Carotid artery atherosclerosis, MRI indices of brain ischemia, aging, and cognitive impairment: the Framingham study

BACKGROUND AND PURPOSE

Carotid atherosclerosis has been associated with increased risk of stroke and poorer cognitive performance in older adults. The relation of carotid atherosclerosis to cognitive impairment and MRI indices of ischemia and aging in midlife is less clear.

METHODS

We studied 1975 Framingham Offspring Study participants free of stroke and dementia with available carotid ultrasound, brain MRI, and neuropsychological testing. We related common and internal carotid artery intima-media thickness and internal carotid stenosis to large white matter hyperintensity (>1 SD above age-specific mean), total brain volume, hippocampal volume, silent cerebral infarcts, and neuropsychological measures of verbal memory, executive function, and nonverbal memory measures.

RESULTS

We observed that internal carotid artery intima-media thickness, but not common carotid artery intima-media thickness, was associated with higher prevalence of silent cerebral infarcts (OR, 1.21; 95% CI, 1.03-1.43; P<0.05), large white matter hyperintensity (OR, 1.19; 95% CI, 1.03-1.38; P<0.05), lower total brain volume (-0.05 per SD; P<0.05), and poorer performance in verbal memory (-0.06 per SD; P<0.05) and nonverbal memory measures (-0.08 per SD; P<0.01), but not with hippocampal volume. Internal carotid stenosis >or=25% was associated with a higher prevalence of large white matter hyperintensity (adjusted OR, 1.77; 95% CI, 1.25-2.53) and lower total brain volume (-0.11 per SD; P=0.042) but not with silent cerebral infarcts or hippocampal volume. Internal carotid stenosis >or=50% was associated with higher prevalence of silent cerebral infarcts (OR, 2.53; 95% CI, 1.17-5.44), large white matter hyperintensity (OR, 2.35; 95% CI, 1.08-5.13), and poorer performance on executive function (-0.39 per SD; P<0.05), but not with total brain volume or hippocampal volume.

CONCLUSIONS

Carotid atherosclerosis markers were associated with MRI indices of brain ischemia and aging and with cognitive impairment in a community-based sample of middle-aged adults. Our data suggest that internal carotid artery intima-media thickness may be a better marker for cognitive impairment than common carotid artery intima-media thickness.

Chronic stress burden, discrimination, and subclinical carotid artery disease in African American and Caucasian women

This study examined the association between a composite index of stress that included measures of life events, ongoing stress, discrimination, and economic hardship and subclinical carotid disease among 109 African America and 225 Caucasian premenopausal women. African Americans reported more chronic stress and had higher carotid intima-media thickness (IMT) as compared with Caucasians. Among African Americans only, the composite stress index and unfair treatment were associated with higher IMT. These effects were partially mediated by biological risk factors. African American who reported experiencing racial discrimination had marginally more carotid plaque than did those who did not report experiencing racial discrimination. The results suggest that African Americans may be particularly vulnerable to the burden of chronic stress.

Hopelessness and 4-year progression of carotid atherosclerosis. The Kuopio Ischemic Heart Disease Risk Factor Study

The importance of hope has long been recognized, whereas a lack of hope, or "giving up," is generally believed to have a negative impact on psychological well-being and physical health. Recently, hopelessness has been identified as a strong, independent predictor of cardiovascular disease morbidity and mortality in both American and Finnish populations. In this study we examined the association between high levels of hopelessness and progression of carotid atherosclerosis in participants (n = 942) in the Kuopio Ischemic Heart Disease Study, a population-based study of middle-aged men from eastern Finland who underwent carotid ultrasonography at baseline and 4 years later. Men reporting high levels of hopelessness at baseline had faster progression of carotid atherosclerosis, assessed by four measures of intima-media thickening (IMT), than men reporting low to moderate levels of hopelessness. Further analyses revealed significant interactions between hopelessness and initial level of atherosclerosis, such that the effects of high hopelessness on progression were greatest among men who had baseline mean IMT values at or above the median. Moreover, progression was greatest among men reporting high levels of hopelessness at both baseline and follow-up. Traditional coronary risk factors and use of cholesterol-lowering and antihypertensive medications did not account for much variance in the observed relationships. These findings indicate that hopelessness contributes to accelerated progression of carotid atherosclerosis, particularly among men with early evidence of atherosclerosis, and that chronically high levels of hopelessness may be especially detrimental. Additional research is needed to identify the contributory pathways and/or mechanisms underlying these relationships.

Interaction of workplace demands and cardiovascular reactivity in progression of carotid atherosclerosis: population based study

OBJECTIVE

To examine the combined influence of workplace demands and changes in blood pressure induced by stress on the progression of carotid atherosclerosis.

