Carotid intima-media thickness: knowledge and application to everyday practice

Intertemporal Decision-Making, Diabetes Self-Management, and Health Outcomes in Patients With Type 2 Diabetes

PURPOSE

The purpose of this study was to identify the independent factors associated with intertemporal decision-making and to examine its relationship with diabetes self-management behaviors, glucose variability, and diabetes complications in patients with diabetes.

METHODS

A cross-sectional study using convenience sampling (n = 368) was conducted in patients with type 2 diabetes (T2DM) between November 2021 and April 2023. Data were collected using self-reported questionnaires and retrieval of clinical information from medical records. Intertemporal decision-making was operationalized using delay discounting. The outcome variables included diabetes self-management behaviors, A1C, diabetic retinopathy, and carotid artery disease. Hierarchical regression and binary logistic regression models were used to explore the relationships among intertemporal decision-making, self-management, A1C, and carotid artery disease.

RESULTS

The analyses showed that intertemporal decision-making was negatively associated with physical activity and carotid artery disease, in which individuals with lower delay discounting tended to have healthier physical activity; when the delay discounting rate increased 1 unit, the risk of the carotid artery disease increased by 39.8%.

CONCLUSIONS

The study reveals that a lower delay discounting can promote healthier physical activity and decrease the incidence of carotid artery disease. These results offer new knowledge for researchers and clinicians to consider intertemporal decision-making in developing interventional programs to improve physical activity and reduce carotid artery complication in patients with T2DM when providing care.

Early detection of cardiovascular risk markers through non-invasive ultrasound methodologies in periodontitis patients

Objectives

This narrative review aims to update the current evidence and offer insight into the new non-invasive ultrasound techniques used to early identify degenerative vascular changes in subjects with periodontitis and to investigate if these methodologies could be useful to identify subclinical cardiovascular disease (CVD) dysfunction in periodontitis patients and to monitor changes in CVD risk after periodontal treatment.

Methods

Studies examining the assessment of vascular endothelial function through the latest methodologies were analyzed. Systematic reviews, observational studies, and clinical trials in the English language were identified using PubMed, Web of Science, and Google Scholar databases with key search terms such as "periodontitis," "endothelial dysfunction (ED)," "arterial stiffness," and "periodontal therapy."

Results

Several mechanisms are involved in the association between periodontitis and CVD. The key players are periodontal bacteria and their toxins, which can enter the circulation and infiltrate blood vessel walls. The increase in proinflammatory molecules such as interleukins and chemokines, c-reactive protein, fibrinogen, and oxidative stress also plays a decisive role. In addition, an increase in parameters of ED, arterial stiffness, and atherosclerosis, such as carotid intima-media thickness, pulse wave velocity, and flow-mediated dilatation, has been shown in periodontal patients.

Conclusions

The literature today agrees on the association of periodontitis and CVD and the positive role of periodontal therapy on systemic inflammatory indices and cardiovascular outcomes. Hopefully, these non-invasive methodologies could be extended to periodontal patients to provide a comprehensive understanding of the CVD-periodontitis link from the perspective of a personalized medicine approach in periodontology.

Common carotid artery intima media thickness (CIMT) in patients with prediabetes and newly diagnosed type 2 diabetes mellitus

AIM

To evaluate the relationship between common carotid artery intima media thickness (CIMT) in patients with prediabetes and new-onset diabetes mellitus without proven cardiovascular disease and some classic cardio-metabolic risk factors.

PATIENTS AND METHODS

The study included 461 obese patients with an average age of 53.2 ± 10.7 years, divided into three groups - group 1 without carbohydrate disturbances (n = 182), group 2 with prediabetes (n = 193) and group 3 with newly diagnosed diabetes mellitus (n = 86).

RESULTS

The patients with new-onset diabetes had significantly higher mean CIMT values compared to those with prediabetes or without carbohydrate disturbances and a higher frequency of abnormal IMT values. CIMT correlated significantly with age, systolic BP, diastolic BP and fasting blood glucose and showed a high predictive value for the presence of diabetic neuropathy and sudomotor dysfunction. Patients with abnormal CIMT values had a higher incidence of arterial hypertension, dyslipidemia, metabolic syndrome, peripheral neuropathy, and sudomotor dysfunction. Patients who developed type 2 diabetes during follow-up had a significantly higher initial mean CIMT, which showed the highest predictive value for the risk of new-onset diabetes, with CIMT≥0.7 mm having 53 % sensitivity and 83 % specificity for the risk of progression to diabetes mellitus.

CONCLUSION

Patients with new-onset diabetes mellitus had significantly greater intima media thickness of the common carotid artery and a greater frequency of abnormal CIMT values compared to those with normoglycemia and prediabetes. CIMT has a high predictive value for the presence of diabetic neuropathy, sudomotor dysfunction and the risk of new onset diabetes.

The Relationship between Subclinical Hypothyroidism and Carotid Intima-Media Thickness as a Potential Marker of Cardiovascular Risk: A Systematic Review and a Meta-Analysis

BACKGROUND AND OBJECTIVES

Thyroid dysfunction is known to have significant consequences on the cardiovascular system. The correlation between carotid intima-media thickness (CIMT) and subclinical hypothyroidism (SCH) has been frequently evaluated in clinical studies in recent years. This study aimed to evaluate the significance of this association through a meta-analysis.

METHODS

We conducted a systematic search of PubMed, MedLine, Scopus, and Web of Science databases using the keywords 'subclinical hypothyroidism and carotid intima-media thickness', from the beginning of each database until January 2023. We established the inclusion and exclusion criteria and considered studies that met the inclusion criteria. We used Jamovi for statistical analysis of the data.

RESULTS

We identified 39 observational studies that met the inclusion criteria, with 3430 subjects: 1545 SCH and 1885 EU. Compared to euthyroid subjects (EU), subjects with subclinical hypothyroidism (SCH) had significantly increased carotid intima-media thickness (CIMT) values; the estimated average mean difference was 0.08 (95% CI 0.05 to 0.10), p < 0.01, I2 = 93.82%. After the sensitivity analysis, a total of 19 from the 39 abovementioned studies were analyzed, with most studies showing a positive association between SCH and thickening of the carotid wall; the estimated average mean difference was 0.04 (95% CI 0.02 to 0.07), p = 0.03, I2 = 77.7. In addition, female sex, advanced age, and high cholesterol levels statistically significantly influenced this association.

CONCLUSIONS

Our meta-analysis indicates a significant positive association between SCH and increased CIMT, but with some limitations.

Threshold values of brachial cuff-measured arterial stiffness indices determined by comparisons with the brachial-ankle pulse wave velocity: a cross-sectional study in the Chinese population

Background

Arterial Velocity-pulse Index (AVI) and Arterial Pressure-volume Index (API), measured by a brachial cuff, have been demonstrated to be indicative of arterial stiffness and correlated with the risk of cardiovascular events. However, the threshold values of AVI and API for screening increased arterial stiffness in the general population are yet to be established.

Methods

The study involved 860 subjects who underwent general physical examinations (M/F = 422/438, age 53.4 ± 12.7 years) and were considered to represent the general population in China. In addition to the measurements of AVI, API and brachial-ankle pulse wave velocity (baPWV), demographic information, arterial blood pressures, and data from blood and urine tests were collected. The threshold values of AVI and API were determined by receiver operating characteristic (ROC) analyses and covariate-adjusted ROC (AROC) analyses against baPWV, whose threshold for diagnosing high arterial stiffness was set at 18 m/s. Additional statistical analyses were performed to examine the correlations among AVI, API and baPWV and their correlations with other bio-indices.

Results

The area under the curve (AUC) values in ROC analysis for the diagnosis with AVI/API were 0.745/0.819, 0.788/0.837, and 0.772/0.825 (95% CI) in males, females, and all subjects, respectively. Setting the threshold values of AVI and API to 21 and 27 resulted in optimal diagnosis performance in the total cohort, whereas the threshold values should be increased to 24 and 29, respectively, in order to improve the accuracy of diagnosis in the female group. The AROC analyses revealed that the threshold values of AVI and API increased markedly with age and pulse pressure (PP), respectively.

Conclusions

With appropriate threshold values, AVI and API can be used to perform preliminary screening for individuals with increased arterial stiffness in the general population. On the other hand, the results of the AROC analyses imply that using threshold values adjusted for confounding factors may facilitate the refinement of diagnosis. Given the fact that the study is a cross-sectional one carried out in a single center, future multi-center or follow-up studies are required to further confirm the findings or examine the value of the threshold values for predicting cardiovascular events.

