Arteriosclerosis and Atherosclerosis Assessment in Clinical Practice: Methods and Significance

Alongside cancer, cardiovascular disease (CVD) exhibits the highest rates of morbidity and mortality globally, in western society as well as in Asian countries. Aging is a serious problem for the Asian population as progression toward a super-aged society is moving at a remarkably high rate. This increased rate of aging leads to increased CVD risk and, consequently, high CVD incidence. However, aging is not the only deleterious factor of vascular problems; hypertension, hypercholesterolemia, diabetes mellitus, and kidney disease may induce atherosclerosis and arteriosclerosis (i.e., arterial stiffening), and the progression of these diseases ultimately leads to cardiovascular, cerebrovascular, chronic kidney, or peripheral artery disease. Despite the existence of several guidelines on the treatment of risk factors such as hypertension and CVD, there is still an ongoing debate regarding the clinical need for assessment of arteriosclerosis and atherosclerosis, which act as a bridge between cardiovascular risk factors and CVD. In other words, although arteriosclerosis and atherosclerosis are essential to our understanding of vascular diseases, the need for additional tests beyond the conventional diagnosis method remains disputed. This is presumably due to insufficient discussion on how to apply such tests in clinical practice. This study aimed to fill this gap.

Impact of atherosclerosis on the postoperative complications of colorectal surgery in older patients with colorectal cancer

BACKGROUND

Atherosclerosis is associated with various comorbidities; nonetheless, its effect on the postoperative complications of colorectal surgery in older patients with colorectal cancer (CRC) remains unclear. This study aimed to evaluate the impact of atherosclerosis on the postoperative complications of colorectal surgery in older adults with CRC.

METHODS

Patients aged ≥ 65 years who underwent surgery for CRC between April 2017 and October 2020 were enrolled. To evaluate atherosclerosis, we prospectively calculated the cardio-ankle vascular index (CAVI) measured by the blood pressure/pulse wave test and abdominal aortic calcification (AAC) score from computed tomography. Risk factors for Clavien-Dindo grade ≥ III postoperative complications were evaluated by univariate and logistic regression analyses.

RESULTS

Overall, 124 patients were included. The mean CAVI value and AAC score were 9.5 ± 1.8 and 7.0 ± 8.0, respectively. Clavien-Dindo grade ≥ III postoperative complications were observed in 14 patients (11.3%). CAVI (odds ratio, 1.522 [95% confidence interval, 1.073-2.160], p = 0.019), AAC score (1.083 [1.009-1.163], p = 0.026); and operative time (1.007 [1.003-1.012], p = 0.001) were identified as risk factors for postoperative complications. Based on the optimal cut-off values of CAVI and AAC score, the probability of postoperative complications was 27.8% in patients with abnormal values for both parameters, which was 17.4 times higher than the 1.6% probability of postoperative complications in patients with normal values.

CONCLUSIONS

Atherosclerosis, particularly that assessed using CAVI and AAC score, could be a significant predictor of postoperative complications of colorectal surgery in older adults with CRC.

The independent association between salivary alpha-amylase activity and arterial stiffness in Japanese men and women: the Toon Health Study

