High prevalence of ultrasound detected carotid atherosclerosis in subjects with low Framingham risk score: potential implications for screening for subclinical atherosclerosis

Subclinical atherosclerosis as detected by carotid ultrasound and associations with cardiac and HIV ‐specific risk factors; the Archi‐Prevaleat project

OBJECTIVES

To evaluate the prevalence of carotid intima-media thickness (IMT) and plaques in a cohort of people living with HIV (PLWH), the role of cardiovascular risk factors, the impact of the antiretroviral regimens and the difference between naïve and experienced patients in the onset of carotid lesions.

METHODS

This project was initiated in 2019 and involves eight Italian centres. Carotid changes were detected using a power colour-Doppler ultrasonography with 7.5 MHz probes. The following parameters were evaluated: IMT of both the right and left common and internal carotids, data regarding risk factors for cardiovascular disease, HIV viral load, CD4 cell counts, serum lipids, glycaemia and body mass index. The associations between pathological findings and potential risk factors were evaluated by logistical regression, with odds ratios (ORs) and 95% confidence intervals (95% CI)s.

RESULTS

Among 1147 evaluated PLWH, with a mean age of 52 years, 347 (30.2%) had pathological findings (15.8% plaques and 14.5% IMT). Besides the usual risk factors, such as older age, male sex and dyslipidaemia, CD4 cell nadir < 200 cells/mL (adjusted OR = 1.51, 95% CI: 1.14-1.99) and current use of raltegravir (adjusted OR = 1.54, 95% CI: 1.01-2.36) were associated with higher prevalence of pathological findings.

CONCLUSIONS

Our data show that the current overall percentage of carotid impairments remains high. Colour-Doppler ultrasonography could play a pivotal role in identifying and quantifying atherosclerotic lesions among PLWH, even at a very premature stage, and should be included in the algorithms of comorbidity management of these patients.

Sex-specific risk factors of carotid atherosclerosis progression in a high-risk population of cardiovascular disease

BACKGROUND

The progression of carotid intima-media thickness (cIMT) and plaques are associated with cardiovascular health, especially for high-risk population of cardiovascular disease (CVD).

HYPOTHESIS

Risk factors for atherosclerosis may vary by sex. This study aimed to investigate the sex-specific risk factors of cIMT and plaque progression.

METHODS

We selected subjects who were identified as high-risk population of CVD, and collected their carotid ultrasound data and baseline characteristics. Linear regression and logistic regression analyses were used to identify risk factors for cIMT and plaque progression. Sex-specific risk factors were identified respectively.

RESULTS

A total of 7908 participants were included. The mean age was 57.75 ± 9.45 years and 61.51% were female. During mean follow-up of 1.92 ± 0.89 years, the median annual cIMT change rate was -7.25 μm/year. Seven hundred and fifteen subjects free from plaques at baseline developed plaque. Age, smoking, hypertension, and diabetes were common risk factors for carotid atherosclerosis progression in all participants. Smoking and alcohol drinking were significantly associated with increased cIMT change in women, while hypertension and antihypertensive medication were significant in men. Increased total cholesterol and diabetes were significantly associated with new plaque presence in women, while smoking, increased triglyceride, and dyslipidemia were significant in men (p ˂ .05 for all cases). The association of baseline cIMT and smoking with annual cIMT change rate and increased total cholesterol with new plaque presence were significantly differentiated between both sexes (p for interaction ˂ .05).

CONCLUSIONS

The risk factors for cIMT and plaque progression differed by sex.

Association of Early and Supernormal Vascular Aging categories with cardiovascular disease in the Chinese population

Background

Early Vascular Aging and Supernormal Vascular Aging are two extreme phenotypes of vascular aging, and people in the two categories demonstrate distinct clinical characteristics and cardiovascular prognosis. However, the clinical implication of vascular aging categories in the Asian or Chinese population has not been investigated. We aimed to investigate the association between vascular aging categories and cardiovascular events in a Chinese cohort.

Methods

We explored the association of vascular aging categories with incident cardiovascular disease in a community cohort in Shanghai, China, which included 10,375 participants following up for 4.5 years. Vascular age was predicted by a multivariable linear regression model including classical risk factors and brachial-ankle pulse wave velocity. Early and Supernormal vascular aging groups were defined by 10% and 90% percentiles of Δ-age, which was calculated as chronological minus vascular age.

Results

We found that cardiovascular risk significantly increased in Early [hazard ratio (HR), 1.597 (95% CI, 1.043–2.445)] and decreased in Supernormal [HR, 0.729 (95% CI, 0.539–0.986)] vascular aging individuals, comparing with normal vascular aging subjects. The associations were independent of the Framingham risk score. Early vascular aging individuals also showed an elevated risk of total mortality [HR, 2.614 (95% CI, 1.302–5.249)]. Further, the associations of vascular aging categories with cardiovascular risk were much stronger in females than in males. Vascular aging categories with different cutoff levels expressed as percentiles (10th, 20th, and 25th) of Δ-age showed similar associations with cardiovascular risk.

Conclusions

In conclusion, the vascular aging categories could identify people with different levels of cardiovascular risk in the Chinese population, particularly in women.

Regional and demographic variations of Carotid artery Intima and Media Thickness (CIMT): A Systematic review and meta-analysis

Background and objective

Carotid artery intima media thickness (CIMT) is a strong predictor of Coronary Heart Disease (CHD) and independent phenotype of early atherosclerosis. The global variation of CIMT and its demographic association is yet unclear. We evaluated regional variations of CIMT based on WHO regions and assessed the differences by age and sex.

Methods

A systematic search was conducted on studies published between 1980 January up to December 2020. PubMed, Oxford Medicine Online, EBSCO, Taylor & Francis, Oxford University Press and Embase data bases were used for searching. Supplementary searches were conducted on the Web of Science and Google Scholar. Grey literature was searched in “Open Grey” website. The two major criteria used were “adults” and “carotid intima media”. The search strategy for PubMed was created first and then adapted for the Oxford Medicine Online, EBSCO, Taylor & Francis, Oxford University Press and Embase databases. Covidence software (Veritas Health Innovation, Melbourne, Australia; http://www.covidence.org) was used to manage the study selection process. Meta-analyses were done using the random-effects model. An I2 ≥ 50% or p< 0:05 were considered to indicate significant heterogeneity.

Results

Of 2847 potential articles, 46 eligible articles were included in the review contributing data for 49 381 individuals (mean age: 55.6 years, male: 55.8%). The pooled mean CIMT for the non-CHD group was 0.65mm (95%CI: 0.62–0.69). There was a significant difference in the mean CIMT between regions (p = 0.04). Countries in the African (0.72mm), American (0.71mm) and European (0.71mm) regions had a higher pooled mean CIMT compared to those in the South East Asian (0.62mm), West Pacific (0.60mm) and Eastern Mediterranean (0.60mm) regions. Males had a higher pooled mean CIMT of 0.06mm than females in the non CHD group (p = 0.001); there were also regional differences. The CHD group had a significantly higher mean CIMT than the non-CHD group (difference = 0.23mm, p = 0.001) with regional variations. Carotid artery segment-specific-CIMT variations are present in this population. Older persons and those having CHD group had significantly thicker CIMTs.

Conclusions

CIMT varies according to region, age, sex and whether a person having CHD. There are significant regional differences of mean CIMT between CHD and non-CHD groups. Segment specific CIMT variations exist among regions. There is an association between CHD and CIMT values.

