Carotid Ultrasound Evaluation Research Articles

Evaluation of Cardiovascular Risk in People with Type 1 Diabetes: A Comprehensive and Specific Proposed Practical Approach.

People living with type 1 diabetes (T1D) have an increased risk of cardiovascular disease (CVD), and it is the leading cause of morbidity and mortality in this population. CVD risk increases with each uncontrolled risk factor, even in individuals with good glycaemic control. Recommendations for assessing CVD risk in the T1D population are extended from those for type 2 diabetes (T2D) even though the physiopathology and underlying mechanisms of atherosclerosis in T1D are poorly understood and differ from those in T2D. Unlike the assessment of microvascular complications, which is well established in T1D, this is far from being the case for the comorbidities and risk associated with CVD. Aside from classical cardiovascular comorbidities, carotid ultrasound can be useful to stratify CVD risk. The utilization of specific risk scales such as the Steno Type 1 Risk Engine can help to more accurately classify cardiovascular risk in these individuals. The cornerstones of the management of cardiovascular risk in T1D are the promotion of the Mediterranean diet, tight glycaemic control (glycated haemoglobin (HbA1c) < 7%), blood pressure < 130/80mmHg in most patients, and low-density lipoprotein (LDL) cholesterol < 100mg/dL in moderate-risk individuals, < 70mg/dL in high-risk individuals, and < 55mg/dL in very high-risk individuals. Conventional medical follow-up of patients with T1D should be individualized (approximately 2-3 visits per year), and a carotid ultrasound evaluation is recommended every 5 years in the absence of significant preclinical atherosclerosis or more often in those with severe preclinical atherosclerosis. Antithrombotic therapy is recommended in those receiving secondary prevention, those with stenosis > 50% in any arterial bed, and those with an impaired ankle-brachial index. This document is a proposal of a practical approach for the evaluation, classification, and management of CVD risk in individuals living with T1D.

Autonomic dysfunction and cardiovascular risk in psoriatic arthritis.

Psoriatic arthritis (PsA) is an inflammatory disease with a high prevalence of cardiovascular (CV) events due to traditional cardiovascular risk factors and increased systemic inflammation. In this review, our objectives were to (i) evaluate the cardiovascular events and risk factors and (ii) investigate the relationship between autonomic dysfunction and CV diseases in PsA. A systematic review of the literature was done on the Medline/PubMed, Scopus, and the Directory of Open Access Journals databases between January 2017 and July 2022. After screening and exclusions, 73 studies were included for the final review. Patients with PsA have a greater risk of CV diseases and increased traditional CV risk factors, including hypertension, diabetes mellitus, obesity, metabolic syndrome, and dyslipidemia. Although autonomic dysfunction is more common in PsA than in the general population, its relationship with increased CV diseases in these patients is still unclear. Limitations in explaining CV risk in these patient groups complicate patient assessment as cardiovascular risk factors are linked to the morbidity and mortality of PsA, and it is essential to improve an optimal screening and management strategy for CV disease. All CV risk scoring systems cannot fully assess the CV risk in these patients, so in addition to scoring systems, carotid ultrasound evaluation may be a part of the CV evaluation.

Coronary artery calcium score in people living with HIV. Results from the French CAC study

