Analysis of Carotid Ultrasound Findings on Cardiovascular Events in Patients with Coronary Artery Disease during Seven-Year Follow-Up

Heterogeneous Carotid Plaque Predicts Cardiovascular Events after Percutaneous Coronary Intervention

AIM

The relationship between carotid artery ultrasound findings and clinical outcomes in patients who undergo percutaneous coronary intervention (PCI) has not been completely elucidated.

METHODS

This single-center retrospective study investigated 691 patients who underwent PCI and carotid ultrasound testing. Maximum carotid intima-media thickness (CIMT) was defined as the greatest CIMT at the maximally thick point among the common carotid artery, carotid bulb, and internal carotid artery. A carotid plaque was defined as vessel wall thickening with a CIMT ≥ 1.5 mm. The characteristics of carotid plaque (heterogeneity, calcification, or irregular/ulcerated surface) were evaluated visually. Patients were divided into those with and without heterogeneous carotid plaque (maximum CIMT ≥ 1.5 mm and heterogeneous texture). The endpoint was the incidence of a major adverse cardiovascular event (MACE) defined as a composite of cardiovascular (CV) death, myocardial infarction, and ischemic stroke.

RESULTS

Among 691 patients, 309 were categorized as having a heterogeneous plaque. Patients with heterogeneous plaques were at a higher risk of MACE than those without (p=0.002). A heterogeneous plaque was independently associated with MACE after adjusting for covariates (hazard ratio [HR], 1.71; 95% confidence interval [CI], 1.01-2.90; p=0.046). Calcified or irregular/ulcerated plaques were correlated with a higher incidence of MACE, but both were not independently associated with MACE (HR, 1.35; 95% CI, 0.69-2.64, p=0.38 and HR, 0.98; 95% CI, 0.57-1.69; p=0.95, respectively).

CONCLUSION

The presence of a heterogeneous carotid plaque in patients who underwent PCI predicted future CV events. These patients may require more aggressive medical therapy and careful follow-up.

Association of Intima-Media Thickness Measured at the Common Carotid Artery With Incident Carotid Plaque: Individual Participant Data Meta-Analysis of 20 Prospective Studies

Background The association between common carotid artery intima-media thickness (CCA-IMT) and incident carotid plaque has not been characterized fully. We therefore aimed to precisely quantify the relationship between CCA-IMT and carotid plaque development. Methods and Results We undertook an individual participant data meta-analysis of 20 prospective studies from the Proof-ATHERO (Prospective Studies of Atherosclerosis) consortium that recorded baseline CCA-IMT and incident carotid plaque involving 21 494 individuals without a history of cardiovascular disease and without preexisting carotid plaque at baseline. Mean baseline age was 56 years (SD, 9 years), 55% were women, and mean baseline CCA-IMT was 0.71 mm (SD, 0.17 mm). Over a median follow-up of 5.9 years (5th-95th percentile, 1.9-19.0 years), 8278 individuals developed first-ever carotid plaque. We combined study-specific odds ratios (ORs) for incident carotid plaque using random-effects meta-analysis. Baseline CCA-IMT was approximately log-linearly associated with the odds of developing carotid plaque. The age-, sex-, and trial arm-adjusted OR for carotid plaque per SD higher baseline CCA-IMT was 1.40 (95% CI, 1.31-1.50; I²=63.9%). The corresponding OR that was further adjusted for ethnicity, smoking, diabetes, body mass index, systolic blood pressure, low- and high-density lipoprotein cholesterol, and lipid-lowering and antihypertensive medication was 1.34 (95% CI, 1.24-1.45; I²=59.4%; 14 studies; 16 297 participants; 6381 incident plaques). We observed no significant effect modification across clinically relevant subgroups. Sensitivity analysis restricted to studies defining plaque as focal thickening yielded a comparable OR (1.38 [95% CI, 1.29-1.47]; I²=57.1%; 14 studies; 17 352 participants; 6991 incident plaques). Conclusions Our large-scale individual participant data meta-analysis demonstrated that CCA-IMT is associated with the long-term risk of developing first-ever carotid plaque, independent of traditional cardiovascular risk factors.

Association between Colorectal Adenoma and Carotid Atherosclerosis in Korean Adults

Background: Colorectal neoplasm, including colorectal adenoma, is associated with old age, cigarette smoking, and the presence of metabolic syndromes. These are also risk factors for cardiovascular disease. Carotid ultrasonography is a noninvasive test that can predict the risk of cardiovascular disease and may be another test that may provide indications of these risk factors. This study aimed to investigate the association between colorectal adenomatous polyps and carotid atherosclerosis. Methods: This study included 548 adults who underwent colonoscopy and carotid ultrasonography for a health examination between March 2013 and December 2017 at a university hospital in South Korea. Abnormal carotid sonography findings included either increased carotid intima-media thickness or presence of carotid plaques. Results: The proportion of subjects with overall colorectal adenomatous polyps was 31.0% (170/548). Colorectal adenoma was more prevalent in the presence of abnormal carotid ultrasonography findings (38.6% vs. 27.6%, p = 0.013). Colorectal adenomatous polyp was significantly associated with abnormal carotid ultrasonography findings (OR = 1.65; 95% CI, 1.12–2.42, p = 0.011) in a multivariate analysis after adjusting for age, sex, cigarette smoking, alcohol consumption, and presence of metabolic syndrome. Conclusion: Colorectal adenoma is significantly associated with carotid atherosclerosis.