Association of Local Arterial Stiffness and Windkessel Model Parameters with Ageing in Normotensives and Hypertensives

Computation of arterial stiffness is a well-established, widely accepted method for estimating vascular age. Although carotid-femoral pulse wave velocity is typically used for vascular age assessment, most recent studies have reported the need to consider a combination of local and regional stiffness indices possessing distinct association with the vascular structure and/or function for better prediction of early vascular ageing syndrome. In this work, we investigate the association of clinically validated local stiffness (obtained using biomechanical relations), global stiffness (obtained from 3-element Windkessel modelling), and pulse contour indices from the aorta with ageing and their distribution in normotensives and hypertensives. The analysis was performed on 420 (virtual) subjects (age: 65 ± 11 years) with an equal proportion of hypertensive (age: 65 ± 11 years) and normotensive (age: 65 ± 11 years) subjects. Multivariate linear regression analysis revealed an independent association of each of the indices with age (Adjusted r = 0.75 p < 0.01). Specific stiffness index (r = 0.67, p < 0.001), Augmentation index (r = 0.55, p< 0.001) and total arterial compliance (r = -0.50, p < 0.001) depicted highest correlation with age. There was a significant difference (> 16%, p < 0.001) in mean values of the measured indices between hypertensive and normotensive subjects. The study findings further emphasize the need to combine multiple non-invasive vascular markers to capture the unique aspects of age-induced arterial wall remodelling for reliable monitoring and management of the early vascular ageing syndrome. Clinical Relevance- This study demonstrates an independent and combined predictive role of local/global stiffness and pulse contour indices in ageing.

Unbiased plasma proteomics discovery of biomarkers for improved detection of subclinical atherosclerosis

Background

Imaging of subclinical atherosclerosis improves cardiovascular risk prediction on top of traditional risk factors. However, cardiovascular imaging is not universally available. This work aims to identify circulating proteins that could predict subclinical atherosclerosis.

Methods

Hypothesis-free proteomics was used to analyze plasma from 444 subjects from PESA cohort study (222 with extensive atherosclerosis on imaging, and 222 matched controls) at two timepoints (three years apart) for discovery, and from 350 subjects from AWHS cohort study (175 subjects with extensive atherosclerosis on imaging and 175 matched controls) for external validation. A selected three-protein panel was further validated by immunoturbidimetry in the AWHS population and in 2999 subjects from ILERVAS cohort study.

Findings

PIGR, IGHA2, APOA, HPT and HEP2 were associated with subclinical atherosclerosis independently from traditional risk factors at both timepoints in the discovery and validation cohorts. Multivariate analysis rendered a potential three-protein biomarker panel, including IGHA2, APOA and HPT. Immunoturbidimetry confirmed the independent associations of these three proteins with subclinical atherosclerosis in AWHS and ILERVAS. A machine-learning model with these three proteins was able to predict subclinical atherosclerosis in ILERVAS (AUC [95%CI]:0.73 [0.70–0.74], p < 1 × 10⁻⁹⁹), and also in the subpopulation of individuals with low cardiovascular risk according to FHS 10-year score (0.71 [0.69–0.73], p < 1 × 10⁻⁶⁹).

Interpretation

Plasma levels of IGHA2, APOA and HPT are associated with subclinical atherosclerosis independently of traditional risk factors and offers potential to predict this disease. The panel could improve primary prevention strategies in areas where imaging is not available.

Machine Learning Approach to Classify Cardiovascular Disease in Patients With Nonalcoholic Fatty Liver Disease in the UK Biobank Cohort

Background Nonalcoholic fatty liver disease (NAFLD) is the most prevalent liver disease worldwide. Cardiovascular disease (CVD) is the leading cause of mortality among patients with NAFLD. The aim of our study was to develop a machine learning algorithm integrating clinical, lifestyle, and genetic risk factors to identify CVD in patients with NAFLD. Methods and Results We created a cohort of patients with NAFLD from the UK Biobank, diagnosed according to proton density fat fraction from magnetic resonance imaging data sets. A total of 400 patients with NAFLD with subclinical atherosclerosis or clinical CVD, defined by disease codes, constituted cases and 446 NAFLD cases with no CVD constituted controls. We evaluated 7 different supervised machine learning approaches on clinical, lifestyle, and genetic variables for identifying CVD in patients with NAFLD. The most significant clinical and lifestyle variables observed by the predictive modeling were age (59 years [54.00-63.00 years]), hypertension (145 mm Hg [134.0-156.0 mm Hg] and 85 mm Hg [79.00-93.00 mm Hg]), waist circumference (98 cm [95.00-105.00 cm]), and sedentary lifestyle, defined as time spent watching TV >4 h/d. In the genetic data, single-nucleotide polymorphisms in IL16 and ANKLE1 gene were most significant. Our proposed ensemble-based integrative machine learning model achieved an area under the curve of 0.849 using the random forest modeling for CVD prediction. Conclusions We propose a machine learning algorithm that identifies CVD in patients with NAFLD through integration of significant clinical, lifestyle, and genetic risk factors. These patients with NAFLD at higher risk of CVD should be flagged for screening and aggressive treatment of their cardiometabolic risk factors to prevent cardiovascular morbidity and mortality.

Incidence and predictors of progression of carotid atherosclerosis in a low-income Chinese population-a prospective cohort study

OBJECTIVE

More than 200 million individuals have been diagnosed with carotid atherosclerosis (CAS) in China. We aimed to investigate the incidence and potential predictors of CAS progression in a low-income rural area in China.

METHODS

A population-based cohort study was conducted on individuals aged ≥45 years from 2014 to 2019. Multivariable analyses were used to investigate the predictors of carotid plaque (CP) formation, plaque number, and carotid intima-media thickness (CIMT).

RESULTS

A total of 1479 participants were finally enrolled in this study. The incidence rate of CP was 42.9 cases per 1000 person-years, and the progression of median CIMT was 137.50 μm over five years. The risk of CP formation increased 2-fold in participants aged ≥75 years (P = 0.002) compared with those aged 45-54 years. The corresponding risk was 59% higher in participants with hypertension (P = 0.001) and 73% higher in alcohol drinkers (P = 0.006). With each 1- standard deviations (SD) increase in high- and low-density lipoprotein cholesterol levels, the risk of CP occurrence decreased by 16% (P = 0.016) and increased by 29% (P = 0.002), respectively. Participants aged ≥75 years exhibited a 3.3-fold higher risk of having a high number of plaques than those aged 45-54 years (P = 0.014). Moreover, older age and the waist-to-hip ratio were independent predictors of CIMT progression.

CONCLUSIONS

This is the first longitudinal study to explore the incidence and predictors of CAS progression in a low-income rural population in China with a high prevalence of stroke. More detailed and precise strategies for prevention and intervention of CAS progression are necessary, especially in low-income rural areas in China.

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.

High Burden of Carotid Atherosclerosis in Rural Northeast China: A Population-Based Study

Objective: Carotid atherosclerosis is a known marker of increased cardiovascular risk. We aimed to assess the current epidemiology of carotid atherosclerosis, carotid plaque and related risk factors in rural northeast China.

Methods: The population-based, cross-sectional study was conducted in 5,838 adults aged ≥40 years residing in rural northeast China in 2017–2018. A multi-stage cluster sampling method was used to select the representative sample. Carotid atherosclerosis was defined as carotid intima-media thickness (CIMT) ≥1.0 mm or presence of plaque.