The association of gestational age and birthweight with blood pressure, cardiac structure, and function in 4 years old: a prospective birth cohort study

BACKGROUND

Current evidence relating birthweight and gestational age to cardiovascular risk is conflicting. Whether these factors have independent or interactive impacts on cardiovascular parameters during early childhood remains unclear. The goal of this study was to explore whether there were any independent and interactive effects of gestational age and birthweight on blood pressure, left ventricle (LV) structure, and function in 4 years old.

METHODS

This study included 1194 children in the Shanghai Birth Cohort from 2013 to 2016. Information about the mothers and children was recorded at time of birth using a questionnaire. Follow-up measurements, including anthropometric, blood pressure, and echocardiography, were taken between 2018 and 2021, when the children were 4 years old. Multiple linear or logistic regressions and restricted cubic spline were used to explore the association of birthweight and gestational age with cardiovascular measurements.

RESULTS

Gestational age had a significant negative correlation with both systolic blood pressure [β =  - 0.41, 95% CI: (- 0.76, - 0.07)] and mean arterial pressure [β =  - 0.36, 95%CI: (- 0.66, - 0.07)]. The risk of prehypertension decreased with increased gestational age [OR = 0.54, 95% CI: (0.32, 0.93)]. The relationship between birthweight with blood pressure was U-shape (P for non-linear < 0.001). The wall thickness, volume, mass, and cardiac output of LV increased with birthweight, though the ejection fraction [β =  - 1.02, 95% CI: (- 1.76, - 0.27)] and shorten fraction [β = 0.72, 95% CI: (- 1.31, - 0.14)] decreased with birthweight. The risk of LV hypertrophy was not associated with birthweight [OR = 1.59, 95% CI: (0.68, 3.73)].

CONCLUSIONS

In this study, we found different associations of birthweight and gestational age with cardiovascular measurements in the offspring at 4 years old. Gestational age influenced blood pressure independent of birthweight. Heart size and function at 4 years old was influenced mostly by birthweight and not by gestational age.

Maternal plasma perfluoroalkyl substances concentrations in early pregnancy and cardiovascular development in offspring: A prospective cohort study

BACKGROUND

High maternal plasma perfluoroalkyl substances (PFAS) concentrations has been associated with adverse birth outcomes, but data on early childhood cardiovascular health is limited. This study aimed to assess the potential association between maternal plasma PFAS concentrations during early pregnancy and cardiovascular development in offspring.

MATERIAL AND METHODS

Cardiovascular development was assessed through blood pressure measurement, echocardiography and carotid ultrasound examinations among 957 children from the Shanghai Birth Cohort aged at 4 years old. Maternal plasma concentrations of PFAS were measured at mean gestational age of 14.4 (SD:1.8) weeks. The joint associations between PFAS mixture concentrations and cardiovascular parameters were analyzed using a Bayesian kernel machine regression (BKMR). The potential association of individual PFAS chemicals concentrations was explored using multiple linear regression.

RESULTS

In BKMR analyses, carotid intima media thickness (cIMT), interventricular septum thickness in diastole and systole, posterior wall thicknesses in diastole and systole, and relative wall thickness were significantly lower when all log10-transformed PFAS were fixed at 75th percentile in comparison to at their 50th percentile[Estimated overall Risk:-0.31 (95%CI: -0.42, -0.20), -0.09 (95%CI: -0.11, -0.07), -0.21 (95%CI: -0.26, -0.16), -0.09 (95%CI: -0.11, -0.07), -0.07 (95%CI: -0.10, -0.04) and -0.005 (95%CI: -0.006, -0.004)].Furthermore, maternal plasma concentrations of individual short-chain PFAS was associated with a decrease in left ventricular wall thickness, intraventricular septum thickness and enlarged chamber volume, and long-chain with a decrease in cIMT.

CONCLUSIONS

Our findings suggest that maternal plasma PFAS concentrations during early pregnancy was adversely associated with cardiovascular development in offspring, including thinner cardiac wall thickness and cIMT.

Magnesium—A More Important Role in CKD–MBD than We Thought

Chronic kidney disease (CKD) is associated with different complications, including chronic kidney disease–mineral and bone disorder (CKD–MBD), which represents a systemic disorder that involves the presence of different mineral or bone structure abnormalities (i.e., modification of bone turnover, strength, volume, etc.), including even vascular calcification development. Even if, over the years, different pathophysiological theories have been developed to explain the onset and progression of CKD–MBD, the influence and importance of serum magnesium level on the evolution of CKD have only recently been highlighted. So far, data are inconclusive and conflicting; therefore, further studies are necessary to validate these findings, which could be useful in developing a better, more adequate, and personalized management of CKD patients.

Associations Between the Macular Microvasculatures and Subclinical Atherosclerosis in Patients With Type 2 Diabetes: An Optical Coherence Tomography Angiography Study

Objective

To investigate the associations between the macular microvasculature assessed by optical coherence tomography angiography (OCTA) and subclinical atherosclerosis in patients with type 2 diabetes.

Methods

We included patients with type 2 diabetes who received comprehensive medical and ophthalmic evaluations, such as carotid ultrasonography and OCTA at a hospital-based diabetic clinic in a consecutive manner. Among them, 254 eyes with neither diabetic macular edema (DME) nor history of ophthalmic treatment from 254 patients were included. The presence of increased carotid intima-media thickness (IMT) (&gt;1.0 mm) or carotid plaque was defined as subclinical atherosclerosis. OCTA characteristics focused on foveal avascular zone (FAZ) related parameters and parafoveal vessel density (VD) were compared in terms of subclinical atherosclerosis, and risk factors for subclinical atherosclerosis were identified using a multivariate logistic regression analysis.

Results

Subclinical atherosclerosis was observed in 148 patients (58.3%). The subclinical atherosclerosis group were older (p &lt; 0.001), had a greater portion of patients who were men (p = 0.001) and who had hypertension (p = 0.042), had longer diabetes duration (p = 0.014), and lower VD around FAZ (p = 0.010), and parafoveal VD (all p &lt; 0.05). In the multivariate logistic regression analysis, older age (p ≤ 0.001), male sex (p ≤ 0.001), lower VD around FAZ (p = 0.043), lower parafoveal VD of both superficial capillary plexus (SCP) (p = 0.011), and deep capillary plexus (DCP) (p = 0.046) were significant factors for subclinical atherosclerosis.

Conclusion

The decrease in VD around FAZ, and the VD loss in parafoveal area of both SCP and DCP were significantly associated with subclinical atherosclerosis in patients with type 2 diabetes, suggesting that common pathogenic mechanisms might predispose to diabetic micro- and macrovascular complications.

Mikrovaskuläre Pathologien bei Patienten mit Psoriasis vulgaris mittels Nagelfalzkapillarmikroskopie identifiziert: Ergebnisse einer prospektiven kontrollierten Studie

Hintergrund: Die Psoriasis gilt als unabhängiger kardiovaskulärer Risikofaktor und Treiber einer Atherogenese. Mikrovaskuläre Veränderungen in psoriatischen Plaques sind gut beschrieben, wohingegen Veränderungen außerhalb betroffener Hautareale kaum untersucht wurden. In dieser Studie wurden Nagelfalzkapillaren von Psoriasispatienten in nicht betroffener Haut systematisch untersucht. Patienten und Methodik: Prospektive Studie mit Untersuchung von Nagelfalzkapillaren bei Psoriasispatienten im Vergleich zu gesunden Kontrollen mittels digitaler Videokapillarmikroskopie. Es wurden 21 kapillarmikroskopische Parameter bewertet und die Ergebnisse mit Charakteristika der Patienten und der Psoriasiserkrankung, mit Laborparametern und Messungen der Intima-Media-Dicke der Arteria carotis communis korreliert. Ergebnisse: Die 77 Psoriasispatienten (24 mit zusätzlicher Psoriasisarthritis) und 71 Kontrollen zeigten sich hinsichtlich demographischer Merkmale und relevanter Einflussfaktoren für eine Mikroangiopathie ausbalanciert. Im Vergleich zur Kontrollgruppe zeigten Psoriasispatienten eine signifikante Minderung der kapillaren Dichte, häufigere Kapillarerweiterung mit mehr Verzweigungen, Torquierungen und kapillaren Unregelmäßigkeiten. Zusätzlich zeigten Psoriasispatienten signifikant höhere inflammatorische Serummarker und eine gesteigerte Intima-Media-Dicke. In unserem Kollektiv bestand kein Zusammenhang zwischen Krankheitsdauer oder Schweregrad der Psoriasis und spezifischen Kapillarveränderungen. Schlussfolgerungen: Die Nagelfalzkapillaren der untersuchten Psoriasispatienten zeigten ausgeprägte mikrovaskuläre Veränderungen, welche mit erhöhten Markern einer systemischen Entzündung und Frühzeichen einer Atherosklerose korrelierten. Weitere Studien sind erforderlich, um die Rolle der digitalen Videokapillarmikroskopie in der Bewertung des kardiovaskulären Risikos von Psoriasispatienten zu untersuchen.

