Distribution and correlates of sonographically detected carotid artery disease in the Cardiovascular Health Study. The CHS Collaborative Research Group

Rapid Carotid Screening by Duplex: A Prospective Single Centre Assessment

OBJECTIVE

A novel carotid quick scan (CQS) protocol was developed to rapidly screen for carotid atherosclerosis greater than 50% stenosis in a vascular outpatient setting. This study assessed accuracy and time saved.

MATERIAL & METHODS

The CQS was developed by consensus agreement between vascular surgeons and accredited clinical vascular scientists through a modified Delphi technique. The protocol comprised a rapid B-mode then colour flow transverse sweep of the common and internal carotid arteries, with internal carotid artery velocity assessment. One hundred outpatients attending with peripheral artery disease or abdominal aortic aneurysm were recruited. CQS sensitivity, specificity and accuracy was assessed against a conventional full carotid duplex study, performed to UK and ESVS guidelines.

RESULTS

Twenty four percent of patients (n = 100) had >50% carotid NASCET stenosis. CQS achieved an excellent accuracy of 96.5% in detecting >50% stenosis when compared to full duplex; Cohen's ƙ = .88, (95%CI .79-.97; P < .001), sensitivity 91.4%, specificity 97.6%, positive predictive value (PPV) 88.9% and negative predictive value (NPV) 98.2%. Median (IQR) time to complete the CQS was 13 sec (±12) per side, compared to 151 sec (±78) per side for the full carotid duplex. In the presence of >50% carotid disease, median CQS time was 25 sec (±31) per side compared to 214 (±104) by full scan.

CONCLUSION

CQS as a carotid screening tool is rapid, accurate and acceptable to the population and workforce. It would be simple to roll out in all vascular laboratories to reduce the time and cost burden of excluding significant carotid disease in any group.

Peak systolic velocity ratio for evaluation of internal carotid artery stenosis correlated with plaque morphology: substudy results of the ANTIQUE study

Background

Accurate assessment of carotid stenosis severity is important for proper patient management. The present study aimed to compare the evaluation of carotid stenosis severity using four duplex sonography (DUS) measurements, including peak systolic velocity (PSV), PSV ratio in stenosis and distal to stenosis (PSVICA/ICA ratio), end-diastolic velocity (EDV), and B-mode, with computed tomography angiography (CTA), and to evaluate the impact of plaque morphology on correlation between DUS and CTA.

Methods

Consecutive patients with carotid stenosis of ≥40% examined using DUS and CTA were included. Plaque morphology was also determined using magnetic resonance imaging. Spearman's correlation and Kendall's rank correlation were used to evaluate the results.

Results

A total of 143 cases of internal carotid artery stenosis of ≥40% based on DUS were analyzed. The PSVICA/ICA ratio showed the highest correlation [Spearman's correlation r = 0.576) with CTA, followed by PSV (r = 0.526), B-mode measurement (r = 0.482), and EDV (r = 0.441; p < 0.001 in all cases]. The worst correlation was found for PSV when the plaque was calcified (r = 0.238), whereas EDV showed a higher correlation (r = 0.523). Correlations of B-mode measurement were superior for plaques with smooth surface (r = 0.677), while the PSVICA/ICA ratio showed the highest correlation in stenoses with irregular (r = 0.373) or ulcerated (r = 0.382) surfaces, as well as lipid (r = 0.406), fibrous (r = 0.461), and mixed (r = 0.403; p < 0.01 in all cases) plaques. Nevertheless, differences between the mentioned correlations were not statistically significant (p > 0.05 in all cases).

Conclusion

PSV, PSVICA/ICA ratio, EDV, and B-mode measurements showed comparable correlations with CTA in evaluation of carotid artery stenosis based on their correlation with CTA results. Heavy calcifications and plaque surface irregularity or ulceration negatively influenced the measurement accuracy.

Vascular Aging: Assessment and Intervention

Vascular aging represents a collection of structural and functional changes in a blood vessel with advancing age, including increased stiffness, vascular wall remodeling, loss of angiogenic ability, and endothelium-dependent vasodilation dysfunction. These age-related alterations may occur earlier in those who are at risk for or have cardiovascular diseases, therefore, are defined as early or premature vascular aging. Vascular aging contributes independently to cardio-cerebral vascular diseases (CCVDs). Thus, early diagnosis and interventions targeting vascular aging are of paramount importance in the delay or prevention of CCVDs. Here, we review the direct assessment of vascular aging by examining parameters that reflect changes in structure, function, or their compliance with age including arterial wall thickness and lumen diameter, endothelium-dependent vasodilation, arterial stiffness as well as indirect assessment through pathological studies of biomarkers including endothelial progenitor cell, lymphocytic telomeres, advanced glycation end-products, and C-reactive protein. Further, we evaluate how different types of interventions including lifestyle mediation, such as caloric restriction and salt intake, and treatments for hypertension, diabetes, and hyperlipidemia affect age-related vascular changes. As a single parameter or intervention targets only a certain vascular physiological change, it is recommended to use multiple parameters to evaluate and design intervention approaches accordingly to prevent systemic vascular aging in clinical practices or population-based studies.

Ambient RNAs removal of cortex-specific snRNA-seq reveals Apoe+ microglia/macrophage after deeper cerebral hypoperfusion in mice

BACKGROUND

Ambient RNAs contamination in single-nuclei RNA sequencing (snRNA-seq) is a challenging problem, but the consequences of ambient RNAs contamination of damaged and/or diseased tissues are poorly understood. Cognitive impairments and white/gray matter injuries are characteristic of deeper cerebral hypoperfusion mouse models induced by bilateral carotid artery stenosis (BCAS), but the molecular mechanisms still need to be further explored. More importantly, the BCAS mice can also offer an excellent model to examine the signatures of ambient RNAs contamination in damaged tissues when performing snRNA-seq.

METHODS

After the sham and BCAS mice were established, cortex-specific single-nuclei libraries were constructed. Single-nuclei transcriptomes were described informatically by the R package Seurat, and ambient RNA markers of were identified in each library. Then, after removing ambient RNAs in each sample using the in silico approaches, the combination of CellBender and subcluster cleaning, single-nuclei transcriptomes were reconstructed. Next, the comparison of ambient RNA contamination was performed using irGSEA analysis before and after the in silico approaches. Finally, further bioinformatic analyses were performed.

RESULTS

The ambient RNAs are more predominant in the BCAS group than the sham group. The contamination mainly originated from damaged neuronal nuclei, but could be reduced largely using the in silico approaches. The integrative analysis of cortex-specific snRNA-seq data and the published bulk transcriptome revealed that microglia and other immune cells were the primary effectors. In the sequential microglia/immune subgroups analysis, the subgroup of Apoe⁺ MG/Mac (microglia/macrophages) was identified. Interestingly, this subgroup mainly participated in the pathways of lipid metabolism, associated with the phagocytosis of cell debris.

CONCLUSIONS

Taken together, our current study unravels the features of ambient RNAs in snRNA-seq datasets under diseased conditions, and the in silico approaches can effectively eliminate the incorrected cell annotation and following misleading analysis. In the future, snRNA-seq data analysis should be carefully revisited, and ambient RNAs removal needs to be taken into consideration, especially for those diseased tissues. To our best knowledge, our study also offers the first cortex-specific snRNA-seq data of deeper cerebral hypoperfusion, which provides with novel therapeutic targets.

Low-grade carotid artery stenosis is associated with progression of brain atrophy and cognitive decline. The SMART-MR study

Asymptomatic low-grade carotid artery stenosis (LGCS) is a common finding in patients with manifest arterial disease, however its relationship with brain MRI changes and cognitive decline is unclear. We included 902 patients (58 ± 10 years; 81% male) enrolled in the Second Manifestations of Arterial Disease - Magnetic Resonance (SMART-MR) study without a history of cerebrovascular disease. LGCS was defined as 1-49% stenosis on baseline carotid ultrasound, whereas no LGCS (reference category) was defined as absence of carotid plaque. Brain and white matter hyperintensity (WMH) volumes and cognitive function were measured at baseline and after 4 (n = 480) and 12 years (n = 222) of follow-up. Using linear mixed-effects models, we investigated associations of LGCS with progression of brain atrophy, WMH, and cognitive decline. LGCS was associated with greater progression of global brain atrophy (estimate -0.03; 95%CI, -0.06 to -0.01; p = 0.002), and a greater decline in executive functioning (estimate -0.02; 95%CI, -0.031 to -0.01; p < 0.001) and memory (estimate -0.012; 95%CI, -0.02 to -0.001; p = 0.032), independent of demographics, cardiovascular risk factors, and incident brain infarcts on MRI. No association was observed between LGCS and progression of WMH. Our results indicate that LGCS may represent an early marker of greater future brain atrophy and cognitive decline.

The effects of melatonin administration on carotid intima-media thickness and pulse wave velocity in diabetic nephropathy: A randomized, double-blind, placebo-controlled trial

BACKGROUND

Previous studies have reported that melatonin intake is inversely associated with reduced markers of atherosclerosis development such as carotid intima-media thickness (CIMT).

