposures to traffic-related air pollution of PM2.5abs, PM10, NO2, and NOx were positively associated with subclinical atherosclerosis in middle-aged adults.

High normal albuminuria is associated with arterial stiffness and carotid atherosclerosis in Korean patients with type 2 diabetes

BACKGROUND AND AIMS

Current evidence suggests that high normal albuminuria is significantly associated with increased cardiovascular risk. This study investigated the association between urine albumin-to-creatinine ratio (ACR) within the normal range and subclinical atherosclerosis in Korean patients with type 2 diabetes.

METHODS AND RESULTS

This cross-sectional study involved 521 type 2 diabetic patients with normoalbuminuria. Brachial-ankle pulse wave velocity (baPWV) measurement and ultrasound assessment of carotid atherosclerosis was done. Subclinical atherosclerosis was assessed by the presence of high baPWV (>1682 cm/s), carotid atherosclerosis (intima-media thickness >0.8 mm or the presence of plaques), and carotid stenosis (≥50% of luminal narrowing). Across the tertiles of ACR, there was a trend for an increasing prevalence of high baPWV (16.8%, 20.0%, and 38.2%, P < 0.001), carotid atherosclerosis (46.9%, 55.4%, and 64.7%, P < 0.001), and carotid stenosis (12.7%, 16.0%, and 30.1%, P < 0.001). In multivariate analysis, patients in the highest ACR tertile had an odds ratio of 2.05 (95% confidence interval [CI], 1.13-3.72, P = 0.019) for high baPWV, 1.78 (95% CI, 1.08-2.93, P = 0.024) for carotid atherosclerosis, and 2.72 (95% CI, 1.44-5.11, P = 0.002) for carotid stenosis compared to those in the lowest tertile. The relation of ACR with carotid atherosclerosis and stenosis remained significant even in patients without diabetic retinopathy.

CONCLUSION

High normal albuminuria was significantly associated with atherosclerotic vascular changes, independent of retinopathy and other cardiovascular risk factors. High normal albuminuria may be an early marker for subclinical atherosclerosis in type 2 diabetes.

Association between levels of serum bisphenol A, a potentially harmful chemical in plastic containers, and carotid artery intima-media thickness in adolescents and young adults

OBJECTIVE

Bisphenol A (BPA) is a chemical produced at high volumes and used widely in food and drink packaging. In adults, elevated BPA concentrations are associated with cardiovascular disease. BPA exposure is plausibly linked to atherosclerosis in adolescents and young adults, but evidence is lacking to date.

METHODS

We recruited 886 subjects (12-30 years of age) from a population-based sample of adolescents and young adults based on a mass urine screening to determine the relationship between serum levels of BPA and carotid intima-media thickness (CIMT).

RESULTS

The geometric mean (standard deviation) of concentrations of BPA were 1.72 (5.5) ng/mL After controlling for confounding factors, linear regression analyzes showed a 1-unit increase in natural log BPA was significantly associated with an increase in mean CIMT (mm) (β = 0.005, 95% C.I. = 0.003-0.007, p < 0.001) and other measurement of CIMT (including right and left side of common carotid artery, carotid bulb and internal carotid artery).

CONCLUSION

Higher serum concentrations of BPA were associated with increased CIMT in this cross-sectional study of adolescents and young adults. Studies to clarify the mechanisms of these associations are needed.