Pre-clinical carotid atherosclerosis and sCD163 among virally suppressed HIV patients in Botswana compared with uninfected controls

Objectives

Human immune deficiency virus (HIV) is associated with increased cardiovascular disease (CVD) risk, yet the relationship between HIV and carotid atherosclerosis / monocyte activation among virally suppressed HIV-infected patients in sub-Saharan Africa is not well understood.

Methods

We measured traditional CVD risk factors, bilateral distal common carotid intima media thickness (cIMT), presence of carotid plaque and plasma sCD163 levels among virally suppressed HIV-infected adults and HIV-uninfected controls, in a cross-sectional study in Gaborone, Botswana. The associations between HIV status, traditional CVD risk factors, sCD163 and outcome of cIMT were assessed in univariate and multivariate linear regression models.

Results

We enrolled 208 HIV-infected adults (55% Female, mean age 39 years) who had undetectable HIV-1 RNA on antiretroviral therapy and 224 HIV-uninfected controls (47% Female, mean age 37 years). There was no difference in cIMT between study groups, with mean cIMT 0.607mm and 0.599mm in HIV-infected and HIV-uninfected, respectively (p = 0.37). Plasma sCD163 was significantly higher in HIV-infected versus HIV-uninfected persons (1917ng/ml vs 1593ng/ml, p = 0.003), but was not associated with cIMT (p = 0.43 among all, p = 0.72 for HIV-infected only). In the final multivariate model, increased cIMT was associated with older age, being treated for hypertension, and higher non-HDL cholesterol among all (p<0.001, p = 0.03, p<0.001 respectively), and with older age and waist-hip ratio in HIV-infected participants (p = 0.02 & p = 0.02 respectively). Carotid plaque was present in a significantly higher proportion of HIV-infected adults (RR 2.15, 95% CI 1.22, 3.81).

Conclusions

HIV-infected participants aged 30–50 years who have achieved viral suppression did not have increased cIMT when compared to HIV-uninfected controls in Botswana. However, well-controlled HIV was associated with excess monocyte activation. Future work should explore the impact of subclinical atherosclerosis on CVD events among HIV-infected and -uninfected adults in Botswana.

Carotid Atherosclerosis and Electrocardiographic Left Ventricular Hypertrophy in the General Population: The Namwon Study

This study aimed to investigate the relationship between carotid atherosclerosis and left ventricular hypertrophy on electrocardiogram (ECG-LVH) on adults living in the community. A total of 9,266 adults who participated in the Namwon Study were included in this analysis. Carotid atherosclerosis, including intima-media thickness (IMT) and plaques, were assessed using high-resolution B-mode ultrasound. ECG-LVH was determined using the Sokolow-Lyon voltage (SokV) and Cornell voltage (CorV) criteria. The prevalence of ECG-LVH was 12.7% using the SokV criteria and 9.7% using the CorV criteria. After full adjustment, compared to the lowest quartile of common carotid artery IMT (CCA-IMT), the odds ratios and 95% confidence intervals for ECG-LVH of the carotid IMT quartiles 2, 3, and 4 increased linearly as follows: 1.54 (1.24-1.90), 1.62 (1.31-2.02), and 1.91 (1.54-2.38), respectively, for the SokV criteria (p<0.001); and 1.33 (1.05-1.68), 1.41 (1.11-1.78), and 1.48 (1.16-1.88), respectively, for the CorV criteria (p=0.003). Positive associations between the carotid bulb IMT (CB-IMT) quartiles and the ECG-LVH were also observed, although the magnitudes of association between CB-IMT and ECG-LVH were slightly lower than those of CCA-IMT. However, no significant association between carotid plaques and ECG-LVH as defined by the SokV or CorV criteria was found. The present study demonstrated that increased carotid IMT, but not carotid plaques, is significantly associated with LVH defined by various ECG criteria in a large population.

The coexistence of carotid and lower extremity atherosclerosis further increases cardio-cerebrovascular risk in type 2 diabetes

Background

Both carotid and lower limb atherosclerosis are associated with increased cardiovascular and cerebrovascular risks. However, it is still unclear whether the concomitant presence of carotid and lower extremity atherosclerosis further increases the cardiovascular and cerebrovascular risks. Therefore, our aim is to investigate whether the coexistence of carotid and lower extremity atherosclerosis was associated with higher cardiovascular and cerebrovascular risks in patients with type 2 diabetes.

