Factors Associated with Intima-Media Complex Thickness of the Common Carotid Artery in Japanese Noncardioembolic Stroke Patients with Hyperlipidemia: The J-STARS Echo Study

Intima-Media Thickness in the Carotid Bifurcation is Related to Silent Brain Infarction: A Cross-Sectional Study

AIMS

Carotid intima-media thickness (IMT) measurement is used to assess subclinical atherosclerosis. We aimed to examine the association between the maximum IMT by location and the occurrence of silent brain infarction (SBI).

METHODS

Overall, 280 Japanese individuals (92 females, 52.6±5 years old) underwent a medical check-up at our hospital in Tokyo in 2015. Carotid IMT was measured at each site on ultrasound images (common carotid artery [CCA], internal carotid artery, or bifurcation). The risk factors for arterial dysfunction were evaluated. SBI was assessed using magnetic resonance imaging (MRI). The cross-sectional relationship between carotid maximum IMT and SBI was evaluated.

RESULTS

Of the 280 individuals, 18 (6.4%) were diagnosed with SBI on MRI. The mean age of the SBI(-) and SBI(+) groups was 51.9±10.6 and 63.6±18.6 years, respectively. The correlation coefficients between the carotid maximum IMT at each location were very weak (correlation coefficient range: 0.180-0.253). The percentage of participants with SBI increased significantly with increasing maximum CCA and bIMT values. After adjusting for confounders, SBI was found to be significantly associated with the maximum bIMT (per 0.1-mm increase) (adjusted odds ratio [aOR], 1.10; 95% confidence interval [CI]: 1.03-1.17). When bIMT was categorized according to three groups (＜1.0 mm, 1.0-＜2.0 mm, and ≥ 2.0 mm), a significant SBI risk was also observed with an increase by each category of bIMT (aOR: 3.96, 95% CI: 1.63-9.52, P=0.002).

CONCLUSION

The maximum bIMT was found to be the main determinant of SBI. A significant SBI risk was associated with an increase in each category of the maximum bIMT. Therefore, the maximum bIMT might be a useful predictor of future stroke in Japanese stroke-free medical check-up participants.

Sonographic assessment of carotid intima-media thickness in healthy young Thai adults

Purpose

Early detection of carotid stenosis can reduce cardiovascular risk. In this study, the maximum-carotid intimamedia thickness (CIMT), the mean-CIMT, and the presence of plaque were examined in healthy young Thai adults. Additionally, correlations between CIMT and cardiovascular risk factors were assessed.

Materials and Methods

Left and right carotid arteries of 302 participants (15-45 years old) were scanned, with CIMT measured at the far walls of the common carotid artery, carotid bulb, and internal carotid artery. Demographics and risk factors were assessed using a questionnaire. Ten random participants were re-scanned after 4 weeks.

Results

The study included 123 (40.70%) male and 179 (59.30%) female participants. The max-CIMT, mean-CIMT, and plaque thickness were 0.400±0.100, 0.403±0.095 and 1.520±0.814 mm, respectively. Male participants had significantly higher CIMT values for nearly all locations and age groups. The right-sided CIMT values were higher for all locations. The carotid bulb had the greatest CIMT values (0.437±0.178 mm), followed by the common (0.403±0.095 mm) and internal (0.361±0.099 mm) carotid arteries. Plaque was present in 18 locations (1.00%), affecting 15 participants (4.97%). These plaques were found in the right carotid bulb (n=9; 0.50%), left carotid bulb (n=7; 0.39%), and right internal carotid artery (n=2; 0.11%). Adjusted multivariable regression revealed significant positive associations between CIMT and male, increased age and "other" occupation (P<0.05).

Conclusion

Both max-CIMT and mean-CIMT were approximately 0.4 mm. Plaque was observed in 4.97% of patients, with an average thickness of 1.5 mm. The most influential risk factors for increased CIMT were sex, age, and occupation.

Ischemic stroke in the setting of supratherapeutic International Normalized Ratio following coronavirus disease 2019 infection: a case report

BACKGROUND

SARS-CoV-19 infection is associated with an increased risk of thrombotic events. We present a case of acute middle cerebral artery ischemic stroke in a patient with SARS-CoV-19 infection despite being on warfarin with supratherapeutic INR (International Normalized Ratio).