Abstract Background People living with HIV (PLWH) have a higher risk of CAD. Whether coronary artery calcification (CAC) score could better stratify the CV risk remains debated in this middle age population. Purpose We conducted the French CAC score study to compare the CAC score between PLHIV and HIV− subjects at intermediate risk. Methods 689 subjects (257 PLHIV and 432 HIV−) were consecutively addressed for CV risk evaluation including CAC score assessment in 2 centers between 2013 and 2019. Subjects were included if they were 18 years'old or older, had no known cardiovascular disease and had a CAC score along with cardiometabolic assessment. Results The mean age of the cohort was 59.3 years ± 10.7 and predominantly male (54%). PLHIV were younger (55.8 years ± 9.1 vs 61.3±11.3, p&amp;lt;0.004), with a lower rate of diabetics (18% vs 26%, p=0.009) and lower levels of total cholesterol, LDLc, and HDLc (2.0 mmol/l vs, 2.2 mmol/l; 1.2 mmol/L vs 1.3 mmol/L; and 1.2 mmol/L vs 1.4 mol/L respectively, all p&amp;lt;0.001). The prevalence of hypertension, dyslipidemia and obesity was similar between PLHIV and the HIV− group (40%, 43% and 21%, respectively). No differences were observed in CV therapies prescribed including antihypertensive drugs and statins between PLHIV and the HIV− group (39% vs 37%, p=0.54 and 46% vs 39%, p=0.065). In contrast, PLHIV had higher rate of triglycerides (1.4 mmol/L vs 1.2 mmol/L, p=0.01), higher rate of active smoking (28% vs 14%, p&amp;lt;0.001), CRP level (4.0 mg/L vs 2.9 mg/L, p&amp;lt;0.001) along with higher black ethnicity representation (17% vs 5%;, p&amp;lt;0.001). 96% of PLHIV were under antiretroviral therapy at the time of enrollment with 88% who had been exposed to protease inhibitors. In subjects who had carotid and/or limb ultrasound evaluation (67% and 45% respectively in PLHIV and HIV), no increased rate of arterial stenosis &amp;gt;50% was found (13% vs 8%, p=0.16). Concerning, CV risk estimation using 10-year ASCVD and HEART scores, we observed that the median ASCVD score was similar between PLHIV and HIV− group (10.7% vs 9.8, p=0.15) but that PLHIV had a higher HEART score (3.0% vs 2.0%, p&amp;lt;0.001). The repartition between the ASCVD or HEART scores classes between the 2 groups was similar with 80% of the cohort classified as low or intermediate CV risk with the ASCVD score and 88% at intermediate or borderline CV risk with the HEART score. However, no statistically significant differences was found between the 2 groups regarding the prevalence of CAC = 0 (41% vs 44%, p=0.52) and the median CAC score (7.7 vs 8.2, p=0.81). Conclusion In this cohort of subjects at intermediate CV risk according to CV risk scores estimation (ASCVD or HEART scores), PLHIV had a similar prevalence of CAC = 0 and median CAC scores as compared to HIV− subjects despite a younger age (6 years). Longitudinal follow up will explore whether this similar CAC score evaluation will be translated into higher CV events. Funding Acknowledgement Type of funding sources: None.

Assessment of Compatibility Between Cardiologists and Radiologists for Interpreting and Reporting Carotid Duplex Ultrasound Images

Objective: This study aimed to evaluate the degree of agreement between cardiologists and radiologists for interpreting and reporting carotid duplex ultrasound images. Methods: This prospective observational study was conducted in a cardiology outpatient clinic. For the sample size calculation, according to the kappa (2 raters) hypothesis testing method, assuming minimum acceptable kappa of 0.6, expected kappa of 0.8, a significance level of 0.05, power of 90%, and considering the expected dropout rate of 10% in the study, 116 patients were enrolled in the study. Demographic findings, personal histories, and laboratory test results were recorded. Carotid artery duplex ultrasonography was performed simultaneously and recorded by cardiologists and radiologists. Results: This study included 116 patients who were treated in cardiology outpatient clinics for ischemic stroke, trans-ischemic attack, amaurosis fugax, dizziness, and severe headache complaints. While 50.9% of them are female, 49.1% were male. The age range of patients included in the study was a minimum of 32 years and a maximum of 71 years. Their mean age and deviation were 58.6 ± 10.1. Examination of their distribution according to chronic disease states revealed that 44.8% had hypertension, 58.6% were smokers, 36.2% had diabetes mellitus, 22.4% had dyslipidemia, 13.8% had ischemic heart disease, 29.3% had chronic obstructive pulmonary disease, and 16.4% had congestive heart failure. According to the criteria for carotid stenosis measurement of ≤50% and &gt;50%, a significant and almost perfect agreement was found between the measurements by cardiologists and radiologists (Cohen’s kappa coefficient κ= 0.811; P &lt;.0001). Conclusion: Diagnostic compatibility with radiologists was found to be near-perfect for carotid ultrasound evaluation.

A Multifactorial Analysis of Extracranial Carotid Disease: A Comprehensive Approach to Sonographic Criteria.