Psychological stress is considered to be a potential contributor in the development of arterial stiffness. However, an independent association between arterial stiffness and biological markers of stress has not yet been established. We examined the independent association between salivary alpha-amylase (sAA) activity and arterial stiffness, not mediated by cardiometabolic disease associated with arterial stiffness, in a sample of healthy Japanese men and women. Participants (992 in total, 296 men and 696 women aged 30-79 years) had neither previous cardiovascular events or stroke, nor coexisting hypertension, diabetes, or dyslipidemia. Arterial stiffness was measured by the cardio-ankle vascular index (CAVI), and increased CAVI was defined as a CAVI value of 9 or higher. A saliva sample was collected in the morning and sAA was measured with a commercial assay kit. Higher sAA activity was positively associated with greater arterial stiffness particularly among women (β = 0.070; 95% CI = 0.014-0.126; p = 0.01), and not across all participants (β = 0.042; 95% CI = -0.005-0.089; p = 0.08) and in men (β = -0.005; 95% CI = -0.097-0.087; p = 0.91). The association was strongest in the group of women aged 60 years and older (β = 0.121; 95% CI = 0.018-0.224; p = 0.02). Although the association between sAA and increased CAVI (CAVI ≥ 9) was not significant in all and sex subgroups, odds ratios (OR) for CAVI ≥ 7 were significantly high in all participants (OR = 1.25; 95% CI = 1.03-1.53) and women (OR = 1.43; 95% CI = 1.12-1.82). Elevation of sAA was associated with an increase in arterial stiffness, particularly for women aged 60 years or older.

Insights into Friedman stage II and III OSA patients through drug-induced sleep endoscopy

Background

The Friedman staging is a classic system to predict outcomes of obstructive sleep apnea (OSA) surgery. Increasing stage indicates more severe upper airway (UA) obstruction and worse surgical successful rate. In previous studies, the UA obstruction between stages were usually assessed based on awake examination. Drug-induced sleep endoscopy (DISE) is a new method that can evaluate airway collapse characteristics during sleep. Therefore, we planned to compare Friedman staging and DISE findings and fulfill the knowledge gap on the correlation between awake and sedated UA examination.

Methods

Retrospective case series study that assessed patients with OSA who underwent DISE. Subjects were classified to stage II and stage III groups based on Friedman staging system. UA collapse characteristics based on velum, oropharynx, tongue base, epiglottis (VOTE) classification, including single/multiple obstruction sites, single/combined upper and lower obstruction levels, collapse degree and patterns in different sites, and surgical results among the groups were analyzed.

Results

A total of 175 cases were analyzed. No significant differences were found in baseline measurements between groups. Stage III patients (n=102) had a higher proportion (74.5%) with 3 or 4 obstruction sites than stage II (57.5%, n=73). Velum (V) + oropharynx (O) + tongue base (T) was the most common multi-sites combined obstruction pattern with 33% in stage II and 37% in stage III, isolated lower level obstruction was the least with 6% and 4%, respectively. No significant differences were found in obstruction sites and levels. 106 patients underwent surgeries and 33 had post-surgical sleep study, 73.7% and 63.6% response rate were found in stage II and III with no significant difference.

Conclusions

Upper and lower combined obstruction was the main pattern of collapse in both, Friedman stage II and III patients. Patients with OSA and Friedman stage III had more than 2 sites of obstruction than stage II patients.

How Are Sleep Characteristics Related to Cardiovascular Health? Results From the Population-Based HypnoLaus study

Background Although sleep characteristics have been linked to cardiovascular disease and cardiovascular risk factors, the association between sleep characteristics measured by polysomnography and cardiovascular health ( CVH ) remains unknown. Methods and Results In a population-based sample (n=1826), sleep characteristics were assessed by both sleep questionnaires and polysomnography. Global, behavioral, and biological CVH were defined according to the American Heart Association. Multinomial logistic regressions were performed to estimate relative risk ratios and 95% CI . Strong dose-response associations were found between all oxygen saturation-related variables (oxygen desaturation index, mean oxygen saturation, and percentage of total sleep time spent under 90% oxygen saturation) and obstructive sleep apnea (severity categories and apnea/hypopnea index) and global, behavioral, and biological CVH . Mean oxygen saturation had the strongest positive association (relative risk ratios 1.31 [ CI 1.22-1.41]; 1.78 [ CI 1.55-2.04] for intermediate relative to ideal CVH ), and oxygen desaturation index had the strongest negative association (relative risk ratios 0.71 [ CI 0.65-0.78]; 0.45 [ CI 0.34-0.58] for intermediate relative to ideal CVH ) with global CVH , and these associations were also the most robust in sensitivity analyses. The impacts of sleep architecture and sleep fragmentation were less consistent. Conclusions Mean oxygen saturation, oxygen desaturation index, and apnea/hypopnea index were associated with CVH . Conversely, most variables related to sleep architecture and sleep fragmentation were not consistently related to CVH . Sleep-disordered breathing and the associated oxygen (de)saturation were associated with CVH more strongly than with sleep fragmentation.