Results: The mean CIMT was 0.72 ± 0.13 mm and increased with age in this population. Among 2,457 individuals with carotid atherosclerosis, 2,333 were diagnosed with carotid plaque, and 210 individuals were moderate or severe carotid stenosis. Crude prevalence of carotid atherosclerosis and plaque were 42.1 and 40.0%, significantly higher in men than in women (p < 0.001). The age-standardized prevalence of carotid atherosclerosis and carotid plaque were 33.1 and 31.5%, respectively. Advancing age, men, hypertension, diabetes, current smoking, ever-smoking and lack of exercise were risk factors for carotid atherosclerosis. Hypertension (69.1%), dyslipidemia (26.0%) and diabetes (16.1%) were highly prevalent in participants with carotid atherosclerosis. However, the control rates of those comorbidities were frustratingly low (4.7, 8.2, and 14.2%, respectively).

Conclusions: The high prevalence of carotid atherosclerosis, carotid plaque, carotid stenosis and uncontrolled risk factors indicated the high burden of cardiovascular disease in rural northeast China, particularly in men. Strategies of prevention and management of atherosclerosis and related risk factors were urgently needed in rural northeast China.

Support for increased cardiovascular risk in non-segmental vitiligo among Egyptians: A hospital-based, case-control study

BACKGROUND

Data have been accumulating in the past few years that identify vitiligo as a disorder with systemic implications.

RESULTS AND METHODS

In this hospital-based, cross-sectional, case-control study, 50 patients with non-segmental vitiligo and 50 age- and sex-matched controls underwent analysis of serum lipid profile, oxidative stress biomarkers and carotid duplex. Hydrogen peroxide (H₂ O₂ ) and malondialdehyde (MDA) were significantly higher in patients than controls (p-value < .001, <.001, respectively); on the other hand, total antioxidant capacity (TAC) was significantly lower in patients than controls (p-value = .001). A significantly higher percentage of patients had hypercholesterolemia and borderline high, high or very high levels of LDL-C, compared to controls (p-value = .001 and .001, respectively). Atherosclerotic plaques and increased common carotid intima media thickness were significantly detected in patients versus controls.

DISCUSSION

Results of the present study suggest that a subset of patients with vitiligo are at a higher risk of developing dyslipidemia and atherosclerosis, which might increase their future risk for the development of cardiovascular disease. Confirmation of these findings would subsequently influence investigative and the treatment strategies in the management plan of vitiligo patients in the near future.

SIGNIFICANCE

Vitiligo patients might be at a higher risk of developing dyslipidemia and atherosclerosis, which might increase their risk for the development of cardiovascular disease necessitating prophylactic measures to improve prognosis. Our results might influence the investigative and treatment strategies in the management plan of vitiligo patients in the near future.

Recommendations for the Assessment of Carotid Arterial Plaque by Ultrasound for the Characterization of Atherosclerosis and Evaluation of Cardiovascular Risk: From the American Society of Echocardiography

Atherosclerotic plaque detection by carotid ultrasound provides cardiovascular disease risk stratification. The advantages and disadvantages of two-dimensional (2D) and three-dimensional (3D) ultrasound methods for carotid arterial plaque quantification are reviewed. Advanced and emerging methods of carotid arterial plaque activity and composition analysis by ultrasound are considered. Recommendations for the standardization of focused 2D and 3D carotid arterial plaque ultrasound image acquisition and measurement for the purpose of cardiovascular disease stratification are formulated. Potential clinical application towards cardiovascular risk stratification of recommended focused carotid arterial plaque quantification approaches are summarized.

Ultrasound-based stroke/cardiovascular risk stratification using Framingham Risk Score and ASCVD Risk Score based on "Integrated Vascular Age" instead of "Chronological Age": a multi-ethnic study of Asian Indian, Caucasian, and Japanese cohorts

Background

Vascular age (VA) has recently emerged for CVD risk assessment and can either be computed using conventional risk factors (CRF) or by using carotid intima-media thickness (cIMT) derived from carotid ultrasound (CUS). This study investigates a novel method of integrating both CRF and cIMT for estimating VA [so-called integrated VA (IVA)]. Further, the study analyzes and compares CVD/stroke risk using the Framingham Risk Score (FRS)-based risk calculator when adapting IVA against VA.

Methods

The system follows a four-step process: (I) VA using cIMT based using linear-regression (LR) model and its coefficients; (II) VA prediction using ten CRF using a multivariate linear regression (MLR)-based model with gender adjustment; (III) coefficients from the LR-based model and MLR-based model are combined using a linear model to predict the final IVA; (IV) the final step consists of FRS-based risk stratification with IVA as inputs and benchmarked against FRS using conventional method of CA. Area-under-the-curve (AUC) is computed using IVA and benchmarked against CA while taking the response variable as a standardized combination of cIMT and glycated hemoglobin.

Results

The study recruited 648 patients, 202 were Japanese, 314 were Asian Indian, and 132 were Caucasians. Both left and right common carotid arteries (CCA) of all the population were scanned, thus a total of 1,287 ultrasound scans. The 10-year FRS using IVA reported higher AUC (AUC =0.78) compared with 10-year FRS using CA (AUC =0.66) by ~18%.

Conclusions

IVA is an efficient biomarker for risk stratifications for patients in routine practice.

Increased carotid plaque burden in patients with family medical history of premature cardiovascular events in the absence of classical risk factors

INTRODUCTION

The hypothesis that relates atherosclerosis to traditional risk factors (TRF) seems to be not as adequate as previously thought; other risk factors (RF) need to be considered to prevent atherosclerosis progression. Although a family medical history of premature cardiovascular events (FHx) has been considered the putative RF for decades, it has not been incorporated routinely into cardiovascular risk evaluation along with another RF. The objective of this study was to investigate whether FHx is associated with a higher atherosclerotic burden, measured as carotid total plaque area (TPA) in a population having no traditional RF.

MATERIAL AND METHODS

The study included 4,351 primary care patients in Argentina. After excluding a personal history of cardiovascular disease (CVD) and TRF: hypertension, diabetes mellitus, hypercholesterolemia, smoking history, and body mass index (BMI) > 25 kg/cm², 34 patients with FHx were identified. Compared to 56 matched controls TPA was 86% higher in FHx patients (p < 0.05). A second analysis performed in hypertensive patients but no other TRF; 32 patients with FHx were identified.

RESULTS

Compared with 44 matched controls, TPA was 77% higher in FHx patients (p < 0.05). A final analysis using a generalized linear model with TPA progression as the response variable suggests that TPA progresses more rapidly in FHx patients compared to controls.

CONCLUSIONS

The FHx was associated with increased TPA burden and progression in the absence of other TRF. This supports ultrasound screening in FHx patients in order to detect high-risk patients who may benefit from early intervention.

Combination of Endoglin and ASCVD Risk Assessment Improves Carotid Subclinical Atherosclerosis Recognition

Aim: Our study investigated the association between soluble endoglin and carotid subclinical atherosclerosis.

Methods: We used endoglin as an adjunct to atherosclerotic cardiovascular disease (ASCVD) risk, in recognition of carotid clinical atherosclerosis, in order to explore a new model to refine risk assessment. Out of 3,452 participants, 978 subjects with detected soluble endoglin were enrolled in a cross-sectional investigation in Fujian Province were enrolled. Soluble endoglin concentration in serum samples was evaluated using an enzyme-linked immunosorbent assay method. Carotid ultrasonography was used to detect intima-media thickness and carotid plaque.