The present study brings a pictorial review aimed to discuss the multifactorial interpretation of extracranial carotid atheromatous disease, contemplating not only the degree of stenosis but also the arterial flow patterns, the intima-media thickness and the morphological characteristics of the atheromatous plaque. We merged the recommendations contained in the different reference literature on the topic to give a comprehensive approach to ultrasound criteria for diagnostic carotid examination. We infer that the carotid ultrasound evaluation must include important predictors of cardiovascular risk, which should be written in the ultrasound reports, thus allowing the adequate clinical approach to the disease.

Issues with carotid stenosis detection by ultrasound in patients with left ventricular assist devices

The study by Kronfli et al1 was a small retrospective study of patients using a left ventricular assist device (LVAD) who had undergone carotid duplex ultrasound evaluation. Given the increasing utility of LVADs and their hemodynamic effects, it seems prudent to study the criteria for arterial stenosis in such patients. It was observed that the peak systolic velocity was decreased and the end-diastolic velocity and velocity ratios were increased. There were also three different flow pumps: 21 with axial flow, 13 with centrifugal flow, and 2 with pulsatile flow.

SUB-CLINICAL DAMAGE TO THE TARGET ORGANS (TOD) IN HYPERTENSIVE PATIENTS, ABOUT 300 PATIENTS

Objective: HTA is considered to be a silent killer. TOD is an indicator of cardiovascular risk in people with hypertension. The main objective of our study is to describe the sub-clinical TOD in hypertensive patients. Design and method: This is a descriptive study, conducted between October 2016 and October 2019. It included all asymptomatic hypertensive patients over the age of 35 of both sexes. Screening for infraclinical cardiac, vascular and renal damage is carried out with; the evaluation of the left ventricular hypertrophy (LVH) ultrasound and electric. Intima media thickness measurement by 2D carotid ultrasound and screening and evaluation of plaques. The measurement of pulsed pressure. Measuring the ABI for obliterating arterial disease. And finally, the estimate of urinary albumin excretion (UEA) and creatinine clearance according to MDRD. Results: 300 patients included in our series, these are 120 men and 180 women. The average age is 59.75 years. The prevalence of TOD is estimated at 72.3%, the prevalence of electrical LVH is 17.3%, the ultrasound LVH is 29%. Carotid hypertrophy is observed in 34.9% and the presence of stenotic plaques affect 9.1% of patients AOMI is found in 9%. Pathological pulsed pressure is found in 34.3%. UAE is pathological in 23.30% of our patients for A2 and 5.7% for A3. The creatinine clearance is less than 60 ml / min in 11%. The main independent risk factors associated with TOD are the value of SBP and Age. Pulse pressure&gt; 60 mmHg is associated with all TOD and the IMT is correlated with all screening tests for TOD. The SCORE score is predictive only for carotid lesions, it is not predictive for LVH or albuminuria. The SCORE score is not very predictive for AOMI and renal failure. Conclusions: Subclinical TOD is frequent in our series. The major modifiable independent risk factor is the value of SBP. Special attention to pulse pressure as a cardiovascular risk factor and marker of arterial stiffness A strategy for screening for target organ damage coupled with effective therapy targeting SBP is the only way to prevent cardiovascular, neurovascular and renal complications.

Association Between the Framingham Risk Score and Carotid Artery Intima-Media Thickness in Patients With Human Immunodeficiency Virus

Cardiovascular diseases (CVD) are more prevalent among HIV-infected subjects. We examined the associations between carotid artery intima-media thickness (CIMT), conventional CVD risk factors, and HIV-related risk factors among Hispanics with HIV infection. This cross-sectional study involved 96 consecutive HIV patients on stable antiretroviral therapy and without history of CVD in a university-based outpatient clinic who underwent carotid ultrasound evaluation. Increased CIMT was defined as common carotid artery-CIMT values greater than or equal to seventy-fifth percentile for the patient's age, sex, and race/ethnicity based on CIMT nomograms from large population studies. The sample was comprised of 96 Hispanic Americans aged 39.7 ± 11.9, 89% of whom were men, 64% were on a protease inhibitor, and 11% had increased CIMT (95% confidence intervals 5.9% to 19.6%). In univariable analysis, increased CIMT was significantly associated (p <0.05) with older age, metabolic syndrome, intermediate/high Framingham risk score, HIV infection duration ≥5 years, integrase inhibitors, and protease inhibitors. In multivariable analysis, only Framingham risk score (p = 0.009) was independently associated with increased CIMT. The median common carotid artery-CIMT value was significantly greater in patients with intermediate/high compared with those with low Framingham risk score (0.60 vs 0.49 mm; p <0.001). In conclusion, given the significant association between increased CIMT and Framingham risk score, adherence to prevention guidelines to reduce CVD risk factor burden in this population is strongly recommended.

