Reduced progression of carotid intima media thickness by pictorial presentation of subclinical atherosclerosis 3-year follow-up from VIPVIZA a randomized controlled trial

Background

Reduced progression of carotid intima media thickness (cIMT) and atherosclerotic plaque assessed by carotid ultrasound has been reported in pharmacological intervention studies. We have previously provide evidence for improved primary prevention of cardiovascular diseases by pictorial presentation of subclinical atherosclerosis severity based on reduction in traditional risk scores in 1-year follow-up.

Purpose

We aimed to investigate if pictorial presentation of subclinical atherosclerosis severity affected cIMT and plaque progression over a 3-year follow-up period in comparison with a routine primary prevention program.

Methods

Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA) study is a population-based, randomized controlled trial with blinded evaluators (PROBE design). Participants aged 40, 50 and 60 years were enrolled from a prevention program within the routine primary care. Carotid ultrasound examinations were made at baseline and at 3-year follow-up (n: 3154). The ultrasound examinations included standardized measurements of cIMT in the far wall of common carotid artery at predefined angles due to Meijer's arc. Used angles was 240 degrees for left-mean-cIMT and 120 degrees for right-mean-cIMT. Detection of plaque was based on Mannheim consensus and plaque prevalence was evaluated as absent, unilateral or bilateral plaques. Total plaque area (TPA) was a sum of plaque areas and measured off-line form the longitudinal 2D B-mode images. At baseline, the intervention group (n: 1575) and their primary care physicians received a pictorial presentation describing the severity of subclinical atherosclerosis with graphs and colored figures based on measured cIMT and plaque prevalence (Figure 1). The control group with respective physician (n: 1579) did not receive any information about ultrasound results. The bilateral, left and right mean cIMT, plaque prevalence and TPA at 3-year follow-up were compared between groups. Analysis was performed by analysis of covariance and ordinal proportional odds models. Bonferroni correction was applied to account for multiple comparisons, each individual test was performed using α = 0.01.

Results

Reduced cIMT progression in the intervention group was found in left-mean-cIMT with an estimated group difference of −0.011 mm (p=0.001). Estimated group difference of right- and bilateral-mean-cIMT were both −0.005 mm (p=0.223 and 0.036, respectively) (Figure 2). No significant difference between groups was found for plaque prevalence or TPA.

Conclusion

Intervention by pictorial presentation of subclinical atherosclerotic severity reduced the progression of cIMT in comparison with a traditional cardiovascular preventive program only. This was largely driven by changes in the left carotid artery. Long-term follow-up will be required to elucidate if the intervention will have a protective effect on future risk of cardiovascular events.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): The Heart Foundation of Northern Sweden, Västerbotten County Council. Figure 1Figure 2

[Family reactions to the vegetative state: a follow-up after 5 years]

Few studies to date have investigated the experience of family members of those who, following acute brain injury, traumatic or otherwise, find themselves in a vegetative state (VS), in particular how families cope, year after year, with care of the patient in hospital, what coping strategies are implemented to cope with everyday life, if the high levels of depression and anxiety, typical of such a difficult situation, modify as time passes, if the place of care chosen for the patient --at home or in a long-term hospital structure--influences the emotional state of the family members. This paper presents the results of a survey conducted on 30 family members of patients in VS, 25 of whom were long-term hospital inpatients and 5 home-based. Results are compared with the findings which emerged from a longitudinal study carried out on 16 family members tested in 2000 and re-evaluated, utilizing the same assessment tools, 5 years later. The results reveal a picture of significant emotional and psychophysical distress, high levels of anxiety and depression and the use mainly of situation-focused coping strategies. Family relations appear little satisfying even if over time they tend to improve. The comparison at 5 years reveals levels of anxiety, depression and emotional burnout superior to the norm and almost unchanged despite the passage of time. The comparison is slightly better for those who take part in mutual help groups under the guidance of a psychologist; these subjects tend to use coping strategies more centered on the expression of their emotions. Group therapy, when its goal is to help care givers share their own personal experience concerning the caring relationship, appears to facilitate the development of new strategies and resources to cope with daily living.

[Surgical repair of degenerative atrial valve: long-term results]

BACKGROUND

The advantages of mitral valve repair in myxomatous regurgitation are well established. The durability of this reconstructive procedure is variable. The timing of operation is the surgeon dilemma. The aim of this study was to evaluate the early and long-term results of mitral valve repair in myxomatous regurgitation.

METHODS

Between January 1990 and December 1997, 121 patients (77 males, 44 females) were operated on for myxomatous regurgitation with mitral valve repair. The surgical indication was based on the severity of mitral valve insufficiency and left ventricular dysfunction rather than the functional class. The surgical techniques were: quadrangular resection of the posterior mitral leaflet and sliding suture, triangular resection of the anterior mitral leaflet, chordal transposition and neo-chords suture, prosthetic ring (Carpentier-Edwards and Biflex rings) suture.

RESULTS

There was 1 hospital death (0.8%). Long-term follow-up between 6 months and 107 months was available in 100% surviving patients. There were 6 late deaths, 3 for cardiac and 3 for non-cardiac events.

CONCLUSIONS

Valve repair in mitral regurgitation caused by myxomatous disease provides excellent survival results at 51 months. Adverse outcome occurs in patients with preoperative left ventricular dysfunction, even if asymptomatic.

Comparison between single and double internal mammary artery grafts: results over ten years

BACKGROUND

In view of the superior patency of the internal mammary artery (IMA), grafting of this vessel to the left anterior descending artery is advantageous in terms of survival and quality of life; the benefits of using both the mammary arteries remain unproved.

METHODS

Among the patients operated upon during the period 1988-1990, we randomly selected 150 patients in whom one IMA (group 1) was grafted and 150 patients in whom both IMAs (group 2) were grafted. The survival and event free curves of these two groups of patients were designed using the Kaplan-Mayer method; the log-rank test was used to assess the statistical difference between the curves and to determine whether, in the long term, benefits were superior in patients in whom both IMAs were grafted.

RESULTS

Patients in group 1 were older (p = 0.002). In this group there were more patients with diabetes (p = 0.004) and with peripheral vascular disease (p = 0.047). There were more female patients in group 2 (p < 0.02) and more coronary vessels were grafted (p = 0.03). Follow-up was complete (100%) and equivalent in duration for both groups (109 +/- 30 months for group 1 and 110 +/- 33 months for group 2, p = NS). The survival rate at 10 years was equal for both groups (82.5 +/- 3.4% for group 2 vs 82.9 +/- 3.2% for group 1, p = NS) and so was the freedom from cardiac death. The provocative test for myocardial ischemia was more frequently positive in group 1 than in group 2 (21 vs 10 cases, p = 0.054). Freedom from new myocardial infarction (p = NS), angina recurrence (p = NS) and reoperation (p = NS) was equally distributed during follow-up. Group 2 patients more frequently necessitated coronary angioplasty but the difference was not significant (p = 0.17). Survival free from angina recurrence, new myocardial infarction, coronary angioplasty and reoperation was more frequent in group 2 (respectively 74.6 +/- 3.8 vs 70.7 +/- 4.1%) but the difference was not statistically significant (p = NS).

CONCLUSIONS

After 12 years of follow-up, patients submitted to grafting of a single IMA more frequently presented with inducible myocardial ischemia, but neither survival nor the quality of life were superior in the patients in whom both IMAs were grafted.