OBJECTIVE

This study was designed to assess the effects of melatonin administration on CIMT and pulse wave velocity (PWV) in patients with diabetic nephropathy (DN).

MATERIALS AND METHODS

This randomized, double-blind, placebo-controlled trial was conducted on 32 DN patients. Subjects were assigned to receive melatonin or placebo (starch) for 24 weeks. Individuals in the melatonin group (n = 19) received 10 mg/day. CIMT and PWV levels were taken at the study baseline and after 24 weeks of intervention.

RESULTS

After 24 weeks of intervention, melatonin intake did not affect mean levels of left (P = 0.51) and right (P = 0.16) CIMT and maximum levels of left (P = 0.76) and right (P = 0.15) CIMT, and PWV (P = 0.55) compared with the placebo. In addition, within-group difference demonstrated a significant reduction in mean levels of right CIMT (P = 0.01) in the melatonin group. We did not observe any significant change in C-reactive protein (CRP) concentrations after melatonin intake (P = 0.81).

CONCLUSIONS

Melatonin intake did not affect mean levels of left and right CIMT and maximum levels of left and right CIMT, PWV, CRP levels compared with the placebo. In addition, within-group difference demonstrated a significant reduction in mean levels of right CIMT in the melatonin group. This trial was registered at www.irct.ir as http://www.irct.ir: IRCT20200527047584N2.

Comprehensive assessment of systemic arteriosclerosis in relation to the ocular resistive index in acute coronary syndrome patients

This study aimed to investigate the relationship between ocular vascular resistance parameters, evaluated by laser speckle flowgraphy (LSFG), and systemic atherosclerosis, renal parameters and cardiac function in acute coronary syndrome (ACS) patients. We evaluated 53 ACS patients between April 2019 and September 2020. LSFG measured the mean blur rate (MBR) and ocular blowout time (BOT) and resistivity index (RI). 110 consequent patients without a history of coronary artery disease who visited ophthalmology as a control group. Significant positive correlations were observed between ocular RI and systemic parameters in ACS patients, including intima-media thickness (r = 0.34, P = 0.015), brachial-ankle pulse-wave velocity (r = 0.41, P = 0.002), cystatin C (r = 0.32, P = 0.020), and E/e’ (r = 0.34, P = 0.013). Ocular RI was significantly higher in the ACS group than in the control group in male in their 40 s (0.37 ± 0.02 vs. 0.29 ± 0.01, P < 0.001) and 50 s (0.36 ± 0.02 vs. 0.30 ± 0.01, P = 0.01). We found that the ocular RI was associated with systemic atherosclerosis, early renal dysfunction, and diastolic cardiac dysfunction in ACS patients, suggesting that it could be a useful non-invasive comprehensive arteriosclerotic marker.

Three-dimensional ultrasound for carotid vessel wall volume measurement

Objectives:

The intima–media thickness (IMT) of the carotid artery can now be detected on a three-dimensional (3D) plane. The 3D vessel wall volume (VWV) more accurately represents vascular conditions. Through 3D ultrasound, we established a standardized method for carotid VWV measurement.

Materials and Methods:

A total of thirty patients without stroke or cardiovascular disease who received carotid duplex sonography were retrospectively reviewed. Gray-scale 3D images from the distal common carotid artery (CCA) to internal carotid artery on both sides were acquired using a single-sweep 3D transducer and analyzed offline by using the vascular plaque quantification function of the Philips QLAB software. Then, the 3D IMT(QLAB intima–media thickness [QIMT]), total plaque volume (TPV), and VWV were measured by a neurologist and a technician, and the interobserver variability was assessed.

Results:

The mean two-dimensional (2D) carotid IMT was 0.65 ± 0.12 mm. The mean QIMT, TPV, and VWV measured by observer 1 were 0.68 ± 0.18 mm, 26 ± 12 mm³, and 94 ± 10 mm³, respectively. The Bland–Altman plot of the mean differences between the QIMT, TPV, and VWV values measured by observers 1 and 2 showed that those of observer 2 were within two standard deviations of those of observer 1. Intraclass correlation coefficients (ICCs) indicated strong correlations in QIMT (ICC = 0.76), TPV (ICC = 0.85), and VWV (ICC = 0.90; P < 0.001) between observers 1 and 2. Both 2D IMT and 3D QIMT exhibited a positive linear correlation with age.

Conclusion:

This study established a standardized VWV measurement through 3D ultrasound. Reasonable interobserver differences were obtained within a 95% limit of agreement and high reliability (ICC = 0.90). The VWV 1 cm from the CCA bifurcation was quantified with a mean value of 94.2 mm³. Further studies on the 3D ultrasound quantification of carotid arteries are warranted.

Survival and Prognostic Factors After Carotid Artery Stenting in Patients with Concomitant Coronary Disease

AIM: The aim of the study was to analyze the prognostic factors in patients after carotid artery stenting (CAS). METHODS: In 329 patients after CAS, the median survival (MS) and overall survival (OS) were calculated for a follow-up period of 2–101 months. All patients underwent coronary angiography before carotid stenting and, if indicated, coronary revascularization. Four groups of factors were analyzed: Carotid disease, coronary artery disease (CAD), underlying cardiac pathology, and concomitant diseases. RESULTS: MS in all patients was 86 months, OS at 1, 3, 5, and 9 years was - 94%, 85%, 73%, and 51%, respectively. Event free survival was 85 months. Log Rank-Mantel-Cox analysis demonstrated significantly reduced MS in 21 tested factors, most of them related to CAD. Two-step multifactorial Cox regression analysis defined only 7 of them as independent prognostic factors for the survival of patients after CAS: Left main stenosis, complete revascularization, late myocardial infarction, stroke, age over 70 years, valvular disease, and carotid score. CONCLUSION: Survival of patients after CAS is limited mainly by CAD and underlying cardiac pathology. Staged revascularization treatment strategy may improve the prognosis and survival of patients with both carotid and coronary disease.

Association of Estimated Cardiorespiratory Fitness in Midlife With Cardiometabolic Outcomes and Mortality

IMPORTANCE

The associations of estimated cardiorespiratory fitness (eCRF) during midlife with subclinical atherosclerosis, arterial stiffness, incident cardiometabolic disease, and mortality are not well understood.

OBJECTIVE

To examine associations of midlife eCRF with subclinical atherosclerosis, arterial stiffness, incident cardiometabolic disease, and mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 2962 participants in the Framingham Study Second Generation (conducted between 1979 and 2001). Data were analyzed from January 2020 to June 2020.

EXPOSURES

eCRF was calculated using sex-specific algorithms (including age, body mass index, waist circumference, physical activity, resting heart rate, and smoking) and was categorized as: (1) tertiles of standardized eCRF at examination cycle 7 (1998 to 2001); (2) tertiles of standardized average eCRF between examination cycles 2 and 7 (1979 to 2001); and (3) eCRF trajectories between examination cycles 2 and 7, with the lowest tertile or trajectory (ie, low eCRF) as referent group.

MAIN OUTCOMES AND MEASURES

Subclinical atherosclerosis (carotid intima-media thickness [CIMT], coronary artery calcium [CAC] score); arterial stiffness (carotid-femoral pulse wave velocity [-1000/CFPWV]); incident hypertension, diabetes, chronic kidney disease (CKD), cardiovascular disease (CVD), and mortality after examination cycle 7.

RESULTS

A total of 2962 participants were included in this cohort study (mean [SD] age, 61.5 [9.2] years; 1562 [52.7%] women). The number of events or participants at risk after examination cycle 7 (at a mean follow-up of 15 years) was 728 of 1506 for hypertension, 214 of 2268 for diabetes, 439 of 2343 for CKD, 500 of 2608 for CVD, and 770 of 2962 for mortality. Compared with the low eCRF reference value, high single examination eCRF was associated with lower CFPWV (β [SE], -11.13 [1.33] ms/m) and CIMT (β [SE], -0.12 [0.05] mm), and lower risk of hypertension (hazard ratio [HR], 0.63; 95% CI, 0.46-0.85), diabetes (HR, 0.38; 95% CI, 0.23-0.62), and CVD (HR, 0.71; 95% CI, 0.53-0.95), although it was not associated with CKD or mortality. Similarly, compared with the low eCRF reference, high eCRF trajectories and mean eCRF were associated with lower CFPWV (β [SE], -11.85 [1.89] ms/m and -10.36 [1.54] ms/m), CIMT (β [SE], -0.19 [0.06] mm and -0.15 [0.05] mm), CAC scores (β [SE], -0.67 [0.25] AU and -0.63 [0.20] AU), and lower risk of hypertension (HR, 0.54; 95% CI, 0.34-0.87 and HR, 0.48; 95% CI, 0.34-0.68), diabetes (HR, 0.27; 95% CI, 0.15-0.48 and HR, 0.31; 95% CI, 0.18-0.54), CKD (HR, 0.63; 95% CI, 0.40-0.97 and HR, 0.64; 95% CI, 0.44-0.94), and CVD (HR, 0.46; 95% CI, 0.31-0.68 and HR, 0.43; 95% CI, 0.30-0.60). Compared with the reference value, a high eCRF trajectory was associated with lower risk of mortality (HR, 0.69; 95% CI, 0.50-0.95).

