Carotid intima-media thickness: Current evidence, practices, and Indian experience

Systemic Lupus Erythematosus and Cardiovascular Diseases: A Systematic Review

Systemic lupus erythematosus (SLE) is an autoimmune condition characterized by multi-organ involvement. The clinical presentation often varies from mild to moderate to severe. The cardiovascular system may also be affected, often portending a poor prognosis for patients. Although the relationship between SLE and cardiovascular disorders has been extensively explored through case reports and literature reviews, few systematic reviews explicitly focusing on this association have been conducted. In light of this, this systematic review aims to analyze the extent of the association between SLE and cardiovascular diseases (CVDs), by exploring the risk of developing CVDs, including myocardial infarction (MI), atherosclerosis, myocarditis, pericarditis and arrhythmias, in SLE patients vs. non-SLE patients. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to perform the systematic review. A detailed search was done covering the period from March 2003 to March 2023 using three databases: PubMed, Google Scholar, and Cochrane. The PubMed search identified 597 articles, while Google Scholar and Cochrane searches yielded 559 and three articles, respectively. Of the 1159 articles retrieved, we chose eight for final consideration, after excluding papers that did not discuss the role of SLE in CVDs, papers published earlier than 2003, and papers with incomplete data. The eight studies chosen included two narrative reviews, two systematic reviews, and four observational studies. In this systematic review, SLE was proven to have a strong relationship with diverse CVDs, including rare ones scarcely discussed in the literature, such as vasculitis and aortic dissection. All eight of the final papers indicated a connection between SLE and CVDs, based on the systematic analysis of these articles, which revealed that most recent research supports a higher risk of peripheral arterial occlusive disease (PAOD), MI, pericarditis, myocarditis, and other cardiovascular disorders in individuals with SLE. These associations may have certain gray areas, as patient characteristics and comorbidities often affect the extent of illness and long-term prognosis. Larger-scale studies are required to probe this relationship further and research the etiopathogenesis involved in order to improve patient outcomes. The effects of SLE on the heart are, however, unequivocal.

Poor quality sleep is associated with greater carotid intima media thickness among otherwise healthy resident doctors

Background

Sleep is important for maintaining the metabolic processes in the body, and hence, disruption in sleep leads to metabolic derangement and accelerated atherosclerosis. The effect of sleep duration on subclinical atherosclerosis has been examined in several studies; however, data regarding sleep quality is lacking. The study aimed to assess the association between sleep quality and carotid intima-media thickness among healthy young doctors.

Materials and Methods

This was an observational cross-sectional study among 110 healthy young resident doctors. Anthropometric data were recorded and morning fasting venous blood samples were collected to assess fasting blood sugar, lipid profile and glycosylated haemoglobin (HbA1c). Pittsburgh Sleep Quality Index and Berlin questionnaire assessed subjective sleep quality and risk for obstructive sleep apnea, respectively. Carotid ultrasonography was done to detect the intima-media thickness.

Results

Average age of the participants was 26.45 (±1.43) years, and 51.8% were male. Self-reported poor sleep quality was found in 54.5%. Carotid intima-media thickness (CIMT) was increased among 44.5% of participants. In the multivariate analysis, only poor sleep quality appeared to be associated with higher CIMT (P < 0.001, OR = 7.4; 95% CI = 2.70-20.32). When different components of sleep quality was analyzed through multivariate logistic regression, subjective sleep onset latency (>30 min), sleep efficiency (<85%) and sleep disturbance was found to be associated with the increased CIMT.

Conclusion

Poor sleep quality, especially prolonged sleep onset latency, poor sleep efficiency, and sleep disturbance are associated with increased carotid intima-media thickness among healthy young adults.

Carotid intima media thickness (CIMT) in adults in the AWI-Gen Nairobi site study: Profiles and predictors

BACKGROUND

Carotid intima media thickness (CIMT) is used as a marker of subclinical and asymptomatic atherosclerotic vascular disease. Increased CIMT is associated with future cerebrovascular and cardiovascular events. There is limited data on the profile and correlates of CIMT in Africa. The aim of this study was to describe the profile and correlates of CIMT in apparently normal younger-age adults in an urban setting in Kenya.

METHODS

This study used population-based data collected from 2003 adults between the ages of 40 and 60 years in two slums of Nairobi as part of a genetic study. CIMT was measured using LOGIQ e (GE Healthcare, CT, USA) ultrasound on both left and right carotid arteries, whereby maximum, mean, and minimum values were recorded. Age- and sex-specific CIMT measurements were calculated and their association with basic sociodemographic, behavioral and body composition indicators were investigated.

RESULTS

The median (IQR) CIMT were 0.58 (0.51, 0.66) and 0.59 (0.53, 0.66) in men and women, respectively. About 16% of the study population had CIMT greater than 0.7mm, the cut off for higher CIMT. Nearly 60% had CIMT values ≥75th percentile. Age, current use of alcohol, systolic blood pressure, subcutaneous fat thickness, pulse rate and pulse pressure were found to be the main predictors of CIMT in our study population.

CONCLUSION

This study provided population-based reference values and predictors for CIMT for an adult population living in urban poor settings in Kenya. Future studies need to consider biochemical and genetic predictors of CIMT in this population.

Assessment of the predictive value of carotid color Doppler ultrasound Crouse score combined with hs-CRP in elderly diabetics with cerebral infarction

BACKGROUND

Both the carotid Crouse score and high-sensitivity C-reactive protein (hs-CRP) levels are commonly used to evaluate atherosclerosis and vascular inflammatory response. This study was to investigate the correlation between the Crouse score and high-sensitivity C-reactive protein (hs-CRP) and cerebral infarction (CI) in elderly diabetics.

METHODS

We compared the carotid Crouse scores and hs-CRP levels between 2 groups of diabetic patients with and without CIs (n=100 each) and the relationship between changes in these indices and CI.