Results: The mean 10-year ASCVD risk by the new Pooled Cohort Equations accounted for 10.04% (± 12.35). The mean soluble endoglin level was 15.35 ng/ml (± 6.64). Multivariable regression demonstrated that age, systolic blood pressure, diastolic blood pressure, total cholesterol, high density lipoprotein cholesterol, and serum uric acid were independent determinants of soluble endoglin. Adding tests of ASCVD and endoglin together, in parallel, will increase the sensitivity and decrease specificity in recognizing carotid subclinical atherosclerosis. Evaluating the added value of endoglin to the ASCVD risk model showed significantly improved discrimination with analysis of C-statistics, continuous net reclassification index and integrated discrimination index. Both ASCVD risk and soluble endoglin showed positively linear correlation with carotid intima-media thickness (cIMT) (β = 0.006, P < 0.001; β = 0.485, P < 0.001). Even with adjustment for other factors, the relationship between log-transformed soluble endoglin with cIMT was still significant (β = 0.369, P < 0.001).

Conclusions: The combination of ASCVD risk and endoglin levels increases carotid atherosclerosis recognition.

Obesity, dynapenia and high cardiovascular risk co-exist in post-liver transplant setting: results of a cross-sectional study

BACKGROUND

Cardiovascular disease is a major cause of death in post-liver transplantation (LT). The aim of this study was to evaluate LT patients as to the carotid intima-media thickness (CIMT) and its association with nutritional status, dietary intake, metabolic profile and cardiovascular risk factors.

METHODS

In this cross-sectional study, adult patients with more than 12 months of post-transplant follow-up underwent clinical, laboratory, functional and nutritional evaluation by 3-day-diet-record, anthropometry and dynamometry. CIMT was evaluated by Doppler ultrasonography.

RESULTS

Sixty-nine post-LT patients [males 61%, median of age 59 (51-64) years were included; median time post-liver transplantation 2.8 (1.4-6.3) years]. High prevalence of malnutrition was found (45% of arm muscle area < p15 and 71% of handgrip strength < p30). Excess weight was present in 72% of patients, body mass index ≥ 30 kg/m² in 35% and metabolic syndrome in 51%. Abnormal CIMT was found in 54% of the sample. Patients with abnormal CIMT presented higher cardiovascular risk Score, LDL cholesterol, higher prevalence of high-sensitive C-reactive protein ≥ 1 mg/L and higher intake of saturated and trans fatty acids (P < 0.05 for all).

CONCLUSIONS

Abnormal IMT was commonly found in LT patients presenting at the same time with overweight and dynapemia. These results were associated with higher LDL-cholesterol levels, high-sensitive C-reactive protein ≥ 1 mg/L and higher intake of saturated and trans fatty acids. Preventive measures, including dietary advice, are required for all post-liver transplantation patients to minimize cardiovascular risk.

Risk Marker Variability in Subclinical Carotid Plaques Based on Ultrasound is Influenced by Cardiac Phase, Echogenicity and Size

Identification of risk markers based on quantitative ultrasound texture analysis of carotid plaques has the ability to define vulnerable components that correlate with increased cardiovascular risk. However, data describing factors with the potential to influence the measurement variability of risk markers are limited. The aim of this study was to evaluate the influence of electrocardiogram-guided image selection, plaque echogenicity and area on carotid plaque risk markers and their variability in asymptomatic carotid plaques. Plaque risk markers were measured in 57 plaques during three consecutive heartbeats at two cardiac cycle time instants corresponding to the electrocardiogram R-wave (end diastole) and end of T-wave (end systole), resulting in six measurements for each plaque. Risk marker variability was quantified by computing the coefficient of variation (CV) across the three heartbeats. The CV was significantly higher for small plaques (area <15 mm2, 10%) than for large plaques (area >15 mm2, 6%) (p < 0.001) in measurements of area, and the CV for measurements of gray-scale median were higher for echolucent plaques (<40, 15%) than for echogenic plaques (>40, 9%) (p < 0.001). No significant differences were found between systole and diastole for the mean of any risk marker or the corresponding CV value. However, in a sub-analysis, the echolucent plaques were found to have a higher CV during systole compared with diastole. The variability also caused plaque type reclassification in 16% to 25% of the plaques depending on cutoff value. The results of this study indicate that echolucent and small plaques each contribute to increased risk marker variability. Based on these results, we recommend that measurements in diastole are preferred to reduce variation, although we found that it may not be possible to characterize small plaques accurately using contemporary applied risk markers.

Carotid Artery Atherosclerosis: A Review on Heritability and Genetics

Carotid atherosclerosis (CAS) is associated with increased cardiovascular risk, and therefore, assessing the genetic versus environmental background of CAS traits is of key importance. Carotid intima-media-thickness and plaque characteristics seem to be moderately heritable, with remarkable differences in both heritability and presence or severity of these traits among ethnicities. Although the considerable role of additive genetic effects is obvious, based on the results so far, there is an important emphasis on non-shared environmental factors as well. We aimed to collect and summarize the papers that investigate twin and family studies assessing the phenotypic variance attributable to genetic associations with CAS. Genes in relation to CAS markers were overviewed with a focus on genetic association studies and genome-wide association studies. Although the role of certain genes is confirmed by studies conducted on large populations and meta-analyses, many of them show conflicting results. A great focus should be on future studies elucidating the exact pathomechanism of these genes in CAS in order to imply them as novel therapeutic targets.

Risk of major adverse cardiovascular events in subjects with asymptomatic mild carotid artery stenosis

This study aimed to test the hypothesis that the risk of major adverse cardiovascular events (MACE) is similar for subjects with asymptomatic mild and moderate carotid artery stenosis (CAS). We enrolled a total of 453 subjects with asymptomatic CAS (30-69%) detected on baseline screening Doppler ultrasound (DUS) examination between January 2008 and December 2010. The follow-up DUS findings and MACE occurrence (fatal or nonfatal myocardial infarction or stroke and all-cause mortality) were compared between subjects with mild (30-49%) and moderate (50-69%) CAS during the 8-year follow-up period. There was no significant difference in the occurrence of MACE between subjects with mild (n = 289) and moderate (n = 164) CAS (13.8% vs. 15.9%, respectively; p = 0.56), although there was a nonsignificant trend toward an increased risk of major ipsilateral stroke in subjects with moderate CAS (1.4% vs. 4.3%; p = 0.06). Multivariate regression analysis indicated that worsening CAS was independently associated with MACE occurrence (hazard ratio [HR], 4.40; 95% confidence interval [CI], 2.65-7.27; p < 0.01), whereas an increased serum high-density lipoprotein cholesterol level was correlated with a decreased risk of MACE (HR, 0.42; 95% CI, 0.23-0.75; p < 0.01). The cumulative risk of MACE in subjects with asymptomatic mild CAS is similar to that in subjects with asymptomatic moderate CAS.

Normal LDL-Cholesterol Levels Are Associated With Subclinical Atherosclerosis in the Absence of Risk Factors

BACKGROUND

Absence of cardiovascular risk factors (CVRFs) is traditionally considered low risk for atherosclerosis; however, individuals without CVRFs, as currently defined, still have events.

OBJECTIVES

This study sought to identify predictors of subclinical atherosclerosis in CVRF-free individuals.

METHODS

Participants from the PESA (Progression of Early Subclinical Atherosclerosis) study (n = 4,184) without conventional CVRFs were evaluated (n = 1,779; 45.0 ± 4.1 years, 50.3% women). CVRF freedom was defined as no current smoking and untreated blood pressure <140/90 mm Hg, fasting glucose <126 mg/dl, total cholesterol <240 mg/dl, low-density lipoprotein cholesterol (LDL-C) <160 mg/dl, and high-density lipoprotein cholesterol ≥40 mg/dl. A subgroup with optimal CVRFs (n = 740) was also defined as having blood pressure <120/80 mm Hg, fasting glucose <100 mg/dl, glycosylated hemoglobin <5.7%, and total cholesterol <200 mg/dl. We evaluated ultrasound-detected carotid, iliofemoral, and abdominal aortic plaques; coronary artery calcification; serum biomarkers; and lifestyle. Adjusted odds ratios (with 95% confidence interval) and ordinal logistic regression models were used.