CONCLUSIONS AND RELEVANCE

In this cohort study, higher midlife eCRF was associated with lower burdens of subclinical atherosclerosis and vascular stiffness, and with a lower risk of hypertension, diabetes, chronic kidney disease, cardiovascular disease, and mortality. These findings suggest that midlife eCRF may serve as a prognostic marker for subclinical atherosclerosis, arterial stiffness, cardiometabolic health, and mortality in later life.

Preclinical carotid atherosclerosis as an indicator of polyvascular disease: a narrative review

Carotid atherosclerotic lesions are correlated with atherosclerotic deterioration of the arterial wall in other vascular territories and with cardiovascular events. The detection of pre-symptomatic carotid lesions like intima-media thickness (IMT) and asymptomatic carotid plaques is possible by non-invasive ultrasound duplex scanning. Current measurement guidelines suggest an average measurement of IMT within 10 mm of the segment of the common carotid artery. The thickening of intima-media appears in a long subclinical period of atherosclerosis. Therefore, the determination of IMT has emerged as one of the methods for determining early structural deterioration of the arterial wall. A close interrelationship was shown between IMT and risk factors of atherosclerosis, their duration, and intensity. Different studies demonstrated that increased IMT is a powerful predictor of coronary, cerebrovascular, and peripheral arterial occlusive disease and their complication. A recent meta-analysis indicated a minimal improvement in the risk estimation of cardiovascular events after adding IMT to the Framingham Risk Score. These findings influenced the latest ACC/AHA guidelines which again recommend the use of carotid IMT measurement for individual risk assessment. The presence of atherosclerotic plaques indicates that the atherosclerotic process is already ongoing. The findings of different studies are equivocal that carotid plaques independently predict cardiovascular events and improve risk predictions for coronary artery disease when added to the Framingham Risk Score. However, besides the size of plaque and grade of stenosis, the structure of plaque calcification, vascularization, lipid core, and the surface of plaques are important indicators of related risks for cardiovascular events.

Imaging retinal microvascular manifestations of carotid artery disease in older adults: from diagnosis of ocular complications to understanding microvascular contributions to cognitive impairment

Carotid artery stenosis (CAS) is a consequence of systemic atherosclerotic disease affecting the aging populations of the Western world. CAS is frequently associated with cognitive impairment. However, the mechanisms contributing to the development of vascular cognitive impairment (VCI) associated with CAS are multifaceted and not fully understood. In addition to embolization and decreased blood flow due to the atherosclerotic lesion in the carotid artery, microcirculatory dysfunction in the cerebral circulation also plays a critical role in CAS-related VCI. To better understand the microvascular contributions to cognitive decline associated with CAS and evaluate microvascular protective effects of therapeutic interventions, it is essential to examine the structural and functional changes of the microvessels in the central nervous system (CNS). However, there are some limitations of in vivo brain vascular imaging modalities. The retinal microvasculature provides a unique opportunity to study pathogenesis of cerebral small vessel disease and VCI, because the cerebral circulation and the retinal circulation share similar anatomy, physiology and embryology. Similar microvascular pathologies may manifest in the brain and the retina, thus ocular examination can be used as a noninvasive screening tool to investigate pathological changes in the CNS associated with CAS. In this review, ocular signs of CAS and the retinal manifestations of CAS-associated microvascular dysfunction are discussed. The advantages and limitation of methods that are capable of imaging the ocular circulation (including funduscopy, fluorescein angiography, Doppler sonography, optical coherence tomography [OCT] and optical coherence tomography angiography [OCTA]) are discussed. The potential use of dynamic retinal vessel analysis (DVA), which allows for direct visualization of neurovascular coupling responses in the CNS, for understanding microvascular contributions to cognitive decline in CAS patients is also considered.

Cardiovascular damage phenotypes and all-cause and CVD mortality in older adults

PURPOSE

The association between CVD risk factors and mortality is well established, however, current tools for addressing subgroups have focused on the overall burden of disease. The identification of risky combinations of characteristics may lead to a better understanding of physiologic pathways that underlie morbidity and mortality in older adults.

METHODS

Participants included 5067 older adults from the Cardiovascular Health Study, followed for up to 6 years. Using latent class analysis (LCA), we created CV damage phenotypes based on probabilities of abnormal brain infarctions, major echocardiogram abnormalities, N-terminal probrain natriuretic peptide, troponin T, interleukin-6, c reactive-protein, galectin-3, cystatin C. We assigned class descriptions based on the probability of having an abnormality among risk factors, such that a healthy phenotype would have low probabilities in all risk factors. Participants were assigned to phenotypes based on the maximum probability of membership. We used Cox-proportional hazards regression to evaluate the association between the categorical CV damage phenotype and all-cause and CVD-mortality.

RESULTS

The analysis yielded 5 CV damage phenotypes consistent with the following descriptions: healthy (59%), cardio-renal (11%), cardiac (15%), multisystem morbidity (6%), and inflammatory (9%). All four phenotypes were statistically associated with a greater risk of all-cause mortality when compared with the healthy phenotype. The multisystem morbidity phenotype had the greatest risk of all-cause death (HR: 4.02; 95% CI: 3.44, 4.70), and CVD-mortality (HR: 4.90, 95% CI: 3.95, 6.06).

CONCLUSIONS

Five CV damage phenotypes emerged from CVD risk factor measures. CV damage across multiple systems confers a greater mortality risk compared to damage in any single domain.

Race Differences in High-Grade Carotid Artery Stenosis

Background and Purpose

Despite a higher incidence of stroke and a more adverse cardiovascular risk factor profile in Blacks and Hispanics compared with Whites, carotid artery revascularization is performed less frequently among these subpopulations. We assessed racial differences in high-grade (≥70% diameter-reducing) carotid stenosis.

Methods

Consecutive clients in a Nationwide Life Line for-Profit Service to screen for vascular disease, 2005 to 2019 were evaluated in a cross-sectional study. The prevalence of high-grade stenosis, defined by a carotid ultrasound peak systolic velocity of ≥230 cm/s, was assessed. Participants self-identified as White, Black, Hispanic, Asian, Native American, or other. Race/ethnic differences were assessed using Poisson regression. The number of individuals in the United States with high-grade stenosis was estimated by applying prevalence estimates to 2015 US Census population estimates.

Results

The prevalence of high-grade carotid stenosis was estimated in 6 130 481 individuals. The prevalence of high-grade stenosis was higher with increasing age in all race-sex strata. Generally, Blacks and Hispanics had a lower prevalence of high-grade stenosis compared with Whites, while Native Americans had a higher prevalence. For example, for men aged 55 to 65, the relative risk of stenosis compared with Whites was 0.40 (95% CI, 0.29–0.55) and 0.61 (95% CI, 0.46–0.81) for Blacks and Hispanics, respectively; and 1.53 (95% CI, 1.12–2.10) for Native Americans. When these prevalence estimates were applied to the Census estimates of the US population, an estimated 327 721 individuals have high-grade stenosis, of whom 7% are Black, 7% Hispanic, and 43% women.

Conclusions

Despite their having a more adverse cardiovascular risk profile, there was a lower prevalence of high-grade carotid artery stenosis for both the Black and Hispanic relative to the White clients. This lower prevalence of high-grade stenosis is a potential contributor to the lower use of carotid revascularization procedures in these minority populations.

Evaluation of the relationship between pseudo-hypertension and the parameters of subclinical atherosclerosis

BACKGROUND

Methods using for determining the subclinical atherosclerosis have gained growing interest in the recent years. However, the effects of pseudo-hypertension on the parameters of subclinical atherosclerosis are uncertain. We aimed to evaluate the relationship between pseudo-hypertension and subclinical atherosclerosis in individuals diagnosed with pseudo-hypertension.

METHODS

A total of 122 patients who underwent radial elective coronary angiography were included in the present study. These patients were divided into two groups based on the difference between invasive and noninvasive blood pressure (BP) measurements: pseudo-hypertension group who had a difference ≥15 mmHg in SBP or ≥10 mmHg in DBP levels between invasive and noninvasive measurements (n = 28), and the other group who did not have any difference as described on these levels (n = 94). In order to evaluate the subclinical atherosclerosis; flow-mediated dilatation (FMD), carotid intima-media thickness (IMT), pulse wave velocity (PWV), and augmentation index were recorded in all patients. Two groups were compared with respect to these parameters.

RESULTS

The median age of the pseudo-hypertension group was 76 years, while the median age of the other group was 63.5 years (P < 0.0001). The incidence of concomitant hypertension was higher in the pseudo-hypertension group as compared to the other group (P < 0.001). There was a significant difference in augmentation index, cardiac output, PWV, FMD, and IMT values between two groups (P = 0.016, P = 0.023, P <0.001, P < 0.001, P < 0.001, respectively).

CONCLUSIONS

The present results demonstrated that there was a strong correlation between pseudo-hypertension and the parameters of subclinical atherosclerosis; augmentation index, PWV, FMD, and carotids IMT.

