The Atherosclerosis Burden Score (ABS): a Convenient Ultrasound-Based Score of Peripheral Atherosclerosis for Coronary Artery Disease Prediction

Subclinical Atherosclerosis Progression in Low-Risk, Middle-Aged Adults: Carotid Leads Femoral in IMT Increase but Not in Plaque Formation

This study investigated subclinical atherosclerosis progression in low-risk, middle-aged adults (N = 141; a mean age of 49.6 ± 4.7 years) using a 5-year ultrasound follow-up. We compared the involvement of the carotid and femoral arteries.

METHODS

Clinical data, risk factors, carotid/femoral intima-media thickness (IMT), and plaque presence were analyzed.

RESULTS

Cardiovascular risk factors and scores increased significantly at follow-up. Both carotid and femoral mean IMT increased (p < 0.001). While plaque prevalence rose and was similar in both arteries (carotid: 4.8% to 17.9%, femoral: 3.6% to 17.7%, p < 0.001 for both), the progression of plaque burden was greater in femorals. Notably, the carotid mean IMT demonstrated a faster yearly progression rate compared to the mean femoral IMT. The prevalence of pathological nomogram-based mean IMT right or left was higher in the carotids (52.9% to 78.8%, p < 0.001) compared to femorals (23.2% to 44.7%, p < 0.001), with a significant increase at the end of follow-up in both territories.

CONCLUSIONS

This study demonstrates significant subclinical atherosclerosis progression in low-risk, middle-aged adults over 5 years. Carotid arteries showed a faster progression rate of mean IMT and a higher prevalence of pathological nomogram-based mean IMT compared to the femoral arteries. However, plaque burden was similar in both territories, with greater progression in femorals. Identifying carotid and femoral atherosclerosis burden may be a valuable tool for risk stratification in this population.

Prevalence and Burden of Carotid and Femoral Atherosclerosis in Subjects Without Known Cardiovascular Disease in a Large Community Hospital in South-America

INTRODUCTION

Clinical guidelines recommend measurement of arterial (carotid and femoral) plaque burden by vascular ultrasound (VUS) as a risk modifier in individuals at low or moderate risk without known atherosclerotic cardiovascular disease (ASCVD).

AIM

To evaluate the prevalence of carotid and femoral plaques by age and sex, the burden of subclinical atherosclerosis (SA), and its association with classic CVRF in subjects over 30 years of age without ASCVD.

METHODS

We prospectively enrolled 5775 consecutive subjects referred for cardiovascular evaluation and determined the prevalence and burden of SA using 2D-VUS in carotid and femoral arteries.

RESULTS

Sixty-one percent were men with a mean age of 51.3 (SD 10.6) years. Overall, plaque prevalence was 51% in carotid arteries, 39.3% in femoral arteries, 62.4% in carotid or femoral arteries, and 37.6% in neither. The prevalence of plaques and SA burden showed an increasing trend with age, being higher in men than in women and starting before the age of 40, both in the carotid and femoral sites. There was also an increasing prevalence of plaques according to the number of CVRF, and interestingly we found a high prevalence of plaques in subjects with 0 or 1 classic CVRF.

CONCLUSIONS

We observed an increased prevalence and burden of carotid or femoral SA, higher in men, beginning before the fourth decade of life and increasing with age. Despite a significant association with classic CVRF, a significant number of subjects with low CVRF were diagnosed with SA.

Peripheral Artery Disease Ultrasound Assessment in Predicting the Severity of Coronary Artery Disease

Atherosclerosis in a progressive disease that is systemic in nature, and hence the simultaneous presentation of coronary artery disease (CAD) and peripheral artery disease (PAD) is not uncommon. As clinically manifested PAD is associated with worse cardiovascular outcomes, the timely identification of subclinical atherosclerosis seems of utmost importance. Ultrasonography (US) is an ideal imaging modality for assessing PAD that is easy to use, accurate, widely available and avoids unnecessary exposure to radiation. Several US parameters have been proposed in the assessment of PAD, with varying prognostic usefulness, depending on disease location. The aim of this review is to summarize the most important evidence available on the association between US-detected atherosclerosis in different vascular sites and the presence and severity of CAD, as well as the impact of the early detection of PAD on the outcomes of patients presenting with CAD.