Blood pressure reverse-dipping is associated with early formation of carotid plaque in senior hypertensive patients

Nocturnal variations in blood pressure (BP) were associated with carotid intima-media thickness. However, the precise relationship between circadian variations of BP and carotid plaques remains unknown. Therefore, the prognostic value of reverse-dipper pattern of BP for carotid plaque was investigated. In this cross-sectional study, a total of 524 hypertensive patients were recruited and evaluated with ambulatory BP monitoring between April 2012 and June 2013. Carotid plaque was classified into Grade 0 (normal or no observable plaque), Grade 1 (mild stenosis, 1%-24% narrowing), and Grade 2 (moderate stenosis, ≥25% narrowing). Multinomial logistic regression was applied to analyze the relationship between different degrees of carotid plaque and ambulatory BP monitoring results. Reverse-dipper pattern of BP was more common in older patients, smokers, and those with elevated fasting glucose. The incidences of coronary artery disease, lacunar infarction, and diabetes were also higher among hypertensive with reverse-dipper pattern. Multinomial logistic regression analysis showed that reverse dipper (odds ratio [OR] 2.500; 95% confidence interval [CI] 1.320-4.736; P = 0.005), age (OR 1.089; 95% CI 1.067-1.111; P < 0.001), smoke (OR 1.625; 95% CI 1.009-2.617; P = 0.046), and diabetes (OR 1.759; 95% CI 1.093-2.830; P = 0.020) were significantly different between mild carotid plaque and normal. Our results also suggested that mild carotid plaque was closely related to reverse-dipper pattern of BP (2.308; 95% CI 1.223-4.355; P = 0.010). Reverse-dipper pattern of BP may be a risk factor for carotid atherosclerosis and play a crucial role in the early formation of carotid plaque.

Common carotid artery end-diastolic velocity is independently associated with future cardiovascular events

BACKGROUND

Carotid ultrasound is widely used to measure haemodynamic parameters, such as intima-media thickness and blood flow velocities (i.e. peak-systolic velocity [PSV], end-diastolic velocity [EDV], and resistive index [RI]). However, the association between blood flow velocities and cardiovascular events remains unclear.

DESIGN AND METHODS

Baseline data, including quantitative ultrasonography, were obtained from 3146 adults as part of the Cardiovascular Diseases Risk Factor Two-Township Study. Occurrence of ischaemic heart disease (IHD) and stroke was determined from insurance claims and death certificates. The hazard ratio (HR) of CVD (IHD and stroke combined) was calculated for EDV and PSV of the common carotid artery using Cox models. Net reclassification index and integrated discrimination index were used to evaluate the capacity of EDV to predict IHD, stroke, and CVD.

RESULTS

Median follow-up was 12.8 years. There were 220 cases of IHD and 247 cases of stroke. The HR (95% CI) for CVD from univariate analysis was 4.54 (3.51-5.85) for EDV <15 cm/s relative to EDV ≥ 20 cm/s (p < 0.0001), and 3.23 (2.51-4.15) for PSV < 65 cm/s relative to PSV ≥ 80 cm/s (p < 0.0001). The HR (95% CI) for CVD from multivariate analysis was 1.66 (1.22-2.26) for EDV < 15 cm/s relative to EDV ≥ 20 cm/s, and 1.39 (1.03-1.89) for PSV < 65 cm/s relative to PSV ≥ 80 cm/s. EDV slightly but significantly improved prediction of CVD (integrated discrimination index 0.56%, p = 0.016).

CONCLUSIONS

Low common carotid EDV and PSV were independently associated with future CVD, and EDV improved the prediction of future CVD. More prospective studies are required in different ethnic groups to understand the significance and implication of these findings.