Carotid artery intima-media thickness in adults receiving long-term home parenteral nutrition

BACKGROUND AND AIMS

Nutrition regimen in parenteral nutrition (PN) patients allows for a control of diet components. This may affect the process of lipid deposition in the vascular wall and change the risk of atherosclerosis. This study aims to examine the effect of long-term PN in adults on carotid intima-media thickness.

METHODS AND RESULTS

Thirty long-term PN patients (15 men and 15 women, mean age 64.7 ± 8.5 years) and thirty healthy volunteers (HV) (15 men and 15 women, mean age 64.9 ± 8.77 years) entered the study. Total amino acid and lipid formulation intake as well as duration of PN were calculated for PN patients. The common carotid artery intima-media thickness (CCA IMT) was examined in both groups. A lower CCA IMT (right/left mean: PN - 776 ± 121 vs HV - 848 ± 121 μm, p < 0.05; right/left maximum CCA IMT: PN - 935 ± 139 vs HV - 1024 ± 135 μm, p < 0.05) in PN patients was observed. A lower serum level of total (PN - 131.43 ± 43.12 vs HV - 209.2 ± 48.01 mg/dl, p < 0.05) and HDL (PN- 44.16 ± 12.45 vs HV - 72.57 ± 25.04 mg/dl, p < 0.05) cholesterol was reported in the PN patients. A correlation between patients' age and CCA IMT was observed in the control group, but not in the PN patients (right/left mean CCA IMT - PN: r = 0.48, p-0.007 vs HV: p-0.073; right/left maximum CCA IMT - PN: r = 0.48, p-0.008, vs HV: p-0.073).

CONCLUSIONS

Long term PN in adults is associated with lower CCA IMT. Long-term PN patients are a unique group in which carotid intima-media thickness does not correlate with the age.

Prevalence of asymptomatic atherosclerosis of extracranial vessels among hypertensive patients in southern Egypt: An extracranial duplex study

Objectives:

The prevalence of atherosclerosis in extracranial vessels among hypertensive patients in southern Egypt is still unknown. Carotid ultrasound is an accurate method used to identify and follow patients with cerebrovascular disorders. The aim of our study is to detect the prevalence and pattern of extracranial atherosclerosis among those patients.

Methods:

Our case-control study was performed from January 2017 to January 2018, including 200 subjects, 100 patients recruited consecutively from the Hypertension Clinic in Assiut University hospitals, Egypt, and 100 healthy controls. Detailed history collection and thorough physical examinations were carried out for each patient. All subjects underwent extracranial ultrasound. We omitted patients with history of ischemic stroke and TIAs.

Results:

The presence of increased intima media thickness was detected in 37 patients (37%). 22 patients (22%) had internal carotid artery (ICA) stenosis, 17 patients (17%) had non-significant stenosis <50%, while five patients (5%) had stenosis 50-69%. 9% had stenosis < 50% in vertebral artery. In addition, age and uncontrolled hypertension have a greater impact on increasing the CCA intima media thickness, which is considered an early sign of atherosclerosis.

Conclusions:

Uncontrolled hypertension is an important risk factor for atherosclerosis and hence ischemic stroke (IS). The cost of screening is considered low compared to IS management. Greater emphasis should be directed toward regular screening programs in this risky population.

Reduced insulin clearance is linked to subclinical atherosclerosis in individuals at risk for type 2 diabetes mellitus

Hyperglycemia and insulin resistance contribute to vascular damage and are regulated by different pathophysiological processes. The aim of the study was to systematically investigate the relative contributions of multiple fasting state- and oral glucose tolerance test (oGTT)-derived glycemic traits to carotid intima-media thickness (cIMT), a surrogate parameter of subclinical atherosclerosis, in individuals with increased risk for type 2 diabetes mellitus (T2D). 667 volunteers (417 women and 250 men, mean age 44.1 years), who were free of cardiovascular disease (CVD), were included in this cross-sectional study. Glucose tolerance, insulin sensitivity, insulin secretion and insulin clearance were assessed by frequently sampled 75 g oGTT. CIMT was measured by high-resolution ultrasound. Insulin clearance was associated with cIMT in univariate analysis (ß_st = − 0.17, p < 0.0001) and in a stepwise regression analysis on 15 variables possibly affecting cIMT, age (r² = 0.3923, p < 0.0001), insulin clearance (r² = 0.4564, p < 0.0001), systolic blood pressure (r² = 0.4733, p < 0.0001), body mass index (BMI) (r² = 0.4804, p = 0.002), gender (r² = 0.4831, p = 0.013), and fasting insulin clearance (r² = 0.4857, p = 0.030) turned out to be significant determinants of cIMT. In a cross-validated model resulting from this analysis, insulin clearance was found to be an independent determinant of cIMT (ß_st = − 0.16, p < 0.0001) even after adjusting for traditional CVD risk factors. Reduced insulin clearance may be an early marker of damage on the vasculature, independent of classical CVD risk factors. Reduced insulin clearance should be considered with regard to vascular insulin resistance.

Regional Variation in Genetic Control of Atherosclerosis in Hyperlipidemic Mice

Atherosclerosis is a polygenic disorder that often affects multiple arteries. Carotid arteries are common sites for evaluating subclinical atherosclerosis, and aortic root is the standard site for quantifying atherosclerosis in mice. We compared genetic control of atherosclerosis between the two sites in the same cohort derived from two phenotypically divergent Apoe-null (Apoe ^-/-) mouse strains. Female F2 mice were generated from C57BL/6 (B6) and C3H/He (C3H) Apoe ^-/- mice and fed 12 weeks of Western diet. Atherosclerotic lesions in carotid bifurcation and aortic root and plasma levels of fasting lipids and glucose were measured. 153 genetic markers across the genome were typed. All F2 mice developed aortic atherosclerosis, while 1/5 formed no or little carotid lesions. Genome-wide scans revealed 3 significant loci on chromosome (Chr) 1, Chr15, 6 suggestive loci for aortic atherosclerosis, 2 significant loci on Chr6, Chr12, and 6 suggestive loci for carotid atherosclerosis. Only 2 loci for aortic lesions showed colocalization with loci for carotid lesions. Carotid lesion sizes were moderately correlated with aortic lesion sizes (r = 0.303; P = 4.6E-6), but they showed slight or no association with plasma HDL, non-HDL cholesterol, triglyceride, or glucose levels among F2 mice. Bioinformatics analyses prioritized Cryge as a likely causal gene for Ath30, Cdh6 and Dnah5 as causal genes for Ath22 Our data demonstrate vascular site-specific effects of genetic factors on atherosclerosis in the same animals and highlight the need to extend studies of atherosclerosis to sites beyond aortas of mice.

Thalamic Atrophy Plays a Crucial Role in the Effect of Asymptomatic Carotid Stenosis on Cognitive Impairment

Purpose

Our objectives were to assess the abnormalities of subcortical nuclei by combining volume and shape analyses and potential association with cognitive impairment.

Patients and Methods

Twenty-nine patients with severe ACS of the unilateral internal carotid artery and 31 controls were enrolled between January 2017 to August 2018. All participants underwent a comprehensive neuropsychological evaluation, blood lipid biochemical measurements, and structural magnetic resonance imaging (MRI) to measure subcortical volumes and sub-regional shape deformations. Basic statistics, correction for multiple comparisons. Seventeen ACS patients underwent carotid endarterectomy (CEA) within one week after baseline measurements, cognitive assessments and MRI scans were repeated 6 months after CEA.

Results

The ACS patients had higher apolipoprotein B/apolipoprotein A1 (ApoB/ApoA1) ratio and worse performance in all cognitive domains than controls. Moreover, the ACS patients showed more profound thalamic atrophy assessed by shape and volume analysis, especially in the medial dorsal thalamus. No significant differences were found in other subcortical nuclei after multiple comparisons correction. At baseline, thalamic atrophy correlated with cognitive impairment and ApoB/ApoA1 ratio. Furthermore, mediation analysis at baseline showed that the association of carotid intima-media thickness with executive functioning was mediated by thalamic volume. After CEA, cognitive improvement and increase in the bilateral medial dorsal thalamic volume were observed.

Conclusion

Our study identified the distinct atrophy of subcortical nuclei and their association with cognition in patients with ACS. Assessments of the thalamus by volumetric and shape analysis may provide an early marker for cerebral ischemia and reperfusion after CEA.

Differential rates of progression of low-grade carotid stenosis detected by follow-up ultrasound: A single institution experience

OBJECTIVES

The growing body of evidence suggesting that lifestyle changes and aggressive medical management reduce the risk of strokes in patients with carotid stenosis has fostered interest in noninvasive screening. The objective of this study was to develop recommendations for follow-up carotid ultrasound surveillance of patients with <60% carotid stenosis.

METHODS

This retrospective observational cohort study includes 2956 patients seen between August 1998 and March 2015 in 4440 visits. Data analysis was restricted to 7710 carotid ultrasounds. Primary outcome was progression of carotid stenosis as defined by the "bulb" method: baseline stenosis of 0%-39% progressed to 40%-59% on subsequent examination, baseline stenosis of 0%-39% progressed to ≥60%, or baseline of 40%-59% progressed to ≥60%. Progression was estimated using Cox proportional hazard ratios and the Kaplan-Meier method.