CASE PRESENTATION

A 68-year-old Caucasian female with multiple comorbidities was admitted to the hospital with symptoms of upper respiratory tract infection. A rapid antigen test confirmed the diagnosis of COVID-19 pneumonia, and intravenous remdesivir was initiated. On the fifth day of admission, the patient experienced sudden onset confusion, slurred speech, left-sided hemiplegia, right-sided eye deviation, and left-sided facial droop. Imaging studies revealed an occlusion of the distal anterior M2 segment of the right middle cerebral artery, and an MRI of the brain confirmed an acute right MCA infarction. Notably, the patient was receiving warfarin therapy with a supratherapeutic INR of 3.2.

CONCLUSIONS

This case report highlights the potential for thromboembolic events, including stroke, in patients with COVID-19 infection, even when receiving therapeutic anticoagulation therapy. Healthcare providers should be vigilant for signs of thrombosis in COVID-19 patients, particularly those with pre-existing risk factors. Further research is necessary to understand the pathophysiology and optimal management of thrombotic complications in COVID-19 patients.

Correlation study on the relationship between dyslipidemia and carotid intima-media thickness in patients with diabetes mellitus

Objective

To investigate the correlation between dyslipidemia and carotid intima-media thickness (IMT) in patients with diabetes mellitus.

Methods

A descriptive research design was adopted in this study. One hundred and twenty patients with Type-2 diabetes mellitus who were admitted to the physical examination center of The Fourth Hospital of Hebei Medical University from June 2020 to June 2021 for physical examination were recruited to the experimental group. The 120 patients were divided into three groups according to carotid IMT: normal group, thickened group, and plaque group. Forty healthy people who underwent a physical examination during the same period were recruited as the control group. The differences in IMT in various parts of the experimental group and the control group and the differences in blood lipid indexes were compared and analyzed. In addition, the correlation between mean IMT of bilateral common carotid arteries and blood lipid levels in normal, thickened and plaque groups was compared and analyzed.

Results

The intima-media thicknesses of the internal carotid artery and bilateral common carotid arteries of the patients in the experimental group were significantly thicker than those in the healthy control group, the levels of TC, TG and LDL were higher than those in the control group, while the level of HDL was lower than that in the control group, with a statistically significant difference (p=0.00). The levels of fasting plasma glucose (FPG), glycosylated hemoglobin (HbA1c), TG, TC and LDL were positively correlated with the mean IMT of bilateral common carotid arteries (p<0.05), while the level of HDL was negatively correlated with the mean IMT of bilateral common carotid arteries (p<0.05).

Conclusion

Dyslipidemia and glucose metabolism in patients with Type-2 diabetes mellitus have a close bearing on carotid IMT. Clinically, patients with Type-2 diabetes mellitus can be judged by monitoring carotid IMT for dyslipidemia, atherosclerosis and other related complications.

Association of HbA1c with carotid artery plaques in patients with coronary heart disease: a retrospective clinical study

BACKGROUND AND AIMS

Haemoglobin A1c (HbA1c) levels have been shown to be related to carotid artery plaques. However, studies on the relationship between HbA1c levels and carotid artery plaques in patients with coronary heart disease (CHD) are limited and inconsistent. Our objective was to examine the correlation between HbA1c levels and carotid artery plaques in patients with CHD.

METHODS

The study comprised 9275 Chinese adults with CHD from January 1, 2014, to September 30, 2020. HbA1c levels were assessed, and colour Doppler ultrasound was used to evaluate the carotid artery, including plaque presence, intima-media thickness, and plaque echo properties, to investigate the association between HbA1c and carotid plaque. A logistic regression model was used to assess the association between carotid artery plaques, carotid plaque echogenicity, and HbA1c.

RESULTS

The HbA1c level of the plaque-present group was higher than that of the plaque-absent group [6.1 (5.6-7.2) vs. 5.8 (5.5-6.5), p < 0.001]. In multiple linear regression analysis, intima-media thickness was associated with HbA1c (p < 0.001). Logistic regression showed that a higher HbA1c level was associated with plaque incidence as well as hyperechoic and heterogeneous plaques (p < 0.001). These associations persist after adjusting for age, sex, blood pressure, lipid profiles, alcohol consumption, and tobacco exposure.