RESULTS

Subclinical atherosclerosis (plaque or coronary artery calcification) was present in 49.7% of CVRF-free participants. Together with male sex and age, LDL-C was independently associated with atherosclerosis presence and extent, in both the CVRF-free and CVRF-optimal groups (odds ratio [×10 mg/dl]: 1.14 to 1.18; p < 0.01 for all). Atherosclerosis presence and extent was also associated in the CVRF-free group with glycosylated hemoglobin levels.

CONCLUSIONS

Many CVRF-free middle-aged individuals have atherosclerosis. LDL-C, even at levels currently considered normal, is independently associated with the presence and extent of early systemic atherosclerosis in the absence of major CVRFs. These findings support more effective LDL-C lowering for primordial prevention, even in individuals conventionally considered at optimal risk. (Progression of Early Subclinical Atherosclerosis [PESA] Study; NCT01410318).

Impact of diabetes duration and degree of carotid artery stenosis on major adverse cardiovascular events: a single-center, retrospective, observational cohort study

BACKGROUND

We aimed to investigate the impact of diabetes duration and carotid artery stenosis (CAS) on the occurrence of major adverse cardiovascular events (MACE) in patients with type 2 diabetes mellitus (T2DM) without clinical cardiovascular disease.

METHODS

A total of 2006 patients with T2DM, without clinical cardiovascular disease, aged >50 years, and who underwent baseline carotid Doppler ultrasound screening with regular follow-ups at the outpatient clinic of our diabetes center, were stratified into four subgroups according to diabetes duration and CAS degree. The primary outcomes included the occurrence of MACE, defined as fatal or nonfatal stroke and myocardial infarction, and all-cause mortality.

RESULTS

The difference in the MACE incidence was significantly greater in patients with a longer diabetes duration (≥10 years) and significant CAS (50-69% luminal narrowing) (p < 0.001). Analysis of individual MACE components indicated a trend towards an increased incidence of stroke (p < 0.001), parallel to a longer diabetes duration and significant CAS. In contrast, the risk of myocardial infarction was significantly higher in patients with a diabetes duration <10 years and significant CAS (p = 0.039). Multivariate regression analysis showed that patients with both a longer diabetes duration and significant CAS demonstrated additive and very high risks of MACE (hazard ratio [HR], 2.07; 95% confidence interval [CI] 1.17-3.66; p = 0.012) and stroke (HR, 3.38; 95% CI 1.54-7.44; p = 0.002).

CONCLUSIONS

The risk of MACE is significantly greater in patients with T2DM, without clinical cardiovascular disease, who have both a longer diabetes duration and significant CAS, compared with those who have a shorter duration and/or nonsignificant CAS.

Relationship between carotid atherosclerosis and coronary artery calcification in asymptomatic diabetic patients: A prospective multicenter study

BACKGROUND

The value of screening sub-clinical atherosclerosis in asymptomatic patients with type 2 diabetes mellitus (T2DM) remains controversial.

HYPOTHESIS

An integrated model incorporating carotid intima-media thickness (CIMT) and carotid plaque with traditional risk factors can be used to predict prevalence and severity of coronary artery calcification in asymptomatic T2DM patients.

METHODS

A cohort of 262 asymptomatic T2DM patients were prospectively studied with carotid ultrasound to evaluate CIMT and carotid plaque and also a computed tomography coronary artery calcium (CT-CAC) scan.

RESULTS

Carotid plaque was detected in 124 (47%) patients and mean CIMT was 0.75±0.14 mm. Two hundred (76%) patients had a CAC score >0, of whom 57 (22%) had severe coronary atherosclerosis (>400 Au). In this group, carotid plaque was present in 40 (70%) patients (p<0.001). Univariable analysis revealed significant associations between non-zero CAC score and age (p<0.001), hypertension (p=0.01), gender (p=0.003) and duration of diabetes (p=0.004). Carotid plaque and mean CIMT were also significantly associated with non-zero CAC score (odds ratios [95% CI], 3.12 [1.66 -5.85] and 2.98 [0.24 -7.17], respectively). After adjusting for traditional risk factors, carotid plaque continued to be predictive of non-zero CAC score (2.59 [1.17 -5.74]) and CIMT was borderline significant (p=0.05). When analysed with binary logistical regression, the prevalence of carotid plaque significantly predicted severe CAC burden (CAC >400 Au; 3.26 [2.05 -5.19]). Upper CIMT quartiles showed a similar association (2.55 [1.33 -4.87]).

CONCLUSION

Carotid plaque is more predictive of underlying silent coronary atherosclerosis prevalence, severity and extent in asymptomatic T2DM patients.

Contrast-enhanced ultrasonography vs B-mode ultrasound for visualization of intima-media thickness and detection of plaques in human carotid arteries

BACKGROUND

Carotid intima-media thickness (IMT) and plaque are recognized markers of increased risk for cerebrovascular events. Accurate visualization of the IMT and plaques is dependent upon image quality. Ultrasound contrast agents improve image quality during echocardiography-this study assessed whether contrast-enhanced ultrasound (CEUS) improves carotid IMT visualization and plaque detection in an asymptomatic population.

METHODS & RESULTS

Individuals free from known cardiovascular disease, enrolled in a community study, underwent B-mode and CEUS carotid imaging. Each carotid artery was divided into 10 segments (far and near walls of the proximal, mid and distal segments of the common carotid artery, the carotid bulb, and internal carotid artery). Visualization of the IMT complex and plaque assessments was made during both B-mode and CEUS imaging for all enrolled subjects, a total of 175 individuals (mean age 65±9 years). Visualization of the IMT was significantly improved during CEUS compared with B-mode imaging, in both near and far walls of the carotid arteries (% IMT visualization during B-mode vs CEUS imaging: 61% vs 94% and 66% vs 95% for right and left carotid arteries, respectively, P<.001 for both). Additionally, a greater number of plaques were detected during CEUS imaging compared with B-mode imaging (367 plaques vs 350 plaques, P=.02).

CONCLUSION

Contrast-enhanced ultrasound improves visualization of the intima-media complex, in both near and far walls, of the common and internal carotid arteries and permits greater detection of carotid plaques. Further studies are required to determine whether there is incremental clinical and prognostic benefit related to superior plaque detection by CEUS.

Is Carotid Artery Ultrasound Still Useful Method for Evaluation of Atherosclerosis?

Carotid ultrasound is an imaging modality that allows non-invasive assessment of vascular anatomy and function. Carotid intima-media thickness (IMT) has been shown to predict cardiovascular (CV) risk in multiple large studies. However, in 2013, American College of Cardiology/American Heart Association guidelines designated that the carotid IMT as class III evidence level was not recommended for use in clinical practice as a routine measurement of risk assessment for a first atherosclerotic CV event. Following the announcement of this guideline, combined common carotid IMT and plaque, including plaque tissue characterization and plaque burden, using 3D ultrasound was reported to be better than either measurement alone in a variety of studies. Moreover, changes in the intima thickness were related to aging and early atherosclerosis, and remodeling of the media thickness was associated with hypertension. Separate measurement is useful for evaluating the effects of different atherosclerotic risk factors on the arterial wall; however, a more detailed and elaborate technique needs to be developed. If so, separate measurement will play an important role in the assessment of atherosclerosis and arterial wall change according to a variety of risk factors, such as metabolic syndrome. In addition, although carotid blood flow velocity is a useful tool for risk classification and prediction in clinical practice, further clinical research is needed. The value of carotid IMT by ultrasound examination for risk stratification remains controversial, and groups developing future guidelines should consider the roles of plaque presence and burden and hemodynamic parameters in additional risk stratification beyond carotid IMT in clinical practice.