Methods

This cross-sectional study was performed in 2830 hospitalized patients with type 2 diabetes. Based on carotid and lower limb Doppler ultrasound results, the patients were divided into three groups including 711 subjects without atherosclerosis, 999 subjects with either carotid or lower limb atherosclerosis, and 1120 subjects with both carotid and lower limb atherosclerosis. And we compared the clinical characteristics and prevalence of both cardio-cerebrovascular events (CCBVEs) and self-reported cardio- cerebrovascular diseases (CCBVDs) among the three groups.

Results

After adjusting for age, sex, and duration of diabetes, there were significant increases in the prevalence of both CCBVEs (3.8 vs. 11.8 vs. 26.4 %, p < 0.001 for trend) and self-reported CCBVDs (6.9 vs. 19.9 vs. 36.5 %, p < 0.001 for trend) across the three groups (diabetics without atherosclerosis, diabetics with either carotid or lower limb atherosclerosis, and diabetics with both carotid and lower extremity atherosclerosis). A fully adjusted logistic regression analysis also revealed that compared with those without atherosclerosis, those with either carotid or lower limb atherosclerosis had higher risk of CCBVEs (OR 1.724, 95 % CI 1.001–2.966) and self-reported CCBVDs (OR 1.705, 95 % CI 1.115–2.605), and those with concomitant presence of carotid and lower extremity atherosclerosis had the highest risk of CCBVEs (OR 2.869, 95 % CI 1.660–4.960) and self-reported CCBVDs (2.147, 95 % CI 1.388–3.320)(p < 0.001 for trend in CCBVEs and p = 0.002 for trend in CCBVDs, respectively).

Conclusions

Either carotid or lower limb atherosclerosis was obviously related to increased cardio-cerebrovascular risk in type 2 diabetes. The concomitant presence of carotid and lower extremity atherosclerosis further increased cardio-cerebrovascular risk in patients with type 2 diabetes. The combined application of carotid and lower extremity ultrasonography may help identify type 2 diabetics with higher cardio-cerebrovascular risk.

Carotid Artery End-Diastolic Velocity and Future Cerebro-Cardiovascular Events in Asymptomatic High Risk Patients

Background and Objectives

Prognostic value of additional carotid Doppler evaluations to carotid intima-media thickness (IMT) and plaque has not been completely evaluated.

Subjects and Methods

A total of 1119 patients with risk factors for, but without, overt coronary artery disease (CAD), who underwent both carotid ultrasound and Doppler examination were included in the present study. Parameters of interest included peak systolic and end-diastolic velocities, resistive indices of the carotid arteries, IMT, and plaque measurements. The primary end-point was all-cause cerebro-cardiovascular events (CVEs) including acute myocardial infarction, coronary revascularization therapy, heart failure admission, stroke, and cardiovascular death. Model 1 covariates comprised age and sex; Model 2 also included hypertension, diabetes and smoking; Model 3 also had use of aspirin and statin; and Model 4 also included IMT and plaque.

Results

The mean follow-up duration was 1386±461 days and the mean age of the study population was 60±12 years. Amongst 1119 participants, 43% were women, 57% had a history of hypertension, and 23% had diabetes. During follow-up, 6.6% of patients experienced CVEs. Among carotid Doppler parameters, average common carotid artery end-diastolic velocity was the independent predictor for future CVEs after adjustments for all models variables (HR 0.95 per cm/s, 95% confident interval 0.91-0.99, p=0.034 in Model 4) and significantly increased the predictive value of Model 4 (global χ²=59.0 vs. 62.8, p=0.029).

Conclusion

Carotid Doppler measurements in addition to IMT and plaque evaluation are independently associated with future CVEs in asymptomatic patients at risk for CAD.

Associations between Carotid Artery Plaque Score, Carotid Hemodynamics and Coronary Heart Disease

Background: The carotid artery plaque score (PS) is an independent predictor of Coronary Heart Disease (CHD). This study aims to evaluate the combination of PS and carotid hemodynamics to predict CHD. Methods: A total of 476 patients who underwent carotid ultrasonography and coronary angiography were divided into two groups depending on the presence of CHD. PS, carotid intima-media thickness, and carotid blood flow were measured. Receiver operating characteristic curve analysis was performed to establish the best prediction model for CHD presence. Results: Age, sex, carotid intima-media thickness of internal carotid artery and carotid bifurcation, PS, peak systolic velocity (PSA) of right internal carotid artery (RICA), and most resistance index data were significantly related with the presence of CHD. The area under the curve for a collective model, which included factors of the PS, carotid hemodynamics and age, was significantly higher than the other model. Age, PS, and PSA of RICA were significant contributors for predicting CHD presence. Conclusions: The model of PS and PSA of RICA has greater predictive value for CHD than PS alone. Adding age to PS and PSA of RICA further improves predictive value over PS alone.