New Horizons of Arterial Stiffness Developed Using Cardio-Ankle Vascular Index (CAVI)

Arterial stiffness is recognized mainly as an indicator of arteriosclerosis and a predictor of cardiovascular events. Cardio-ankle vascular index (CAVI), which reflects arterial stiffness from the origin of the aorta to the ankle, was developed in 2004. An important feature of this index is the independency from blood pressure at the time of measurement. A large volume of clinical evidence obtained using CAVI has been reported. CAVI is high in patients with various atherosclerotic diseases including coronary artery disease and chronic kidney disease. Most coronary risk factors increase CAVI and their improvement reduces CAVI. Many prospective studies have investigated the association between CAVI and future cardiovascular disease (CVD), and proposed CAVI of 9 as the optimal cut-off value for predicting CVD. Research also shows that CAVI reflects afterload and left ventricular diastolic dysfunction in patients with heart failure. Furthermore, relatively acute changes in CAVI are observed under various pathophysiological conditions including mental stress, septic shock and congestive heart failure, and in pharmacological studies. CAVI seems to reflect not only structural stiffness but also functional stiffness involved in acute vascular functions. In 2016, Spronck and colleagues proposed a variant index CAVI₀, and claimed that CAVI₀ was truly independent of blood pressure while CAVI was not. This argument was settled, and the independence of CAVI from blood pressure was reaffirmed. In this review, we summarize the recently accumulated evidence of CAVI, focusing on the proposed cut-off values for CVD events, and suggest the development of new horizons of vascular function index using CAVI.

Atherosclerosis as a predictor of transient exacerbation of overactive bladder symptoms after robot-assisted laparoscopic radical prostatectomy

OBJECTIVES

To assess whether atherosclerosis is involved in the development of overactive bladder and the function of lower urinary tract after robot-assisted radical prostatectomy.

METHODS

The present cohort consisted of 80 consecutive participants. The preoperative cardio-ankle vascular index was used to evaluate the presence of atherosclerosis. The present cohort was split into two groups, the atherosclerotic group, whose cardio-ankle vascular index was ≥9.0, and the control group, whose index was <9.0. The overactive bladder symptom score and lower urinary tract function were compared for 12 months after surgery.

RESULTS

The total score of the questionnaire was significantly higher at 6 and 9 months after surgery in the atherosclerosis group (P = 0.04, P = 0.03, respectively). Both the urgency and urgency incontinence subscores of the questionnaire showed a parallel tendency to that of the total score after surgery. At 3 months after surgery, there was a significant increase in the prevalence of de novo overactive bladder in the atherosclerosis group (P = 0.04). At 9 and 12 months after surgery, there was a significant decrease of voided volume in the atherosclerotic group (P < 0.01, P = 0.04, respectively).

CONCLUSIONS

Atherosclerosis delays the improvement in both overactive bladder symptoms and storage function postoperatively, and it is involved in the transient increase in the prevalence of de novo overactive bladder. Atherosclerosis might be a predictor of the development of overactive bladder after robot-assisted radical prostatectomy.

Association between nondipping pattern and EndoPAT signal in patients with mild obstructive sleep apnea

OBJECTIVE

To compare vascular endothelial function between dipping (D) and nondipping (ND) patterns in patients with and without mild obstructive sleep apnea (OSA) using EndoPAT, a test of reactive hyperemia used to assess peripheral vascular endothelial function.