CONCLUSION

HbA1c levels are notably associated with carotid artery plaque incidence, intima-media thickness, and plaque echogenicity in patients with CHD. These findings show that different levels of HbA1c may be an indicator for carotid artery plaques and thus, should be observed in patients with CHD.

Hyperlipidemia and hypertension have synergistic interaction on ischemic stroke: insights from a general population survey in China

Background

Hyperlipidemia (HLP) and hypertension (HTN) are both independent risk factors for ischemic stroke. This study aimed to assess whether HTN and HLP have a synergistic effect on the risk of ischemic stroke.

Methods

Between January and August 2013, 11,695 subjects in rural areas of northeastern China were enrolled. The additive and multiplicative scales were used to evaluate the interaction.

Results

The prevalence of ischemic stroke was 5.7%. Using the healthy group (without HTN or HLP) as the reference group, subjects with both HTN and HLP had a higher risk of ischemic stroke (odds ratio [OR]: 3.369, 95% confidence interval [CI]: 2.579–4.402), and this OR was greater than that of subjects with only HTN (OR: 1.995, 95% CI 1.526–2.610) or HLP (OR: 1.321, 95% CI 0.937–1.862) (adjusting for age, sex, race, education level, family income, current smoking and drinking status, physical activity, body mass index, diabetes, family history of stroke, and atrial fibrillation). Regarding the additive scale, the relative excess risk due to interaction (OR: 1.053, 95% CI 0.458–1.648) was positive after adjusting for confounders. Moreover, the attributable proportion was 31.3%, which means that 31.3% of the total risk of ischemic stroke was due to the synergistic interaction between HTN and HLP. Furthermore, the synergistic index (S) of ischemic stroke was 1.8 (95% CI 1.157–2.801), which also indicates a synergistic interaction between HTN and HLP. Regarding the multiplicative scale, the interaction effect was also significant after adjusting for confounders (OR: 2.163, 95% CI 1.817–2.575).

Conclusion

The results suggest that the synergistic effect of HTN and HLP on ischemic stroke is significantly higher than the sum of their independent effects. The quantification of the combined effect should help to promote healthy blood pressure and blood lipid levels among the general population.

Association of Flow Parameters and Diameter in the Common Carotid Artery with Impaired Glucose Metabolism

AIM

Diameter, intima-media thickness (IMT), and flow parameters, including resistance index (RI) and pulsatility index (PI), in the common carotid artery (CCA) are markers of arterial remodeling, atherosclerosis, and vascular resistance, respectively. We investigated the differences among these markers in association with plasma glucose level, serum insulin level, and insulin resistance in participants without cardiovascular disease.

METHODS

CCA parameters (including the CCA interadventitial diameter and mean IMT at the time of 75-g oral glucose tolerance testing) were assessed in 4218 participants. RI and PI were assessed in 3380 of these participants. To assess plasma glucose and serum immunoreactive insulin profiles during oral glucose tolerance testing, we used the total areas under the curves (AUCglu and AUCins, respectively). We used the homeostasis model assessment of insulin resistance (HOMA-IR) and the Matsuda index to assess insulin resistance. Insulin secretion was assessed with the HOMA-β.

RESULTS

AUCglu was significantly associated with CCA interadventitial diameter (β=0.048, P＜0.001), RI (β=0.144, P＜0.001), and PI (β=0.103, P＜0.001) but not with mean IMT. AUCins (β=-0.064, P＜0.001) and HOMA-β (β=-0.054, P＜0.001) were significantly and negatively associated with CCA interadventitial diameter, but not with mean IMT. Both HOMA-IR and Matsuda index were significantly associated with RI and PI.

CONCLUSIONS

These findings indicate that all CCA parameters except IMT are associated with impaired glucose metabolism in patients without cardiovascular disease.