RESULTS

Between the four groups (control, diabetic with a large CI, diabetic with a small CI, and diabetic with a lacunar CI) there was a significant difference in the age, sex, Crouse scores and hs-CRP levels, as well as fasting blood glucose and HbA1c (All P<0.05). Logistic regression analysis with CI as the dependent variable showed that the age (OR=1.114, 95% CI: 1.063-1.167, P=0.000), fasting blood glucose (OR=1.260, 95% CI: 1.102-1.570, P=0.039), HbA1c (OR=2.036, 95% CI: 1.348-3.703, P=0.001), Crouse score (OR=2.721, 95% CI: 1.800-4.114, P=0.000) and hs-CRP level (OR=3.364, 95% CI: 2.185-5.180, P=0.000) were risk factors for a CI in combination with diabetes mellitus. Significant differences were found in age, DBP, Crouse scores and hs-CRP levels between the male Diabetic-non-CI subgroup, female Diabetic-non-CI subgroup, male Diabetic-CI subgroup and female Diabetic-CI subgroup (All P<0.05).

CONCLUSION

The carotid Crouse score method has high reliability and reflects the severity of carotid atherosclerosis. The age, sex, FBG, HbA1c, Crouse score, an elevated hs-CRP level, and the occurrence of CI in elderly with diabetes mellitus are closely related. This article is protected by copyright. All rights reserved.

Non-alcoholic fatty liver disease increases risk of carotid atherosclerosis and ischemic stroke: An updated meta-analysis with 135,602 individuals

BACKGROUND/AIMS

Non-alcoholic fatty liver disease (NAFLD) is associated with the development of cardiovascular disease. While existing studies have examined cardiac remodeling in NAFLD, there has been less emphasis on the development of carotid atherosclerosis and stroke. We sought to conduct a meta-analysis to quantify the prevalence, risk factors, and degree of risk increment of carotid atherosclerosis and stroke in NAFLD.

METHODS

Embase and Medline were searched for articles relating to NAFLD, carotid atherosclerosis, and stroke. Proportional data was analysed using a generalized linear mixed model. Pairwise meta-analysis was conducted to obtain odds ratio or weighted mean difference for comparison between patients with and without NAFLD.

RESULTS

From pooled analysis of 30 studies involving 7,951 patients with NAFLD, 35.02% (95% confidence interval [CI], 27.36-43.53%) had carotid atherosclerosis with an odds ratio of 3.20 (95% CI, 2.37-4.32; P<0.0001). Pooled analysis of 25,839 patients with NAFLD found the prevalence of stroke to be 5.04% (95% CI, 2.74-9.09%) with an odds ratio of 1.88 (95% CI, 1.23-2.88; P=0.02) compared to non-NAFLD. The degree of steatosis assessed by ultrasonography in NAFLD was closely associated with risk of carotid atherosclerosis and stroke. Older age significantly increased the risk of developing carotid atherosclerosis, but not stroke in NAFLD.

CONCLUSION

This meta-analysis shows that a stepwise increment of steatosis of NAFLD can significantly increase the risk of carotid atherosclerosis and stroke development in NAFLD. Patients more than a third sufferred from carotid atherosclerosis and routine assessment of carotid atherosclerosis is quintessential in NAFLD.

GDF‐15 is associated with atherosclerosis in adults with transfusion‐dependent beta‐thalassemia

Objectives: To study serum growth differentiation factor‐15 (GDF‐15) serum level in β‐thalassemia patients and its relation to carotid intima‐media thickness.

Background: Thalassemia is a common genetic disease resulting in decreased beta‐chains, leading to manifested anemia. It may be subsequently complicated by iron overload, which induces numerous morbidities and even death. Growth differentiation factor‐15 (GDF‐15) is a strong and independent predictor of mortality and disease progression in patients with atherosclerosis alongside with carotid‐intimal media thickness (CIMT).

Patients and methods: This monocentric case‐control study was done on 90 subjects in the period from January 2020 to March 2021. Sixty transfusion‐dependent beta‐thalassemia (TDβT) cases (≥18 years) were selected from the thalassemia clinic of Hematology division at Menoufia University hospitals. We included also 30 sex and age matched healthy as the controls. Routine investigations were done beside. Serum GDF‐15 was measured by ELISA. CIMT was measured by Doppler Ultrasonography.

Results: CIMT on both sides was statistically significant higher in cases (median of 0.08 cm) than in the controls (median of 0.04). GDF‐15 was also significantly higher in cases (median of 1839.89 pg/dl) than in controls (median of 256.14 pg/dl). So, we found that GDF‐15 is a predictor of and associated with atherosclerosis in thalassemic adults (OR = 39.198, p value 0.008, 95% CI: 2.576–596.5).

Conclusion: GDF‐ 15 is increased in TDβT. CIMT (as a marker of subclinical atherosclerosis) is increased in these patients alongside with GDF‐15, is a predictor, and associated with atherosclerosis in thalassemic adults.

Association of HbA1c with carotid artery plaques in patients with coronary heart disease: a retrospective clinical study

BACKGROUND AND AIMS

Haemoglobin A1c (HbA1c) levels have been shown to be related to carotid artery plaques. However, studies on the relationship between HbA1c levels and carotid artery plaques in patients with coronary heart disease (CHD) are limited and inconsistent. Our objective was to examine the correlation between HbA1c levels and carotid artery plaques in patients with CHD.

METHODS

The study comprised 9275 Chinese adults with CHD from January 1, 2014, to September 30, 2020. HbA1c levels were assessed, and colour Doppler ultrasound was used to evaluate the carotid artery, including plaque presence, intima-media thickness, and plaque echo properties, to investigate the association between HbA1c and carotid plaque. A logistic regression model was used to assess the association between carotid artery plaques, carotid plaque echogenicity, and HbA1c.