Endothelial Dysfunction in Pregnancy Complications

The endothelium, which constitutes the inner layer of blood vessels and lymphatic structures, plays an important role in various physiological functions. Alterations in structure, integrity and function of the endothelial layer during pregnancy have been associated with numerous gestational complications, including clinically significant disorders, such as preeclampsia, fetal growth restriction, and diabetes. While numerous experimental studies have focused on establishing the role of endothelial dysfunction in pathophysiology of these gestational complications, their mechanisms remain unknown. Numerous biomarkers of endothelial dysfunction have been proposed, together with the mechanisms by which they relate to individual gestational complications. However, more studies are required to determine clinically relevant markers specific to a gestational complication of interest, as currently most of them present a significant overlap. Although the independent diagnostic value of such markers remains to be insufficient for implementation in standard clinical practice at the moment, inclusion of certain markers in predictive multifactorial models can improve their prognostic value. The future of the research in this field lies in the fine tuning of the clinical markers to be used, as well as identifying possible therapeutic techniques to prevent or reverse endothelial damage.

Nailfold videocapillaroscopy identifies microvascular pathologies in psoriasis vulgaris: Results of a prospective controlled study

BACKGROUND

Psoriasis is considered an independent cardiovascular risk factor, evidentially driving atherosclerosis. However, little is known about changes in the microvasculature of non-lesional skin in psoriasis patients. This study systematically examined capillary pathologies in psoriasis patients by digital video nailfold capillaroscopy.

PATIENTS AND METHODS

Prospective study comparing nailfold capillaries of psoriasis patients with those of healthy controls. Nailfold capillaries were evaluated for 21 parameters and results were correlated with characteristics of patients and psoriatic disease, laboratory parameters, and measurements of carotid intima-media thickness.

RESULTS

77 psoriasis patients (24 patients with additional psoriatic arthritis) and 71 controls were well-matched for demographic features and for relevant confounding factors causing microangiopathy. In comparison with controls, psoriasis patients showed a significant loss of capillaries, capillary expansion with increased ramifications and tortuosity and capillary irregularities. Moreover, in psoriasis patients we found significantly elevated serum markers of inflammation and significantly increased intima-media-thickness measurements. We found no effect of disease duration nor disease activity on capillary changes.

CONCLUSIONS

Nailfold capillaries of psoriasis patients showed marked microvascular abnormalities accompanied by increased markers of systemic inflammation and atherosclerosis. Prospective cohort studies are needed to assess the role of nailfold capillaroscopy for predicting the cardiovascular risk of psoriasis patients.

The association between carotid disease, arterial stiffness and diabetic retinopathy in type 2 diabetes: the Fremantle Diabetes Study Phase II

AIM

To determine whether macrovascular disease assessed by carotid ultrasonography and arterial stiffness by pulse wave velocity are independently associated with diabetic retinopathy in type 2 diabetes.

METHODS

A random subgroup of surviving participants with type 2 diabetes from the Fremantle Diabetes Study Phase II were invited to take part in this sub-study in 2018-2019. In addition to standardized questionnaires, a physical examination and fasting biochemical tests, each underwent dilated colour fundus photography, carotid arterial ultrasonography with measurement of the intima-media thickness (IMT) and quantification of the degree of stenosis, and pulse wave analysis calculation of the carotid-femoral pulse wave velocity (cfPWV). The cross-sectional association between arterial disease parameters and diabetic retinopathy was assessed using generalized estimating equation models which enabled both eyes to be included in the analysis.

RESULTS

Some 270 participants [mean ± sd age 72 ± 9 years, 153 (57%) men and median (IQR) diabetes duration 15 (11-22) years] were included in analysis. Of 524 assessable eyes, 82 (16%) had diabetic retinopathy. In multivariable analysis, significant independent associates of diabetic retinopathy were age at diabetes diagnosis (inversely), HbA_1c , insulin treatment and urinary albumin to creatinine ratio (all P ≤ 0.022), as well as cfPWV [odds ratio (OR) 1.13, 95% confidence interval (CI) 1.03, 1.23 per 1 m/s increase; P = 0.008] and common carotid artery (CCA) IMT ≥1 mm (OR 2.95, 95% CI 1.21, 7.23; P = 0.018).

CONCLUSIONS

The association between diabetic retinopathy and CCA IMT suggests that carotid disease may share cardiovascular risk factors with diabetic retinopathy. The association between diabetic retinopathy and cfPWV may reflect the consequences of altered intravascular haemodynamics.

The "Hitchhiker's Guide to the Galaxy" of Endothelial Dysfunction Markers in Human Fertility

Endothelial dysfunction is an early event in the pathogenesis of atherosclerosis and represents the first step in the pathogenesis of cardiovascular diseases. The evaluation of endothelial health is fundamental in clinical practice and several direct and indirect markers have been suggested so far to identify any alterations in endothelial homeostasis. Alongside the known endothelial role on vascular health, several pieces of evidence have demonstrated that proper endothelial functioning plays a key role in human fertility and reproduction. Therefore, this state-of-the-art review updates the endothelial health markers discriminating between those available for clinical practice or for research purposes and their application in human fertility. Moreover, new molecules potentially helpful to clarify the link between endothelial and reproductive health are evaluated herein.

Non-invasive evaluation of the common carotid artery in normal adults using ultrasound radiofrequency data technology

AIM

To evaluate the changes in CCA-IMT and vascular elasticity in healthy subjects in relation to age using radiofrequency data technology, to produce reference values for potential clinical applications.

MATERIALS AND METHODS

The following variables were measured in 160 subjects using radiofrequency data techniques: CCA-IMT, carotid distensibility (CD), local pulse-wave velocity (PWVβ), and stiffness (β). The subjects were divided into four age groups (30-39, 40-49, 50-59, and 60-69 years), with 20 men and 20 women in each group. The above parameters were compared among the different age groups.

RESULTS

CCA-IMT increased significantly with age (p<0.05). CD decreased significantly in the 40-49-years compared with the 30-39-years age group (p<0.05). PWVβ showed a significant increase in the 30-39-, 40-49-, and 50-59-years age groups (p<0.05). β increased significantly in the 50-59- compared with the 40-49-years age group (p<0.05). Compared with the 50-59-years age group, CD, PWVβ, and β showed no significant changes in the 60-69-years age group (p>0.05), with mean values of 329.39 ± 102.06 μm, 7.22 ± 1.91 m/s, and 10.04 ± 4.91, respectively.

CONCLUSION

Ultrasound radiofrequency data technology provides a non-invasive method for quantitatively and accurately assessing increased CCA-IMT and reduced vascular elasticity in healthy subjects in different age groups. The reference values produced in this study will be useful in clinical practice.

The Role of the Adipokines in the Most Common Gestational Complications

Adipocytokines are hormonally active molecules that are believed to play a key role in the regulation of crucial biological processes in the human body. Numerous experimental studies established significant alterations in the adipokine secretion patterns throughout pregnancy. The exact etiology of various gestational complications, such as gestational diabetes, preeclampsia, and fetal growth abnormalities, needs to be fully elucidated. The discovery of adipokines raised questions about their potential contribution to the molecular pathophysiology of those diseases. Multiple studies analyzed their local mRNA expression and circulating protein levels. However, most studies report conflicting results. Several adipokines such as leptin, resistin, irisin, apelin, chemerin, and omentin were proposed as potential novel early markers of heterogeneous gestational complications. The inclusion of the adipokines in the standard predictive multifactorial models could improve their prognostic values. Nonetheless, their independent diagnostic value is mostly insufficient to be implemented into standard clinical practice. Routine assessments of adipokine levels during pregnancy are not recommended in the management of both normal and complicated pregnancies. Based on the animal models (e.g., apelin and its receptors in the rodent preeclampsia models), future implementation of adipokines and their receptors as new therapeutic targets appears promising but requires further validation in humans.