Radiation effects on atherosclerosis in atomic bomb survivors: a cross-sectional study using structural equation modeling

Past reports indicated that total-body irradiation at low to moderate doses could be responsible for cardiovascular disease risks, but the mechanism remains unclear. The purpose of this study was to investigate the association between radiation exposure and atherosclerosis, an underlying pathology of cardiovascular diseases, in the Japanese atomic bomb survivors. We performed a cross-sectional study measuring 14 clinical-physiological atherosclerosis indicators during clinical exams from 2010 to 2014 in 3274 participants of the Adult Health Study cohort. Multivariable analyses were performed by using a structural equation model with latent factors representing underlying atherosclerotic pathologies: (1) arterial stiffness, (2) calcification, and (3) plaque　as measured with indicators chosen a priori on the basis of clinical-physiological knowledge. Radiation was linearly associated with calcification (standardized coefficient per Gy 0.15, 95 % confidence interval: CI [0.070, 0.23]) and plaque (0.11, 95 % CI [0.029, 0.20]), small associations that were comparable to about 2 years of aging per Gy of radiation exposure, but not with arterial stiffness (0.036, 95 % CI [− 0.025, 0.095]). The model fitted better and had narrower confidence intervals than separate ordinary regression models explaining individual indicators independently. The associations were less evident when the dose range was restricted to a maximum of 2 or 1 Gy. By combining individual clinical-physiological indicators that are correlated because of common, underlying atherosclerotic pathologies, we found a small, but significant association of radiation with atherosclerosis.

Small Dense Low-Density Lipoprotein Cholesterol and Carotid Intimal Medial Thickness Progression

AIM

The association between small dense low-density lipoprotein cholesterol (sdLDL-C) levels and carotid intimal medial thickness (cIMT) progression has not been evaluated fully. We assessed specialized lipoproteins, including sdLDL-C, with regard to cIMT progression in a prospective observational study in Japan.

METHODS

Plasma total cholesterol, direct LDL-C, sdLDL-C, LDL-triglycerides (LDL-TG), high-density lipoprotein cholesterol (HDL-C), HDL2-C, HDL3-C, triglycerides, Lp(a), and adiponectin were measured in 2,030 men and women (median age 59 years, free of cardiovascular disease (CVD) and off cholesterol lowering medication). At both baseline and after a five-year follow-up, cIMT was assessed. Univariate, multivariate regression, and least square analyses were performed to examine the relationships between direct LDL-C, sdLDL-C, and other lipoproteins with cIMT progression.

RESULTS

The median cIMT at baseline was 0.63 mm and five-year progression was 0.18 mm. After adjustment for standard CVD risk factors, including age, gender, systolic blood pressure, total cholesterol, HDL-C, smoking, diabetes, and hypertension treatment, only direct LDL-C, sdLDL-C, and the sdLDL-C/LDL-C ratio were associated with cIMT progression. Even in subjects with direct LDL-C ＜100 mg/dL, who were considered at low CVD risk, elevated sdLDL-C were associated with cIMT progression (P for trend=0.009) in a model with established CVD risk factors, although the sdLDL-C/LDL-C ratio did not. Those correlations did not change by including triglycerides as a controlling factor or excluding premenopausal women from the analyzed population.

CONCLUSIONS

Small dense LDL-C has a stronger relationship with cIMT progression than LDL-C does; therefore, measuring sdLDL-C may allow for the formulation of optimal therapy for CVD prevention.

Changes in the Gut Microbiota are Associated with Hypertension, Hyperlipidemia, and Type 2 Diabetes Mellitus in Japanese Subjects

The human gut microbiota is involved in host health and disease development. Therefore, lifestyle-related diseases such as hypertension (HT), hyperlipidemia (HL), and type 2 diabetes mellitus (T2D) may alter the composition of gut microbiota. Here, we investigated gut microbiota changes related to these diseases and their coexistence. This study involved 239 Japanese subjects, including healthy controls (HC). The fecal microbiota was analyzed through the isolation of bacterial genomic DNA obtained from fecal samples. Although there were no significant differences in the microbial structure between groups, there was a significant difference in the α-diversity between HC and the patients in whom two diseases coexisted. Moreover, Actinobacteria levels were significantly increased, whereas Bacteroidetes levels were significantly decreased in all disease groups. At the genus level, Bifidobacterium levels were significantly increased in the HL and T2D groups, as were those of Collinsella in all disease groups. In contrast, Alistipes levels were significantly lower in the HL group. Furthermore, metabolic enzyme families were significantly increased in all disease groups. Interestingly, the structure and function of the gut microbiota showed similar profiles in all the studied diseases. In conclusion, several changes in the structure of the gut microbiota are associated with T2D, HT, and HL in Japanese subjects.