RESULTS

More than 10% of patients progressed in the 40%-59% baseline group within 12 months compared to 78 months for the 0%-39% baseline group. Patients who progressed had a higher proportion of peripheral vascular disease, and current/former smoking compared to those who did not. While there were statistically significant correlations between medication classes and comorbidities, none of the medications studied appeared to slow carotid stenosis progression.

CONCLUSIONS

In our experience, for patients with a 0%-39% carotid stenosis, follow-up examination should be performed at 6-year intervals. For patients with 40%-59% carotid stenosis, follow-up should be obtained annually to identify those who progress to a level requiring intervention. Future studies should examine whether study findings can be replicated using other approaches for determining carotid stenosis.

The effect of metformin on carotid intima-media thickness (CIMT): A systematic review and meta-analysis of randomized clinical trials

Metformin administration has been reported to influence the carotid intima-media thickness (CIMT) in humans. However, since previously conducted studies have yielded inconsistent results, the exact effect of metformin on CIMT remains unclear. Causes that could lead to inconsistency in reported research could be the duration and dose of the intervention, as well as the sample size. To address this inconsistency, we conducted a systematic review and meta-analysis to evaluate the influence of metformin on CIMT in human subjects. We identified eligible studies by searching several electronic databases (EMBASE, PubMed-MEDLINE, Web of Science and Google Scholar) up to December 12, 2019. Data were pooled using the random-effects model. Combining data from 1087 participants (9 studies), our meta-analysis revealed that the administration of metformin resulted in a significant reduction in CIMT (WMD = -0.049 mm; 95% CI: -0.095, -0.004). Stratified analyses showed that an intervention lasting ≥12 months (WMD: -0.084 mm, 95% CI: -0.145, -0.024) and an intake of metformin ≤1500 mg/day (WMD: -0.081 mm, 95% CI: -0.132, -0.029) resulted in a significantly greater reduction in CIMT. However, an intervention duration of less than 12 months and an intake of metformin ˃1500 mg/day yielded no significant effects on CIMT. The results of the current study confirm that metformin administration is associated with a significant reduction in CIMT. Taking into account that CIMT reflects the burden of atherosclerosis, the clinical utility of metformin might also be related to its anti-atherogenic effects.

Assesment of Carotid Stenosis with CT Angiography and Color Doppler Ultrasonography

Introduction:

Color Doppler and CT angiography are diagnostic methods commonly used to determine the degree of carotid stenosis.

Aim:

To evaluate how the degree of carotid stenosis determined by the Color Doppler correlates with the degree of stenosis determined by the CT angiography.

Material and Methods:

The study was designed as a retrospective study. It included 42 patients with carotid stenosis. From medical records we collected anamnestic data (gender, age and risk factors - hypertension, hyperlipidemia, diabetes, smoking and obesity) and the results regarding the degree of carotid stenosis determined by Color Doppler and CT angiography.

Results:

Out of the total number of patients (n=42), 73.8% were males and 26.2% were females. Average age of examined patients was 65.24±8.61. Most frequent risk factor of atherosclerosis was hypertension, followed by hyperlipidemia and smoking. NASCET grading distinguishes: first (0-29%), second (30-69%) and third (70-99%) degree of carotid stenosis. According to the Color Doppler evaluation findings, the second degree had 8 patients and 34 patients had the third degree of carotid stenosis. CT angiography have shown that 35 patients had third degree carotid stenosis, while 7 patients had the second degree carotid stenosis. In only one case results of evaluated methods differed regarding assessment of carotid stenosis. We have found that there is a significant positive correlation of the degree of carotid stenosis determined by the Color Doppler with the degree of stenosis determined by CT angiography (p=0.0002). Risk factors of atherosclerosis did not have a significant correlation with the degree of carotid stenosis (p>0.05).

Conclusion:

The degree of carotid stenosis estimated by the Color Doppler positively correlates with the degree of stenosis estimated by CT angiography.

Validation of Risk Prediction Models to Detect Asymptomatic Carotid Stenosis

Background Significant asymptomatic carotid stenosis (ACS) is associated with higher risk of strokes. While the prevalence of moderate and severe ACS is low in the general population, prediction models may allow identification of individuals at increased risk, thereby enabling targeted screening. We identified established prediction models for ACS and externally validated them in a large screening population. Methods and Results Prediction models for prevalent cases with ≥50% ACS were identified in a systematic review (975 studies reviewed and 6 prediction models identified [3 for moderate and 3 for severe ACS]) and then validated using data from 596 469 individuals who attended commercial vascular screening clinics in the United States and United Kingdom. We assessed discrimination and calibration. In the validation cohort, 11 178 (1.87%) participants had ≥50% ACS and 2033 (0.34%) had ≥70% ACS. The best model included age, sex, smoking, hypertension, hypercholesterolemia, diabetes mellitus, vascular and cerebrovascular disease, measured blood pressure, and blood lipids. The area under the receiver operating characteristic curve for this model was 0.75 (95% CI, 0.74-0.75) for ≥50% ACS and 0.78 (95% CI, 0.77-0.79) for ≥70% ACS. The prevalence of ≥50% ACS in the highest decile of risk was 6.51%, and 1.42% for ≥70% ACS. Targeted screening of the 10% highest risk identified 35% of cases with ≥50% ACS and 42% of cases with ≥70% ACS. Conclusions Individuals at high risk of significant ACS can be selected reliably using a prediction model. The best-performing prediction models identified over one third of all cases by targeted screening of individuals in the highest decile of risk only.

To fast or not to fast: Lipid measurement and cardiovascular disease risk estimation in rural sub-Saharan Africa

Background

Cardiovascular disease (CVD) morbidity and mortality are increasing in sub-Saharan Africa (sSA), highlighting the need for tools to enable CVD risk stratification in the region. Although non-HDL-cholesterol (nHDL-C) has been promoted as a method to measure lipids without a requirement for fasting in the USA, its diagnostic validity has not been assessed in sSA. We sought to estimate: 1) the association between LDL-cholesterol (LDL-C) and nHDL-C, 2) the impact of fasting on their measurement, and 3) their correlation with carotid atherosclerosis, within a rural Ugandan population with high HIV prevalence.

Methods

We collected traditional CVD risk factors, blood for serum lipid levels, self-reported fasting status, and performed carotid ultrasonography in 301 participants in rural Uganda. We fit regression models, stratified by fasting status, to estimate associations between carotid intima media thickness (cIMT), LDL-C, and nHDL-C.

Results

Median age was 50 years (interquartile range = 46-54), 49% were female, 51% were HIV-positive, and at the time of blood collection, 70% had fasted overnight. Mean LDL-C, nHDL-C, and triglycerides in the non-fasting and fasting groups were 85 vs 88 mg/dL (P = 0.39), 114 vs 114 mg/dL (P = 0.98), and 130 vs 114 mg/dL (P = 0.05) mg/dL, respectively. In unadjusted models, mean cIMT (mm) was associated with both increased LDL-C (β = 0.0078 per 10mg/dL, P < 0.01) and nHDL-C (β = 0.0075, P < 0.01), and these relationships were similar irrespective of fasting status. After adjustment for traditional CVD risk factors, we observed similar associations, albeit with muted effect sizes within the fasting group.

Conclusions

We found a high correlation between LDL-C and nHDL-C, and both were correlated with cIMT, irrespective of fasting or HIV serostatus in rural Uganda. Our findings support use of either fasting or non-fasting serum lipids for CVD risk estimation in rural sSA.

Do anti-tumour necrosis factor-α biologics affect subclinical measures of atherosclerosis and arteriosclerosis? A systematic review

AIMS

Inflammatory cytokines, particularly tumour necrosis factor-α (TNFα), are thought to promote arterial disease through a variety of mechanisms leading to arteriosclerosis and atherosclerosis. We reviewed the existing evidence of the effect of anti-TNFα treatment on arteriosclerosis and atherosclerosis in chronic inflammatory disease.

METHODS

We performed a systematic review of studies examining effects of monoclonal antibodies against TNFα on subclinical measures of arteriosclerosis (arterial pulse wave velocity) and atherosclerosis (endothelial function measured by flow-mediated dilation or forearm blood flow responses to endothelium-dependent agonists, and common carotid intima-media thickness).

RESULTS

We identified 60 studies (of 854 potential studies identified using a systematic search) in which effects of anti-TNFα biologics on these measures were assessed in patients receiving anti-TNFα therapy for a clinical indication (usually an inflammatory disease such as an inflammatory arthritis, psoriasis or inflammatory bowel disease). Of these, only 6 were randomised clinical controlled trials. Whilst many observational studies and noncontrolled studies reported positive findings, positive finding were reported in only 1 of 6 randomised clinical controlled trials.

CONCLUSIONS

There is no strong evidence for an effect of anti-TNFα biologics on the subclinical measures of arteriosclerosis or atherosclerosis examined in this review. This does not exclude a positive effect of TNFα biologics on clinical outcomes through alternate pathways including those induced by remission of the primary inflammatory disease.