DESIGN

Population based follow up study of unestablished as well as traditional risk factors for carotid atherosclerosis, ischaemic heart disease, and other outcomes.

SETTING

Eastern Finland.

SUBJECTS

591 men aged 42-60 who were fully employed at baseline and had complete data on the measures of carotid atherosclerosis, job demands, blood pressure reactivity, and covariates.

MAIN OUTCOME MEASURES

Change in ultrasonographically assessed intima-media thickness of the right and left common carotid arteries from baseline to 4 year follow up.

RESULTS

Significant interactions between workplace demands and stress induced reactivity were observed for all measures of progression (P < 0.04). Men with large changes in systolic blood pressure (20 mm Hg or greater) in anticipation of a maximal exercise test and with high job demands had 10-40% greater progression of mean (0.138 v 0.123 mm) and maximum (0.320 v 0.261 mm) intima-media thickness and plaque height (0.347 v 0.264) than men who were less reactive and had fewer job demands. Similar results were obtained after excluding men with prevalent ischaemic heart disease at baseline. Findings were strongest among men with at least 20% stenosis or non-stenotic plaque at baseline. In this subgroup reactive men with high job demands had more than 46% greater atherosclerotic progression than the others. Adjustment for atherosclerotic risk factors did not alter the results.

CONCLUSIONS

Men who showed stress induced blood pressure reactivity and who reported high job demands experienced the greatest atherosclerotic progression, showing the association between dispositional risk characteristics and contextual determinants of disease and suggesting that behaviourally evoked cardiovascular reactivity may have a role in atherogenesis.

Effects of stress reduction on carotid atherosclerosis in hypertensive African Americans

BACKGROUND AND PURPOSE

African Americans suffer disproportionately higher cardiovascular disease mortality rates than do whites. Psychosocial stress influences the development and progression of atherosclerosis. Carotid intima-media thickness (IMT) is a valid surrogate measure for coronary atherosclerosis, is a predictor of coronary outcomes and stroke, and is associated with psychosocial stress factors. Stress reduction with the Transcendental Meditation (TM) program decreases coronary heart disease risk factors and cardiovascular mortality in African Americans. B-mode ultrasound is useful for the noninvasive evaluation of carotid atherosclerosis.

METHODS

This randomized controlled clinical trial evaluated the effects of the TM program on carotid IMT in hypertensive African American men and women, aged >20 years, over a 6- to 9-month period. From the initially enrolled 138 volunteers, 60 subjects completed pretest and posttest carotid IMT data. The assigned interventions were either the TM program or a health education group. By use of B-mode ultrasound, mean maximum IMT from 6 carotid segments was used to determine pretest and posttest IMT values. Regression analysis and ANCOVA were performed.

RESULTS

Age and pretest IMT were found to be predictors of posttest IMT values and were used as covariates. The TM group showed a significant decrease of -0.098 mm (95% CI -0. 198 to 0.003 mm) compared with an increase of 0.054 mm (95% CI -0.05 to 0.158 mm) in the control group (P=0.038, 2-tailed).

CONCLUSIONS

Stress reduction with the TM program is associated with reduced carotid atherosclerosis compared with health education in hypertensive African Americans. Further research with this stress-reduction technique is warranted to confirm these preliminary findings.

Does low socioeconomic status potentiate the effects of heightened cardiovascular responses to stress on the progression of carotid atherosclerosis?

OBJECTIVES

This study examined whether heightened cardiovascular reactivity and low socioeconomic status had synergistic effects on the progression of carotid atherosclerosis in a population of eastern Finnish men.

METHODS

Data from the Kuopio Ischemic Heart Disease Risk Factor Study were used to measure 4-year progression of intima-media thickness in 882 men according to cardiovascular reactivity and socioeconomic status. Associations were examined in relation to risk factors and were stratified by baseline levels of atherosclerosis and prevalent ischemic heart disease.

RESULTS

The effect of reactivity on atherosclerotic progression depended on socioeconomic status. Men who had heightened cardiovascular responsiveness to stress and were born into poor families, received little education, or had low incomes had the greatest atherosclerotic progression.

CONCLUSIONS

An understanding of associations between individual risk factors and disease should be based on etiologic hypotheses that are conceived at the population level and involve fundamental social and economic causes of disease. This study demonstrates how examining the interaction of an individual biological predisposition will low socioeconomic status over the life course is etiologically informative for understanding the progression of atherosclerotic vascular disease.

Neuropsychometric changes in patients after carotid endarterectomy

BACKGROUND AND PURPOSE

One hundred twelve patients undergoing elective carotid endarterectomy for symptomatic and asymptomatic carotid artery stenosis were enrolled in a prospective study to evaluate the incidence of change in postoperative cerebral function.