Carotid intima-media thickness and plaque in cardiovascular risk assessment

Carotid intima-media thickness (CIMT) has been shown to predict cardiovascular (CV) risk in multiple large studies. Careful evaluation of CIMT studies reveals discrepancies in the comprehensiveness with which CIMT is assessed-the number of carotid segments evaluated (common carotid artery [CCA], internal carotid artery [ICA], or the carotid bulb), the type of measurements made (mean or maximum of single measurements, mean of the mean, or mean of the maximum for multiple measurements), the number of imaging angles used, whether plaques were included in the intima-media thickness (IMT) measurement, the report of adjusted or unadjusted models, risk association versus risk prediction, and the arbitrary cutoff points for CIMT and for plaque to predict risk. Measuring the far wall of the CCA was shown to be the least variable method for assessing IMT. However, meta-analyses suggest that CCA-IMT alone only minimally improves predictive power beyond traditional risk factors, whereas inclusion of the carotid bulb and ICA-IMT improves prediction of both cardiac risk and stroke risk. Carotid plaque appears to be a more powerful predictor of CV risk compared with CIMT alone. Quantitative measures of plaques such as plaque number, plaque thickness, plaque area, and 3-dimensional assessment of plaque volume appear to be progressively more sensitive in predicting CV risk than mere assessment of plaque presence. Limited data show that plaque characteristics including plaque vascularity may improve CV disease risk stratification further. IMT measurement at the CCA, carotid bulb, and ICA that allows inclusion of plaque in the IMT measurement or CCA-IMT measurement along with plaque assessment in all carotid segments is emerging as the focus of carotid artery ultrasound imaging for CV risk prediction.

Cardiovascular events in patients with atherothrombotic disease: a population-based longitudinal study in Taiwan

Background

Atherothrombotic diseases including cerebrovascular disease (CVD), coronary artery disease (CAD), and peripheral arterial disease (PAD), contribute to the major causes of death in the world. Although several studies showed the association between polyvascular disease and poor cardiovascular (CV) outcomes in Asian population, there was no large-scale study to validate this relationship in this population.

Methods and Results

This retrospective cohort study included patients with a diagnosis of CVD, CAD, or PAD from the database contained in the Taiwan National Health Insurance Bureau during 2001–2004. A total of 19954 patients were enrolled in this study. The atherothrombotic disease score was defined according to the number of atherothrombotic disease. The study endpoints included acute coronary syndrome (ACS), all strokes, vascular procedures, in hospital mortality, and so on. The event rate of ischemic stroke (18.2%) was higher than that of acute myocardial infarction (5.7%) in our patients (P = 0.0006). In the multivariate Cox regression analyses, the adjusted hazard ratios (HRs) of each increment of atherothrombotic disease score in predicting ACS, all strokes, vascular procedures, and in hospital mortality were 1.41, 1.66, 1.30, and 1.14, respectively (P≦0.0169).

Conclusions

This large population-based longitudinal study in patients with atherothrombotic disease demonstrated the risk of subsequent ischemic stroke was higher than that of subsequent AMI. In addition, the subsequent adverse CV events including ACS, all stroke, vascular procedures, and in hospital mortality were progressively increased as the increase of atherothrombotic disease score.

Cardiovascular risk factor profiles for peripheral artery disease and carotid atherosclerosis among Chinese older people: a population-based study

OBJECTIVES

Epidemiological data concerning atherosclerotic disease among older people in rural China are sparse. We seek to determine prevalence and cardiovascular risk factor profiles for peripheral artery disease (PAD) and carotid atherosclerosis (CAS) among Chinese older people living in a rural community.

METHODS

This cross-sectional study included 1499 participants (age ≥60 years, 59.0% women) of the Confucius Hometown Aging Project in Shandong, China. From June 2010-July 2011, data were collected through interviews, clinical examinations, and laboratory tests. PAD was defined as an ankle-brachial index ≤0.9. Carotid intima-media thickness (cIMT) and carotid artery stenosis were assessed by ultrasonography. We defined moderate stenosis as carotid stenosis ≥50%, and severe stenosis as carotid stenosis ≥70%. cIMT≥1.81 mm was considered as an increased cIMT (a measure of CAS). Data were analyzed with multiple logistic models.

RESULTS

The prevalence was 5.7% for PAD, 8.9% for moderate stenosis, 1.8% for severe stenosis, and 11.2% for increased cIMT. After controlling for multiple potential confounders, diabetes, an increased low-density lipoprotein cholesterol (LDL-C)/high-density lipoprotein cholesterol (HDL-C) ratio, and hypertension were significantly or marginally associated with PAD. Ever smoking, hypertension, and an increased LDL-C/HDL-C ratio were significantly associated with an increased likelihood of increased cIMT. An increasing number of those cardiovascular risk factors were significantly associated with an increasing odds ratio of PAD and increased cIMT, respectively (p for linear trend <0.001).