RESULTS

The HbA1c level of the plaque-present group was higher than that of the plaque-absent group [6.1 (5.6-7.2) vs. 5.8 (5.5-6.5), p < 0.001]. In multiple linear regression analysis, intima-media thickness was associated with HbA1c (p < 0.001). Logistic regression showed that a higher HbA1c level was associated with plaque incidence as well as hyperechoic and heterogeneous plaques (p < 0.001). These associations persist after adjusting for age, sex, blood pressure, lipid profiles, alcohol consumption, and tobacco exposure.

CONCLUSION

HbA1c levels are notably associated with carotid artery plaque incidence, intima-media thickness, and plaque echogenicity in patients with CHD. These findings show that different levels of HbA1c may be an indicator for carotid artery plaques and thus, should be observed in patients with CHD.

The optimal WC cut-off points for the prediction of subclinical CVD as measured by carotid intima-media thickness among African adults: a cross-sectional study

BACKGROUND

Increased waist circumference (WC) is one of the cardiovascular disease (CVD) risk factors used to predict cardiovascular events. Waist circumference cut-off values for predicting metabolic syndrome and other cardiovascular risks have been previously studied. Carotid intima-media thickness (CIMT) is one of the cardiovascular risk factor recently described and reported to be suitable as it is a direct measurement of vascular quality. Hence the aim of the present study was to determine the optimal WC cut-off point for the prediction of subclinical CVD.

METHODS

The study was a cross-sectional study using quantitative methods, conducted among 1318 adults aged between 40 and 60 years old, residing in a rural Black population in Limpopo province. Carotid Intima-Media Thickness measurements were performed using a LOGIQ ultrasound system (GE Healthcare, CT, USA). Waist Circumference (WC) (cm) was measured to the nearest 0.1 cm. Bivariate correlation, logistic regression and receiver operating characteristic were analysed using the statistical package for social sciences version 26.0 software.

RESULTS

Among the total population, 69% were women and 31% men with a mean age of 53 ± 7 years. Among women, WC at a cut-off value of 95 cm gave the highest sensitivity of 57%, the specificity of 55% and an area under the curve (AUC) of 0.588. In men, an optimum WC cut-off point of 82 cm yielded the highest sensitivity and specificity at 72% and 70% respectively, with an AUC of 0.767 p < 0.001.

CONCLUSION

The traditional waist circumference cut-off points (94 cm for women and 80 cm for men) that are currently used for the diagnosis of metabolic syndrome might not be suitable in the prediction of an increased CIMT.

A Review of Carotid Artery Phantoms for Doppler Ultrasound Applications

Ultrasound imaging systems need tissue-mimicking phantoms with a good range of acoustic properties. Many studies on carotid artery phantoms have been carried out using ultrasound; hence this study presents a review of the different forms of carotid artery phantoms used to examine blood hemodynamics by Doppler ultrasound (DU) methods and explains the ingredients that constitute every phantom with their advantages and disadvantages. Different research databases were consulted to access relevant information on carotid artery phantoms used for DU measurements after which the information were presented systematically spanning from walled phantoms to wall-less phantoms. This review points out the fact that carotid artery phantoms are made up of tissue mimicking materials, vessel mimicking materials, and blood mimicking fluid whose properties matched those of real human tissues and vessels. These materials are a combination of substances such as water, gelatin, glycerol, scatterers, and other powders in their right proportions.

The Adverse Impact of Incense Smoke on Human Health: From Mechanisms to Implications

Incense burning is a very popular activity in daily life among many parts all over the world. A growing body of both epidemiological and experimental evidences has reported the negative effects of incense use on human well-being, posing a potential threat at public significance. This work is a comprehensive review that covers the latest findings regarding the adverse impact of incense smoke on our health, providing a panoramic visualization ranging from mechanisms to implications. The toxicities of incense smoke come directly from its harmful constituents and deposition capacity in the body. Besides, reactive oxygen species-driven oxidative stress and associated inflammation seem to be plausible underlying mechanisms, eliciting various unfavorable responses. Although our current knowledge remains many gaps, this issue still has some important implications.

Relative contribution of vitamin D deficiency to subclinical atherosclerosis in Indian context: Preliminary findings

Asian Indians have a genetic predisposition to atherothrombotic risk. common carotid intima-media thickness (CCIMT) measured by ultrasound is a quantitative marker for atherosclerotic burden and a derived variable, that is, "CCIMT statistical Z-score (Z-score)" is useful for better quantification. The association between vitamin D deficiency and atherosclerosis is inconclusive. Since, vitamin D deficiency is highly prevalent in India, there is a need to study its relative contribution to subclinical atherosclerotic burden.This prospective cross-sectional study (n = 117) in apparently healthy individuals aged 20 to 60 years sought to identify the determinants of CCIMT Z score with CCIMT measured by "echo-tracking" method. A multivariable linear regression analysis was done with CCIMT Z score as dependent variable and the following as independent variables: age, body mass index, waist-to-height ratio, total cholesterol to HDL ratio (TC-HDL ratio), serum vitamin D3 levels (ng/mL), sex, diabetes mellitus, current cigarette smoking status. A diagnostic prediction model was also developed with a threshold value of 1.96 for CCIMT Z score.The mean (SD) for calendar age (y) was 40 (8). There were 26 (22.22%) individuals in sample with CCIMT Z score ≥1.96 (advanced stage) of whom 14 (23.33%) were <40 y (n = 60). The mean score was 1.28 (90th percentile) in the entire sample. Vitamin D3 deficiency with a mean (SD) blood level (ng/mL) of 14.3 (6.4) was noted and prevalence of deficiency was 81%. The final model wasCCIMT Z-score = 0.80 +  (0.841 × current smoking = 1) + (0.156 × TC-HDL ratio) - (0.0263 × vitamin D3 blood level in ng/mL).The decreasing order of association is smoking, TC-HDL ratio, and vitamin D3. With the model, likelihood ratio (95% CIs) was better for positive test 3.5 (1.23-9.94) than that for a negative test 0.83 (0.66-1.02).Internal validation with Bootstrap resampling revealed stability of baseline diagnostic variables.There is substantial subclinical atherosclerotic burden in Indian setting with independent contribution by vitamin D deficiency. The model is valuable in "ruling-in" of the underlying advanced atherosclerosis. The study is limited by convenient sampling and lack of external validation of the model.