Carotid Disease and Retinal Optical Coherence Tomography Angiography Parameters in Type 2 Diabetes: The Fremantle Diabetes Study Phase II

OBJECTIVE

To use optical coherence tomography angiography (OCTA) to determine whether retinal microvascular parameters are associated with carotid arterial disease in people with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Participants (community-based) underwent detailed assessments including carotid ultrasonography and OCTA. Ultrasound images were assessed for mean intima-media thickness (IMT) and the presence of stenosis. OCTA image analysis provided measures of vessel density, foveal avascular zone (FAZ) area, blood flow areas, and retinal thickness. For each OCTA variable, the most parsimonious model was generated using generalized estimating equations, then ipsilateral and contralateral carotid disease-related variables were added to determine their significance.

RESULTS

A total of 474 eyes from 261 participants (mean ± SD age 72.0 ± 9.3 years, 57.1% males, median diabetes duration 15.4 years [interquartile range 11.1-22.4]) were analyzed. When carotid variables were added to the most parsimonious models, the ipsilateral natural logarithm of common carotid artery IMT (coefficient -2.56 [95% CI -4.76, -0.35], P = 0.023) and presence of any ipsilateral stenosis (-0.82 [-1.48, -0.17], P = 0.014) were statistically significantly associated with a lower parafoveal density in the deep capillary plexus. A mean bifurcation IMT ≥1 mm was associated with a decreased vessel density in the 300-μm ring surrounding the FAZ (coefficient -0.79 [-1.50, -0.08], P = 0.030)). Contralateral carotid disease-related variables were also significantly associated with retinal microvascular parameters.

CONCLUSIONS

This is the first study to show that carotid disease is an independent associate of retinal microvascular disease assessed by OCTA in type 2 diabetes. Appropriately intensive management of carotid disease may improve the retinal microcirculation.

Relationship between non-alcoholic fatty liver disease and cardiovascular disease

With the in-depth study of non-alcoholic fatty liver disease (NAFLD), it has been found in recent years that NAFLD is closely related to cardiovascular disease (CVD). It has been proved that NAFLD is not only an important risk factor for CVD, but it is also an important mechanism of atherosclerosis, coronary heart disease, and hypertension in young people. This article reviews the recent progress in the understanding of the relationship between NAFLD and CVD, with an aim to improve the knowledge of CVD physicians on liver disease and provide reference for prevention and treatment of these conditions.

The relationship between carotid disease and retinopathy in diabetes: a systematic review

BACKGROUND

Since studies of the relationship between carotid disease and diabetic retinopathy (DR) have shown apparent inconsistencies, the aim of this study was to conduct a systematic review of available published data.

METHODS

Electronic databases were searched independently by two reviewers, according to an iterative protocol, for relevant articles. The search term used was "diabetes AND (carotid disease OR intima-media OR carotid plaque OR carotid stenosis OR carotid arterial disease OR carotid artery disease OR carotid atherosclerosis) AND (retinopathy OR diabetic retinopathy)".

RESULTS

From 477 publications, 14 studies were included. There were differences in the variables used as markers of carotid disease and DR across the included studies. Ten studies used carotid disease as the dependent variable, and the remainder used DR. All but one study involved cross-sectional data. Most studies reported a statistically significant association between at least one parameter of carotid disease as assessed by ultrasound and DR presence or severity. Only four studies reported no significant association. A common limitation was the use of convenience participant sampling.

CONCLUSIONS

There appears to be an increased likelihood of DR when there is ultrasonographic evidence of carotid disease, and vice versa. The available studies suggest that there may be a direct relationship between DR and carotid macrovascular disease and/or that these complications co-exist due to shared risk factors. If carotid disease is detected, retinal assessment should be performed. If DR is identified, intensive cardiovascular disease risk management should be considered. Additional longitudinal studies are needed to assess the directionality of the association.

Obstructive sleep apnea risk and subclinical atherosclerosis in South Asians living in the United States

OBJECTIVES

The objective of this study was to examine the association between high risk of obstructive sleep apnea (OSA) and subclinical atherosclerosis among South Asians in the United States.

DESIGN

A secondary analysis of cross-sectional data.

SETTING/PARTICIPANTS

A community-based cohort of 906 men and women participating in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study.

MEASUREMENTS

The Berlin Questionnaire was used to screen for OSA risk. Coronary artery calcium (CAC), common carotid artery intima-media thickness (IMT), and internal carotid artery IMT were used as measures of subclinical atherosclerosis.

RESULTS

The majority of participants (59%) with high OSA risk had CAC scores >0 compared with only 41% of participants with low OSA risk (P <.001). The high OSA risk group was older (P =.005), male (P =.04), had higher body mass index (P <.001) and had greater common carotid artery IMT (0.96 ± 0.27 mm) and internal carotid artery IMT (1.33 ± 0.42 mm) measurements. Snoring, sleep-disordered breathing (SDB), and high OSA risk were associated with subclinical atherosclerosis. However, only high OSA risk remained significant in multivariable models after controlling for demographic and clinical factors that included hypertension (HTN), obesity, diabetes, and dyslipidemia.

CONCLUSIONS

High OSA risk, which includes overlapping comorbidities of HTN and obesity, was not associated with the time living in the US but was associated with subclinical atherosclerosis markers. These cardiovascular disease risk factors should include evaluation of the spectrum of SDB among all adults, including South Asian men and women.

Cardiovascular Risk in Fatty Liver Disease: The Liver-Heart Axis-Literature Review

According to the World Health Organization, cardiovascular disease (CVD) remains the leading cause of death worldwide, accounting for approximately 18 million deaths per year. Nevertheless, the worldwide prevalence of metabolic diseases, such as type 2 diabetes mellitus, obesity, and non-alcoholic fatty liver disease (NAFLD), also known to be common risk factors for CVD, have dramatically increased over the last decades. Chronic alcohol consumption is a major cause of chronic liver diseases (CLD) as well as being a major health care cost expenditure accounting for the spending of tremendous amounts of money annually. NAFLD has become one of the major diseases plaguing the world while standing as the most common cause of liver disease in the Western countries by representing about 75% of all CLD. Currently, the most common cause of death in NAFLD remains to be CVD. Several mechanisms have been suggested to be responsible for associating FLD with CVD through several mechanisms including low-grade systemic inflammation, oxidative stress, adipokines, endoplasmic reticulum stress, lipotoxicity and microbiota dysbiosis which may also be influenced by other factors such as genetic and epigenetic variations. Despite of all this evidence, the exact mechanisms of how FLD can causally contribute to CVD are not fully elucidated and much remains unknown. Moreover, the current literature supports the increasing evidence associating FLD with several cardiovascular (CV) adverse events including coronary artery disease, increased subclinical atherosclerosis risk, structural alterations mainly left ventricular hypertrophy, increased epicardial fat thickness, valvular calcifications including aortic valve sclerosis and mitral annular calcification and functional cardiac modifications mainly diastolic dysfunction in addition to cardiac arrhythmias such as atrial fibrillation and ventricular arrythmias and conduction defects including atrioventricular blocks and bundle branch blocks. Patients with FLD should be evaluated and managed accordingly in order to prevent further complications. Possible management methods include non-pharmacological strategies including life style modifications, pharmacological therapies as well as surgical management. This review aims to summarize the current state of knowledge regarding the pathophysiological mechanisms linking FLD with an increased CV risk, in addition to associated CV adverse events and current management modalities.

Erectile dysfunction is associated with subclinical carotid vascular disease in young men lacking widely-known risk factors

This study aimed to gain insight into the underlying pathogenesis of erectile dysfunction in young men under the age of 40 years without widely-known risk factors. Compared with normal controls, patients with erectile dysfunction had increased carotid intima–media thickness, fasting levels of blood glucose and insulin, and homeostatic model assessment index, as well as lower flow-mediated vasodilation and testosterone levels (P < 0.05), though all of these values were within their respective normal range. Multivariate logistic regression analysis identified carotid intima–media thickness, flow-mediated vasodilation, insulin level, and homeostatic model assessment index as significant predictors of erectile dysfunction. Young men with flow-mediated vasodilation <10.65% were 11.645 times more likely to have erectile dysfunction, young men with carotid intima–media thickness >0.623 mm had a 4.16-fold, and young men with homeostatic model assessment index >1.614 had a 5.993-fold greater risk of having erectile dysfunction. In conclusions, in young men with normal results from general clinical screening, an increased carotid intima–media thickness and homeostatic model assessment index and reduced flow-mediated vasodilation were associated with a higher incidence of erectile dysfunction. Erectile dysfunction may appear before the detection of traditional cardiovascular risk factors and may be the earliest clinical sign of subclinical cardiovascular disease.