CONCLUSION

Among Chinese older people living in a rural community, PAD, carotid artery stenosis, and an increased cIMT are relatively uncommon. Cardiovascular risk factor profiles for PAD and CAS are slightly different, with hypertension and an increased LDL-C/HDL-C ratio being associated with an increased likelihood of both PAD and increased cIMT.

Comparative assessment of published atrial fibrillation stroke risk stratification schemes for predicting stroke, in a non-atrial fibrillation population: the Chin-Shan Community Cohort Study

BACKGROUND

In patients at high risk of stroke, such as atrial fibrillation (AF), there has been great interest in developing stroke risk prediction schemes for identifying those at high risk of stroke. Stroke risk prediction schemes have also been developed in non-AF populations, but are limited by lack of simplicity, which is more evident in schemes used in AF populations. We hypothesized that contemporary stroke risk stratification schemes used in assessing AF patients could predict stroke and thromboembolism in a non-AF community population, comparably to that seen in AF populations.

METHODS

We tested the CHADS2 and CHA2DS2-VASc schemes, as well as the AF stroke risk stratification schemes from the Framingham study, Rietbrock et al., 2006 ACC/AHA/ESC guidelines, the 8th American College of Cardiology (ACCP) guidelines and NICE, for predicting stroke in a large community cohort of non-AF subjects, the Chin-Shan Community Cohort Study.

RESULTS

The tested schemes had variable classification into low, moderate and high risk strata, with the proportion classified as low risk ranging from 5.4% (Rietbrock et al. to 59.0% (CHADS2 classical). Rates of stroke also varied in those classified as 'low risk' ranging from 1.1% (Rietbrock et al. to 3.5% (Framingham). All common risk schemes had broadly similar c-statistics, ranging from 0.658 (Framingham) to 0.728 (CHADS2 classical) when assessed as a continuous risk variable for predicting stroke in this population, with clear overlap between the 95% CIs. In an exploratory analysis amongst AF subjects in our population, the c-statistics were broadly similar to those seen in non-AF subjects.

CONCLUSION

Contemporary stroke risk stratification schema used for AF can also be applied to non-AF populations with a similar (modest) predictive value. Given their simplicity (e.g. CHADS2 score), these scores could potentially be used for a 'quick' evaluation of stroke risk in non-AF populations, in a similar manner to AF populations.

Total white blood cell count or neutrophil count predict ischemic stroke events among adult Taiwanese: report from a community-based cohort study

Background

Evidence about whether white blood cell (WBC) or its subtypes can act as a biomarker to predict the ischemic stroke events in the general population is scanty, particularly in Asian populations. The aim of this study is to establish the predictive ability of total WBC count or subtypes for long-term ischemic stroke events in the cohort population in Taiwan.

Methods

The Chin-Shan Community Cohort Study began from 1990 to 2007 by recruiting 1782 men and 1814 women of Chinese ethnicity. Following a total of 3416 participants free from ischemic stroke events at baseline for a median of 15.9 years; we documented 187 new incident cases.

Results

The multivariate relative risk for the comparison of the participants in the fifth and first WBC count quintiles was 1.67 (95% confidence interval [CI], 1.02–2.73; P for trend=0.03), and the corresponding relative risk for neutrophil count was 1.93 (95% CI, 1.13–3.29; P for trend=0.02). The discriminative ability by WBC and neutrophil counts were similar (area under the receiver operating characteristic curve, 0.600 for adding WBC, 0.610 for adding neutrophils, 0.595 for traditional risk factor model). In addition, the net reclassification improvement (NRI) values between the neutrophil and white blood cell count models were not significant (NRI, =-2.60%, P=0.35), indicating the similar discrimination performance for both WBC and neutrophil counts.