METHODS

Patients were evaluated preoperatively and postoperatively before hospital discharge and at follow-up 1 and 5 months later with a battery of neuropsychometric tests. The results were analyzed by both event-rate and group-rate analyses. For event-rate analysis, change was defined as either a decline or improvement in postoperative neuropsychometric performance by 25% or more compared with a preoperative baseline.

RESULTS

Approximately 80% of patients showed decline in one or more test scores, and 60% had one or more improved test scores at the first follow-up examination. The percentage of declined test scores decreased and the percentage of improved test scores increased with subsequent follow-up examinations. Group-rate analysis was similar for group performance on individual tests. However, a decline in performance was seen most commonly on verbal memory tests, and improved performance was seen most commonly on executive and motor tests.

CONCLUSIONS

Neuropsychometric evaluation of patients undergoing carotid endarterectomy for significant carotid artery stenosis demonstrates both declines and improvements in neuropsychometric performance. The test changes that showed decreased performance may be associated with ischemia from global hypoperfusion or embolic phenomena, and the improvement seen may be related to increased cerebral blood flow from removal of stenosis.

Are hostility and anxiety associated with carotid atherosclerosis in healthy postmenopausal women?

OBJECTIVE

In this article, we evaluated the prospective association between measures of trait anger, hostility, and anxiety and indices of carotid atherosclerosis in 200 healthy middle-aged postmenopausal women.

METHODS

Starting in 1983, 541 premenopausal women were evaluated for their levels of standard cardiovascular risk factors and psychosocial attributes, including their scores on Spielberger Trait Anger, Anxiety, and Anger-in, and Public Self-Consciousness. Starting in 1991, the Cook-Medley Hostile Attitudes Scale was also administered. Starting in 1993, 200 women who had been menopausal for at least 5 years were scanned for carotid atherosclerosis using B-mode ultrasound. The scans were scored for average intima-media thickness (IMT) and plaque index.

RESULTS

Women who had high Trait Anger, Anger-In, and Public Self-Consciousness scores had high IMT scores on average 10 years later. Women who had high Cook-Medley scores also had high IMT scores on average 1.5 years later. Multivariate analyses adjusting for the standard cardiovascular risk factors that most highly predicted IMT scores indicated that holding anger in, being self aware, and having hostile attitudes were significant predictors of IMT. Women with higher plaque scores also tended to report holding in their anger.

CONCLUSIONS

Anger suppression and hostile attitudes do predict women's carotid IMT in midlife. Ultrasound measures of carotid atherosclerosis can be used to advance our understanding of the early development of atherosclerosis in women.

Optimistic attitudes protect against progression of carotid atherosclerosis in healthy middle-aged women

OBJECTIVE

Optimistic people report a higher quality of life, engage in more active coping and adopt more health-promoting behaviors than people low in optimism, ie, pessimism. We evaluated whether pessimists are more likely to show progression in carotid disease than optimists.

METHODS

A total of 209 middle-aged healthy premenopausal women enrolled in an epidemiological study of cardiovascular risk factors and had carotid scans 10.4 years and 13.5 years later when they were at least 5 years postmenopausal. Women completed the Life Orientation Test (LOT), a measure of pessimistic and optimistic attitudes, at study entry and at the time of the first carotid scan. Analyses evaluated the association of LOT scores and change in carotid intima medial thickness (IMT) across 3 years.

RESULTS

Multiple linear regression analyses showed that the higher the pessimism scores at study entry, the greater the increase in mean IMT (beta = 0.17, p <.007). A comparison of those in the lowest quartile of LOT scores (most optimistic) with those in the other three quartiles showed that the most optimistic group had less progression than the remaining more pessimistic women (mean percent increase = 1.3 and 6.0 for mean IMT, F = 15.4, p <.001). Women who were chronically optimistic at study entry and at the first carotid scan (bottom quartiles at both times) had less progression in mean IMT than did those who were chronically pessimistic (top quartiles at both times).

CONCLUSIONS

Optimistic women are less likely to show progression of carotid disease in mid-life than are pessimists.