Atherogenic Indices Can Predict Atherosclerosis in Patients with Sarcoidosis

BACKGROUND

Sarcoidosis, a multisystemic disease of unknown etiology, is characterized by non-caseating granulomatous inflammation. This study aimed to investigate the efficiency of atherogenic indices and ultrasonographic evaluation of carotid artery on predicting atherosclerosis in patients with sarcoidosis.

METHODS

The study included 44 subjects followed with diagnosis of sarcoidosis and 53 age and gender matched healthy subjects as controls. Laboratory findings, pulmonary function tests and carotid artery ultrasonography of all participants were evaluated.

RESULTS

Of the participants with sarcoidosis 70.5% was female and the mean age was 35.36±7.18 years, while 64.2% of the control group were female and the mean age was 33.58±8.13 years (P=0.511 and P=0.191, respectively). High-density-lipoprotein cholesterol level in the sarcoidosis group was significantly lower than that of the control group (P=0.017), while other cholesterol levels were higher than those of the controls (P<0.05). Intima-media thickness (IMT) and peak systolic velocity (PSV) of carotid artery were higher in patients with sarcoidosis (P<0.001 and P=0.009, respectively). Atherogenic indices (Atherogenic Index (AI), Atherogenic Coefficient (AC) and Cardiogenic Risk Ratio (CRR)) were higher in sarcoidosis group compared to the controls (P<0.001, for all parameters). IMT was positively correlated with PSV, AI, AC, and CRR. A positive correlation between PSV and atherogenic indices was also detected.

CONCLUSIONS

Sarcoidosis may be a predisposing factor for atherosclerosis. Atherogenic indices, IMT of carotid artery and PSV might be considered predictors for atherosclerosis and cardiovascular diseases in asymptomatic sarcoidosis patients.

Relative Estimate of Revised Cardiovascular Risk Combining Traditional and Non-traditional Image-based CV Markers: A Kerala Based Study

BACKGROUND

Non-traditional image markers can improve the traditional cardiovascular risk estimation, is untested in Kerala based participants.

OBJECTIVE

To identify the relationship between the 'Modified CV risk' categories with traditional and non-traditional image-based risk markers. The correlation and improvement in reclassification, achieved by pooling atherosclerotic non-traditional markers with Intermediate (≥7.5% and <20%) and High (≥20%) 10-year participants is evaluated.

METHODS

The cross-sectional study with 594 participants has the ultrasound measurements recorded from the medical archives of clinical locations at Ernakulum district, Kerala. With carotid Intima-Media Thickness (cIMT) measurement, the Plaque (cP) complexity was computed using selected plaque characteristics to compute the carotid Total Plaque Risk Score (cTPRS) for superior risk tagging. Statistical analysis was done using RStudio, the classification accuracy was verified using the decision tree algorithm.

RESULTS

The mean age of the participants was (58.14±10.05) years. The mean cIMT was (0.956±0.302) mm, with 65.6% plaque incidence. With 94.90% variability around its mean, the Multinomial Logistic Regression model identifies cIMT and cTPRS, age, diabetics, Familial Hypercholesterolemia (FH), Hypertension treatment, the presence of Rheumatoid Arthritis (RA), Chronic Kidney Disease (CKD) as significant (p<0.05). cIMT and cP were found significant for 'Intermediate High', 'High' and 'Very High' 'Modified CV risk' categories. However, age, diabetes, gender and use of hypertension treatment are significant for the 'Intermediate' 'Modified CV risk' category. The overall performance of the MLR model was 80.5%. The classification accuracy verified using the decision tree algorithm has 78.7% accuracy.

CONCLUSION

The use of atherosclerotic markers shows a significant correlation suitable for a nextlevel reclassification of the traditional CV risk.

Relationships between severity of steatosis with glycemic control and carotid intima-media thickness among diabetic patients with ischemic heart disease

Background

Nonalcoholic fatty liver disease (NAFLD) has become one of the major diseases plaguing worldwide. Several studies reported its association with ischemic heart disease (IHD). This study aims to determine the relationships between severity of steatosis with glycemic control and carotid intima-media thickness (CIMT) among a high-risk population of type 2 diabetes mellitus (T2DM) with proven IHD.

Materials and Methods

This was a cross-sectional study involving patients aged between 18 and 65 years diagnosed with T2DM with IHD (n = 150). Ultrasonography of the abdomen to determine NAFLD severity category and CIMT measurements was performed by two independent radiologists. NAFLD was graded according to the severity of steatosis (NAFLD-3, NAFLD-2, NAFLD-1, and NAFLD-0). Comparison between different stages of NAFLD (NAFLD-3, NAFLD-2, NAFLD-1, and NAFLD-0) was analyzed using Chi-square and analysis of variance tests for categorical and continuous variables, respectively.

Results

The prevalence of NAFLD was 71% (n = 107). NAFLD-1 was detected in 39% of the patients, 32% had NAFLD-2, no patients with NAFLD-3, and 29% had non-NAFLD. There were no patients with NAFLD-2 having higher systolic and diastolic blood pressure, weight, body mass index, waist circumference, total cholesterol, triglycerides, high-density lipoprotein cholesterol, and low-density lipoprotein cholesterol. Glycated hemoglobin (HbA1c) concentration was highest within the NAFLD-2. NAFLD-2 showed higher mean CIMT. Every 1% rise in HbA1c for patients with NAFLD significantly increases the CIMT by 0.03 mm (95% CI: 0.009, 0.052, P = 0.006).