Carotid Intima-Media Thickness is a Predictor of Subclinical Myocardial Damage in Men with Type 2 Diabetes Mellitus

BACKGROUND

Type 2 diabetes mellitus (T2DM) promotes the development of atherosclerosis and is a major risk factor for cardiovascular disease. High-sensitivity cardiac troponin I (hs-cTnI) assays fundamentally improved the diagnosis of myocardial injury and even enable the prediction of future cardiovascular events in the general population. However, data about the association of hs-cTnI with cardiovascular risk factors and carotid intima media thickness (cIMT) as a marker of atherosclerosis are limited, especially in patients with T2DM.

METHODS

In this cross-sectional study we analyzed clinical and laboratory parameters of 234 patients (43% women) with T2DM and a median age of 65 years (interquartile range: 57-71). The median duration of diabetes mellitus was 10 years (6-17). Anthropometric data, blood pressure, glycemic parameters and lipid profiles were determined. Hs-cTnI plasma concentrations were measured on an ADVIA Centaur XPT immunoassay analyzer and cIMT was evaluated by high-resolution ultrasound.

RESULTS

Hs-cTnI plasma concentrations were below the gender-specific 99^th  percentile in 93% of T2DM patients with a median concentration of 4.0 ng/l (interquartile range: 2.0-10.0). Hs-cTnI was significantly associated with gender, renal function and C-reactive protein in the entire study cohort. Gender-specific analyses revealed cIMT and renal function to be significantly associated with hs-cTnI in men. Contrary, only age was significantly associated with hs-cTnI in women.

CONCLUSION

In a real-world clinical setting in patients with T2DM, cIMT is a predictor of subclinical myocardial damage in men, but not in women.

Presence of Contralateral Carotid Occlusion Is Associated With Increased Periprocedural Stroke Risk Following CEA but Not CAS: A Meta-analysis and Meta-regression Analysis of 43 Studies and 96,658 Patients

Purpose: To investigate the prognostic role of contralateral carotid artery occlusion (CCO) in perioperative outcomes of patients undergoing carotid artery endarterectomy (CEA) vs carotid artery stenting (CAS). Materials and Methods: The PubMed, Scopus, and Cochrane databases were searched up to September 2018 to identify observational or randomized studies that compared outcomes of carotid revascularization in patients with vs without CCO. Forty-three studies (46 arms) comprising 96,658 patients were selected (75,857 CEA and 20,801 CAS). The CCO group included 9258 patients. Heterogeneity was assessed with the Higgins I² test. I²>75% indicated significant heterogeneity. A random effects model was used to account for heterogeneity among studies. The results were reported as the odds ratios (ORs) with the 95% confidence intervals (CIs). Meta-regression analysis examined potential confounders. Publication bias was quantified by the Egger method. Results: Carotid revascularization in patients with CCO was associated with an increased risk of 30-day mortality (OR 1.75, 95% CI 1.38 to 2.23, p<0.001; I²=0%), stroke (OR 1.77, 95% CI 1.41 to 2.22, p<0.001; I²=46%), transient ischemic attack (TIA) (OR 2.10, 95% CI 1.34 to 3.27, p=0.001; I²=15%), and the composite endpoint of stroke/death (OR 1.78, 95% CI 1.54 to 2.05, p<0.001; I²=0%). No difference was noted in the risk of perioperative myocardial infarction (OR 0.81, 95% CI 0.50 to 1.31; p=0.388; I²=0%). Subgroup analysis demonstrated that CEA in patients with CCO was associated with an increased risk of stroke (OR 2.07, 95% CI 1.72 to 2.49, p<0.001; I²=14%), death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I²=0%), TIA (OR 2.18, 95% CI 1.38 to 3.45, p<0.001; I²=13%), and stroke/death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I²=0%), whereas CCO patients who were treated with CAS were at an increased risk for death (OR 1.65, 95% CI 1.07 to 2.60, p=0.023; I²=0%) but not stroke (OR 0.94, 95% CI 0.61 to 1.47; p=0.080; I²=31%) or TIA (OR 1.18, 95% CI 0.18 to 7.55; p=0.861; I²=43%). The meta-regression analysis did not find any significant association for any of the outcomes, and there was no evidence of publication bias. Conclusion: Carotid revascularization outcomes are adversely affected by the presence of CCO. Patients with CCO have a significantly higher risk of periprocedural stroke, death, and TIA. CEA in patients with CCO is associated with an increased risk of perioperative stroke, death, TIA, and death/stroke, while CAS in the presence of a CCO is associated with an increased risk of periprocedural death but not stroke or TIA.

Proteinuria is Associated with Carotid Artery Atherosclerosis in Non-Albuminuric Type 2 Diabetes: A Cross-Sectional Study

The association of specific urinary proteins other than albumin with cardiovascular (CV) outcomes in patients with type 2 diabetes (T2D) has been shown. In this respect, CV outcomes may differ in non-albuminuric T2D patients who were considered as a low risk group, according to the presence of proteinuria. We investigated the association between proteinuria and atherosclerosis assessed by carotid artery intima-media thickness (CIMT) in non-albuminuric T2D patients. 2047 T2D patients whose urine albumin-to-creatinine ratio was below 30 mg/g were recruited and classified into a non-proteinuria (NP, uPCR < 150 mg/g, n = 1865) group and a non-albuminuric proteinuria (NAP, uPCR ≥ 150 mg/g, n = 182) group. CIMT was compared between the two groups and logistic regression analysis was conducted to verify whether proteinuria could predict deteriorated CIMT status. In this cross-sectional study, mean CIMT of the NAP group were significantly thicker than those of the NP group (0.73 ± 0.16 vs. 0.70 ± 0.14, p = 0.016). The presence of proteinuria is associated with deteriorated CIMT after the adjustment for conventional risk factors (odds ratio, 2.342; 95% confidence interval, 1.082-5.070, p = 0.030) in regression analysis. We postulated that the measurement of urinary protein in conjunction with albumin might be helpful for predicting atherosclerosis, especially for non-albuminuric patients.

Three-dimensional ultrasonographic evaluation of carotid artery plaque surface irregularity

INTRODUCTION

The aim of this study was to evaluate 3-dimensional (3D) ultrasonography (US) in determining the surface irregularity of carotid artery plaques.

MATERIAL AND METHODS

This study included 50 patients (20 females and 30 males) aged between 56 and 82 years with plaques in the carotid artery which were detected during routine neck ultrasound. Simultaneously these cases were evaluated in terms of plaque echogenicities and surface characteristics with 2D and 3D US.

RESULTS

3D imaging was successfully performed in 45 of the 50 cases and the technical success rate was 90%. A single plaque was detected in 64.4% of the patients, with the remaining 35.6% having more than one plaque. The lengths of the plaques ranged from 2 to 12 mm (mean: 3.98 ±1.70 mm); the widths ranged from 1.8 to 3.2 mm (mean: 2.11 ±0.37 mm). No significant difference was found between 2D and 3D plaque echo-structures (observer 1, p = 0.317; observer 2, p = 0.276), but there were significant differences between 2D and 3D plaque surface irregularities (observer 1, p = 0.002; observer 2, p = 0.004). The inter-observer agreement on 2D and 3D plaque echo-structure and surface irregularity was very good (k coefficients were 0.89 and 0.83, respectively, for echo-structure, and 0.91 and 0.95, respectively, for surface irregularity).

CONCLUSIONS

The present study shows that 3D US examination is a valuable non-invasive method for investigation of surface irregularity of carotid artery plaques.

Exercise and Cardiovascular Risk among Masters Athletes with Type 2 Diabetes

PURPOSE OF REVIEW

This review was designed to provide a scientific and clinical framework for the care of physically active men and women with an emphasis on the management of T2DM.

RECENT FINDINGS

The preventative and therapeutic benefits of physical activity (PA) on adult onset or Type 2 Diabetes Mellitus (T2DM) are well established. Individuals diagnosed with or are at risk for T2DM should be counseled and maximally supported to pursue an active or athletic lifestyle. Optimally, this translates into the adoption of an athletic lifestyle. "Masters athletes", men and women above the age of 35 who regularly train for and/or participate in competitive sport, represent a rapidly growing segment of the population. Although the high level of exercise characteristic of this population has numerous health benefits, it does not confer immunity from T2DM or cardiovascular (CV) disease. Providing effective care for men and women above the age of 35 who regularly train for and/or participate in competitive sport requires an understanding of the interplay between basic exercise physiology and the pathogenesis of insulin resistance.

Effect of Preoperative Administration of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor on Carotid Artery Stenting

BACKGROUND

Perioperative embolic stroke is one of the most serious complications during carotid artery stenting (CAS). Proprotein convertase subtilisin/kexin type 9 inhibitor (PCSK9i) is a low-density lipoprotein-lowering drug that inhibits proprotein convertase subtilisin/kexin type 9, which normally binds to the low-density lipoprotein cholesterol (LDL-C) receptor. Its combination with statin significantly decreases LDL-C levels. PCSK9i is expected to achieve lower LDL-C levels than single use of statin. This study aimed to investigate whether perioperative PCSK9i administration stabilizes carotid artery plaque and reduces perioperative complications of CAS.