Effect of intensive lifestyle modification & metformin on cardiovascular risk in prediabetes: A pilot randomized control trial

Background & objectives:

Prediabetes is associated with increased prevalence of cardiovascular disease (CVD). In participants with prediabetes, the effects of exercise and metformin were evaluated on high-sensitivity C-reactive protein (hsCRP) and carotid intima-media thickness (CIMT), surrogate markers of atherosclerosis and CVD compared with standard care.

Methods:

In a pilot randomized control trial, the participants were randomized in to three arms: standard care (STD), intensive lifestyle modification (ILSM) or ILSM and metformin (ILSM+Met) and followed up for six months. Monitoring of ILSM was done by a trained healthcare facilitator. hsCRP, CIMT and other relevant parameters were measured before and after intervention.

Results:

A total of 103 participants were randomized into three arms and followed up for six months. At six months, there was a reduction from baseline in weight and fasting blood sugar (FBS) (P<0.01) in all three arms and a reduction in haemoglobin A_1c (P=0.03) only in the ILSM+Met arm. The differences in hsCRP over six months within the STD, ILSM and ILSM+Met arms were −0.12 (95% confidence interval, −1.81, 2.08), −0.58 (−2.64, 0.43) and −0.11 (−1.84, 1.56), respectively. There was no difference in hsCRP, CIMT (right) or CIMT (left) between the three arms at six months.

Interpretation & conclusions:

There was a reduction in weight and FBS from baseline in all three arms. There was, however, no difference seen in hsCRP and CIMT in the two intervention arms compared to standard care. Larger studies with long-term follow up need to be done to detect differences in risk markers for CVD in prediabetes.

Intima-media thickness of the common carotid arteries as a marker of retinopathy and nephropathy in sickle cell disease

Purpose

This study was conducted to test the hypothesis that the carotid intima-media thickness (CIMT) is higher in patients with sickle cell disease (SCD) than in the normal population, and to determine the relationships of the CIMT with central retinal artery (CRA) and renal artery Doppler indices.

Methods

Forty-four confirmed steady-state SCD patients aged 16 years and above were recruited consecutively. The Doppler velocimetric indices of their right renal artery and both CRAs were obtained. The CIMT was also measured on each side via B-mode ultrasonography. The subjects were categorized by age and sex. Mean and median values for each group were determined. The Spearman correlation test was used to quantify the relationships between CIMT and the Doppler parameters.

Results

The participants had a median age of 24.50 years (interquartile range, 12.50 to 36.50 years). Twenty-three were men (52.3%) and 21 were women (47.7%). The median CIMT was 0.70 mm (IQR, 0.50 to 0.90 mm). Significant correlations with the CIMT were found for the CRA peak systolic velocity (r=0.312, P=0.003), the renal artery resistivity index (RI) (r=0.284, P=0.007), and the renal artery pulsatility index (PI) (r=0.273, P=0.010). There was no significant relationship between the CIMT and the CRA end-diastolic velocity, CRA RI, or CRA PI.

Conclusion

CIMT in SCD patients was higher than in the previously reported age groups of the reference populations. In addition, the CIMT was significantly correlated with the CRA peak systolic velocity, the renal artery RI, and the renal artery PI.

Carotid Intima-Media Roughness and Elasticity in Hypertensive Patients With Normal Carotid Intima-Media Thickness

OBJECTIVES

To investigate carotid intima-media roughness (IMR) in hypertensive patients with normal carotid intima-media thickness (IMT) using automatic identification software and the correlation between carotid IMR and risk factors.

METHODS

This case-control study comprised 61 hypertensive patients with normal carotid IMT and 51 control participants. Carotid IMR, carotid IMT, pulsed wave velocity (PWV), stiffness (β), and arterial compliance were determined by carotid ultrasound and image postprocessing using an automatic identification program and echo-tracking analysis software.

RESULTS

Carotid IMR, mean carotid IMT, maximum carotid IMT, β, and PWV in the hypertension group were higher than those in the control group (58.24 versus 34.61 μm, 641.17 versus 576.48 μm, 746.82 versus 640.55 μm, 9.42 versus 7.35, and 7.10 versus 5.86 m/s, respectively; P < .05), and arterial compliance was lower than that in the control group (0.70 versus 0.95 mm² /kPa; P < .05). Intima-media roughness was correlated with maximum IMT, mean IMT, PWV, β, age, diagnosis of hypertension for greater than 1 year, and pulse pressure. Multivariate logistic regression showed that age, diagnosis of hypertension for greater than 1 year, and pulse pressure were influential factors for IMR in hypertensive patients, with odds ratios of 6.719 (95% confidence interval, 1.658-27.221; P = .008), 4.726 (95% confidence interval, 1.174-19.022; P = .029), and 3.998 (95% confidence interval, 1.033-15.466; P = .045), respectively.

CONCLUSIONS

Carotid IMR and the elasticity index have important clinical importance in evaluating the risk of early atherosclerosis in hypertensive populations.

Effects of sex steroids on cardiovascular risk profile in transgender men under gender affirming hormone therapy

PURPOSE

Gender affirming hormone therapy (HT) in transgender men both improves and impairs several surrogate cardiovascular risk markers. However, few prospective works with long follow-up and control group are available. In this context, this work aimed to assess the changes in the metabolic and cardiovascular risk pattern after 12 months of HT in transgender men. Furthermore, we aimed to investigate early effects on target tissues that may reflect an initial vascular damage.

METHODS

Prospective observational study, including 20 transgender men, attended in the Gender Identity Unit (UIG) of the Hospital Clinic from July 2013 to November 2015. Anthropometric and body composition by dual-energy X-ray absorptiometry (DXA), hormonal, metabolic and coagulation parameters, endothelial dysfunction by flow-mediated dilation (FMD) and intima-media thickness (IMT) by carotid ultrasound, were assessed at baseline, at 6 and 12 months of HT.

RESULTS

We observed an impairment of lipid profile, and increase of homocysteine and leucocytes count, as well as changes in body composition with increased total lean mass together with decreased total fat mass. In addition, higher mean-maximum common IMT was observed after 12 months of HT.

CONCLUSION

Our work shows changes in metabolic and inflammatory parameters after HT after short-medium follow-up, which could increase cardiovascular risk in this setting, together with initial evidence of vascular changes.

Post-trauma cardiovascular risk factors and subclinical atherosclerosis in young adults following the war in Bosnia and Herzegovina

Background: Risk of cardiovascular disease (CVD) has been associated with stress from serving in a war, but it has not been established whether children who experience war-related stress are at increased CVD risk. Objective: This study aimed to compare CVD risk factors in young adults according to whether they experienced traumatic events as children during the 1990-1995 war in Bosnia and Herzegovina, and whether those exposed to trauma have evidence of subclinical atherosclerosis. Method: We examined 372 first-year medical students who were preschool children during the war (1990-1995) (average age 19.5 ± 1.7 years, 67% female) in 2007-2010. They completed the Semi-Structured Interview for Survivors of War. CVD risk factors and carotid intima-media thickness (CIMT) measurements were obtained and compared in individuals with and without trauma. We also examined whether increased CIMT was independently associated with trauma after adjustment for other risk factors. Results: From multiple logistic regression, only elevated triglycerides (> 1.7 mmol/l) were associated with a 5.2 greater odds of having experienced trauma. The mean CIMT of subjects with trauma was greater than that of non-trauma-exposed subjects (0.53 mm vs 0.50 mm, p = 0.07). Moreover, trauma was independently associated with higher CIMT (difference = 0.036 mm, p = 0.024) after adjustment for CVD risk factors. Conclusions: We show that most CVD risk factors are associated with post-war trauma in young adults, and, if present, such trauma is associated with higher triglycerides and higher levels of CIMT in multivariable analysis.

Age-Related Effects of Bariatric Surgery on Early Atherosclerosis and Cardiovascular Risk Reduction

BACKGROUND

Carotid intima-media thickness (CIMT) is increasingly used as a prognostic indicator for early atherosclerosis and the development of cardiovascular disease. The objective of this study is to assess the exact effects of bariatric surgery on CIMT reduction in different age groups.

METHODS

CIMT was measured just proximal to the bifurcation of the carotid artery in 166 patients with mean body mass index of 43.4 kg/m² before and at 6 and 12 months after bariatric surgery. Preoperative CIMT and Framingham Risk Score (FRS) were compared to measurements at 6 and 12 months, postoperatively. Impact of age on CIMT change and cardiovascular risk reduction was analyzed.