A new score for improving cardiovascular risk prediction and prevention

BACKGROUND AND AIMS

The ultrasonographic detection of subclinical atherosclerosis (scATS) at carotid and femoral vascular sites using the atherosclerosis burden score (ABS) improves the risk stratification for atherosclerotic cardiovascular disease beyond traditional cardiovascular (CV) risk factors. However, its predictive value should be further enhanced. We hypothesize that combining the ABS and the Framingham risk score (FHRS) to create a new score called the FHRABS will improve CV risk prediction and prevention. We aim to investigate if incorporating the ABS into the FHRS improved CV risk prediction in a primary prevention setting.

METHODS AND RESULTS

1024 patients were included in this prospective observational cohort study. Carotid and femoral plaques were ultra-sonographic detected. Major incident cardiovascular events (MACEs) were collected. The receiver operating characteristic curve (ROC-AUC) and Youden's index (Ysi) were used to compare the incremental contributions of each marker to predict MACEs. After a median follow-up of 6.0 ± 3.3 years, 60 primary MACEs (5.8%) occurred. The ROC-AUC for MACEs prediction was significantly higher for the FHRABS (0.74, p < 0.024) and for the ABS (0.71, p < 0.013) compared to the FHRS alone (0.71, p < 0.46). Ysi or the FHRABS (42%, p < 0.001) and ABS (37%, p < 0.001) than for the FHRS (31%). Cox proportional-hazard models showed that the CV predictive performance of FHRS was significantly enhanced by the ABS (10.8 vs. 5.5, p < 0.001) and FHRABS (HR 23.30 vs. 5.50, p < 0.001).

CONCLUSIONS

FHRABS is a useful score for improving CV risk stratification and detecting patients at high risk of future MACEs. FHRABS offers a simple-to-use, and radiation-free score with which to detect scATS in order to promote personalized CV prevention.

Liver Stiffness Is Associated with the Burden of Carotid and Systemic Atherosclerosis in an Unorganized Cohort of Patients 40-64 Years Old

Background: The aim of the study is to research the relationship between the severity of liver fibrosis and the burden of carotid and systemic atherosclerosis. Methods: The study includes 163 patients 40 to 64 years of age without atherosclerotic CVD or liver disease. All patients underwent duplex scanning of the carotid and lower limb arteries. All patients underwent transient liver elastometry using the FibroScan (Echosens, France). Results: Carotid plaque was detected in 110 (67.5%) patients. Based on the results of linear regression analysis, relationships between liver stiffness and carotid total plaque area (r = 0.21; p = 0.025) were found. Significant relationships were established between liver stiffness and atherosclerosis burden score based on the results of linear regression (r = 0.17; p = 0.029). Liver stiffness showed moderate diagnostic performance (AUC 0.666; p = 0.01) with regard to generalized atherosclerosis. An increase in liver stiffness >4.5 kPa was associated with an odds ratio of generalized atherosclerosis of 3.48 (95% CI 1.07−11.3; p = 0.038) after adjusting confounding factors. Conclusion: Among patients 40−64 years of age without established atherosclerotic CVD and liver disease, liver stiffness directly correlates with the burden of carotid and systemic atherosclerosis. Liver stiffness showed moderate diagnostic performance (AUC 0.666; p = 0.01) with regard to generalized atherosclerosis.

Elevated Serum Cystatin C and Decreased Cathepsin S/Cystatin C Ratio Are Associated with Severe Peripheral Arterial Disease and Polyvascular Involvement

Peripheral arterial disease (PAD) is frequently associated with atherosclerotic manifestations of the carotids and coronaries. Polyvascular involvement and low ankle−brachial index predict major cardiovascular events and high mortality. Cathepsin S (Cat S) promotes the inflammatory pathways of the arterial wall, while Cystatin C (Cys C) functions as its inhibitor; therefore, Cys C was proposed to be a biomarker of progression in PAD. In a single-center observational study, we investigated the correlations of serum Cys C and Cat S/Cys C ratio in a group of 90 PAD patients, predominantly with polyvascular involvement. Cys C and Cat S/Cys C were associated with ankle−brachial index (ABI) scores <0.4 in univariate and multiple regression models. Furthermore, both markers correlated positively with the plasma Von Willebrand Factor Antigen (VWF: Ag) and Von Willebrand Factor collagen-binding activity (VWF: CB). In addition, Cat S/Cys C was significantly decreased, whereas Cys C increased in subjects with three-bed atherosclerotic involvement. According to our results, high serum Cys C and low Cat S/Cys C ratios may indicate severe peripheral arterial disease and polyvascular atherosclerotic involvement.