METHODS

Nine patients with symptomatic stenosis (North American Symptomatic Carotid Endarterectomy Trial [NASCET] 50%) or asymptomatic stenosis (NASCET ≥ 80%) were included. PCSK9i was administered at least twice (once in 2 weeks) in the outpatient clinic before CAS. Perioperative complications; results from blood tests, magnetic resonance imaging (MRI), magnetic resonance angiography, and carotid ultrasonography (US); and modified Rankin scale score at discharge were assessed.

RESULTS

High intensity on diffusion-weighted imaging was not observed in 8 patients. Changes in carotid plaque characteristics were found with MRI and/or carotid US in 7 patients. The plaque to muscle ratio decreased in 3 patients. The carotid plaque became hyperechoic in 2 patients, and the fibrous cap was seen more clearly on carotid US. Two patients had findings of stabilized plaque on MRI and carotid US, which indicates that plaque transformation was more stable.

CONCLUSIONS

Lowering LDL-C level could reduce ischemic complications, and low LDL-C level affects plaque stability and antithrombus formation. PCSK9i can possibly stabilize carotid plaque and reduce perioperative complications of CAS.

Clinical utility of carotid ultrasonography: Application for the management of patients with diabetes

Carotid ultrasonography is a non-invasive, simple and inexpensive modality to assess the severity of atherosclerosis. This article reviews related articles, summarizes the rationale for the application of carotid ultrasonography in clinical practice, and addresses the features and the limitations of carotid ultrasonography in cardiovascular risk prediction. Numerous large studies have confirmed that various carotid ultrasound measures, such as carotid intima-media thickness, the presence or absence of carotid plaque, plaque number and plaque area, can be independent predictors of cardiovascular diseases in individuals with and without diabetes mellitus. Furthermore, many studies showed that the use of carotid intima-media thickness (especially maximum intima-media thickness, including plaque thickness) and/or carotid plaque in addition to traditional risk factors significantly improved the prediction of the occurrence of cardiovascular diseases, while controversy remains. Several studies showed that the progression of carotid intima-media thickness also can be a surrogate end-point of cardiovascular events. However, the accumulated evidence has not been sufficient. Further study with sufficient power should be carried out. As plaque disruption, which plays a crucial role in the pathogenesis of cardiovascular events, is dependent on the content of lipid in the atheroma and the thickness of the fibrous cap, tissue characterization of a plaque might be useful for determining its fragility. Interestingly, recent studies have shown that ultrasonic tissue characterization of carotid lesions could improve the prediction ability of future cardiovascular diseases. Thus, carotid ultrasonography is a useful modality for better clinical practice of atherosclerosis in patients with diabetes.

A Special Report on Changing Trends in Preventive Stroke/Cardiovascular Risk Assessment Via B-Mode Ultrasonography

PURPOSE OF REVIEW

Cardiovascular disease (CVD) and stroke risk assessment have been largely based on the success of traditional statistically derived risk calculators such as Pooled Cohort Risk Score or Framingham Risk Score. However, over the last decade, automated computational paradigms such as machine learning (ML) and deep learning (DL) techniques have penetrated into a variety of medical domains including CVD/stroke risk assessment. This review is mainly focused on the changing trends in CVD/stroke risk assessment and its stratification from statistical-based models to ML-based paradigms using non-invasive carotid ultrasonography.

RECENT FINDINGS

In this review, ML-based strategies are categorized into two types: non-image (or conventional ML-based) and image-based (or integrated ML-based). The success of conventional (non-image-based) ML-based algorithms lies in the different data-driven patterns or features which are used to train the ML systems. Typically these features are the patients' demographics, serum biomarkers, and multiple clinical parameters. The integrated (image-based) ML-based algorithms integrate the features derived from the ultrasound scans of the arterial walls (such as morphological measurements) with conventional risk factors in ML frameworks. Even though the review covers ML-based system designs for carotid and coronary ultrasonography, the main focus of the review is on CVD/stroke risk scores based on carotid ultrasound. There are two key conclusions from this review: (i) fusion of image-based features with conventional cardiovascular risk factors can lead to more accurate CVD/stroke risk stratification; (ii) the ability to handle multiple sources of information in big data framework using artificial intelligence-based paradigms (such as ML and DL) is likely to be the future in preventive CVD/stroke risk assessment.

Ultrasound assessment of carotid arteries: Current concepts, methodologies, diagnostic criteria, and technological advancements

Following cardiac disease and cancer, stroke continues to be the third leading cause of death and disability due to chronic disease in the developed world. Appropriate screening tools are integral to early detection and prevention of major cardiovascular events. In a carotid artery, the presence of increased intima-media thickness, plaque, or stenosis is associated with increased risk of a transient ischemic attack or a stroke. Carotid artery ultrasound remains a long-standing and reliable tool in the current armamentarium of diagnostic modalities used to assess vascular morbidity at an early stage. The procedure has, over the last two decades, undergone considerable upgrades in technology, approach, and utility. This review examines in detail the current state and usage of this integrally important means of extracranial cerebrovascular assessment.

Visceral Adiposity Index as an Independent Marker of Subclinical Atherosclerosis in Individuals Prone to Diabetes Mellitus

Aims: The visceral adiposity index (VAI) has been proposed as an estimate of visceral adipose tissue (VAT) mass and as an indicator of VAT dysfunction. Both parameters are associated with cardiometabolic risk, including insulin resistance. In this study, we investigated whether VAI is associated with subclinical atherosclerosis in subjects who were free of cardiovascular disease but were at risk of developing diabetes mellitus.

Methods: A total of 731 adults with a median age of 47 years old without diabetes mellitus were included in this cross-sectional study. The anthropometric data, blood pressure, and lipid profiles of 398 women and 333 men were measured. All subjects underwent an oral glucose tolerance test, and carotid intima–media thickness (cIMT) was evaluated by ultrasound. Insulin resistance was estimated using the homeostatic model assessment of insulin resistance (HOMA-IR).

Results: VAI and HOMA-IR (β_st = 0.44, p < 0.0001), VAI and cIMT (β_st = 0.17, p < 0.0001), and HOMA-IR and cIMT (β_st = 0.09, p = 0.0127) were correlated with each other. After adjusting for cofounding variables, VAI is still correlated with HOMA-IR (β_st = 0.42, p < 0.0001). Furthermore, VAI (β_st = 0.07, p = 0.0392) but not HOMA-IR (β_st = 0.03, p = 0.37) was correlated with cIMT independently of other established cardiovascular risk factors.

Conclusion: The calculation of VAI may provide a better estimation of subclinical atherosclerosis than the calculation of HOMA-IR.

Abdominal Fat Tissue Echogenicity: A Marker of Morbid Obesity

PURPOSE

Menopause-related changes may affect regional but also morphological characteristics of adipose tissue. We sought to assess the clinical value of echogenicity of subcutaneous adipose tissue (SAT) and preperitoneal adipose tissue (pPAT) in postmenopausal women without cardiovascular disease.

METHODS

In 244 consecutively recruited postmenopausal women, subclinical atherosclerosis was assessed in the femoral and carotid arteries by intima-media thickness (IMT) and atheromatous plaques using high-resolution ultrasonography. In 41 women with a second visit (median follow-up 41.5 months), carotid atherosclerosis was re-evaluated. Images of SAT and pPAT were ultrasonographically acquired, and their echogenicity was evaluated by grayscale mean (GSMn) using a dedicated software. A control group of 20 healthy premenopausal women was used for comparisons in fat echogenicity.

RESULTS

SAT GSMn but not pPAT was higher in postmenopausal as compared with healthy premenopausal women and was independently associated with metabolic markers of adiposity including body mass index (BMI) and waist circumference (WC). SAT GSMn was associated with carotid IMT and the presence and number of atheromatous plaques [adjusted OR 2.44 and 2.32 per 1-SD increase in GSMn (95% CIs 1.55 to 3.93 and 1.55 to 3.45), respectively]. SAT GSMn conferred incremental value over traditional risk factors, insulin resistance, BMI, and WC for the detection of subclinical atherosclerosis. Increased baseline SAT GSMn was associated with increased rate of progression in carotid IMT.

CONCLUSIONS

SAT echogenicity may serve as a qualitative marker of adiposity, conferring incremental clinical value over BMI and WC in postmenopausal women. Further investigation is warranted to assess the utility of ultrasonography-derived fat echogenicity as a screening method for morbid obesity.

Is Hemispheric Hypoperfusion a Treatable Cause of Cognitive Impairment?

PURPOSE OF REVIEW

To review the current literature that supports the notion that cerebral hemodynamic compromise from internal carotid artery stenosis may be a cause of vascular cognitive impairment that is amenable to treatment by revascularization.