METHODS

The sample consisted of individuals of both genders between 18 and 65 years of age with a body mass index (BMI) of ≤35 kg/m² and apnea/hypopnea index (AHI) of ≤15. The nondipping pattern was considered present when the dip of nocturnal blood pressure (NBP) was <10%. All of the sample underwent clinical and physical evaluation, full polysomnography, 24-hour ambulatory blood pressure monitoring, and EndoPAT evaluation. A generalized linear model was used for statistical analysis.

RESULTS

The sample comprised 120 individuals, 35 in the control group and 85 in the mild OSA group. Four groups were formed: Control-ND, Control-D, Mild OSA-ND, and Mild OSA-D according to nocturnal ABPM patterns. The frequency of nondipping was (34.1%) in the Mild OSA group and (17.1%) in the Control group (p = 0.07). The Mild OSA-ND group had a higher augmentation index (AIx) than the Mild OSA-D group. Regression analysis showed that male gender, higher age, and nondipping status were associated with these results, whereas oxygen desaturation index (ODI) and AHI did not. With respect to the reactive hyperemia index (RHI), the Mild OSA-D group had lower values compared to the Control-ND group, but an association with OSA was not confirmed in the regression model.

CONCLUSION

Nondipping status was associated with a worse augmentation index in both groups independently of AHI or oxygen desaturation index. Male gender, higher age, and nondipping status were associated with augmentation index. ClinicalTrials.gov Identifier: NCT01461486.

Contribution of obstructive sleep apnoea to arterial stiffness: a meta-analysis using individual patient data

BACKGROUND

Arterial stiffness, measured by pulse wave velocity (PWV), is a strong independent predictor of late cardiovascular events and mortality. It is recognised that obstructive sleep apnoea (OSA) is associated with cardiovascular comorbidities and mortality. Although previous meta-analyses concluded that PWV is elevated in OSA, we feel that an individual patient data analysis from nine relatively homogeneous studies could help answer: to what extent does OSA drive arterial stiffness?

METHODS

Individual data from well-characterised patients referred for suspicion of OSA, included in nine studies in which carotid-femoral PWV was measured using a Complior device, were merged for an individual patient data meta-analysis.

RESULTS

893 subjects were included (age: 56±11 (mean±SD), 72% men, 84% with confirmed OSA). Body Mass Index varied from 15 to 81 kg/m² (30±7 kg/m²). PWV ranged from 5.3 to 20.5 m/s (10.4±2.3 m/s). In univariate analysis, log(PWV) was strongly related to age, gender, systolic blood pressure, presence of type 2 diabetes (all p<0.01) as well as to dyslipidaemia (p=0.03) and an Epworth Sleepiness Scale score ≥9 (p=0.04), whereas it was not related to obesity (p=0.54), a severe Apnoea-Hypopnoea Index (p=0.14), mean nocturnal saturation (p=0.33) or sleep time with oxygen saturation below 90% (p=0.47). In multivariable analysis, PWV was independently associated with age, systolic blood pressure and diabetes (all p<0.01), whereas severe OSA was not significantly associated with PWV.

CONCLUSION

Our individual patient meta-analysis showed that elevated arterial stiffness in patients with OSA is driven by conventional cardiovascular risk factors rather than apnoea parameters.

Inverse Relationship between Sleep Duration and Cardio-Ankle Vascular Index in Children

AIM

Poor sleep has been shown to be associated with the development of cardiovascular risk factors, such as obesity, in both adults and children. This study aimed to investigate the relationship between sleep duration and arterial stiffness indices in Japanese children and early adolescents.

METHODS

The data on 102 students (56 males, 46 females; mean age, 11.9±1.8 years) were analyzed. As non-invasive arterial stiffness parameters, the cardio-ankle vascular index (CAVI) and heart-ankle pulse wave velocity (haPWV) were evaluated. Their students' sleep habits (bedtime and wake times on a usual weekday) were investigated using questionnaires, and based on these, their sleep durations were calculated.