Carotid doppler ultrasound evaluation in patients with lichen planus

Background: Lichen planus is a chronic inflammatory disease associated with an increased risk of subclinical atherosclerosis and cardiovascular diseases. This study aimed to evaluate patients with lichen planus using carotid Doppler ultrasound parameters.Methods: Forty patients with lichen planus and 40 controls were included in this study. Common carotid artery intima-media thickness (CIMT) and the number of atherosclerotic plaque weremeasured and compared to the control group. Total cholesterol, triglyceride, low-density lipoprotein (LDL) and high-density lipoprotein (HDL) levels were measured. Leptin level (Pg/ml)was measured using the enzyme-linked immunosorbent assay (ELISA) method (Leptin ELISA kit, Orgenium, Finland).Results: Significant difference was found between the groups in terms of CIMT (P=0.005). The median range for blood leptin level, triglyceride, cholesterol, and LDL was higher for lichen planus patients than for controls. We found a significant difference between the severity of LP and CIMT (P=0.035). No statistical difference was found between LP and the number of atherosclerotic plaque.Conclusions: Our study suggested that measurement of the mean intima media wall thickness of the common carotid artery could be beneficial as a valuable method for early diagnosis of atherosclerosis in lichen planus.

Cardiovascular Risk and Subclinical Atherosclerosis in Senegalese Patients with Rheumatoid Arthritis: A Cross-Sectional Study in a Single Centre

Introduction: Rheumatoid arthritis (RA) is associated with increasing of cardiovascular (CV) morbidity and mortality due to accelerated atherosclerosis. Several studies showed also the increasing of the prevalence of subclinical atherosclerosis, but there are little data from sub-Saharan Africa. The aim of our study was to assess the prevalence of cardiovascular risk factors, subclinical carotid atherosclerosis and the ability of the Systematic Coronary Risk Estimation (SCORE) modified by European League Against Rheumatism (EULAR) to predict the high CV risk in our patients. Patients and Method: We conducted a cross sectional study in Senegalese patients with RA. The RA was retained according to 2010 American College of Rheumatology (ACR)-European League Against Rheumatism (EULAR) criteria. Patients with RA were assessed in a clinical research consultation. Results: We included 50 RA patients. The mean age was 44 years (+/- 12.37) and the sex-ratiowas 0.06. The frequency distribution of traditional cardiovascular risk factors was: hypertension (HT) (30%), diabetes-mellitus (6%), smoking (2%), no-exercise (22%), obesity (16%), metabolic syndrome (8%). Fifty-eight percent of patients were classified at low cardiovascular risk according to mSCORE. 51.7% of patients classified as moderate-risk according to mSCORE, were reclassified as high cardiovascular risk according to carotid ultrasound evaluation (gold-standard). The sensitivity of the mSCORE in the prediction of high CV risk was low at 20%. In the present study, the prevalence of carotid subclinical atherosclerosis was 20%. Age (>45 years) and HT were correlated to subclinical atherosclerosis. Conclusion: In the present study, the prevalence of atherosclerosis in RA patients was higher than expected frequency in comparison with the prevalence in Senegalese general population. We showed that CV risk was underestimated by mSCORE which had a low sensitivity in the prediction of high risk. We showed also the importance of carotid ultrasound for an appropriate stratification of the risk.