RECENT FINDINGS

Converging evidence suggests that successful carotid endarterectomy and carotid artery stenting are associated with reversal of cognitive decline in many patients with severe but asymptomatic carotid artery stenosis. Most of these findings have been derived from cohort studies and comparisons with either normal or surgical controls. Failure to find treatment benefit in a number of studies appears to have been the result of patient heterogeneity or confounding from concomitant conditions independently associated with cognitive decline, such as heart failure and other cardiovascular risk factors, or failure to establish pre-procedure hemodynamic failure. Patients with severe carotid artery stenosis causing cerebral hemodynamic impairment may have a reversible cause of cognitive decline. None of the prior studies, however, were done in the context of a randomized clinical trial with large numbers of participants. The ongoing CREST-2 trial comparing revascularization with medical therapy versus medical therapy alone, and its associated CREST-H study determining whether cognitive decline is reversible among those with hemodynamic compromise may address this question.

Effect of S-equol and Soy Isoflavones on Heart and Brain

BACKGROUND

Observational studies in Asia show that dietary intake of soy isoflavones had a significant inverse association with coronary heart disease (CHD). A recent randomized controlled trial (RCT) of soy isoflavones on atherosclerosis in the US, however, failed to show their benefit. The discrepancy may be due to the much lower prevalence of S-equol producers in Westerners: Only 20-30% of Westerners produce S-equol in contrast to 50-70% in Asians. S-equol is a metabolite of dietary soy isoflavone daidzein by gut microbiome and possesses the most antiatherogenic properties among all isoflavones. Several short-duration RCTs documented that soy isoflavones improves arterial stiffness. Accumulating evidence shows that both atherosclerosis and arterial stiffness are positively associated with cognitive decline/dementia. Therefore, potentially, soy isoflavones, especially S-equol, are protective against cognitive decline/dementia.

METHODS/RESULTS

This narrative review of clinical and epidemiological studies provides an overview of the health benefits of soy isoflavones and introduces S-equol. Second, we review recent evidence on the association of soy isoflavones and S-equol with CHD, atherosclerosis, and arterial stiffness as well as the association of atherosclerosis and arterial stiffness with cognitive decline/ dementia. Third, we highlight recent studies that report the association of soy isoflavones and S-equol with cognitive decline/dementia. Lastly, we discuss the future directions of clinical and epidemiological research on the relationship of S-equol and CHD and dementia.

CONCLUSIONS

Evidence from observational studies and short-term RCTs suggests that S-equol is anti-atherogenic and improves arterial stiffness and may prevent CHD and cognitive impairment/ dementia. Well-designed long-term (≥ 2years) RCTs should be pursued.

Association of dietary pattern with carotid intima media thickness among children with overweight or obesity

BACKGROUND

Since there is no evidence demonstrating the relationship between dietary patterns and subclinical atherosclerosis in children and adolescents, we aimed to examine the association between dietary patterns and carotid intima-media thickness (cIMT) in children and adolescents with overweight and obesity.

METHODS

Data were collected on individuals, aged 6-13 years (n = 339) recruited from primary schools with age- and sex-specific body mass index (BMI) Z-score > 1, based on WHO criteria. Dietary intake was assessed using a valid and reliable food frequency questionnaire and dietary patterns were derived by factor analysis. Measurement of cIMT was performed by means of ultrasonography for the wall of common carotid artery.

RESULTS

The mean ± SD age, BMI Z-score and cIMT of study participants were 9.3 ± 1.7 years, 2.5 ± 0.7 and 0.403 ± 0.057 mm, respectively. Three dietary patterns were identified, which accounted for 23.0% of the total variance, including the healthy, the traditional, and the unhealthy patterns. After adjusting for age, sex, pubertal status, smoking exposure, physical activity, body fat percentage, and intake of magnesium and energy, a significant inverse association was observed between the healthy dietary pattern and cIMT (β = - 0.131, P = 0.019), whereas none were found between cIMT and the traditional (β = - 0.004, P = 0.932) and the unhealthy dietary (β = 0.004, P = 0.942) patterns.

CONCLUSIONS

Results of the present study indicate that adherence to healthy dietary pattern could prevent increased cIMT in children and adolescents with overweight and obesity. Further cohort design research is required to elucidate the association between dietary patterns and cIMT in children and adolescents.

Stroke in the elderly

Stroke remains the second leading cause of death in the world, and its prevalence is projected to rise in the United States and globally. The main driver for increased stroke prevalence is aging of the population; however, best evidenced-based strategies for stroke treatment and prevention are not always followed for older patients. Furthermore, considerable gaps in knowledge exist for stroke prevention and treatment in elderly and very elderly patients. In this chapter, we discuss various aspects of stroke care in the elderly, including the evidence that guides stroke prevention and treatment. We focus on the challenges in managing stroke in the very elderly including the paucity of data to guide management. The sections span the continuum of stroke care, from primary prevention to management of stroke complications. Finally, we highlight the most significant unanswered questions regarding stroke care in the elderly.

Cardiac and Vascular Target Organ Damage in Pediatric Hypertension

Atherosclerosis begins in youth and is associated with the presence of numerous modifiable cardiovascular (CV) risk factors, including hypertension. Pediatric hypertension has increased in prevalence since the 1980s but has plateaued in recent years. Elevated blood pressure levels are associated with impairments to cardiac and vascular structure and both systolic and diastolic function. Blood pressure-related increases in left ventricular mass (LVM) and abnormalities in cardiac function are associated with hard CV events in adulthood. In addition to cardiac changes, key vascular changes occur in hypertensive youth and adults. These include thickening of the arteries, increased arterial stiffness, and decreased endothelial function. This review summarizes the epidemiologic burden of pediatric hypertension, its associations with target organ damage (TOD) of the cardiac and vascular systems, and the impact of these adverse CV changes on morbidity and mortality in adulthood.

Prevalence of Carotid Plaque in a 63- to 65-Year-Old Norwegian Cohort From the General Population: The ACE (Akershus Cardiac Examination) 1950 Study

Background

New data on extracranial carotid atherosclerosis are needed, as improved ultrasound techniques may detect more atherosclerosis, the definition of plaque has changed over the years, and better cardiovascular risk control in the population may have changed patterns of carotid arterial wall disease and actual prevalence of established cardiovascular disease. We investigated the prevalence of atherosclerotic carotid plaques and carotid intima–media thickness (cIMT) and their relation to cardiovascular risk factors in a middle‐aged cohort from the general population.

Methods and Results

We performed carotid ultrasound in 3683 participants who were born in 1950 and included in a population‐based Norwegian study. Carotid plaque and cIMT were assessed according to the Mannheim Carotid Intima–Media Thickness and Plaque Consensus, and a carotid plaque score was used to calculate atherosclerotic burden. The participants were aged 63 to 65 years, and 49% were women. The prevalence of established cardiovascular disease was low (10%), but 62% had hypertension, 53% had hypercholesterolemia, 11% had diabetes mellitus, and 23% were obese. Mean cIMT was 0.73±0.11 mm, and atherosclerotic carotid plaques were present in 87% of the participants (median plaque score: 2; interquartile range: 3). Most of the cardiovascular risk factors, with the exception of diabetes mellitus, obesity and waist–hip ratio, were independently associated with the plaque score. In contrast, only sex, hypertension, obesity, current smoking, and cerebrovascular disease were associated with cIMT.

Conclusions

We found very high prevalence of carotid plaque in this middle‐aged population, and our data support a greater association between cardiovascular risk factors and plaque burden, compared with cIMT.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT01555411.

Assessment of the Relationship between Carotid Intima-Media Thickening and Early-Stage Diabetic Kidney Disease Coupled with Helicobacter pylori Infection

Objective

This study aimed to explore the associations between carotid intima-media thickness (CIMT) and early-stage diabetic kidney disease (DKD) coupled with Helicobacter pylori (H. pylori) infection in type 2 diabetic patients.

Methods

A cross-sectional study including 180 type 2 diabetic participants was conducted to explore the associations between CIMT and early-stage DKD coupled with H. pylori infection, and a stepwise multivariate regression analysis evaluated the correlations of CIMT with clinical and serologic parameters.

Results

The type 2 diabetic patients with early-stage DKD coupled with H. pylori infections had the highest CIMT values. Apolipoprotein B (ApoB), urine albumin/creatinine ratio (UACR), and interleukin-6 (IL-6) were independent predictors of CIMT.

Conclusions

Early-stage DKD coupled with H. pylori infection may synergistically lead to significant CIMT thickening in type 2 diabetic patients. Additionally, ApoB, UACR, and IL-6 levels were important independent risk factors for increased CIMT.

Carotid Intima-Media Thickness as Surrogate for and Predictor of CVD

Carotid artery intima-media thickness (IMT) is a noninvasive measurement of the artery wall thickness, inclusive of atherosclerotic plaque, obtained using ultrasound imaging. In the MESA (Multi-Ethnic Study of Atherosclerosis) study, IMT measurements are used as a surrogate for subclinical cardiovascular disease and as a variable predictive of cardiovascular events. IMT measurements of the common carotid artery are available in more than 99% of the MESA population and are predictive of cardiovascular events. More importantly, IMT and plaque thickness measurements made in the internal carotid artery and carotid bulb are also available in more than 98% of the population and are also strongly predictive of cardiovascular events. This article reviews the techniques used to obtain the MESA IMT values, compares them to those made in other epidemiological studies, and summarizes how they have been used in the MESA study as both surrogates for and predictors of cardiovascular disease.