Conclusions

WBC and neutrophil count had a similar ability to predict the long-term ischemic stroke events among Taiwanese.

Carotid intima-media thickness and apolipoproteins in patients of ischemic stroke in a rural hospital setting in central India: A cross-sectional study

Context:

Carotid intima-media thickness (CIMT) and apolipoproteins have been found as a risk factor for ischemic stroke

Objective:

The objective was to study the carotid intima-media thickness, apolipoproteins, and their relation in patients of ischemic stroke in central rural India.

Settings and Design:

A cross-sectional study was performed in a rural hospital in central India.

Materials and Methods:

In all patients of ischemic stroke proven by computerized tomography (CT), CIMT, apolipoprotein A-I (ApoA-I), and apolipoprotein B(ApoB) were measured.

Statistical Analysis Used:

We used Student's t-test to compare means, a chi-square test to compare proportions, and a Mann-Whitney test to compare medians. A P value <0.05 was considered significant.

Results:

The mean age of our study population (N=106) was 61 years. The mean CIMT was 0.83 mm ranging from a minimum of 0.45 mm to a maximum of 1.096 mm. Mean CIMT was significantly higher than expected 0.67 values, which was calculated according to the age of the study population. The association of decreased ApoA-I < 100 mg/dl and increased ApoB > 90 mg/dl with CIMT > 0.7 mm was statistically significant with P<0.001.

Conclusions:

The CIMT in computerized tomography-proven ischemic stroke was significantly higher than expected for the age of the study population. The relation of decreased ApoA-I and increased ApoB with CIMT > 0.7 mm was also statistically significant.

Differential effects of the changes of LDL cholesterol and systolic blood pressure on the risk of carotid artery atherosclerosis

BACKGROUND

The effects of baseline and changes in blood pressure and low density lipoprotein (LDL) cholesterol on the carotid intima media thickness (IMT) have not been well documented.

METHODS

A total of 2572 adults (mean age 53.8 years, 54.6% women) in a Taiwanese community undertook three blood pressure and LDL cholesterol examinations over 6 years. Latent growth curve modeling was used to investigate the effects of baseline and change in blood pressure and LDL cholesterol on IMT.

RESULTS

Greater baseline LDL and blood pressure were associated with an increase in IMT (0.005 ± 0.002 mm per 1 mg/dL [p = 0.006] and 0.041 ± 0.004 mm mm Hg [p <0.0001], respectively. Change in blood pressure was associated with a significant increase in IMT (0.047 ± 0.016, P = 0.004), whilst the association between change in LDL and change in IMT was not statistically significant (0.008 ± 0.006, P = 0.20).

CONCLUSIONS

Carotid IMT was associated with baseline blood pressure and LDL cholesterol, yet only changes of blood pressure, not LDL cholesterol, were related to carotid IMT during the 6-year observation.

Age- and gender-associated determinants of carotid intima-media thickness: a community-based study

AIM

Few population-based studies have assessed the risk factors of and gender differences in intima-media thickness (IMT) at the common carotid artery (CCA) for different age groups.

OBJECTIVE

Factors determining age and gender differences in IMT were studied in ethnic Chinese participants of the Chin-Shan Community Cardiovascular Cohort in Taiwan.

METHODS

From July 1994 through August 1996, the CCA-IMT of 1203 men and 1487 women aged 35 years or more was measured using high-resolution B-mode carotid ultrasound. Cardiovascular risk factors were recorded for each subject.

RESULTS

The CCA-IMT consistently increased with age and was more in men than in women. For participants aged 55 years or more, women showed a more rapid increase in systolic blood pressure (SBP) and low-density lipoprotein cholesterol (LDL) than men. The gender difference in CCA-IMT became insignificant after 75 years of age. The major determinants of CCA-IMT in addition to age and gender were body mass index at 35-44 years of age, LDL in both genders and SBP in women at 45-54 years old, SBP at 55-64 and 65-74 years old, and women with left ventricular hypertrophy, hypertension with medication, and high LDL levels at 65-74 years old after multivariate linear regression analysis. For those aged over 75 years, SBP was an important determinant of CCA-IMT.