Vascular ultrasound for cardiovascular risk stratification in asymptomatic patients with type-2 diabetes

AIMS

To identify new independent vascular markers to predict cardiovascular events in patients with type-2 diabetes (T2D), and their incremental value compared to the Swedish National Diabetes Register (NDR) risk score.

METHODS

A retrospective cohort study was conducted on 1332 asymptomatic patients with T2D, free from prior CV event, assessed for a cardiovascular work-up, including Duplex ultrasonography to detect plaque on carotid and femoral arteries. The extent of atherosclerosis was rated as atherosclerosis burden score (ABS). Patients were followed up to 5 years and the occurrence of cardiovascular events recorded.

RESULTS

A total of 82 patients (6.2%) experienced a cardiovascular event, including 34 (2.6%) myocardial infarction, 18 (1.4%) cardiac revascularisation and 17 (1.3%) stroke. The independent determinants of these events were male sex (HR = 1.81 [1.13-2.88], p = 0.013) and ABS ≥ 2 (HR = 1.98 [1.21-3.25], p = 0.007). The NDR risk score performed poorly to predict cardiovascular events (area under the curve = 0.56 [0.49-0.63], p = 0.11), whereas screening for atherosclerotic plaques provided significant incremental prognostic value over the NDR score (model χ2 increase: +231%, p = 0.002).

CONCLUSION

Duplex ultrasonography to screen for atherosclerotic plaques improve the estimation of cardiovascular prognosis on top of clinical data and could be routinely used to improve cardiovascular risk stratification.

Femoral plaque burden by ultrasound is a better indicator of significant coronary artery disease over ankle brachial index

The ankle-brachial index is a commonly used tool for identifying peripheral artery disease for cardiovascular risk stratification. An abnormal ankle-brachial index occurs only following extensive peripheral atherosclerosis occlusion, and thus has poor sensitivity for coronary atherosclerosis. There is a critical need for the development of tools that can detect risk prior to advanced stages of atherosclerosis. We sought to determine the sensitivity of femoral ultrasound for coronary artery disease. In this prospective, cross-sectional study, participants (n = 124) underwent ankle-brachial index measurement and femoral ultrasound for assessment of intima-media thickness, maximal plaque height, and total plaque area following coronary angiography. Receiver operating characteristic areas under the curve were plotted for identifying significant coronary artery disease (≥ 50% stenosis). Logistic regression was utilized to evaluate associations. 64% of participants had significant, angiography-confirmed coronary artery disease. Femoral ultrasound plaque area yielded the highest area under the curve for detecting significant coronary disease (area under the curve = 0.731). In contrast, an abnormal ankle-brachial index (≤ 0.90) produced an area under the curve of 0.568. Femoral ultrasound had a higher sensitivity (85%) than the ankle-brachial index (25%) for ruling out significant coronary artery disease. Both ankle-brachial index and femoral ultrasound have similar capacity to detect peripheral artery disease. Femoral ultrasound has a significantly greater discriminatory power than ankle-brachial index to detect clinically significant coronary artery disease. Ultrasound-captured femoral plaque burden directly delineates the extent of peripheral arterial disease and is better at ruling out significant coronary atherosclerosis than the ankle-brachial index.

The atherosclerosis burden score

Purpose: We carried out this study to evaluate the predictive value of atherosclerosis burden score (ABS) to predict coronary artery disease (CAD) among asymptomatic patients without known cardiovascular disease (CVD), as compared to other imaging or functional techniques, namely coronary artery calcium (CAC) score, carotid intima-media thickness (C-IMT), and ankle brachial index (ABI). Patients and methods: This prospective study included 198 asymptomatic consecutive patients referred for evaluation of their cardiovascular (CV) risk and for therapeutic advice. Traditional CV risk factors, ABS, CAC score, C-IMT, ABI and an ECG-synchronized coronary CT-angiography (CCTA) were performed for each patient. We compared the predictive values of these atherosclerosis markers to detect CAD defined as coronary stenosis ≥30% objectivated by CCTA. Results: Among the whole sample, the area under the receiver-operating characteristic curve (ROC-AUC) was significantly higher for CAC score (0.81, p=0.015) than for ABS, the reference (0.70) but these values were lower for C-IMT (0.60, p=0.16) and particularly for ABI (0.56, p=0.0015). However, among patients at intermediate risk of coronary heart disease (CHD), according to Framingham risk score (FRS), the differences between the ROC-AUC values for ABS (0.70) and CAC score (0.76, p=0.36) were less pronounced. Again, as compared to ABS, the ROC-AUC values were lower for C-IMT (0.60, p=0.21) and ABI (0.57, p=0.06). Conclusions: ABS, an ultrasonographic score based on the assessment of carotid and femoral plaque burden, predicts more accurately CAD than other non-radiation tools analyzed here, and has a similar performance to CAC in patients at intermediate CHD risk. Thus, ABS could be an appropriate non-invasive and safe method to improve the detection of high-risk patients who will benefit from a more intensive therapy for the primary prevention of CVD.