Conclusion

These findings suggest additional atherosclerotic risks within the NAFLD-2 group with significantly higher HbA1c and CIMT compared to the NAFLD-1 and NAFLD-0 groups. It is, therefore, vital to incorporate stricter glycemic control among patients with T2DM and IHD with moderate NAFLD as part of atherosclerotic risk management strategy.

Vascular deformation in human atherosclerotic carotid artery evaluated by 2D analysis of ultrasonography

OBJECTIVES

Common carotid artery (CCA) remodelling in the atherosclerosis process is an inherent necessary element that decreases the progress of significant lumen compromise. The present study used a semi-automated method to assess relationships of intima-media thickness (IMT), lumen diameter (LD) and inter-adventitial diameter (IAD) using ultrasound B-mode images of atherosclerotic carotid artery.

METHODS

In the cross-sectional study, 120 male subjects (age range: 40-60 years) were classified into four research groups namely control, mild, moderate, and severe stenosis. The maximum near and far wall IMT, mean of both walls' IMT and IAD, and also LD of the left CCA were extracted for all participants. Pearson correlation coefficient was utilized to investigate relationships of IMT, LD, and IAD.

RESULTS

Results revealed that the maximum far and near wall IMT, mean of both walls' IMT and IAD in the CCA were significantly different in stenosis patients and the control group (p< 0.001). However, there were no significant differences among the four studied groups in terms of LD of CCA (p = 0.65). There was a stronger correlation between mean of both walls' IMT and IAD in comparison with mean far wall IMT and IAD (p < 0.001).

CONCLUSIONS

Results indicated that changes of IAD in the left CCA were associated with carotid deformation, and thus it can be considered as a predictor of atherosclerosis process.

Novel Invasive and Noninvasive Cardiac-Specific Biomarkers in Obesity and Cardiovascular Diseases

Cardiovascular disease (CVD) is the leading cause of fatality and disability worldwide regardless of gender. Obesity has reached epidemic proportions in population across different regions. According to epidemiological studies, CVD risk markers in childhood obesity are one of the significant risk factors for adulthood CVD, but have received disproportionally little attention. This review has examined the evidence for the presence of traditional cardiac biomarkers (nonspecific; lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, creatine kinase, myoglobulin, glycogen phosphorylase isoenzyme BB, myosin light chains, ST2, and ischemia-modified albumin) and novel emerging cardiac-specific biomarkers (cardiac troponins, natriuretic peptides, heart-type fatty acid-binding protein, and miRNAs). Besides, noninvasive anatomical and electrophysiological markers (carotid intima-media thickness, coronary artery calcification, and heart rate variability) in CVDs and obesity are also discussed. Modifiable and nonmodifiable risk factors associated with metabolic syndrome in the progression of CVD, such as obesity, diabetes, hypertension, dyslipidemia, oxidative stress, inflammation, and adipocytokines are also outlined. These underlying prognostic risk factors predict the onset of future microvascular and macrovascular complications. The understanding of invasive and noninvasive cardiac-specific biomarkers and the risk factors may yield valuable insights into the pathophysiology and prevention of CVD in a high-risk obese population at an early stage.

Nonlinear model for the carotid artery disease 10-year risk prediction by fusing conventional cardiovascular factors to carotid ultrasound image phenotypes: A Japanese diabetes cohort study

MOTIVATION

This study presents a novel nonlinear model which can predict 10-year carotid ultrasound image-based phenotypes by fusing nine traditional cardiovascular risk factors (ethnicity, gender, age, artery type, body mass index, hemoglobin A1c, hypertension, low-density lipoprotein, and smoking) with five types of carotid automated image phenotypes (three types of carotid intima-media thickness (IMT), wall variability, and total plaque area).

METHODOLOGY

Two-step process was adapted: First, five baseline carotid image-based phenotypes were automatically measured using AtheroEdge^™ (AtheroPoint^™ , CA, USA) system by two operators (novice and experienced) and an expert. Second, based on the annual progression rates of cIMT due to nine traditional cardiovascular risk factors, a novel nonlinear model was adapted for 10-year predictions of carotid phenotypes.

RESULTS

Institute review board (IRB) approved 204 Japanese patients' left/right common carotid artery (407 ultrasound scans) was collected with a mean age of 69 ± 11 years. Age and hemoglobin were reported to have a high influence on the 10-year carotid phenotypes. Mean correlation coefficient (CC) between 10-year carotid image-based phenotype and age was improved by 39.35% in males and 25.38% in females. The area under the curves for the 10-year measurements of five phenotypes IMT_ave10yr , IMT_max10yr , IMT_min10yr , IMTV_10yr , and TPA_10yr were 0.96, 0.94, 0.90, 1.0, and 1.0. Inter-operator variability between two operators showed significant CC (P < 0.0001).

CONCLUSIONS

A nonlinear model was developed and validated by fusing nine conventional CV risk factors with current carotid image-based phenotypes for predicting the 10-year carotid ultrasound image-based phenotypes which may be used risk assessment.

Pentraxin-3 and endothelial dysfunction

Pentraxin 3 (PTX3) is involved in vascular inflammation and endothelial dysfunction through various mechanisms. Until now, most studies confirmed an important link between PTX3 and endothelial dysfunction and identified several pathogenetic pathways. PTX3 modulates inflammatory cells, thus stimulating vascular inflammation. Within endothelial cells, it decreases nitric oxide (NO) synthesis, inhibits cell proliferation and alters their functions. PTX3 blocks the effect of fibroblast growth factor 2 (FGF2) by making a molecular complex with these molecules inactivating them. However, there are substances like the tumor necrosis factor-inducible gene 6 protein (TSG-6) that block the PTX3-FGF2 interaction. Interacting with P-selectin, it promotes vascular inflammatory response and endothelial dysfunction. PTX3 also increases the matrix metalloproteinases synthesis directly or by blocking NO synthesis. From a clinical point of view, PTX3 positively correlates with arterial hypertension, flow mediated dilation and, with intima media thickness. Therefore, the involvement of PTX3 in the pathogenesis and evaluation of endothelial dysfunction is clear, and it may become a biomarker in this direction, but further studies are needed to determine its reliability in this direction. Last but not least, PTX3 could become an effective therapeutic target for preventing this dysfunction, but further research needs to be conducted.

