Association of extracranial carotid arterial disease and chronic atrial fibrillation with the incidence of new thromboembolic stroke in 1,846 older persons

In a prospective study of 1,846 persons, mean age 81 +/- 8 years, 281 persons (15%) had 40% to 100% extracranial carotid arterial disease and 253 persons (14%) had chronic atrial fibrillation. The Cox regression model showed that significant independent risk factors for new thromboembolic stroke were atrial fibrillation (p = 0.0001, risk ratio 3.3), 40% to 100% extracranial carotid arterial disease (p = 0.0001, risk ratio 2.5), prior stroke (p = 0.0001, risk ratio 2.1), and male gender (p = 0.045, risk ratio 1.2).

Association between plasma homocysteine and extracranial carotid arterial disease in older persons

The data demonstrate that high plasma homocysteine levels and low plasma folate and vitamin B12 levels are associated with a higher prevalence of 40% to 100% extracranial carotid arterial disease (ECAD) in older men and women. Elevated plasma homocysteine levels were observed in 45% of the older men with 40% to 100% ECAD versus 20% of the older men with 0% to 39% ECAD, and in 40% of the older women with 40% to 100% ECAD versus 18% of the older women with 0% to 39% ECAD.

Association of extracranial carotid arterial disease, prior atherothrombotic brain infarction, systemic hypertension, and left ventricular hypertrophy with the incidence of new atherothrombotic brain infarction at 45-month follow-up in 1,482 older patients

Comparison of 239 older patients with 40% to 100% extracranial carotid arterial disease (ECAD) with 1,243 older patients with no significant ECAD showed a higher prevalence of systemic hypertension, left ventricular (LV) hypertrophy, and prior atherothrombotic brain infarction (ABI) and a higher incidence of new ABI in patients with ECAD than in patients without ECAD. A multivariate Cox regression model showed that independent predictors of new ABI were ECAD (risk ratio = 2.5), systemic hypertension (risk ratio = 2.3), prior ABI (risk ratio = 2.3), LV hypertrophy (risk ratio = 2.3), and male sex (risk ratio = 1.3).

Serum ferritin is not a risk factor for extracranial carotid arterial disease in men and women aged > or = 60 years

In a prospective study of 236 men and 568 women aged > or = 60 years, 40% to 100% extracranial carotid arterial disease (ECAD) was present in 46 men (19%) and in 83 women (15%) (p = NS). The percentage of patients with increased serum ferritin levels and the mean serum ferritin levels were not significantly different between men with and without 40% to 100% ECAD, or between women with and without 40% to 100% ECAD.

Association of silent myocardial ischemia with new atherothrombotic brain infarction in older patients with extracranial internal or common carotid arterial disease with and without previous atherothrombotic brain infarction

OBJECTIVE

To correlate silent myocardial ischemia with the incidence of new atherothrombotic brain infarction (ABI) in older patients with 40 to 100% extracranial carotid arterial disease (ECAD) with and without prior ABI.

DESIGN

In a prospective study of 208 older patients with 40 to 100% ECAD diagnosed by carotid duplex ultrasonography, 24-hour ambulatory electrocardiograms were obtained to detect silent myocardial ischemia. At 42-month mean follow-up, silent myocardial ischemia was correlated with the incidence of new ABI in patients with and without prior ABI.

SETTING

A large long-term health care facility where 208 older patients with 40 to 100% ECAD and technically adequate 24-hour ambulatory electrocardiograms for detecting silent myocardial ischemia were studied.

PATIENTS

The 208 patients included 68 men and 140 women, mean age 81 +/- 8 years (range 60 to 100). One-hundred three (50%) of the patients had prior ABI.

MEASUREMENTS AND MAIN RESULTS

Sixty-nine (33%) of the 208 patients had silent myocardial ischemia. Mean follow-up was 42 +/- 25 months (range 3 to 101 months). At follow-up, the incidence of new ABI was 64% in patients with prior ABI and 32% in patients with no prior ABI (P < .0001). At follow-up, the incidence of new ABI was 65% in patients with silent ischemia and 40% in patients with no silent ischemia (P = .0005). The multivariate Cox regression model showed that patients with prior ABI have a 2.5 times higher chance of developing new ABI than those without prior ABI after controlling other prognostic variables. Patients with silent ischemia have a 2.1 times higher probability of developing new ABI than those without silent ischemia after controlling other prognostic variables.

CONCLUSIONS

Prior ABI and silent ischemia are independent risk factors for the development of new ABI in patients with 40 to 100% ECAD. This probably reflects that silent ischemia is a marker for more advanced or more significant atherosclerotic disease rather than a causal factor for ABI.

Left ventricular hypertrophy is more prevalent in patients with systemic hypertension with extracranial carotid arterial disease than in patients with systemic hypertension without extracranial carotid arterial disease

The mechanism of the association between LV hypertrophy and ECAD is unknown and needs to be investigated. Whether LV hypertrophy in patients with systemic hypertension is a marker for ECAD or contributes to ECAD needs to be investigated. The association between LV hypertrophy and significant ECAD was independent of the level of blood pressure in our patients. Coronary atherosclerosis in our patients with signifciant ECAD may have contributed to the increased prevalence of LV hypertrophy. The association between LV hypertrophy and significant ECAD may contribute to the high incidence of stroke in patients with LV hypertrophy. This is currently under investigation by our group.

Are strokes more likely to result from severe carotid atherosclerotic stenoses? If not, why not?

The authors studied by carotid duplex ultrasonography 478 unselected elderly patients (age sixty to one hundred one years, mean 82 +/- 8), in their long-term health care facility. Of these, 108 had previously experienced strokes owing to atherothrombotic brain infarcts, documented by a neurologist, and 370 had not. The degree of extracranial internal or common carotid narrowing in these patients was classified by standard Vmax Doppler criteria as 0-40%, 40-80%, and 80-100% luminal diameter reduction. The authors found that 87% of the patients had little or no carotid stenosis (0-40% luminal diameter reduction). Nevertheless, 79% of the previous strokes had occurred in these patients, and the incidence of strokes in this group was 21%. Severe, but not mild or moderate, degrees of carotid obstruction (80-100% luminal diameter reduction) were associated with a 100% stroke incidence. The authors conclude that strokes most commonly result from causes other than ischemia due to in situ severe extracranial internal or common carotid stenosis or occlusion.

Nicolo Paganini. Musical magician and Marfan mutant?

The thesis is advanced that Nicolo Paganini of Genoa (1782 to 1840), the greatest violin virtuoso of all time, owed his incomparable violin virtuosity to a fortuitous and fortunate coincidence of three factors: a soaring musical genius, a flair for the dramatic and ostentatious, and manual dexterity conferred by being born with the long fingers and hyperextensible joints of Marfan's syndrome. Ordinarily, an inborn connective tissue disorder is a calamity for the patient and a burden for society. In this particular instance, however, Marfan's syndrome bequeathed to posterity a legacy that will ennoble the human spirit for innumerable generations yet to come.