CONCLUSIONS

The CCA-IMT increases with age and its determinants are associated with age and gender. The rapid increase in cardiovascular risk factors in women after 55 years of age attenuates the female advantage in CCA-IMT.

From circulating biomarkers to genomics and imaging in the prediction of cardiovascular events in the general population

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. In the last decades numerous markers have been considered and investigated for the prediction of CV events, but only a few of them resulted in improved global risk assessment beyond traditional risk factors when incorporated into coronary evaluation scores. Recent genetic studies have pointed out a few but consistent loci or genes which are independently associated with CV risk. The idea is fascinating that these genetic markers could lead to improved individual CV risk assessment and tailored pharmacological interventions. In this brief review we will not make a systematic review of all non-genetic and genetic markers of CV risk but we will try to make a brief overview of the most interesting ones with the aim to underline potential 'pros' and 'cons' of their implementation in clinical practice.

Intima-media thickness predicts stroke risk in the Heinz Nixdorf Recall study in association with vascular risk factors, age and gender

BACKGROUND AND PURPOSE

Individual risk stratification requires reliable information on preexisting vascular disease. The intima-media thickness of the common carotid artery (CIMT) is a non-invasively accessible marker of atherosclerosis, which can be used for risk evaluation.

METHODS

In a sample of 3669 initially stroke-free subjects aged 45-75 years belonging to the population-based Heinz Nixdorf Recall cohort, the predictive value of CIMT for incident stroke was evaluated over 85.3 ± 17.4 months in addition to established risk factors.

RESULTS

In a multivariable Cox regression analysis with traditional cardiovascular risk factors including age, gender, systolic blood pressure, LDL and HDL, diabetes, body mass index, smoking and CIMT, CIMT was a moderate stroke predictor (hazard ratio = 1.20 per 0.1 mm, 95% confidence interval = 1.01-1.44; p = 0.043), additional to e.g. age (1.46 per 5 years, 1.21-1.75; p < 0.001), systolic blood pressure (1.16 per 10 mm Hg, 1.04-1.30; p = 0.008) and current smoking (1.93, 1.12-3.31; p = 0.014). CIMT was associated with stroke risk in subjects above but not below 65 years. CIMT predicted stroke events in men, but not women. CIMT discriminated stroke incidence specifically in subjects belonging to the highest Framingham risk score tercile.

CONCLUSIONS

CIMT is a moderate independent stroke predictor, which discriminates stroke incidence in subjects at high vascular risk.

Clinical usefulness of carotid ultrasound to improve stroke risk assessment: ten-year results from the Carotid Atherosclerosis Progression Study (CAPS)

BACKGROUND AND PURPOSE

To prevent strokes it is essential to correctly classify people according to their risk of stroke. The aim of the present study was to assess whether carotid ultrasound improves the stroke risk prediction in asymptomatic individuals.

METHODS

The baseline visit of the Carotid Atherosclerosis Progression Study (CAPS) included assessment of conventional risk factors and carotid ultrasound. During the 10-year follow-up of 4995 subjects, strokes, transient ischaemic attacks (TIA) and deaths were recorded. We assessed the additional usefulness of carotid ultrasound compared to the Framingham Stroke Risk Score (FSRS) with reclassification statistics using four risk categories.

RESULTS

Most risk models were not improved by carotid ultrasound. For individual stroke prediction, intima-media thickness (IMT) or plaque of the internal carotid arteries were more useful than common carotid or bifurcational IMT. The model predicting 'any stroke or death' was significantly improved when ultrasound parameters were included - 339 subjects (7.2%) were reclassified to another risk category (122 were shifted to a higher, 217 to a lower risk category); 182 (53.7%) were correctly reclassified. The net reclassification improvement (NRI) was 7.7% (p = 0.029) and the integrated discrimination improvement (IDI) was 0.73% (p = 0.023).