A systematic approach incorporating family history improves identification of cardiovascular disease risk

BACKGROUND

Although family history (FH) is an independent predictor of cardiovascular disease (CVD) risk, traditional risk scores do not incorporate FH. Nurse practitioners routinely solicit FH but have no mechanism to incorporate the information into risk estimation. Underestimation of risk leaves clinicians misinformed and patients vulnerable to the CVD epidemic.

OBJECTIVE

We examined a systematic approach incorporating FH in CVD risk assessment, validating risk reclassification using carotid intima-media thickness (CIMT), a surrogate measure of atherosclerosis.

METHODS

Of 413 consecutive patients prospectively enrolled in the Integrative Cardiac Health Project Registry, a subgroup of 239 was low or intermediate risk by the Framingham Risk Score. A systematic approach for the assessment of FH was applied to this subgroup of the registry. A positive FH for premature CVD, defined as a first-degree relative having a CVD event before the age of 55 years in men and 65 years in women, conferred reclassification to high risk. Reclassification was validated with CIMT results.

RESULTS

Chart audits revealed adherence to the systematic approach for FH assessment in 100% of cases. This systematic approach identified 115 of 239 (48%) patients as high risk because of positive FH. Of the reclassified patients, 75% had evidence of subclinical atherosclerosis by CIMT versus 55% in the patients not reclassified, P < 0.001. Logistic regression identified positive FH for premature CVD (odds ratio, 2.6; P = 0.001) among all variables, as the most significant predictor of abnormal CIMT, thus increasing risk for CVD.

CONCLUSIONS

The Integrative Cardiac Health Project systematic approach incorporating FH into risk stratification enhances CVD risk assessment by identifying previously unrecognized high-risk patients, reduces variability in practice, and appropriately targets more stringent therapeutic goals for prevention.

Coronary Artery Disease Screening With Carotid Ultrasound Examination by a Primary Care Physician

Background

In this study, we investigated the feasibility of primary care physicians using carotid ultrasound to perform coronary artery disease screening in asymptomatic patients with multiple coronary risk factors.

Methods

We retrospectively collected the data of 135 consecutive asymptomatic patients (mean age: 68.5 ± 8.4 years; male, 75%) who were referred to our institution due to abnormal findings on a carotid ultrasound performed by a primary care physician and who underwent coronary computed tomography angiography.

Results

The mean number of risk factors was 4.1 ± 1.2 and the mean intima-media thickness was 2.00 ± 0.63 mm. Mild (≤ 50%), moderate (51-75%), and severe (> 76%) coronary stenosis was observed in 54 (40%), 27 (20%), and 25 patients (19%), respectively, while no plaque was found in 24 patients (18%), and five patients (4%) could not be evaluated due to calcification. Consequently, coronary angiography was performed in 56 (41%) patients and coronary intervention was required in 31 patients (23%). A multivariate logistic regression analysis demonstrated that the ratio of low-density lipoprotein cholesterol levels to high-density lipoprotein cholesterol levels, the use of calcium channel blockers and the value of the diastolic blood pressure were related to > 50% coronary stenosis.

Conclusions

The use of carotid ultrasound in the coronary artery disease screening by primary care physicians resulted in a high prevalence of coronary artery disease and high probabilities of coronary angiography and revascularization, and thus it is considered to be a useful and feasible strategy for the screening of asymptomatic patients.

Identification by ultrasound evaluation of the carotid and femoral arteries of high-risk subjects missed by three validated cardiovascular disease risk algorithms

Atherosclerotic cardiovascular disease (ASCVD) events are the leading cause of death in the United States and globally. Traditional global risk algorithms may miss 50% of patients who experience ASCVD events. Noninvasive ultrasound evaluation of the carotid and femoral arteries can identify subjects at high risk for ASCVD events. We examined the ability of different global risk algorithms to identify subjects with femoral and/or carotid plaques found by ultrasound. The study population consisted of 1,464 asymptomatic adults (39.8% women) aged 23 to 87 years without previous evidence of ASCVD who had ultrasound evaluation of the carotid and femoral arteries. Three ASCVD risk algorithms (10-year Framingham Risk Score [FRS], 30-year FRS, and lifetime risk) were compared for the 939 subjects who met the algorithm age criteria. The frequency of femoral plaque as the only plaque was 18.3% in the total group and 14.8% in the risk algorithm groups (n = 939) without a significant difference between genders in frequency of femoral plaque as the only plaque. Those identified as high risk by the lifetime risk algorithm included the most men and women who had plaques either femoral or carotid (59% and 55%) but had lower specificity because the proportion of subjects who actually had plaques in the high-risk group was lower (50% and 35%) than in those at high risk defined by the FRS algorithms. In conclusion, ultrasound evaluation of the carotid and femoral arteries can identify subjects at risk of ASCVD events missed by traditional risk-predicting algorithms. The large proportion of subjects with femoral plaque only supports the use of including both femoral and carotid arteries in ultrasound evaluation.

Risk Stratification for Cardiovascular Disease in Women in the Primary Care Setting

BACKGROUND

Traditional risk assessment tools classify the majority of middle-aged women at low risk despite cardiovascular (CV) disease's affecting >50% of women and remaining the leading cause of death. Ultrasound-determined carotid intima-media thickness (CIMT) and/or computed tomographic coronary artery calcium score (CACS) quantify subclinical atherosclerosis and add incremental prognostic value. The aim of this study was to assess the utility of CIMT and CACS to detect subclinical atherosclerosis in younger women.

METHODS

Asymptomatic women aged 50 to 65 years with at least one CV risk factor and low Framingham risk scores were identified prospectively at primary care and cardiology clinics. Mean intimal thickness, plaque on CIMT, and Agatston calcium score for CACS were obtained.

RESULTS

Of 86 women (mean age, 58 ± 4.6 years; mean Framingham risk score, 1.9 ± 1.2; mean low-density lipoprotein cholesterol level, 138.9 ± 37.0 mg/dL), 53 (62%) had high-risk CIMT (51% plaque, 11% CIMT > 75th percentile). In contrast, three women (3.5%) had CACS > 100, all of whom had plaque by CIMT. Of the 58 women with CACS of 0, 32 (55%) had high-risk CIMT (48% plaque, 7% CIMT > 75th percentile).

CONCLUSIONS

In patients referred by their physicians for assessment of CV risk, CIMT in asymptomatic middle-aged women with at least one CV risk factor and low risk by the Framingham risk score identified a large number with advanced subclinical atherosclerosis despite low CACS. Our results suggest that CIMT may be a more sensitive method for CV risk assessment than CACS or traditional risk tools in this population. Further studies are needed to determine if earlier detection would be of clinical benefit.

Coronary artery calcium screening: does it perform better than other cardiovascular risk stratification tools?