Carotid Atherosclerotic Disease and Risk Factors in Patients with Ischemic Stroke – Study Report –

Abstract Ischemic stroke (IS) is the second frequent vascular disease after myocardial infarction, with different clinical and etiological aspects and various risk factors. Large vessel atherosclerotic disease is the most frequent IS causing pathology, followed by cerebral microangiopathy and cardioembolic events. Cervical arteries Doppler ultrasonography helps identifying the subtype of IS, and by revealing the vascular status of the patient, guides the therapeutic decision and secondary IS prevention. The aim of this paper is to present the results of an observational, retrospective, analytical study on a number of 174 patients with acute IS evaluated by Doppler carotid ultrasound in CVASIC Research Centre of Academic Emergency Hospital of Sibiu from January to December 2018. Materials and methods: All patients with IS admitted in our centre received a Doppler carotid ultrasound evaluation. We observed the degree of carotid stenosis, presence of atherosclerotic risk factors and their influence. Results: The mean age of patients was 71.3 years (36 to 92 years range). 16 (9.19%) patients presented occlusion of internal carotid artery (ICA) on the same side as stroke, 37 (21.26%) had severe carotid stenosis (&gt;70%), 31 (17.81%) presented moderate stenosis (50-70%), the remaining patients had mild or no stenosis. 129 (74,13%) patients presented arterial hypertension, 51 (29.31%) patients had diabetes mellitus, 14 (8.04%) were smokers, 81 (46.56%) had dyslipidemia. Conclusions: A large number of patients had severe carotid stenosis and occlusion. The most common risk factor was arterial hypertension, followed by dyslipidemia and diabetes mellitus. Continuous medical education of population at risk regarding good nutrition principles and healthy lifestyle are needed to reduce the social costs of ischemic stroke.

P2642Optimal blood pressure control in relation to target organ physiology in hypertensive men with erectile dysfunction

Abstract Background Target organ damage (TOD) in essential hypertension relates to an adverse prognosis. Middle aged men are considered a population group where cardiovascular risk typically augments and erectile dysfunction (ED) that frequently accompanies both entities refers to a subclinical vascular damage process. Purpose To identify the optimal blood pressure (BP) levels in middle aged hypertensive males with ED in relation to TOD. Methods 258 ED males (mean age: 56 yo) with essential hypertension under medical treatment enrolled the study. All underwent 2D echocardiography and carotid ultrasound evaluation to determine left ventricular mass index (LVMI) and intima – media thickness (IMT) respectively. Carotid – femoral pulse wave velocity (PWV) and augmentation index (AIx) were also assessed as indices of central vascular stiffness and wave reflection physiology (complior &amp; sphygmocor devices). Office brachial blood pressure (BP) measurements where performed according to the current guidelines and an average of three consecutive values was computed. Erectile dysfunction was assessed by using the SHIM-5 score (range 0–25, lower values display a pronounced dysfunction). Results In bivariate analysis brachial systolic blood pressure (bSAP) was positively and strongly associated with LVMI (r=0,6), PWV (r=0,65), AIx (r=0,67, all p&lt;0,001) and IMT (p&lt;0,05, r=0,55). Erectile performance as assessed by the SHIM-5 score was negatively related to PWV, AIX and IMT (r=−0,58, r=−0,45 and r=−0,65 all p&lt;0,001) pointing out the underlying vascular detriment. Interestingly, there were no such correlations regarding the diastolic blood pressure values. Multiple linear regression analysis was performed and the relation of bSAP with LVMI, PWV, AIx and IMT remained significant after adjustment for age, BMI, smoking habits and presence of diabetes mellitus (all p&lt;0,05). We further subdivided our population into three groups according to the values of office bSAP for normal blood pressure (≤129mmHg, n=143,55%), high normal (130–139mmHg, n=59, 23%) and high (≥140mmHg, n=56,22%). In patients with high-normal bSAP, the parameters of PWV and LVMI were significantly higher than in patients with normal BP (independent sample t-test, p: 0,032 and 0,016 respectively). Patients of the high bSAP group as expected, had more extensive cardiac and vascular damage (LVMI, PWV and AIx). Conclusion In essential hypertensive middle aged men with erectile dysfunction, guiding therapy toward normal systolic blood pressure values as compared to the high normal benefits target organ physiology. It is clinically important to identify this vascular patients group in order to adjust regimens and further therapeutic strategies.

Role of Carotid Ultrasound and Systematic Coronary Risk Evaluation Charts for the Cardiovascular Risk Stratification of Patients with Psoriatic Arthritis.