Chronic cerebral hypoperfusion elicits neuronal apoptosis and behavioral impairment

Chronic reductions in cerebral blood flow associated with aging and progressive neurodegenerative disorders can precipitate cognitive failure. To assess whether chronic cerebrovascular insufficiency elicits neuronal apoptosis, apoptotic cell death in the hippocampus was quantitated in a rat model of permanent carotid occlusion. Bilateral carotid artery occlusion (2VO) was shown to induce apoptotic morphology and DNA strand breaks in hippocampal neurons 2 and 27 weeks after ligation. The rate of pyramidal cell apoptosis was higher at chronic (27 weeks) compared to sub-chronic (2 weeks) time points. 2VO-induced apoptosis resulted in a decrease in total pyramidal cell number at 27 weeks but not at earlier time points, indicating progressive neuronal loss. Working and reference memory errors in the radial arm maze were strongly correlated with the number of apoptotic neurons in CA1 but not CA3 pyramidal cell fields. These data provide the first indication that apoptotic loss of pyramidal neurons may play a role in memory impairment associated with clinical conditions of chronic cerebrovascular insufficiency.

Sustained anxiety and 4-year progression of carotid atherosclerosis

Several studies have shown that anxiety disorders are associated with a higher risk of coronary artery disease. However, the relationship between anxiety disorders and atherosclerosis has been studied to a lesser extent. The goal of this study was to examine whether high and stable trait anxiety was associated with the progression of atherosclerosis. The study group consisted of 726 subjects (297 men and 429 women), aged 59 to 71 years, recruited from the electoral rolls of the city of Nantes. The subjects had no history of coronary artery disease at baseline evaluation and or at the 2-year follow-up. Two follow-up examinations were conducted 2 and 4 years after the baseline evaluation. Trait anxiety was evaluated by means of the French translation of the Spielberger Inventory (a 20-item trait inventory, form X-2). The "sustained anxiety" group consisted of men and women with the highest Spielberger Inventory scores at baseline and at the 2-year follow-up examination. Each ultrasound examination included measurement of intima-media thickness and the sites of plaque in the extracranial carotid arteries. Men with sustained anxiety showed a higher 4-year increase of common carotid intima-media thickness than did men without sustained anxiety (adjusted means 0.08 versus 0.04 mm, respectively; P=0.05) and a higher risk of 4-year plaque occurrence (adjusted OR 3.5, 95% CI 1.4 to 8.5). Among women, sustained anxiety was associated with a higher 4-year increase of common carotid intima-media thickness (0.07 versus 0.04 for women with versus women without sustained anxiety, respectively; P=0.07). These results suggest that chronically high levels of anxiety may contribute to accelerating the evolution of carotid atherosclerosis.

Cerebral hemodynamics and cognitive impairment: baseline data from the RECON trial

OBJECTIVE

To determine whether unihemispheral hemodynamic failure is independently associated with cognitive impairment among participants in the National Institute of Neurological Disorders and Stroke-sponsored, multicenter, randomized clinical trial, Randomized Evaluation of Carotid Occlusion and Neurocognition (RECON).

METHODS

Forty-three patients were randomized into RECON after recent symptomatic carotid artery occlusion and asymmetrically increased oxygen extraction fraction (OEF) by PET (OEF ratio >1.13), indicating stage II hemodynamic failure on the side of occlusion. The PET-positive patients were compared with 28 RECON-enrolled patients who met all clinical and radiographic inclusion/exclusion criteria but had no OEF asymmetry. A multivariable regression compared patients with PET OEF >1.13 or ≤1.13, stratifying by TIA vs. stroke as the qualifying event. The dependent variable was a composite neurocognitive score derived from averaging age-normalized z scores on a test battery that included global and internal carotid artery (ICA) side-relevant hemisphere-specific tests.

RESULTS

There were no differences in demographic, clinical, or radiologic characteristics between the PET-positive and PET-negative patients except for PET OEF asymmetry. The unadjusted average neurocognitive z score was -1.45 for the PET-positive and -1.25 for the PET-negative patients, indicating cognitive impairment in both groups but no difference between them (p = 0.641). After adjustment for age, education, side of occlusion, depression, and previous stroke, there was a significant difference between PET-positive and PET-negative patients among those with TIA as a qualifying event (average z score = -1.41 vs. -0.76, p = 0.040). Older age and right ICA side were also significant in this model.

CONCLUSION

Hemodynamic failure is independently associated with cognitive impairment in patients with carotid occlusion. This finding establishes the physiologic parameter upon which the extracranial-intracranial bypass will be tested.