CONCLUSIONS

When carotid ultrasound is not restricted to the common carotid artery but includes the internal carotid segments, the inclusion of ultrasound data into stroke risk models may improve the risk classification of individuals. Further validation in primary prevention cohorts is warranted.

Significance of the intima-media thickness of carotid and thoracic aorta in coronary artery disease in the South Indian population

Background:

Ultrasound detected intima-media thickness (IMT) of the carotid artery and thoracic aorta are possible screening tests to assess the risk of coronary artery disease (CAD) in asymptomatic individuals.

Objective:

Aim of the study was to assess the utility of carotid and aortic IMT as a predictor of CAD and to assess the extent of IMT with severity of CAD in a South Indian population.

Patients and Methods:

A cross-sectional and analytical study was carried out among 40 cases, who had angiographic evidence of CAD against 30 healthy control subjects with a normal treadmill test. At plaque-free regions, the carotid IMT was evaluated by B-mode ultrasonography and thoracic aorta IMT was evaluated by trans-esophageal echocardiography (TEE). The significance of difference in means between two groups was analyzed using one-way ANOVA F-test and the significance of difference in proportions by Chi-square test. Multiple comparisons were done by Bonferroni t test. The correlation between IMT and severity of CAD was assessed by Spearman's method.

Results:

There were 38 males and 2 females among cases with age 51.7 ± 8.3 years, and 28 males and 2 females among control subjects with age 52.2 ± 7.1 years. Increased carotid IMT was noted among 24 cases and 2 control subjects, and the association was significant for CAD [P < 0.001, Chi-square = 20.89, odds ratio (OR) = 21.00, and 95% confidence interval (CI) = 4.78-89.59]. Similarly, 19 cases and one control subject had abnormal IMT with positive correlation for CAD (P < 0.001, Chi-square = 16.39, OR = 28.24, and 95% CI = 4.06-163.21). There was no association between IMT and diabetes, hypertension, or smoking; however, IMT was significantly associated with age and dyslipidemia. Also, there was no correlation between extent of IMT and severity of CAD.

Conclusions:

IMT of the carotid and thoracic aorta is strongly associated with risk of CAD in a South Indian population, and may be used as a non-invasive screening tool for coronary atherosclerosis in resource-limited settings. The presence of dyslipidemia influenced IMT and may be used as a tool to follow patients on hypolipidemic drugs.

Carotid intima-media thickness determined vascular age and the Framingham Risk Score

We examined carotid intima-media thickness (CIMT)-determined vascular age on the Framingham Risk Score (FRS) and the Framingham Heart Age in patients of diverse ethnic origin without a history of diabetes or established cardiovascular disease. In this cross-sectional study, 2291 men and women had CIMT obtained by high resolution B-mode ultrasound in a routine examination between August 1, 2000 and October 1, 2001. We randomly split the population into a training subset (n = 1114) and an analysis subset (n = 1177) using the training subset to regress the average CIMT for each individual on chronologic age. We compared the FRS using CIMT-determined vascular age versus chronologic age in the analysis subset. On average, CIMT-determined vascular age was less than chronologic age, which was less than FRS-heart age in all gender and ethnic groups. For estimated 10-year cardiovascular-disease risk among non-Hispanic whites, only 45.5% of male and 55.6% of female patients were concordant for both measures, and simple Kappa values were low (0.28 for males, 0.32 for females). Among non-Hispanic whites, 40.7% of males and 32.1% of females had greater risk using chronologic age rather than when using CIMT-determined vascular age. Conversely, 13.8% of males and 12.3% of females had a greater risk using CIMT-determined vascular age rather than when using chronologic age. A similar pattern was noted in the other ethnic groups. Our results suggest that CIMT may be very useful in improving risk discrimination in the FRS, and that substituting CIMT-determined vascular age may improve individual cardiovascular risk prediction.