RESULTS

Median follow-up was 12 months; 12% were lost to follow-up. Mean CIMT values at 12 months after bariatric surgery were significantly lower compared to baseline (0.619 vs. 0.587 mm, p = 0.005 in women and 0.675 vs. 0.622 mm, p = 0.037 in men, respectively), and these effects were statistically significant in all age groups. The mean reduction of CIMT for patients < 50 years at 12 months was 0.043 mm (- 7.0%), while CIMT was reduced with 0.013 mm for patients ≥ 50 years (- 1.9%, p = 0.022). At 12 months after bariatric surgery, FRS had decreased with 52% in patients < 50 years as compared with 35% in patients ≥ 50 years (p = 0.025).

CONCLUSIONS

Bariatric surgery resulted in a significant CIMT decrease in patients with morbid obesity in all evaluated age categories. These beneficial effects of bariatric surgery were more pronounced in younger patients, while cardiovascular risk reduction by bariatric surgery appeared inferior in patients of 50 years and older.

Intima-media complex thickness and carotid atherosclerotic plaque formation in Lublin's population in the context of selected comorbidities

Introduction: Atherosclerosis (arteriosclerosis) is a chronic arterial disease of the arteries with chronic inflammatory. The pathology of atherosclerosis is complex, and the atherosclerotic process is multi-factorial, not fully understood. Risk factors of atherosclerotic lesions may include: lipid disorders, hypertension or diabetes. One of the diagnostic methods of discovering atherosclerosis covers the assessment of the intima–media complex thickness by Doppler ultrasonography. Aim: The aim of this report was an evaluation of the relationships between intima–media complex thickness in the right and left carotid arteries and the occurrence of atheromatous plaque in the Lublin population with respect to three possible concomitant medical conditions, mentioned above. Material and methods: A group of 121 subjects was included into the study, all of the participants being residential inhabitants of the Lublin Voivodship. All the participating patients were requested to fill in a questionnaire. After that, the patients were submitted to Doppler sonography concentrated on intima–media complex thickness evaluation. The occurrence of atheromatous plaque was also assessed in obtained sonographic images. Results: There were statistically significant differences for the intima–media complex thickness and for the atheromatous plaque according to all of the reported diseases: hypocholesterolaemia, hypertension and diabetes. Conclusions: The present study confirms that there is a relationship between the thickness of the intima–media complex in the right and left carotid arteries as well as the occurrence of the atherosclerotic plaque regarding the coexistence of specific disease entities in the subjects of the Lublin population.

Evaluating feasibility and accuracy of non-invasive tests for nonalcoholic fatty liver disease in severe and morbid obesity

INTRODUCTION

In obese individuals, nonalcoholic fatty liver disease (NAFLD) is common but often goes undiagnosed, and therefore untreated. The presence of significant fibrosis is a key determinant of NAFLD progression, and liver steatosis has substantial cardiovascular implications. We aimed to determine the diagnostic accuracy of common noninvasive diagnostic tests for steatosis and fibrosis in the obese.

METHODS

We recruited 182 severely and morbidly obese individuals undergoing bariatric surgery (age 44 ± 12 years, body mass index 45.1 ± 8.3 kg/m²). Medical history, blood tests and liver biopsy were taken on the day of surgery. Serum steatosis and fibrosis scores were calculated. In a subgroup of patients, transient elastography with controlled attenuation parameter (TE/CAP) (n = 82) and proton magnetic resonance spectroscopy (¹H-MRS) (n = 49) were performed.

RESULTS

¹H-MRS had excellent diagnostic accuracy for steatosis, with strong correlation to steatosis (r = 0.647, p < 0.001), good AUROC (0.852, p = 0.001), sensitivity (81.3%) and specificity (87.5%). However, due to low feasibility in this cohort (65.3% success), this was substantially decreased with intention-to-diagnose analysis (sensitivity 50.0%, specificity 60.9%). CAP had good feasibility (80.5%), and performed better in intention-to-diagnose analysis (AUROC 0.688, sensitivity 84.8%, specificity 47.2%). Serum steatosis scores performed poorly, with comparable accuracy to ALT. For significant fibrosis, TE had the best accuracy (AUROC 0.903, p = 0.007), which remained reasonable after intention-to-diagnose analysis (sensitivity 100%, specificity 59.0%). A combination approach using CAP with ALT for steatosis and TE with Forn index for fibrosis yielded reasonable overall accuracy.

CONCLUSIONS

¹H-MRS and TE/CAP had greatest accuracy for NAFLD-related steatosis and fibrosis. Failure rates in obesity significantly diminished diagnostic ability. Use of a combination of serum and imaging tests improved overall feasibility of assessment and diagnostic accuracy in obese individuals.

Cardiovascular Assessment in Human Research

A number of noninvasive tests exist for assessing cardiovascular structure and function. This chapter describes protocols for flow-mediated dilation (FMD) of the brachial artery and pulse wave velocity (PWV) and pulse wave analysis (PWA) for measurement of arterial stiffness. The chapter also describes the different methodological approaches involved in applying these techniques for optimizing their validity, comparability, and potential uses as clinical and physiological research tools.

Impaired flow-mediated dilation response and carotid intima-media thickness in patients with type 1 diabetes mellitus with a mean disease duration of 4.1 years

OBJECTIVE

This study aimed at assessing the endothelial function in patients with Type 1 diabetes (T1DM) using flow-mediated dilation (FMD) response and carotid artery intima-media thickness (CIMT).

MATERIALS AND METHODS

This study enrolled 32 T1DM patients (mean disease duration 4.1 years) and 28 age-matched controls (CTL Group). Endothelial function and CIMT were assessed with high-resolution ultrasound using standardized offline measurements.

RESULTS

FMD was significantly lower in patients in the T1DM Group (8.9 ± 3.2%) compared with those in the CTL Group (13.3 ± 4.3%; P-value < 0.0001). Similarly, CIMT differed significantly between T1DM patients (0.525 ± 0.03 mm) and controls (0.508 ± 0.03 mm; P-value = 0.041). Even though, the values are within the normal range for age.

CONCLUSIONS

Patients with T1DM have impaired endothelial function characterized by reduced FMD when compared to controls. However, vascular remodeling as seen by increases in CIMT was not found in this study.

Effects of a liquefied petroleum gas stove intervention on pollutant exposure and adult cardiopulmonary outcomes (CHAP): study protocol for a randomized controlled trial

BACKGROUND

Biomass fuel smoke is a leading risk factor for the burden of disease worldwide. International campaigns are promoting the widespread adoption of liquefied petroleum gas (LPG) in resource-limited settings. However, it is unclear if the introduction and use of LPG stoves, in settings where biomass fuels are used daily, reduces pollution concentration exposure, improves health outcomes, or how cultural and social barriers influence the exclusive adoption of LPG stoves.

METHODS

We will conduct a randomized controlled, field intervention trial of LPG stoves and fuel distribution in rural Puno, Peru, in which we will enroll 180 female participants aged 25-64 years and follow them for 2 years. After enrollment, we will collect information on sociodemographic characteristics, household characteristics, and cooking practices. During the first year of the study, LPG stoves and fuel tanks will be delivered to the homes of 90 intervention participants. During the second year, participants in the intervention arm will keep their LPG stoves, but the gas supply will stop. Control participants will receive LPG stoves and vouchers to obtain free fuel from distributors at the beginning of the second year, but gas will not be delivered. Starting at baseline, we will collect longitudinal measurements of respiratory symptoms, pulmonary function, blood pressure, endothelial function, carotid artery intima-media thickness, 24-h dietary recalls, exhaled carbon monoxide, quality-of-life indicators, and stove-use behaviors. Environmental exposure assessments will occur six times over the 2-year follow-up period, consisting of 48-h personal exposure and kitchen concentration measurements of fine particulate matter and carbon monoxide, and 48-h kitchen concentrations of nitrogen dioxide for a subset of 100 participants.

DISCUSSION

Findings from this study will allow us to better understand behavioral patterns, environmental exposures, and cardiovascular and pulmonary outcomes resulting from the adoption of LPG stoves. If this trial indicates that LPG stoves are a feasible and effective way to reduce household air pollution and improve health, it will provide important information to support widespread adoption of LPG fuel as a strategy to reduce the global burden of disease.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02994680 , Cardiopulmonary Outcomes and Household Air Pollution (CHAP) Trial. Registered on 28 November 2016.