Usefulness of Carotid Ultrasonography for Risk Stratification of Cerebral and Cardiovascular Disease

Carotid ultrasonography is useful for the assessments of the risk stratification for stroke or coronary artery disease, because it is a simple, repeatable, and noninvasive procedure. The carotid intima-media thickness (IMT), which is assessed using carotid ultrasonography, is a widely used surrogate marker for the severity of atherosclerosis. Several large clinical studies showed that increased carotid IMT is associated with the future stroke or cardiovascular events. In addition, in many clinical trials, it has been adopted for surrogate markers of clinical endpoints of medical intervention. Moreover, carotid ultrasonography allows the measurement of the presence and characteristics of plaques and the severity of carotid artery stenosis. The unstable morphology of plaque, such as hypoechoic, ulcer, and mobility, is associated with future ischemic stroke events. The screening tool of asymptomatic carotid artery stenosis is also important, although whether routine carotid ultrasonography assessment is recommended in the general population remains controversial. The screening of carotid artery stenosis using ultrasonography is essential for not only daily clinical settings but also management of patients with acute ischemic stroke. The patients with atherothrombotic stroke with severe internal carotid artery stenosis should be considered to surgical intervention, and duplex ultrasound approach is important to estimate for the severity of carotid stenosis. Physicians should keep in mind the usefulness of carotid ultrasonography for risk stratification of cerebral and cardiovascular disease based on various aspects. In addition, visual assessment or dynamic changes using carotid ultrasonography could provide the various and valuable insights in clinical settings.

Carotid Intima-Media Thickness Progression as Surrogate Marker for Cardiovascular Risk: Meta-Analysis of 119 Clinical Trials Involving 100 667 Patients

BACKGROUND

To quantify the association between effects of interventions on carotid intima-media thickness (cIMT) progression and their effects on cardiovascular disease (CVD) risk.

METHODS

We systematically collated data from randomized, controlled trials. cIMT was assessed as the mean value at the common-carotid-artery; if unavailable, the maximum value at the common-carotid-artery or other cIMT measures were used. The primary outcome was a combined CVD end point defined as myocardial infarction, stroke, revascularization procedures, or fatal CVD. We estimated intervention effects on cIMT progression and incident CVD for each trial, before relating the 2 using a Bayesian meta-regression approach.

RESULTS

We analyzed data of 119 randomized, controlled trials involving 100 667 patients (mean age 62 years, 42% female). Over an average follow-up of 3.7 years, 12 038 patients developed the combined CVD end point. Across all interventions, each 10 μm/y reduction of cIMT progression resulted in a relative risk for CVD of 0.91 (95% Credible Interval, 0.87-0.94), with an additional relative risk for CVD of 0.92 (0.87-0.97) being achieved independent of cIMT progression. Taken together, we estimated that interventions reducing cIMT progression by 10, 20, 30, or 40 μm/y would yield relative risks of 0.84 (0.75-0.93), 0.76 (0.67-0.85), 0.69 (0.59-0.79), or 0.63 (0.52-0.74), respectively. Results were similar when grouping trials by type of intervention, time of conduct, time to ultrasound follow-up, availability of individual-participant data, primary versus secondary prevention trials, type of cIMT measurement, and proportion of female patients.

CONCLUSIONS

The extent of intervention effects on cIMT progression predicted the degree of CVD risk reduction. This provides a missing link supporting the usefulness of cIMT progression as a surrogate marker for CVD risk in clinical trials.

Increased blood pressure is associated with increased carotid artery intima-media thickness in children with repaired coarctation of the aorta

OBJECTIVES

The intima-media thickness of the common carotid artery (cIMT) is a good noninvasive surrogate marker for cardiovascular disease. Regular cIMT monitoring in children with congenital heart disease has great potential. We sought to determine which anthropomorphic and haemodynamic variables were significantly associated with the cIMT in paediatric patients with obesity and children with repaired coarctation of the aorta (CoA).

METHODS

We measured the cIMT in 143 children aged 5 to less than 18 years including normal weight controls (n = 44), children with overweight/obesity (n = 73) and children with repaired CoA (n = 26). cIMT was compared and the association between the cIMT and patient characteristics, including obesity and blood pressure (BP), was investigated.