Cognitive disorders in patients with occlusive disease of the carotid artery: a systematic review of the literature

We present a systematic review of the literature on the prevalence, nature, severity, course, and causes of cognitive deficits in patients with occlusive disease of the carotid artery prior to surgery (if surgery was under discussion). Searches were carried out on Medline and Psychlit from 1980 to 1999 using neurovascular and psychological index terms, and papers and books were checked for further references. Studies describing neuropsychological assessment of groups of patients with carotid obstruction were included. Eighteen studies were found. We extracted from the papers data on study design, demographic characteristics of patients, clinical diagnosis, carotid obstruction, cerebral imaging, time interval between ischemic episode and neuropsychological assessment, neuropsychological assessment procedures, integration and interpretation of test performances, and conclusions of authors. Fourteen studies concluded that there are cognitive deficits both in patients with symptomatic and in those with asymptomatic carotid obstruction; four studies denied cognitive impairment. There were no differences in patient characteristics, study design, or neuropsychological assessment procedures between the 14 studies that found deficits and the 4 that did not. There are indications for a mild, diffuse detrimental effect of carotid occlusive disease on cognitive functioning. However, methodological problems prevent a definitive conclusion. Further research is needed to confirm these findings and to ascertain the neurovascular risk factors for and the natural course of cognitive impairment in patients with carotid occlusive disease.

Carotid atherosclerosis and 10-year changes in cognitive function

BACKGROUND

Carotid atherosclerosis has been suggested to be involved in cognitive decline.

METHODS

The Epidemiology of Hearing Loss Study is a longitudinal study of aging among Beaver Dam residents, WI. In 1998-2000, carotid intima-media thickness (IMT) and plaque were measured by ultrasound; cognitive function was measured by the Mini-Mental State Examination (MMSE). Follow-up examinations were conducted in 2003-2005 and 2009-2010. Incidence of cognitive impairment was defined as an MMSE score <24 or reported physician-diagnosed dementia during the follow-up. In the last examination, five additional cognitive tests were added. The associations of carotid atherosclerosis with incident cognitive impairment and cognitive test performance ten years later were evaluated.

RESULTS

A total of 1651 participants (mean age 66.8 years, 41% men) without cognitive impairment at baseline were included in the incidence analysis. IMT was associated with incidence of cognitive impairment after multiple adjustments (hazard ratio: 1.09, p = 0.02 for each 0.1 mm increase in IMT). A total of 1311 participants with atherosclerosis data at baseline had the additional cognitive tests 10 years later. Larger IMT was associated with longer time to complete the Trail-Making Test-part B after multiple adjustments (0.1 mm IMT: 2.3 s longer, p = 0.02). Plaque was not associated with incident cognitive impairment or cognitive test performance 10 years later.

CONCLUSIONS

In this population-based longitudinal study, carotid IMT was associated with a higher risk of developing cognitive impairment during the 10-year follow-up, and was associated with poorer performance in a test of executive function 10 years later.

White-coat hypertension and carotid artery atherosclerosis: a matching study

BACKGROUND

Blood pressure (BP) measurements obtained in the clinic have long served as the basis for determining risk of hypertensive vascular disease, yet many patients with high BP in the physician's office are normotensive elsewhere. It remains unclear whether such patients with "white coat" hypertension elude the risk of atherosclerosis.

METHODS

Community residents 40 to 70 years of age and not receiving any cardiovascular medications were recruited to participate in a study of cardiovascular risk factors. On the basis of clinic and daytime ambulatory BP and a threshold criterion of 140/90 mm Hg, subjects were classified as having persistent hypertension, white-coat hypertension, or persistent normotension. One-to-one matching was conducted in male participants on the basis of race and BP. Subjects with persistent hypertension and white-coat hypertension were matched on clinic BP, and those with white-coat hypertension and normotension were matched on daytime ambulatory BP.

RESULTS

The 3 matched groups of men (n=40 in each group) were similar in age, smoking status, and fasting glucose and lipid levels. Compared with the normotensive subjects, subjects with either persistent or white-coat hypertension had greater mean body mass index, waist-hip ratio, and fasting insulin concentration. On the basis of standardized duplex ultrasound examination of the carotid arteries, mean maximal intimal-medial thickness and plaque index in subjects with white-coat hypertension were greater than among normotensive subjects and equal to that of the subjects with persistent hypertension.

CONCLUSION

When compared with unmedicated individuals with comparable elevations in clinic BP, individuals with white-coat hypertension appear not to be protected from the atherosclerotic sequelae of hypertension.

A review of carotid atherosclerosis and vascular cognitive decline: a new understanding of the keys to symptomology

This review encourages the reader to consider cerebral vascular disease beyond the traditional clinical end points of major motor and speech strokes and to consider the possible impact of embolic cerebral vascular disease on vascular cognitive decline. This article examines the issue of "silent" strokes in the relationship between the structural stability of atherosclerotic carotid plaque and the development of nonmotor symptomatology, including cognitive decline. It addresses the question of the role of carotid emboli in silent stroke and their cognitive sequelae. In a study of endarterectomy patients, we relate plaque elasticity and its development of mechanical strain features and thinning of stabilizing fibrous cap at the point of these mechanical strain features. The possibility that microemboli from such mechanically unstable carotid plaques could contribute to silent strokes led to a study of cognitive function in such patients. A linear relationship between the process of mechanically unstable areas of carotid plaques and cognitive decline suggests a contributory role for such a process in silent strokes.