Coronary artery calcium (CAC) has been advocated as one of the strongest cardiovascular risk prediction markers. It performs better across a wide range of Framingham risk categories (6%-10% and 10%-20% 10-year risk categories) and also helps in reclassifying the risk of these subjects into either higher or lower risk categories based on CAC scores. It also performs better among population subgroups where Framingham risk score does not perform well, especially young subjects, women, family history of premature coronary artery disease and ethnic differences in coronary risk. The absence of CAC is also associated with excellent prognosis, with 10-year event rate of 1%. Studies have also compared with other commonly used markers of cardiovascular disease risk such as Carotid intima-media thickness and highly sensitive C-reactive protein. CAC also performs better compared with carotid intima-media thickness and highly sensitive C-reactive protein in prediction of coronary heart disease and cardiovascular disease events. CAC scans are associated with relatively low radiation exposure (0.9-1.1 mSv) and provide information that can be used not only for risk stratification but also can be used to track the progression of atherosclerosis and the effects of statins.

Carotid artery plaque in women with rheumatoid arthritis and low estimated cardiovascular disease risk: a cross-sectional study

Introduction

We previously reported that most patients with rheumatoid arthritis (RA) and moderate cardiovascular disease (CVD) risk according to the Systematic COronary Evaluation score (SCORE) experience carotid artery plaque. In this study, we aimed to identify patient characteristics that can potentially predict carotid plaque presence in women with RA and a concurrent low CVD risk according to the SCORE.

Methods

A cohort of 144 women with an evaluated low risk of CVD (SCORE value of zero) was assembled amongst 550 consecutive patients with RA that underwent CVD risk factor recording and carotid artery ultrasound. Participants had no established CVD, moderate or severe chronic kidney disease, or diabetes. We assessed carotid plaque(s) presence and its associated patient characteristics.

Results

Carotid artery plaque was present in 35 (24.3%) of women with RA. Age, the number of synthetic disease-modifying agents (DMARDs) and total cholesterol concentrations were independently associated with plaque in multivariable stepwise backward regression analysis (odds ratio (95% confidence interval) = 1.15 (1.07 to 1.24), P <0.0001, 1.51 (1.05 to 2.17), P = 0.03 and 1.66 (1.00 to 2.73) P = 0.04), respectively). The area under the curve (AUC) of the receiver operating curve (ROC) for the association with plaque was 0.807 (P <0.0001), 0.679 (P = 0.001) and 0.599 (P = 0.08) for age, total cholesterol concentrations and number of synthetic DMARDs used, respectively. The optimal cutoff value in predicting plaque presence for age was 49.5 years with a sensitivity and specificity of 74% and 75%, respectively, and for total cholesterol concentration, it was 5.4 mmol/l with a sensitivity and specificity of 63% and 70%, respectively. The plaque prevalence was 37.5% in patients (n = 80; 55.6%) with age >49.5 years or/and total cholesterol concentration of >5.4 mmol/l, respectively, compared to only 7.8% in those (n = 64; 44.4%) with age ≤49.5 years or/and total cholesterol concentration of ≤5.4 mmol/l, respectively.

Conclusions

Approximately one-third of women with RA who experience a low SCORE value and are aged >49.5 years or/and have a total cholesterol concentration of >5.4 mmol/l, experience high-risk atherosclerosis, which requires intensive CVD risk management.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-015-0576-7) contains supplementary material, which is available to authorized users.

Diagnostic utility of carotid artery duplex ultrasonography in the evaluation of syncope: a good test ordered for the wrong reason

AIMS

Syncope refers to a transient loss of consciousness and postural tone secondary to cerebral hypoperfusion. Guidelines recommend against neurovascular testing in cases of syncope without neurologic symptoms; however, many pursue carotid artery duplex ultrasonography (CUS) due to the prognostic implications of identified cerebrovascular disease. Our objective was to determine the diagnostic utility of CUS in the evaluation of syncope and the identification of new or severe atherosclerosis with the potential to change patient management.

METHODS AND RESULTS

We reviewed records of 569 patients with CUS ordered for the primary indication of syncope through an accredited vascular laboratory at an academic, urban medical centre. Findings on CUS, patient demographic, clinical and laboratory information, and medications within 6 months of the CUS exam were reviewed. Bivariate relationships between key medical history characteristics and atherosclerosis status (known vs. new disease) were examined. Among 495 patients with complete information, cerebrovascular findings could potentially explain syncope in 2% (10 patients). Optimization of cardiovascular risk factors would benefit patients with known (56.6%) and new atherosclerosis (33.5%) with suboptimal lipid control, (LDL > 70 in 42.2 and 34.9% respectively; LDL > 100 in 15.7 and 20.4%), and those not on high-intensity statin therapy (80 and 87.5%) or antiplatelet medications (13.2 and 50.6%).

CONCLUSION

CUS is a low-yield diagnostic test in the evaluation of syncope, but it is useful in the diagnosis of atherosclerosis and identification of subjects who would benefit from optimal medical therapy.

Vascular age to determine cardiovascular disease risk: A systematic review of its concepts, definitions, and clinical applications

BACKGROUND

Vascular age is an alternate means of representing an individual's cardiovascular risk. Little consensus exists on what vascular age represents and its clinical utility has not been determined. We systematically reviewed the literature to provide a comprehensive overview of different methods that have been used to define vascular age, and to examine its potential clinical value in patient communication and risk prediction.

DESIGN

This was a systematic review with data sources of PubMed and Embase.

RESULTS

We identified 39 articles on vascular age, 20 proposed to use vascular age as a communication tool and 19 proposed to use vascular age as a means to improve cardiovascular risk prediction. Eight papers were methodological and 31 papers reported on vascular age in study populations. Of these 31 papers, vascular age was a direct translation of the absolute risk estimated by existing cardiovascular risk prediction models in 15 papers, 12 derived vascular age from the reference values of an additional test, and in three papers vascular age was defined as the age at which the estimated cardiovascular risk equals the risk from non-invasive imaging observed degree of atherosclerosis. One trial found a small effect on risk factor levels when vascular age was communicated instead of cardiovascular risk.

CONCLUSION

Despite sharing a common name, various studies have proposed distinct ways to define and measure vascular age. Studies into the effects of vascular age as a tool to improve cardiovascular risk prediction or patient communication are scarce but will be required before its clinical use can be justified.

Carotid intima-media thickness and plaque in cardiovascular risk assessment

Carotid intima-media thickness (CIMT) has been shown to predict cardiovascular (CV) risk in multiple large studies. Careful evaluation of CIMT studies reveals discrepancies in the comprehensiveness with which CIMT is assessed-the number of carotid segments evaluated (common carotid artery [CCA], internal carotid artery [ICA], or the carotid bulb), the type of measurements made (mean or maximum of single measurements, mean of the mean, or mean of the maximum for multiple measurements), the number of imaging angles used, whether plaques were included in the intima-media thickness (IMT) measurement, the report of adjusted or unadjusted models, risk association versus risk prediction, and the arbitrary cutoff points for CIMT and for plaque to predict risk. Measuring the far wall of the CCA was shown to be the least variable method for assessing IMT. However, meta-analyses suggest that CCA-IMT alone only minimally improves predictive power beyond traditional risk factors, whereas inclusion of the carotid bulb and ICA-IMT improves prediction of both cardiac risk and stroke risk. Carotid plaque appears to be a more powerful predictor of CV risk compared with CIMT alone. Quantitative measures of plaques such as plaque number, plaque thickness, plaque area, and 3-dimensional assessment of plaque volume appear to be progressively more sensitive in predicting CV risk than mere assessment of plaque presence. Limited data show that plaque characteristics including plaque vascularity may improve CV disease risk stratification further. IMT measurement at the CCA, carotid bulb, and ICA that allows inclusion of plaque in the IMT measurement or CCA-IMT measurement along with plaque assessment in all carotid segments is emerging as the focus of carotid artery ultrasound imaging for CV risk prediction.