Nonalcoholic fatty liver disease: implications for cardiovascular risk

Nonalcoholic fatty liver disease (NAFLD) is a growing epidemic in the USA affecting ∼30% of the population. It has been closely linked to metabolic syndrome and type 2 diabetes, with strong implications for cardiovascular disease (CVD). This review focuses on the relationship between NAFLD and CVD and the proposed interactions interlinking these two diseases. This appraisal also discusses treatments targeting NAFLD in the context of CVD. NAFLD is a multisystem disease and ultimately the goals of therapy are to ameliorate CVD and prevent coronary artery disease morbidity and mortality.

Impact of nonalcoholic fatty liver disease on multiple human body systems

Non-alcoholic fatty liver disease (NAFLD) is a clinicpathologic syndrome characterized by hepatocellular steatosis and fat deposition in individuals in the absence of significant alcohol intake and other specific factors that can impair liver function. According to epidemiological investigations, NAFLD has become one of the most common liver diseases in China. More and more studies show that NAFLD can influence many human body systems. This paper reviews the possible effect of NAFLD on the cardiovascular system, digestive system, respiratory system, urinary system, metabolic system and nervous system.

Comparison of Carotid Intima Media Thickness in Children of Patients with and without Premature Coronary Artery Disease

INTRODUCTION

Increased Carotid Intima Medial Thickness (CIMT) is associated with cardiovascular risk factors and vascular events like Coronary Artery Disease (CAD) and stroke.

AIM

This study was designed to identify whether CIMT is increased in the children of parents with premature coronary artery disease and compare it with age and sex matched controls who are children of normal individuals. We also tried to compare and correlate the changes in CIMT if any, among the study group with relation to family history of diabetes and hypertension.

MATERIALS AND METHODS

It was an observational prospective case control study. Twenty five cases (children of parents with premature coronary artery disease) were recruited as per the inclusion and exclusion criteria. Age and sex matched controls were recruited from the paediatric Outpatient Department (OPD). The CIMT was measured using ultrasound Doppler as per the protocol by the Mannheim intima media thickness consensus statement.

RESULTS

Ten children out of 25 controls had CIMT of 0.05 cm and 5 out of 25 cases had CIMT of 0.07 cm. The association between cases and controls was not statistically significant. Even though the CIMT increases after 10 years, there is no statistically significant association between cases and controls in the different age groups. Out of the total 48% of the children among the case group had family history of hypertension whereas 28% in the control group. A 33% of children in the case group with family history of hypertension had CIMT of 0.07 cm; 46% of children in case group without family history of hypertension had CIMT of 0.05 cm. This difference was statistically significant (p=0.005). There was no significant association between family history of diabetes mellitus and CIMT in both groups.

CONCLUSION

There was significant association between CIMT in children with family history of premature CAD and family history of hypertension when compared with no family history of hypertension with premature CAD. There was no significant association between CIMT of children with and without family history of premature CAD.

Nonalcoholic fatty liver disease - A multisystem disease?

Non-alcoholic fatty liver disease (NAFLD) is one of the most common comorbidities associated with overweight and metabolic syndrome (MetS). Importantly, NAFLD is one of its most dangerous complications because it can lead to severe liver pathologies, including fibrosis, cirrhosis and hepatic cellular carcinoma. Given the increasing worldwide prevalence of obesity, NAFLD has become the most common cause of chronic liver disease and therefore is a major global health problem. Currently, NAFLD is predominantly regarded as a hepatic manifestation of MetS. However, accumulating evidence indicates that the effects of NAFLD extend beyond the liver and are negatively associated with a range of chronic diseases, most notably cardiovascular disease (CVD), diabetes mellitus type 2 (T2DM) and chronic kidney disease (CKD). It is becoming increasingly clear that these diseases are the result of the same underlying pathophysiological processes associated with MetS, such as insulin resistance, chronic systemic inflammation and dyslipidemia. As a result, they have been shown to be independent reciprocal risk factors. In addition, recent data have shown that NAFLD actively contributes to aggravation of the pathophysiology of CVD, T2DM, and CKD, as well as several other pathologies. Thus, NAFLD is a direct cause of many chronic diseases associated with MetS, and better detection and treatment of fatty liver disease is therefore urgently needed. As non-invasive screening methods for liver disease become increasingly available, detection and treatment of NAFLD in patients with MetS should therefore be considered by both (sub-) specialists and primary care physicians.

Increased carotid intima-media thickness in Brazilian adolescents with type 1 diabetes mellitus

BACKGROUND

Increased carotid intima-media thickness (CIMT), a marker of subclinical atherosclerosis, is an independent predictor of future cardiovascular events, and has been reported in children with various chronic diseases, including type 1 diabetes mellitus (DM1).

OBJECTIVES

Evaluate CIMT and its association with cardiovascular risk factors in Brazilian adolescents with DM1.

METHODS

Cross-sectional study of 118 adolescents, 57 with DM1 and no chronic complications related to the disease, and 61 healthy individuals. Clinical, biochemical, and high-resolution B-mode ultrasonographic evaluations according to the Consensus Statement of the American Society of Echocardiography CIMT Task Force were performed.

RESULTS

Adolescents with diabetes (66.6% female) were 14.5 ± 2.9 years old and had 9.0 ± 4.0 years of disease duration. The healthy adolescents (62.3% female) were 14.3 ± 2.6 years old. All the adolescents had blood pressure within their reference ranges. In 66% of DM1 adolescents the systolic blood pressure was >50th percentile. Increased CIMT was observed in adolescents with diabetes compared with those in the control group: 0.53 vs 0.51 mm (p < 0.004) on the right side, and 0.55 vs 0.51 mm (p < 0.001) on the left side. CIMT presented independent and positive associations with diabetes duration, total cholesterol level, low-density lipoprotein cholesterol level, and systolic blood pressure percentile in DM1 adolescents.

CONCLUSIONS

Increased CIMT was observed in young Brazilian adolescents with DM1, and was associated with cardiovascular risk factors. CIMT assessment may be useful for the early identification and monitoring of cardiovascular risk in this age group.

Associations of Novel and Traditional Vascular Biomarkers of Arterial Stiffness: Results of the SAPALDIA 3 Cohort Study

BACKGROUND AND OBJECTIVES

There is a lack of evidence concerning associations between novel parameters of arterial stiffness as cardiovascular risk markers and traditional structural and functional vascular biomarkers in a population-based Caucasian cohort. We examined these associations in the second follow-up of the Swiss Cohort Study on Air Pollution and Lung and Heart Diseases in Adults (SAPALDIA 3).

METHODS

Arterial stiffness was measured oscillometrically by pulse wave analysis to derive the cardio-ankle vascular index (CAVI), brachial-ankle (baPWV) and aortic pulse wave velocity (aPWV), and amplitude of the forward and backward wave. Carotid ultrasonography was used to measure carotid intima-media thickness (cIMT) and carotid lumen diameter (LD), and to derive a distensibility coefficient (DC). We used multivariable linear regression models adjusted for several potential confounders for 2,733 people aged 50-81 years.

RESULTS

CAVI, aPWV and the amplitude of the forward and backward wave were significant predictors of cIMT (p < 0.001). All parameters were significantly associated with LD (p < 0.001), with aPWV and the amplitude of the forward wave explaining the highest proportion of variance (2%). Only CAVI and baPWV were significant predictors of DC (p < 0.001), explaining more than 0.3% of the DC variance.

CONCLUSION

We demonstrated that novel non-invasive oscillometric arterial stiffness parameters are differentially associated with specific established structural and functional local stiffness parameters. Longitudinal studies are needed to follow-up on these cross-sectional findings and to evaluate their relevance for clinical phenotypes.

Endothelial function and carotid intima media thickness in obstructive sleep apnea without comorbidity

PURPOSE

The objective of this study was to evaluate endothelial function and carotid intima media thickness (CIMT) in moderate to severe obstructive sleep apnea (OSA) without comorbidities.

METHODS

It is an observational case control study in which endothelial function was assessed using flow-mediated dilatation (FMD) and peripheral arterial tonometry (PAT), and carotid artery ultrasound was used to measure CIMT in study group subjects that included 20 normotensive, non-diabetic, treatment naïve, and moderate to severe OSA patients, and 20 normotensive, non-diabetic, and non-OSA subjects served as a control group. Study was conducted in Polysomnography Laboratory, Department of Internal Medicine, All India Institute of Medical Sciences (AIIMS) Hospital, New Delhi.