RESULTS

BMI z score, sex and the presence of CoA were significant independent predictors of cIMT. The cIMT was significantly greater in children with overweight/obesity (0.53 ± 0.06 mm) relative to normal weight controls (0.51 ± 0.04 mm), as well as in CoA patients with abnormally high BP (0.57 ± 0.08 mm) versus CoA patients with normal BP (0.52 ± 0.05 mm) and controls (0.51 ± 0.04 mm). CoA patients with normal BP did not have significantly increased cIMT.

CONCLUSION

cIMT was positively associated with BMI z score, male sex and CoA repair in children. The increased cIMT in children with repaired CoA was because of those with abnormally high BP, which was masked in clinic for most of these patients. These findings warrant further investigations into the cIMT and other atherosclerotic risk factors to determine their potential clinical impact in these highly susceptible patients.

Association of Waist-to-Height Ratio, Metabolic Syndrome, and Carotid Atherosclerosis in Individuals with a High Risk of Stroke: A Cross-Sectional Study of 9605 Study Participants

Background: To determine the association of waist-to-height ratio (WHtR), metabolic syndrome (MetS), and carotid atherosclerosis (CAS) in individuals with a high risk of stroke. Methods: We performed a cross-sectional analysis of 9605 study responders from eight urban area communities in Northern China. Height, weight, waist circumference, blood pressure (BP), and blood lipid were measured. Information of population characteristics, smoking status, alcohol consumption, physical activity, and diet were determined by validated questionnaire. Results: A total of 9605 study responders were included in this study. The average age was 60 ± 9 years with 5911 (61.5%) patients being females. The prevalence of MetS and CAS was 26.2% and 75.1%, respectively. WHtR was significantly associated with CAS using our final adjusted model [odds ratio (OR): 1.233, 95% confidence interval (CI): 1.096-1.378]. The association of CAS with hypertension and hyperglycemia were statistically significant among factors that constitute MetS. Additional risk factors affecting the development of CAS included age, previous stroke, and smoking history (P < 0.05). Conclusion: WHtR was determined to perform better compared with other traditional indicators for correlating CAS. We believe that WHtR is a better indicator for the early identification of CAS in individuals with a high risk of stroke. This will facilitate the early detection and intervention of CAS.

Effect of Statin on Stroke Recurrence Prevention at Different Infarction Locations: A Post Hoc Analysis of The J-STARS Study

Aim: Posterior circulation stroke (PCS) has different clinical features and prognosis compared with anterior circulation stroke (ACS), and whether the effect of statin therapy on stroke prevention differs according to infarction location remains unclear. This post hoc analysis of the J-STARS study aimed to compare the usefulness of statin at different infarction locations (i.e., ACS and PCS).

Methods: In the J-STARS study, 1578 patients were randomly assigned to the pravastatin or control group. The subjects were divided into two subgroups (ACS and PCS groups) based on the arteries responsible for the infarction. Cox proportional hazards models were used to investigate whether the all stroke recurrence rate was different between the ACS and PCS groups.

Results: The PCS group (n = 499) had a significantly higher prevalence of diabetes than the ACS group (n = 1022) (30.7% vs. 19.8%, P < 0.001). During the follow-up (4.9 ± 1.4 years), the incidence of all stroke was significantly lower in the pravastatin group than in the control group among patients with PCS (adjusted hazard ratio [HR] 0.46, 95% confidence interval [CI] 0.25–0.83, P = 0.009); however, the stroke recurrence rates were not significantly different between both groups among patients with ACS (adjusted HR 1.32, 95% CI 0.93–1.88, P = 0.123). A significant interaction between the ACS and PCS groups in terms of pravastatin effects was noted (P = 0.003 for interaction).

Conclusions: Pravastatin significantly reduced the recurrence rate of all stroke among patients with PCS. Thus, the effect of statin on the recurrence of stroke may differ according to infarction location.

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.