Socioeconomic status and progression of carotid atherosclerosis. Prospective evidence from the Kuopio Ischemic Heart Disease Risk Factor Study

Socioeconomic status (SES) is importantly associated with cardiovascular morbidity and mortality, but no information exists on the relationship between SES and progression of atherosclerotic vascular disease. We investigated the association between education and income and the 4-year progression of carotid atherosclerosis in a population-based sample of Finnish men. Data from the Kuopio Ischemic Heart Disease Risk Factor Study were used to estimate changes in maximum and mean intima-media thickness (IMT) and maximum plaque height across levels of SES in 1022 men. Associations between SES and atherosclerotic progression were examined in relation to risk factors and stratified by baseline levels of atherosclerosis and prevalent ischemic heart disease (IHD). There were significant, inverse, graded relationships between levels of education and income for all three progression measures, which were largely unaffected by risk factor adjustment. For education, the age- and baseline IMT-adjusted maximum progression for those with primary schooling or less was 0.28 mm and for those who graduated from high school, 0.24 mm (P = .05). Compared with the lowest SES group, men with the highest SES had 14% to 29% less atherosclerotic progression, depending on the measure used. Associations of the same magnitude were evident in subgroups without advanced baseline IMT and in men who were free of IHD. These results show that men with poor education and low income have significantly greater progression of carotid atherosclerosis than men with more advantages. The findings strengthen the contention that SES plays a significant role early in the atherosclerotic disease process and that reducing the burden of atherosclerotic vascular disease associated with lower SES will require approaches that focus on all stages of the life course.

Hostility, social support, and carotid artery atherosclerosis in the National Heart, Lung, and Blood Institute Family Heart Study

This cross-sectional study investigates the association of hostility and social support (measured by standardized instruments) to carotid artery atherosclerosis in men and women with a high familial risk for coronary heart disease (CHD) and those with low to medium risk. The hypothesis was that high hostility and low social support would have a stronger association in subjects with a familial predisposition to CHD. There were 535 low- to medium-risk women, 491 low- to medium-risk men, 1,950 high-risk women, and 1,667 high-risk men in the study. The extent of carotid artery atherosclerosis was assessed by B-mode ultrasound imaging. A lesion was defined as an intimal-medial far wall thickness of 1 mm in the common, internal, or carotid bifurcation, or identification of plaque at any site. Odds ratios and their 95% confidence intervals were calculated using generalized estimating equations (GEE) for logistic regression. Family was specified as the clustering variable, and robust SEEs were obtained that account for dependence of the data within families. After controlling for age, education, body mass index, ever having smoked, ever drinking > 5 drinks a day, and metabolic index, hostility was significantly associated with increased odds of carotid lesions in only high-risk women. High-risk women showed a significantly reduced odds of carotid lesions with high social support, but the extent of this protection was reduced when age and education were included in the equation. A combination of high hostility and low social support was associated with higher odds than hostility alone in both high-risk men and women. These results suggest that women with a high familial predisposition for CHD may be more vulnerable to cardiovascular influences from hostility and social support than high-risk men or men and women with low to medium risk.

Associations between life stress and subclinical cardiovascular disease are partly mediated by depressive and anxiety symptoms

BACKGROUND

Stress experienced during childhood or adulthood has been associated with cardiovascular disease (CVD), but it is not clear whether associations are already prevalent on a subclinical cardiovascular level. This study investigates associations between indicators of life stress and subclinical CVD, and whether these are mediated by depression and anxiety.

METHODS

Subjects were 650 participants of the Netherlands Study of Depression and Anxiety, aged 20-66 years, with or without (27.5%) depressive and anxiety disorders. Life stress included childhood trauma, negative life events and recently experienced daily hassles or job strain. Subclinical CVD was measured as 1) carotid atherosclerosis (intima-media thickness and the presence of plaques) using B-mode ultrasonography, and 2) central arterial stiffness (heart rate normalized augmentation index) using calibrated radial applanation tonometry.

RESULTS

Increased central arterial stiffness was shown in subjects who had experienced childhood trauma (per SD increase: β=.07; p=.01), or reported recently experienced daily hassles (per SD increase: β=.06; p=.02), negative life events (per SD increase: β=.05; p=.03), or job strain (high versus low: β=.09; p=.01). Associations between life stress and arterial stiffness appeared to be partly mediated by severity of depressive and anxiety symptoms. No significant associations were found for childhood life events, nor between indicators of life stress and carotid atherosclerosis.