RESULTS

FMD was significantly lower in the moderate to severe OSA group compared to non-OSA group (mean ± SD, 8.3 ± 2.8 vs. 13.4 ± 4.1 %; p = 0.0001). Reactive hyperemia index (RHI) was also significantly lower in the OSA group (1.55 ± 0.27 vs. 2.01 ± 0.48, p = 0.0007). CIMT was observed to be significantly higher in the OSA group compared to the non-OSA group (0.54 ± 0.09 vs. 0.48 ± 0.08 mm; p = 0.049). In the OSA group, FMD, RHI, and CIMT did not show a significant correlation with OSA disease severity indices [apnea hypopnea index (AHI), oxygen desaturation index (ODI), and minimum O₂ saturation].

CONCLUSION

Endothelial function in macrovascular and microvascular circulation is significantly impaired in moderate to severe OSA patients without comorbidities. These patients also show evidence of subclinical atherosclerosis, in the form of increased CIMT.

Determinants of Preclinical Atherosclerosis Are Different in Type 1 and Type 2 Diabetic Women

Diabetes mellitus type 2 ranks among the strongest predictors of cardiovascular diseases (CVD) while the association of type 1 diabetes with CVD is more complex. We studied differences between type 1 and 2 diabetic women regarding association of cardiovascular risk factors with preclinical atherosclerosis expressed as intima-media thickness of common carotid (IMT CCA) and femoral arteries (IMT CFA) measured by high resolution ultrasound. Women with type 1 (n=203) and type 2 diabetes (n=123) were examined with regard to the presence of cardiovascular risk factors. In type 1 diabetic women strong association between IMT CCA and body mass index, waist circumference, and total body fat was found in contrast to type 2 diabetic women. In type 2 diabetic women strong association between IMT CCA and fasting glucose, glycated hemoglobin, and atherogenic index of plasma (log TG/HDL cholesterol) was observed in contrast to type 1 diabetic women. In type 1 diabetic women, IMT CFA was associated with body fat in contrast to type 2 diabetic women. Preclinical atherosclerosis in type 1 diabetic women was strongly associated with factors reflecting body fat and its distribution, while in type 2 diabetic women preclinical atherosclerosis was associated with markers reflecting glucose and lipid metabolic disorders.

Effect of Shoushen granule on arterial elasticity in patients with carotid atherosclerosis: a clinical randomized controlled trial

OBJECTIVE

To investigate the effectiveness of Shoushen granule, Chinese herbal preparation, on carotid artery elasticity in patients with carotid atherosclerosis.

METHODS

The total of 156 carotid atherosclerosis patients were randomly divided into the intervention group (83 cases, treated with Shoushen granule) and the control group (73 cases, treated with pravastatin). Brachial-ankle pulse wave velocity baPWV) and Ankle-Brachial Pressure Index (ABI) were measured by automated arteriosclerosis detector. The changes of common carotid artery intima-media thickness (IMT) and parameters of the carotid artery elasticity in patients, including stiffness parameter (β), pressure-strain elastic modulus (Ep), arterial compliance (Ac), augmentation index (AI), and pulse wave velocity (PWV) were detected by Echo-Tracking (ET) technique before and after 24 week treatment. In the meantime, levels of blood lipid, and liver and renal function were measured respectively.

RESULTS

After 24 weeks, baPWV, MT and parameters of the carotid artery elasticity (β, Ep, AI and PWVβ) were markedly decreased in intervention group compared with those of before treatment (P < 0.01), but the level of Ac was increased significantly (P < 0.01). And there were no significant differences compared with control group on the same period (P > 0.05).

CONCLUSION

In this pilot study, it was demonstrated ET technology and automated arteriosclerosis detector could be used to evaluate carotid artery elasticity effectively, and the action of Shoushen granule on carotid atherosclerosis might be related to the regulation of carotid artery elasticity.

Assessment and relevance of carotid intima-media thickness (C-IMT) in primary and secondary cardiovascular prevention

Interventions aimed to prevent cardiovascular diseases (CVD) are more effective if administered to subjects carefully selected according to their CVD risk. Usually, this risk is evaluated on the basis of the presence and severity of conventional vascular risk factors (VRFs); however, atherosclerosis, the main pathologic substrate of CVD, is not directly revealed by VRFs. The measurement of the arterial wall, using imaging techniques, has increased the early identification of individuals prone to develop atherosclerosis and to quantify its changes over time.

B-mode ultrasound is a technique which allows a non-invasive assessment of the arterial wall of peripheral arteries (e.g. extracranial carotid arteries), and provides measures of the intima-media thickness complex (C-IMT) and additional data on the occurrence, localization and morphology of plaques.

Being an independent predictor of vascular events, C-IMT has been considered as a tool to optimize the estimation of CVD risk but this application is still a matter of debate. Though the technique is innocuous, relatively inexpensive and repeatable, its use in the clinical practice is limited by the lack of standardized protocols and clear guidelines.

This review outlines the rationale for the potential use of C-IMT in the stratification of cardio- and cerebro-vascular risk and discusses several topics related to the measurement of this variable, which are still controversial among experts of the field.

Role of ultrasound in the diagnosis and treatment of nonalcoholic fatty liver disease and its complications

We review the role of liver ultrasonography (US) and related techniques as non-invasive tools in predicting metabolic derangements, liver histology, portal hypertension and cardiovascular risk as well as allowing early diagnosis and management of hepatocellular carcinoma in patients with nonalcoholic fatty liver disease. In this setting, US detects fatty changes as low as ≥20% and hepatic steatosis identified ultrasonographically, in its turn, closely mirrors coronary and carotid atherosclerosis burden. Semi-quantitative US indices (to exclude nonalcoholic steatohepatitis) and sonoelastography (to quantify fibrosis) help in predicting liver histology and selecting patients to submit to liver biopsy. Surveillance for hepatocellular carcinoma conducted through biannual US is mandatory and US has a role in guiding locoregional treatment and in evaluating the efficacy of treatment. High-intensity focused ultrasound can be delivered with precision resulting in coagulative necrosis of hepatocellular carcinoma without puncturing the liver. Costs and inconveniences have so far hampered its diffusion.

Measurements of carotid intima media thickness in non-invasive high-frequency ultrasound images: the effect of dynamic range setting

Background

Carotid intima media thickness (CIMT) measured with ultrasound (US) is widely used as biomarker for arteriosclerosis and as surrogate endpoint in interventional studies to assess efficacy of drug therapies. Strict US protocols are necessary to ensure reproducibility. The range of US signal intensities used for image formation, the dynamic range (DR), is rarely reported in studies and little is known about its effect on CIMT measurements in humans. The purpose of this study was to quantify the impact of DR on measurements of CIMT.

Methods

US was used to examine 313 carotid arteries in participants from two different clinical studies. For each artery, images with DR of 40, 55, 70 and 85 dB were captured from the same frozen US frame. Mean CIMT (CIMT_mean), maximum CIMT (CIMT_max) and standard deviation of CIMT (CIMT_sd) were obtained for all images. CIMT for different DRs were compared using student t-test.

Results

CIMT_mean for 40, 55, 70 and 85 dB were 0.529, 0.564, 0.590 and 0.605 mm respectively. For CIMT_max the corresponding values were 0.626, 0.667, 0.698, and 0.716 mm. CIMT_mean and CIMT_max increased significantly for increasing DR steps (p < 0.01). The relative change in CIMT_mean and CIMT_max were largest between 40 and 55 dB (6.7% and 7.0%) and smallest between 70 and 85 dB (2.6% and 2.7%) indicating a declining dependency for increasing DR.

Conclusions

DR significantly changes CIMT measurements and the changes are most prominent for lower DRs. The effect of changing DR is larger in human arteries than in phantoms. Reporting the DR will therefore increase the validity of CIMT data.

[Cardiovascular screening programme in the Central Hungarian region. The Budakalász Study]

INTRODUCTION

The reduction in mortality due to prevention programmes observed in some European countries is not currently reached in Hungary. Effective prevention is based on the screening of risk factors and health state of the population.

AIM

The goal of this study was to develop a longitudinal, population-based screening programme in the Central Hungarian region in order to collect information on the health state and cardiovascular risk profile of the citizens and discover new potential cardiovascular risk factors.

METHOD

The Budakalász Study is a self-voluntary programme involving the adult population (>20 yrs, approx. 8000 persons), and it consists of questionnaires, non-invasive tests (anthropometry, cardiac echo, carotid duplex scan, blood pressure measurement, ankle-brachial index), venous blood sample collection and laboratory tests.

RESULTS

Until January, 2014, 2420 persons (30% of the population, male: 41.2%, average age 54.8 years) participated in the programme. Cardiovascular morbidity was higher in contrast to a former national survey. The number of risk factors and, therefore, 10-year cardiovascular risk were also elevated in this population.

CONCLUSIONS

These findings underline the importance of screening programmes and effective therapies.