Sex Hormone Levels - Estradiol, Testosterone, and Sex Hormone Binding Globulin as a Risk Marker for Atherosclerotic Coronary Artery Disease in Post-menopausal Women

CONTEXT

Sex hormones levels determine the risk of occurrence of coronary artery disease (CAD) in post-menopausal (PM) women.

AIMS

To investigate the relationship between sex hormones (estradiol and testosterone)/sex hormone binding globulin (SHBG) and cardiovascular risk factors in PM women. In addition, we learned the association between these sex hormones/SHBG and the occurrence of atherosclerotic CAD event in PM women.

SETTINGS AND DESIGN

Cross-sectional case- control study.

SUBJECTS AND METHODS

Subjects recruited in the present study were from the cardiology outpatient clinic or Emergency department Guwahati Medical College and Hospital, Assam. The subjects were grouped into two categories after appropriate exclusion criteria: Cases - PM women with documented CAD (n = 40) and controls - Healthy PM women (n = 30). The medical history, clinical examination, and investigations including serum estradiol, total testosterone, SHBG, free testosterone index (FTI), high-sensitivity C-reactive protein (hs-CRP), lipid profile, carotid intima-media thickness (CIMT), fasting plasma glucose (FPG), and postprandial plasma glucose (PPPG) were done and analyzed.

STATISTICAL ANALYSIS USED

Pearson correlation between sex hormones and CAD risk factors was done. The association between sex hormones and CAD risk factors among PM women was analyzed by multiple logistic regression. The statistical significance was set at the 0.05 level.

RESULTS

The mean age of all the subjects was 62.27 ± 6.9 years. Among the cases, a significant positive correlation was found between total testosterone/FTI and waist circumference, W/H ratio, triglyceride levels, hs-CRP, and CIMT (P < 0.01). In addition, a significant negative correlation was found between total testosterone and FTI with high-density lipoprotein-cholesterol levels (P < 0.01). The multiple logistic regression analysis showed that total testosterone levels (P < 0.01) and SHBG (P < 0.01) are independently associated with the occurrence of atherosclerotic CAD in PM.

CONCLUSION

We conclude that increased serum testosterone levels and low SHBG in PM women are associated with the development of atherosclerotic cardiovascular risk factors.

Plasma Galectin-3 and Sonographic Measures of Carotid Atherosclerosis in the Atherosclerosis Risk in Communities Study

Galectin-3 is a β-galactoside-binding lectin that plays a role in the regulation of several conditions that are associated with atherosclerosis. The goal of this cross-sectional study was to assess the association of plasma galectin-3 concentrations with sonographic measures of carotid atherosclerosis in the Atherosclerosis Risk in Communities study. Linear regression was used to determine the difference and 95% confidence intervals (CIs) for carotid intima-media thickness (cIMT) by categorical and continuous representations of galectin-3. Logistic regression was used to determine the odds ratio and 95% CI, separately, for dichotomized cIMT (75th percentile = 0.9 mm) and carotid plaque and/or shadowing. Compared to those in the first quintile of galectin-3, those in the fifth quintile of galectin-3 level had higher cIMT (mean difference: 0.020 mm after multivariable adjustment; P trend = .04). Moreover, compared to those in the lowest galectin-3 quintile, those in the highest galectin-3 quintile had higher odds of carotid plaque/and or shadowing (odds ratio 1.13 after multivariable adjustment; P trend = .014). Higher levels of galectin-3 are associated with greater carotid atherosclerosis. Our findings provide support for the role of inflammatory biomarkers in the pathogenesis of atherosclerosis and suggest galectin-3 as a possible target for intervention in the prevention or management of atherosclerotic disease.

Factors associated with carotid intima-media thickness in patients on maintenance hemodialysis

PURPOSE

The aim of this study was to analyze the association of the carotid intima-media thickness (CIMT) with various parameters in patients on maintenance hemodialysis (mHD).

METHODS

A cross-sectional study was conducted, enrolling 68 subjects (41 men, 27 women) on mHD in the Hemodialysis Unit, Sanglah Hospital, Denpasar, Indonesia. CIMT was measured with B-mode ultrasonography using a USG Sonoace 8000 and a 7.5 MHz linear transducer.

RESULTS

CIMT was higher in subjects with cardiovascular disease (CVD) compared with those without CVD (0.6494 vs 0.7288 mm; P=0.026), and in men compared with women (0.7056 vs 0.6141 mm; P=0.003). CIMT was correlated with age (R=0.607; P<0.001), plasma albumin (R=-0.291, P=0.016), serum phosphate (R=-0.294, P=0.015), calcium-phosphate product (R=-0.284, P=0.011), and plasma high-sensitivity C-reactive protein (R=0.279, P=0.030). However, after multiple linear regression testing, only age consistently had a role in determining the CIMT value (β=0.452, P<0.001).

CONCLUSION

Subjects with CVD have higher CIMT than those without CVD and men had higher CIMT than women. In addition, older age, higher high-sensitivity C-reactive protein, and lower albumin, phosphate, and calcium-phosphate product levels were correlated with higher CIMT. Age was the most important marker for CIMT in subjects on mHD.

Association of carotid intima-media thickness with exercise tolerance test in type 2 diabetic patients

Aims

Atherosclerosis and ischemic heart disease are more common in diabetic patients. Atherosclerosis process can disturb the normal functioning of the vascular endothelium and increase vessel wall thickness. The aim of this study was the comparison of Carotid intima-media thickness (CIMT) with Exercise tolerance test as an alternative way to evaluate cardiac ischemia in diabetic patients.