CONCLUSIONS

Childhood trauma and recent life stress were associated with increased central arterial stiffness. This suggests that life stress - partly via depression and anxiety - might enhance the development and progression of CVD.

Work-related psychosocial factors and carotid atherosclerosis

BACKGROUND

In order to better understand the role of work environment in the earlier stages of the cardiovascular disease process, we wanted to investigate the influence of work-related psychosocial factors on preclinical atherosclerosis.

METHODS

Cross-sectional data was used to examine the association between psychological job demands, job decision latitude, and carotid atherosclerosis in 2658 vocationally-active Swedish men and women, ages 46-65, from the general population. Odds ratios of carotid plaque prevalence and carotid artery intima-media thickness (IMT), determined by B-mode ultrasound, were estimated across combinations of job demands and decision latitude.

RESULTS

Women in job situations with high demands and low decision latitude ('job strain') showed a high plaque prevalence odds (odds ratio [OR] = 1.68, 95% CI: 1.14, 2.48), and a thicker IMT in the carotid bifurcation area (mean difference: 0.15 mm, 95% CI: 0.07, 0.23) compared with women in job situations with low demands and high decision latitude ('relaxed'). Adjustment for covariates only slightly reduced the magnitude of these associations. No such associations were seen in men. However, women in job situations with high demands and high decision latitude ('active') also showed high odds for carotid plaque, and a thicker IMT in the carotid bifurcation, compared with women in 'relaxed' job situations. In men, those in 'active' job situations had a low carotid plaque prevalence odds, while IMT in the carotid bifurcation did not differ from those in 'relaxed' job situations. Results showed only weak associations with IMT in the common carotid artery (CCA) in both men and women.

CONCLUSION

The specific hypothesis that high job demands interact synergistically with low decision latitude in the development of carotid atherosclerosis could not be supported in this study, neither in men nor in women. Instead a more complex pattern of interaction between job demands and decision latitude was shown.

Cynical hostility and carotid atherosclerosis in African American and white women: the Study of Women's Health Across the Nation (SWAN) Heart Study

BACKGROUND

Hostility is associated with increased cardiovascular disease mortality and morbidity and may be related to subclinical atherosclerosis; less is known about this association among women and minority groups.

METHODS

We examined the association between hostility and intimal-medial thickening (IMT) as well as presence/absence of plaque in the carotid arteries in middle-aged white and African American women. Hostility was measured by a 13-item questionnaire and IMT and plaque were assessed by B-mode ultrasonography in 589 participants from the Chicago and Pittsburgh sites of the SWAN.

RESULTS

In age- and site-adjusted models, each 1-point increment in hostility score predicted a significant 0.0057-mm higher mean IMT (P < .0001) and 0.0081-mm higher maximum IMT (P < .0001)--effects that were identical in magnitude to each 1-year increment in age. Adjustments for race, education, body mass index, resting systolic blood pressure, and smoking diminished these associations, but they remained significant (P < or = .01). With hostility scores modeled in approximate tertiles, high scorers (> or = 6) had greater mean (P = .0005) and maximum (P = .0004) IMT than low scorers (0 or 1); moderate and low scorers did not differ (age-adjusted mean values for low, moderate, and high scorers were 0.657, 0.662, and 0.694 mm, respectively, for mean IMT; those for low, moderate, and high scorers were 0.855, 0.860, and 0.906 mm, respectively, for maximum IMT). Hostility was unrelated to presence of plaque and did not interact with race, education, smoking, and body mass index.

CONCLUSIONS

Hostility is related to small but significantly greater subclinical atherosclerosis in middle-aged women; this association is not explained by traditional risk factors.

Ultrasound Markers of Carotid Atherosclerosis and Cognition: The Northern Manhattan Study

BACKGROUND AND PURPOSE

Ultrasound markers of carotid atherosclerosis may be related to cognitive status. We hypothesized that individuals with greater carotid intima-media thickness (cIMT) and carotid plaque burden would exhibit worse cognition.

METHODS

One thousand one hundred sixty-six stroke-free participants from the NOMAS (Northern Manhattan Study) underwent carotid ultrasound and neuropsychological examination. Among them, 826 underwent a second neuropsychological examination an average of 5 years later. cIMT and plaque were assessed by a standardized B-mode ultrasound imaging and reading protocol. We used multivariable linear regression to examine cIMT, carotid plaque presence, and carotid plaque area as correlates of domain-specific neuropsychological Z scores cross-sectionally and over time. We also investigated possible effect modification by APOE ε4 allele, age, and race/ethnicity.