The role of carotid ultrasound for cardiovascular risk stratification beyond traditional risk factors

Primary prevention and early detection of cardiovascular disease is important, as it is the leading cause of death throughout world. Risk stratification algorithms, such as Framingham Risk Score and European Systematic Coronary Risk Evaluation, that utilize a combination of various traditional risk factors have been developed to improve primary prevention. However, the accuracy of these algorithms for screening high risk patients is moderate at best. Accordingly, the use of biomarkers or imaging studies may improve risk stratification. Carotid ultrasound, which measures both carotid intima-media thichkness (cIMT) and carotid plaque, is useful in detecting the degree of subclinical carotid atherosclerosis, and has the advantage of being noninvasive and safe. Several large epidemiologic studies have indicated that cIMT and carotid plaque are closely related with other cardiovascular risk factors and may be useful for risk reclassification in subjects deemed to be at intermediate risk by traditional risk scores. Moreover, recent clinical guidelines for management of hypertension or dyslipidemia highlight the usefulness of cIMT in high risk patients. In this article, we review evidence for the usefulness of measurement of cIMT and carotid plaque for cardiovascular risk stratification.

All men with vasculogenic erectile dysfunction require a cardiovascular workup

An association between erectile dysfunction and cardiovascular disease has long been recognized, and studies suggest that erectile dysfunction is an independent marker of cardiovascular disease risk. Therefore, assessment and management of erectile dysfunction may help identify and reduce the risk of future cardiovascular events, particularly in younger men. The initial erectile dysfunction evaluation should distinguish between predominantly vasculogenic erectile dysfunction and erectile dysfunction of other etiologies. For men believed to have predominantly vasculogenic erectile dysfunction, we recommend that initial cardiovascular risk stratification be based on the Framingham Risk Score. Management of men with erectile dysfunction who are at low risk for cardiovascular disease should focus on risk-factor control; men at high risk, including those with cardiovascular symptoms, should be referred to a cardiologist. Intermediate-risk men should undergo noninvasive evaluation for subclinical atherosclerosis. A growing body of evidence supports the use of emerging prognostic markers to further understand cardiovascular risk in men with erectile dysfunction, but few markers have been prospectively evaluated in this population. In conclusion, we support cardiovascular risk stratification and risk-factor management in all men with vasculogenic erectile dysfunction.

Impact of atherosclerosis detection by carotid ultrasound on physician behavior and risk-factor management in asymptomatic hypertensive subjects

BACKGROUND

There are limited data regarding the impact of atherosclerosis detection by carotid ultrasound (CUS) on physician prevention efforts and risk-factor management for cardiovascular disease.

HYPOTHESIS

Atherosclerosis detection by CUS in asymptomatic hypertensive patients would lead to physician prevention efforts, including target low-density lipoprotein cholesterol (LDL-C) level and prescription. Also, it may improve risk-factor management.

METHODS

A total of 347 asymptomatic hypertensive subjects (age 61 ± 8 years, 189 men) were prospectively recruited from 22 hospitals. Prior to CUS, physicians were surveyed regarding target LDL-C level. After CUS, patients were classified into positive CUS (n = 182) and negative CUS (n = 165) groups based on CUS results. Physicians were resurveyed to assess whether the initial target LDL-C goals were changed. At 6 months, cardiovascular risk-factor modification status was reassessed.

RESULTS

The proportion of lowered target LDL-C levels was significantly larger in the positive CUS group than in the negative CUS group (52% vs 23%, P < 0.001). These results were observed even in subjects who had low and moderate risk according to National Cholesterol Education Program-Adult Treatment Panel III guidelines. Lipid-lowering agents were similarly added or switched to another class in both groups (7% in the positive CUS group vs 11% in the negative CUS group, P = 0.153). LDL-C was significantly decreased in the positive CUS group (Δ = -24 ± 38 mg/dL, P < 0.001), whereas it was not significantly decreased in the negative CUS group (Δ = -6 ± 31 mg/dL, P = 0.105).

CONCLUSIONS

Atherosclerosis detection by CUS lowered physicians' target LDL-C level and improved cardiovascular risk management in terms of LDL-C reduction.

Characterization of vascular disease risk in postmenopausal women and its association with cognitive performance

OBJECTIVES

While global measures of cardiovascular (CV) risk are used to guide prevention and treatment decisions, these estimates fail to account for the considerable interindividual variability in pre-clinical risk status. This study investigated heterogeneity in CV risk factor profiles and its association with demographic, genetic, and cognitive variables.

METHODS

A latent profile analysis was applied to data from 727 recently postmenopausal women enrolled in the Kronos Early Estrogen Prevention Study (KEEPS). Women were cognitively healthy, within three years of their last menstrual period, and free of current or past CV disease. Education level, apolipoprotein E ε4 allele (APOE4), ethnicity, and age were modeled as predictors of latent class membership. The association between class membership, characterizing CV risk profiles, and performance on five cognitive factors was examined. A supervised random forest algorithm with a 10-fold cross-validation estimator was used to test accuracy of CV risk classification.

RESULTS

The best-fitting model generated two distinct phenotypic classes of CV risk 62% of women were "low-risk" and 38% "high-risk". Women classified as low-risk outperformed high-risk women on language and mental flexibility tasks (p = 0.008) and a global measure of cognition (p = 0.029). Women with a college degree or above were more likely to be in the low-risk class (OR = 1.595, p = 0.044). Older age and a Hispanic ethnicity increased the probability of being at high-risk (OR = 1.140, p = 0.002; OR = 2.622, p = 0.012; respectively). The prevalence rate of APOE-ε4 was higher in the high-risk class compared with rates in the low-risk class.

CONCLUSION

Among recently menopausal women, significant heterogeneity in CV risk is associated with education level, age, ethnicity, and genetic indicators. The model-based latent classes were also associated with cognitive function. These differences may point to phenotypes for CV disease risk. Evaluating the evolution of phenotypes could in turn clarify preclinical disease, and screening and preventive strategies. ClinicalTrials.gov NCT00154180.

Carotid Doppler ultrasonography as a surrogate for coronary CT angiography to exclude subclinical coronary atherosclerosis in asymptomatic patients with a negative coronary calcium score

PURPOSE

To evaluate the diagnostic accuracy of carotid Doppler ultrasonography (CDU) to predict the presence of subclinical coronary atherosclerosis in asymptomatic subjects with a zero coronary calcium score.

METHODS

Retrospective study of CDU and coronary CT angiography (CTA) findings in 118 asymptomatic subjects with a zero calcium score. CDU was considered abnormal when carotid intima-media thickness was >75 percentile or was ≥ 1 mm, or in presence of carotid plaque(s). We analyzed the diagnostic accuracy of CDU to predict the presence of non-calcified coronary plaque in comparison with coronary CTA.

RESULTS

The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of abnormal CDU to identify the presence of non-calcified coronary plaque on coronary CTA were 82.4% [(14/17); 95% confidence interval (CI), 56.6%-96.2%], 53.5% [(54/101); 95% CI, 43.3%-63.5%], 23.0% [(14/61); 95% CI, 13.1%-35.6%], and 94.7% [(54/57); 95% CI, 85.4%-98.9%], respectively.

CONCLUSIONS

Although CDU has a low PPV for identifying the presence of non-calcified plaque on coronary CTA, its NPV is high to exclude subclinical coronary atherosclerosis in asymptomatic subjects with a zero calcium score.