Methods

In a cross-sectional study, 30 diabetic patients with positive exercise test and 30 diabetic patients with negative exercise test were enrolled. CIMT of the carotid artery in both groups of patients was measured.

Result

CIMT in the patients with positive and negative exercise test were 1.04 ± 0.21 mm and 0.61 ± 0.11 mm, respectively (P < 0.001). CIMT in positive exercise test group was positively associated with age and negatively associated with gender, FBS, HDL and LDL cholesterol and in negative exercise group was negatively associated with gender, age, FBS, HDL and LDL cholesterol.

Conclusion

Considering observed significant positive association between CIMT with result of exercise tolerance test (ETT) in type 2 diabetic patients, it may possible to use CIMT as an inexpensive and non-invasive method for evaluation of ischemic heart disease in diabetic patients.

Diabetes and Stroke: More than just accelerated atherosclerosis?

Editorial

Carotid artery stenosis screening: where are we now?

Stroke poses a significant burden on healthcare and is the second largest cause of death globally. Both medical and surgical interventions to reduce the risk of stroke in asymptomatic patients have been shown to be effective but identifying the target at risk population is more problematic. Screening for carotid artery stenosis offers one pathway for this, as there is some correlation between risk of stroke and extent of stenosis. Identification of patients who are at risk of cardiovascular disease as well as stroke, allows initiation of effective medical treatment of modifiable risk factors to address this risk. In addition, carotid intima-media thickness is a way of assessing systemic atherosclerosis and may be valuable in risk stratification of patients for cardiovascular disease. Given the low prevalence of stenosis in the general population and the risks associated with undergoing surgical intervention, population wide screening is not recommended. This recommendation has not changed over the last 15 years, since the last major studies evaluating management and outcomes were published. However, both medical and surgical/endovascular treatments have advanced over that time. Further studies are underway to compare current treatments for the appropriate management of both symptomatic and asymptomatic patients with stenosis. Two of these trials, ECST-2 and CREST-2, are expected to be completed in the next 2-4 years and the results may initiate changes in the recommendations. The use of carotid intima-media thickness alongside traditional risk scores is controversial and more research is required in this area.

Oxidative DNA Damage and Carotid Intima Media Thickness as Predictors of Cardiovascular Disease in Prediabetic Subjects

Prediabetes is considered as a risk factor for the development of diabetes mellitus and cardiovascular disease. The present study was conducted with the aim of finding out the relationship between oxidative DNA damage and carotid intima media thickness for the prediction of cardiovascular disease in prediabetic subjects. The study included 100 prediabetic subjects and 100 normal individuals as controls. In both cases and controls, 8-OHdG was measured by ELISA, and CIMT was measured by B mode ultrasonography. Both 8-OHdG and CIMT were significantly higher in subjects with prediabetes as compared to controls (185.80 ± 10.72 pg/mL vs. 126.13 ± 16.01 pg/mL, p < 0.001 and 0.70 ± 0.04 mm vs. 0.57 ± 0.03 mm, p < 0.001, respectively). There was significant and positive correlation of IGT with 8-OHdG (r = 0.783; p < 0.001) and CIMT (r = 0.787; p < 0.001) in prediabetic subjects. Moreover, 8-OHdG showed significant positive correlation with CIMT (r = 0.704; p < 0.001) in prediabetic subjects. In conclusion, increased 8-OHdG and CIMT in prediabetic subjects indicate that biochemical changes of atherosclerosis start even before the onset of diabetes mellitus. Hence, 8-OHdG and CIMT could be used as indicators of cardiovascular disease risk in these subjects.

Factors associated with carotid Intima media thickness and carotid plaque score in community-dwelling and non-diabetic individuals

Background

The carotid intima media thickness (cIMT) and carotid plaque score (cPS) are respective markers of early and late stage subclinical atherosclerosis. Relationships between some laboratory parameters and subclinical atherosclerosis are not yet clear in community dwelling individuals and non-diabetic subjects, so we try to elucidate these relationships and find a model to predict early and late stage subclinical atherosclerosis.

Methods

We examined relationships of the cIMT and cPS with different laboratory and demographic data of 331 subjects from a community-based prospective cohort study, using univariate and multivariate analyses.

Results

In regression models and after multiple adjustments, only systolic blood pressure (SBP), age, glycated hemoglobin (HBA1c), and waist circumference (WC) were determinants of the cIMT, and only age, SBP, HBA1c, and blood urea nitrogen (BUN) were determinants of a cPS of > 2 in all individuals. Only HBA1c lost its association with regard to predicting the cIMT in non-diabetic subjects.

Conclusions

HBA1c at > 5.9% can determine early and late stage subclinical atherosclerosis in community dwelling individuals, but only late stage subclinical atherosclerosis in non-diabetic subjects.

Heritability of the femoral intima media thickness

BACKGROUND

The measurement of femoral intima-media thickness (IMT) is underutilized in the clinical practice, although it is a surrogate marker of cardiovascular disease.

MATERIALS AND METHODS

388 Hungarian and Italian twins (121 monozygotic, 73 dizygotic pairs) underwent bilateral B-mode sonography of femoral arteries. IMT was measured by semiautomated software, where available, or by calipers.

RESULTS

Within-pair correlation in monozygotic twins was higher than in dizygotics for each parameter. Age-, sex- and country-adjusted genetic effect accounted for 43.9% (95% confidence interval, CI 21.3%-65.2%) and 47.2% (95% CI, 31.4%-62.6%) of the variance of common and superficial femoral artery IMT, respectively, and unshared environmental effect for 56.1% (95% CI 34.6%-78.5%) and 52.8% (95% CI, 37.2%-68.5%). These results did not change significantly after correcting for body mass index or central systolic blood pressure.

CONCLUSIONS

Genetic factors have a moderate role in the determination of common and superficial femoral IMT; however, the influence of environmental (lifestyle) factors remains still relevant. Environmental factors may have a role in influencing the genetic predisposition for femoral vascular hypertrophy.