The Role of Carotid and Femoral Plaque Burden in the Diagnosis of Coronary Artery Disease

PURPOSE OF REVIEW

With limitations of cardiovascular disease risk stratification by traditional risk factors, the role of noninvasive imaging techniques, such as vascular ultrasound, has emerged as a prominent utility for decision-making in coronary artery disease. A review of current guidelines and contemporary approaches for carotid and femoral plaque assessment is needed to better inform the diagnosis, management, and treatment of atherosclerosis in clinical practice.

RECENT FINDINGS

The recent consensus-based guidelines for carotid plaque assessment in coronary artery disease have been established, supported by some outcomes-based research. Currently, there is a gap of evidence on the use of femoral ultrasound to detect atherosclerosis, as well as predict adverse cardiovascular outcomes. The quantification and characterization of individualized plaque burden are important to stratify risk in asymptomatic or symptomatic atherosclerosis patients. Standardized quantification guidelines, supported by further outcomes-based research, are required to assess disease severity and progression.

Prevalence and Characteristics of Carotid Artery High-Risk Atherosclerotic Plaques in Chinese Patients With Cerebrovascular Symptoms: A Chinese Atherosclerosis Risk Evaluation II Study

Background

Carotid atherosclerotic plaque rupture is an important source of ischemic stroke. However, the prevalence of high‐risk plaque (HRP) defined as plaques with luminal surface disruption, a lipid‐rich necrotic core occupying >40% of the wall, or intraplaque hemorrhage in Chinese population remains unclear. This study uses carotid magnetic resonance imaging (CMRI) to investigate HRP prevalence in carotid arteries of Chinese patients with cerebrovascular symptoms.

Methods and Results

Patients with cerebral ischemic symptoms in the anterior circulation within 2 weeks and carotid plaque determined by ultrasound were recruited and underwent CMRI. The HRP features were identified and compared between symptomatic and asymptomatic arteries. Receiver‐operating‐characteristic analysis was used to calculate area‐under‐the‐curve (AUC) of stenosis and maximum wall thickness for discriminating presence of HRP. In 1047 recruited subjects, HRP detected by CMRI was nearly 1.5 times more prevalent than severe stenosis (≥50%) in this cohort (28% versus 19%, P<0.0001). Approximately two thirds of HRPs were found in arteries with <50% stenosis. The prevalence of HRP in symptomatic carotid arteries was significantly higher than that of the contralateral asymptomatic carotid arteries (23.0% versus 16.4%, P=0.001). Maximum wall thickness was found to be a stronger discriminator than stenosis for HRP (AUC: 0.93 versus 0.81, P<0.0001).

Conclusions

There are significantly more high‐risk carotid plaques than carotid arteries with ≥50% stenosis in symptomatic Chinese patients. A substantial number of HRPs were found in arteries with lower grade stenosis and maximum wall thickness was a stronger indicator for HRP than luminal stenosis.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov/. Unique identifier: NCT02017756.

Femoral Artery Ultrasound Examination

We compared intima–media thickness (IMT) and the prevalence of plaques in the common carotid artery (CCA) and common femoral artery (CFA) in apparently healthy participants. This multicenter study included 322 participants (59.9% female; age 20-78 years, mean 52.1 ± 15.3 years) who underwent Echo-color Doppler examination of the CCA and CFA bilaterally. Prevalence and composition of plaque were recorded. A significant ( P < .01) difference between mean CCA-IMT and mean CFA-IMT was detected (0.70 vs 0.73 mm). Plaque prevalence was significantly higher in the CFA compared to the CCA (40.7% vs 30.4%). Atherosclerotic plaques were found in both CFA and CCA in 46% of the cases, solely in CFA in 38%, and in CCA alone in 17%. The observed difference in plaque prevalence was even greater when only fibrolipid isolated plaques were considered (CFA 39.4% vs CCA 22.1%). In a healthy general population, atherosclerotic plaques were present in the CFA but not in the CCA in over one-third of the cases. Further studies must confirm whether ultrasonography of the CFA might be introduced in the screening protocols for cardiovascular risk assessment.

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

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