Carotid artery plaque screening using abdominal aortic calcification on lumbar radiographs

Aim

Arteriosclerotic disease is increasing due to aging of the population, and is associated with diabetes, hypertension, hyperlipidemia, obesity, and smoking. This disease may result in fatal cerebrovascular disease, and especially cardiogenic cerebral embolism caused by artery plaque-based atherothrombotic cerebral infarction. The study was performed to examine the relationship of abdominal aortic calcification (AAC) on lumbar radiographs with carotid intima-media complex thickness (IMT), factors associated with carotid artery plaque, and cutoff values in middle-aged and elderly people.

Patients and methods

The subjects were 309 healthy volunteers (average age 63 years) who attended a health checkup supported by a local government in 2015. The AAC-24 score was determined on lumbar lateral standing radiographs and was categorized as 0 (54% of subjects),1–4 (31%), and ≥5 (severe, 15%). Carotid ultrasonography was used to evaluate IMT of the common carotid artery. Carotid artery plaque was defined as IMT >1.1 mm. Body mass index (BMI), hypertension, diabetes mellitus (DM), dyslipidemia, smoking, alcohol intake, and osteoporosis were examined.

Results

Of 309 cases, 142 (46%) had AAC and 104 (34%) had carotid artery plaque. Thus, 15% (n = 45) had severe AAC. Age, prevalence of DM and carotid artery plaque increased with severity of AAC. In patients with carotid artery plaque (n = 104), age (67.8±7.5 vs. 61.0±10.1 years), % male (56% vs. 39%), BMI (22.9±2.8 vs. 23.7±3.5), AAC rate (58% vs. 40%) and AAC-24 score (3 (0, 8) vs. 0 (0, 2)) were all significantly higher than in those (n = 205) without carotid artery plaque. In multivariate analysis, age (OR 1.172), male gender (OR 1.654), AAC (OR 1.352), and AAC-24 ≥5 (OR 4.191) were significantly associated with carotid artery plaque. Combining AAC-24 with age significantly increased the AUC from 0.632 to 0.834 (p<0.05).

Conclusion

There was a significant relationship between AAC on lumbar radiographs and carotid IMT.

Clinical Utility of Carotid Ultrasonography in the Prediction of Cardiovascular Events in Patients with Diabetes: A Combined Analysis of Data Obtained in Five Longitudinal Studies

Aim: It remains unclear whether measures used in carotid ultrasonography such as the intima–media thickness (IMT) and ultrasonic tissue characterization of the carotid using the gray-scale median (GSM) can add prognostic information beyond the conventional cardiovascular risk markers in pati ents with diabetes.

Methods: This study employed a combined analysis of data obtained in five longitudinal studies including a total of 3263 patients with diabetes but without apparent cardiovascular disease (CVD) at baseline. The associations between carotid ultrasonography measures and the first occurrence of CVD (488 cases), which were defined as cardiovascular death, coronary artery diseases, stroke, or peripheral artery disease, were analyzed.

Results: Common carotid artery (CCA)-mean-IMT, CCA-max-IMT, Max-IMT, plaque-GSM, and the presence of low-GSM echolucent plaques at baseline were prognostic factors for CVD even after adjustment for conventional risk factors. Time-dependent receiver-operating-characteristic (ROC) curve analysis indicated that the use of CCA-mean-IMT, CCA-max-IMT, and Max-IMT in addition to the conventional risk factors improved significantly the prediction of occurrence of CVD. Increments in the CCA-mean-IMT (hazard ratio [HR] 2.37 for every 0.1-mm/year increment [95% confidence interval [CI]: 1.63–3.47], p < 0.001), Max-IMT (HR 1.51 for every 0.1-mm/year increment [95% CI: 1.07–2.14], p = 0.020), and Mean-GSM (HR 0.22 for every 10-U/year increment [95% CI: 0.06–0.76], p = 0.016) during the observation period were also prognostic factors for CVD even after adjusting for the baseline value of the respective measure.

Conclusions: Addition of carotid ultrasonography measures to conventional risk factors significantly improved the stratification of patients by cardiovascular risk. Changes over time in carotid ultrasonography measures may be used as therapeutic outcome measures.

Abbreviations: CAC, coronary artery calcium; CCA, common carotid artery; CVD, cardiovascular disease; DM, diabetes mellitus; FRS,Framingham Risk Score; GSM, gray-scale median; HR, hazard ratio; IMT, intima–media thickness; PAD, peripheral artery disease