Hepatic steatosis is associated with cardiometabolic risk in a rural Indian population: A prospective cohort study

BACKGROUND/OBJECTIVES

While adiposity and hepatic steatosis are linked to cardiovascular risk in developed countries, their prevalence and impact in low-income countries are poorly understood. We investigated the association of anthropomorphic variables and hepatic steatosis with cardiometabolic risk profiles and subclinical cardiovascular disease (CVD) in a large rural Indian cohort.

METHODS

In 4691 individuals in the Birbhum Population Project in West Bengal, India, we performed liver ultrasonography, carotid ultrasound and biochemical and clinical profiling. We assessed the association of hepatic steatosis and anthropomorphic indices (BMI, waist circumference) with CVD risk factors (dysglycemia, dyslipidemia, hypertension) and subclinical CVD (by carotid intimal-medial thickness).

RESULTS

Rural Indians exhibited a higher visceral adiposity index and pro-atherogenic dyslipidemia at a lower BMI than Americans. Individuals with any degree of hepatic steatosis by ultrasound had a greater probability of dysglycemia (adjusted odds ratio, OR=1.67, 95% CI 1.31-2.12, P<0.0001) and pro-atherogenic dyslipidemia (OR=1.33, 95% CI 1.07-1.63, P=0.009). We observed a positive association between liver fat, adiposity and carotid intimal-medial thickness (CIMT) in an unadjusted model (β=0.02, P=0.0001); the former was extinguished after adjustment for cardiometabolic risk factors.

CONCLUSIONS

In a large population of rural Indians, hepatic steatosis and waist circumference were associated with prevalent cardiometabolic risk and subclinical CVD at lower BMI relative to multi-ethnic Americans, though the association of the former with subclinical CVD was extinguished after adjustment. These results underscore the emerging relevance of hepatic steatosis and adiposity in the developing world, and suggest efforts to target these accessible phenotypes for cardiometabolic risk prevention.

Association of Risk Estimates of Three Different Cardiovascular Risk Assessment Tools with Carotid Intima Media Thickness in Patients with Type 2 Diabetes

INTRODUCTION

Risk assessment tools used to calculate the Cardiovascular Disease (CVD) risk such as the Framingham Risk Score (FRS), United Kingdom Prospective Diabetes study (UKPDS) risk engine and the World Health Organization (WHO) risk score have not been tested on their ability to detect subclinical atherosclerosis in most developing countries.

AIM

To study the association between the calculated CVD risk scores using each of these tools and Carotid Intima Medial Thickness (CIMT), a surrogate marker of atherosclerosis, in a group of patients with Type 2 diabetes (T2DM) in Sri Lanka.

MATERIALS AND METHODS

We calculated CVD risk scores of 68 randomly selected patients with T2DM with no history or symptoms of CVD and measured their CIMT using B-mode ultrasonography (USS). Carotid USS was considered positive when the maximum carotid IMT was 0.9mm or when arteriosclerotic plaques were detected. The 10-year CVD risk was calculated using the FRS, the UKPDS risk engine and the WHO risk score. Pearson correlation was used to study the association between CVD risk scores with CIMT.

RESULTS

Of the 68 patients studied, 50% were males and their mean age (SD) was 56.9 (±9.6) years. The mean age at onset and duration of diabetes were 44.3(±9.1) and 12.2(±7.6) years respectively. Of the scoring methods, UKPDS tool had weak, but significantly positive (r = 0.26, p < 0.05) and FRS had positive but not significant association (r= 0. 21) with CIMT. There was a negative association between CIMT and WHO risk score (r= - 0.07).

CONCLUSION

Of the three CVD risk assessment tools, both UKPDS risk engine and FRS have almost equal ability (former being marginally superior) in predicting underlying atherosclerotic vascular disease in patients with T2DM. Negative association of the WHO risk score with CIMT argues against its utility for CVD screening. These findings highlight the need for developing more sensitive and reliable CVD risk assessment tools for developing countries.

Prevalence and risk factors of carotid intima-media thickness in asymptomatic individual subjects in a tertiary care center in India

BACKGROUND

Carotid intima-media thickness (IMT) is increasingly identified as a marker of atherosclerosis and increased risk of cerebrovascular disease.

AIM

We aimed to investigate the prevalence of carotid IMT in asymptomatic Indian individuals, more than 40 years of age, and correlate it with other risk factors for cerebrovascular ischemia.

MATERIALS AND METHODS

Individuals attending outpatient services of Nizam's Institute of Medical Sciences, who were asymptomatic for cerebrovascular ischemia underwent detailed history and carotid Doppler examination. IMT on mid common carotid artery (CCA) was measured. All subjects' blood was taken for biochemical estimation of fasting blood sugar and total cholesterol levels.

RESULTS

Out of 1,392 subjects, 571 (41%) had abnormal IMT and 821 (59%) had normal IMT. On comparison of the two groups, the factors significantly associated with abnormal IMT were mean older age (59 vs 50.7 years; P < 0.0001) and higher prevalence of hypertension (257 (45%) vs 236 (28.7%); P < 0.0001), diabetes (159 (27.8%) vs 139 (16.9%); P < 0.0001), and hypercholesterolemia (124 (21.7%) vs113 (13.7%); P = 0.0001). After adjustment with multiple logistic regression, significant predictors were age (odds 3.2; 95% confidence interval (CI) 2.5-4.1), male gender (odds 1.5; 95% CI 1.1-1.9), hypercholesterolemia (odds 1.5; 95% CI 1.1-2.0), hypertension (odds 1.4; 95% CI 1.1-1.8), and diabetes (odds 1.3; 95% CI 1.0-1.7).

CONCLUSION

We found age, sex, hypertension, diabetes, and hypercholesterolemia to be independent risk factor for abnormal IMT in asymptomatic subjects over 40 years of age.