RESULTS

Participants had a mean (SD) age of 70 (9) years and were 60% women, 66% Hispanic, 15% white, and 18% black. Those with greater cIMT exhibited worse episodic memory after adjustment for demographics and vascular risk factors (β=-0.60; P=0.04). APOE ε4 carriers with greater cIMT exhibited worse episodic memory (β=-1.31; P=0.04), semantic memory (β=-1.45; P=0.01), and processing speed (β=-1.21; P=0.03). Participants with greater cIMT at baseline did not exhibit significantly greater cognitive decline after adjustment. APOE ε4noncarriers with greater cIMT exhibited greater declines in executive function (β=-0.98; P=0.06). Carotid plaque burden was not significantly associated with cognition at baseline or over time.

CONCLUSIONS

Subclinical carotid atherosclerosis was associated with worse cognition among those at higher risk for Alzheimer disease. Interventions targeting early stages of atherosclerosis may modify cognitive aging.

Mediation and modification of the association between hopelessness, hostility, and progression of carotid atherosclerosis

Hopelessness and hostility are linked to progression of carotid atherosclerosis (PCA). The purpose of this study was to replicate such relations and to evaluate the role of biological pathways involving hyperactivation of the sympathetic nervous system (SNS) and the hypothalamic-pituitary-adrenocortical (HPA) axis. PCA was evaluated by 4-year change in three ultrasound measures of intima-media thickness (IMT) in 1027 men aged 42-60 years at baseline. Effect modification and mediation of relationships between psychosocial factors and PCA were examined for the measures systolic blood pressure (SBP), fibrinogen, and waist-to-hip ratio (WHR), levels of which are indicative of activity along these pathways. Hopelessness and hostility were associated with PCA. Fibrinogen mediated to a moderate extent the association between hopelessness and PCA. SBP significantly modified the relation between hostility and PCA in participants of moderate hostility. The above biological pathways are implicated in the mechanisms connecting hopelessness, hostility, and PCA.

Intima-Media Thickness and Cognitive Function in Stroke-Free Middle-Aged Adults: Findings From the Coronary Artery Risk Development in Young Adults Study

BACKGROUND AND PURPOSE

The relationship between carotid artery intima-media thickness (IMT) and cognitive function in midlife remains relatively unexplored. We examined the association between IMT and cognitive function in a middle-aged epidemiological cohort of 2618 stroke-free participants.

METHODS

At the year 20 visit (our study baseline), participants from the Coronary Artery Risk Development in Young Adults study had IMT measured by ultrasound at the common carotid artery. Five years later, participants completed a cognitive battery consisting of the Rey Auditory-Verbal Learning Test of verbal memory, the Digit Symbol Substitution Test of processing speed, and the Stroop test of executive function. We transformed cognitive scores into standardized z scores, with negative values indicating worse performance.

RESULTS

Mean age at baseline was 45.3 years (SD, 3.6). Greater IMT (per 1 SD difference of 0.12 mm) was significantly associated with worse performance on all cognitive tests (z scores) in unadjusted linear regression models (verbal memory, -0.16; 95% confidence interval [CI], -0.20 to -0.13; processing speed, -0.23; 95% CI, -0.27 to -0.19; and executive function, -0.17; 95% CI, -0.20 to -0.13). In models adjusted for sociodemographics and vascular risk factors that lie earlier in the causal pathway, greater IMT remained negatively associated with processing speed (-0.06; 95% CI, -0.09 to -0.02; P, 0.003) and borderline associated with executive function (-0.03; 95% CI, -0.07 to 0.00; P, 0.07) but not with verbal memory.

CONCLUSIONS

We observed an association between greater IMT and worse processing speed-a key component of cognitive functioning-at middle age above and beyond traditional vascular risk factors. Efforts targeted at preventing early stages of atherosclerosis may modify the course of cognitive aging.

Validity and reliability of the Toronto Alexithymia Scale (TAS) in a population study

Alexithymia refers to the difficulties an individual has to experience and express his feelings. Various self-report questionnaires have been introduced to measure alexithymia, but only a few rigorous validity studies of this concept have been carried out in nonclinical populations. The aim of this study was to evaluate the psychometric properties of the Toronto Alexithymia Scale (TAS) in a population sample of 1560 middle-aged men from eastern Finland. The modified version of the TAS applied in this study had a factor structure that matched the previous results and the theoretical concept of alexithymia. Internal consistency of the total TAS scale, as well as the 8 month retest reliability, were adequate. The TAS correlated fairly well with an interview-based evaluation of alexithymic features. The results suggest that the TAS could be a useful screening instrument for alexithymic features in a population study, but the scale would probably need some revisions.