RESULTS

The CAVI values in the males and females were 4.8±0.9 and 4.7±0.9 (arbitrary unit), respectively. haPWV values in the males and females were 5.5±0.6 and 5.4±0.6 m/s, respectively. Sleep duration in the males, but not in the females, was negatively correlated with CAVI (r=－0.356) and haPWV (r=－0.356), suggesting that students with short sleep duration could have increased arterial stiffness. After adjusting for confounders, such as age, sex, systolic blood pressure, heart rate, adiposity, and physical fitness, the correlation of sleep duration with CAVI, but not with haPWV, was still significant (partial r=－0.253, p＜0.05).

CONCLUSION

Our findings suggest that shorter sleep duration influences arterial stiffening even in childhood.

Atherosclerosis as a predictor of delayed recovery from lower urinary tract dysfunction after robot-assisted laparoscopic radical prostatectomy

AIMS

The aim of the present study was to investigate whether atherosclerosis could be associated with lower urinary tract dysfunction in the early postoperative period after robot-assisted laparoscopic radical prostatectomy (RARP).

METHODS

Eighty consecutive patients undergoing RARP were investigated. The severity of atherosclerosis was evaluated by the cardio-ankle vascular index (CAVI) before RARP. Patients were divided into two groups, the atherosclerotic group (CAVI ≥9.0) and the control group (CAVI <9.0). International Prostate Symptom Score (IPSS), quality of life (QOL) index, uroflowmetry, post-void residual urine volume (PVR), frequency-volume charts, and the 1-hr pad test were compared between the two groups. Assessments were performed before RARP, and then at 1, 3, and 6 months after RARP.

RESULTS

Preoperative subjective and objective parameters were not significantly different between the two groups. The voiding symptom score of the IPSS and the QOL index was significantly higher in the atherosclerotic group at 3 months after RARP (P = 0.035, P = 0.001, respectively). The maximum flow rate was consistently lower in the atherosclerotic group, reaching a significant difference at 6 months after RARP (P = 0.027). IPSS total and storage symptom scores, PVR, frequency, and urine loss were not significantly different between the groups after RARP.

CONCLUSIONS

Atherosclerosis delayed the improvement of both voiding symptoms and voiding function after RARP, leading to aggravation of QOL in the early postoperative period. Atherosclerosis may be a predictor of slower recovery from transient lower urinary tract dysfunction immediately after RARP. Neurourol. Urodynam. 35:920-925, 2016. © 2015 Wiley Periodicals, Inc.

Associations of serum β-carotene and retinol concentrations with insulin resistance: the Toon Health Study

OBJECTIVE

Although green and yellow vegetables have beneficial effects against type 2 diabetes, the relationship of their nutritive content with insulin resistance is poorly understood. The aim of this study was to examine the associations of serum β-carotene and retinol concentrations with glucose and insulin concentrations.

METHODS

We recruited 951 Japanese men and women ages 30 to 79 y who were not undergoing treatment for diabetes and measured their serum β-carotene and retinol concentrations. A 75-g oral glucose tolerance test was performed and the homeostasis model assessment for insulin resistance (HOMA-IR) and the Matsuda Index were calculated as measures of insulin resistance. Several confounding factors were adjusted for with multivariable logistic models.

RESULTS

Multivariable-adjusted odds ratios of the highest quartile of serum β-carotene compared with the lowest quartile for HOMA-IR >1.6 and Matsuda Index <4.9 were 0.56 (95% confidence interval, 0.34-0.94) and 0.62 (0.37-1.02), respectively. When stratified by sex and overweight status, these associations were observed for women and non-overweight individuals. Serum retinol concentration was not associated with either index. Furthermore, according to the nutritional survey, serum β-carotene concentration was associated with green and yellow vegetable intake (P = 0.01).

CONCLUSION

Our findings suggest that higher serum β-carotene levels, associated with higher intake of green and yellow vegetables, confer beneficial effects against insulin resistance.