The assessment of the cardiovascular (CV) risk is recommended in patients with chronic inflammatory rheumatic diseases. The objectives of this study were to assess the CV risk profile in a cohort of patients with psoriatic arthritis (PsA), to determine the presence of subclinical cardiovascular disease by carotid ultrasound (US), and to study the association of CV disease to PsA characteristics. This was a cross-sectional multicentric descriptive study. The clinical CV risk was calculated with Systematic Coronary Risk Evaluation (SCORE) charts. Common carotid US was conducted to evaluate the carotid wall intima-media thickness and the presence of atheroma plaques. Patients were reclassified upon US results. Multivariate analyses were performed to identify associations of US carotid abnormalities with the classical CV risk factors and PsA characteristics. The study included 176 patients with PsA. The SCORE-estimated CV risk was intermediate in 65.3% of the patients. In the US study, 32% of the patients had abnormalities, and 30.8% of the patients were upgraded and reclassified as very high risk owing to the presence of atheroma. Subclinical CV disease was associated with age and dyslipidemia but not with other risk factors. It was associated with axial disease in the subgroup with intermediate risk, and with C-reactive protein levels in patients with high risk. Many patients with PsA have clinical estimated intermediate or high risk of a fatal CV event. A carotid US study detects subclinical vascular disease and may be useful to depict the real risk. The presence of atheroma is only partially explained by the classic CV risk factors.

PP.09.26] RADIATION-INDUCED VASCULAR DAMAGE IN HODGKIN LYMPHOMA SURVIVORS

Objective: New chemotherapeutic drugs and radiation therapy have significantly improved cancer patient's survival, although the cardiovascular (CV) side effects of cancer treatment are increasingly important. In previous studies, an increased risk of cerebrovascular complications such as stroke and transient ischemic attack was described in patients undergoing neck radiotherapy. Aim of our study was to evaluate vascular carotid structural (IMT, plaque) and functional (carotid stiffness) damage, and changes in arterial stiffness (Carotido-femoral pulse wave velocity; cf-PWV) in Hodgkin Lymphoma survivors previously treated with radiotherapy. Design and method: We enrolled 206 Hodgkin lymphoma survivors (mean age 54 ± 14 years, 51% males, mean follow-up of 9 ± 6 years). CV risk factors were investigated and atherosclerotic carotid damage was assessed by standard carotid ultrasound evaluation for intima-media thickness (IMT) measurement (MeanMax-IMT, CBMax, Tmax; n = 167); in 141 patients radiofrequency-based carotid stiffness analysis (distensibility; distensibility coefficient, DC; compliance coefficient; CC)was also performed. Cf-PWV measurement were obtained in 154 patients. Results: a significant correlation between radiotherapy dose and: MeanMax-IMT (r = 0.20; p < 0.05),Tmax (r = 0.20; p < 0.05), distensibility (r = 0.24; p < 0.05),DC (r = 0.24; p < 0.05),CC (r = 0.24; p < 0.05)was observed. Patients were divided into 4 groups according to radiotherapy dose (Dose: 20–30; 31–36; 37–42; >42 Gy). An increase in Tmax (1.27 ± 0.61, 1.35 ± 0.59, 1.46 ± 0.69, 1.76 ± 1.12 mm, p for trend < 0.05) and in the prevalence of carotid plaque (29%, 31%, 47% and 55%, p for trend < 0.05) was observed as related to dose-category. One-hundred-seventeen patients received neck irradiation (67 bilateral;50 unilateral). In unilaterally irradiated patients, MeanMaxIMT was greater in the irradiated side as compared to unirradiated carotid artery and the difference reached statistical significance in the group of patients who received a high radiotherapy dose (0.97 ± 0.35 vs 0.92 ± 0.34 p < 0.05). Cf-PWV was significantly greater only in patients that received high dose (>42 Gy), as compared to all the other dose groups (9.7 ± 2.3 vs 8.3 ± 2.2, 8.0 ± 1.5 and 8.3 ± 1.4, p < 0.05). Conclusions: In this large number of Hodgkin Lymphoma survivors, carotid IMT, plaque prevalence and aortic and carotid stiffness were significantly related with radiotherapy doses. Carotid IMT, carotid and aortic stiffness were significantly higher in the irradiated carotid arteries, but only at doses >42 Gy, suggesting that there may be a dose threshold for radiotherapy-induced carotid wall damage.

Carotid Doppler ultrasound evaluation in patients with pulsatile tinnitus.

A wide range of conditions, including atherosclerosis, may lead to pulsatile tinnitus. The objective of this study was to evaluate the patients with pulsatile tinnitus by means of carotid Doppler ultrasound parameters. Thirty-four patients with pulsatile tinnitus were enrolled in the study. Internal carotid artery intima-media thickness (IMT), blood flow velocities and arterial lumen diameters (LD) were measured and compared with the control group. Mean end diastolic velocity (EDV) (32.29±17.22) and IMT (1.06±0.36) values were significantly higher and mean LD (6.69±1.20) was significantly lower compared to the control group. Peak systolic velocity and EDV values were significantly higher in patients whose IMT were greater than 1mm. Pulsatile tinnitus may be the first symptom of a severe, life threatening disease. Doppler sonography is a noninvasive, safe and easily applicable diagnostic tool for the evaluation of the vascular structures, in patients with pulsatile tinnitus.

Abstract W P353: Benign Natural History of Occlusion in Asymptomatic Carotid Stenosis

Introduction: One commonly stated reason for stenting of asymptomatic carotid stenosis is to prevent carotid occlusion. However, the Circle of Willis provides substantial protection against occlusion, so this objective may be misguided. In the NASCET trial, patients with near occlusion of the internal carotid had a lower risk of stroke than did patients with lesser degrees of stenosis. We studied the effects of progression to occlusion among patients with asymptomatic stenosis of the internal carotid artery (ICA). Methods: We studied the outcome of all consecutive patients in our clinic database with asymptomatic carotid stenosis of ≥60% at baseline between 1991 and 2010, who were followed for at least two years with carotid ultrasound and clinical evaluation. Results: 370 patients were included; mean age ± SD 68.8 ± 10.3; 210 (56.8%) were men. Systolic blood pressure was 149.8 ± 22.2, low-density lipoprotein 2.3 ± 1.1 mmol/L, smoking pack-years 24.5 ± 23.3. Only one individual (0.03%) with near occlusion of the ICA developed a new ipsilateral internal carotid artery (ICA) occlusion within a year. This patient experienced episodes of ipsilateral amaurosis fugax before the occlusion (which occurred after he was referred for endarterectomy), but remained asymptomatic after the ICA was totally occluded. Conclusion: Occlusion of asymptomatic carotid stenosis is a rare and usually benign occurrence. In patients with asymptomatic carotid stenosis. The risk of stroke from carotid occlusion is well below the risk of stroke from stenting. Preventing ICA occlusion is not a valid reason to perform carotid stenting in patients with asymptomatic carotid stenosis.

Subclinical atherosclerosis: independent predictor of cardiovascular events in a 20-years follow up of patients with or without metabolic syndrome

Purpose: To evaluate the influence of carotid atherosclerosis and metabolic syndrome (MetS) on the prediction of cardiovascular events during a 20-years follow-up. Methods: We studied a population of 529 asymptomatic patients, divided into 2 groups according to the results of the carotid ultrasound evaluation: one without atherosclerotic lesions (198 patients) and a second one with an increased carotid IMT or asymptomatic carotid plaque (331 patients). In each of these groups, we identified two subgroups of subjects with and without MetS. Cardiovascular endpoints were investigated in a 20-years follow-up: acute myocardial infarction, angina, transient ischemic attack, ischemic stroke, abdominal aortic aneurysm, thromboendarterectomy and cardiovascular death. Results: During the follow-up there were 242 cardiovascular events, 144 among patients with MetS (251 patients) and 98 among healthy controls (178 patients) (57.4% vs. 35.2%; P<0.0001). Moreover 63 events occurred in patients with normal carotid arteries while 179 events occurred in patients with subclinical atherosclerosis (31.8% vs. 54.1%; P<0.0001). Among 144 total events occurred in patients with MetS, 36 happened in the subgroup of 80 patients with normal carotid arteries and 108 happened in the subgroup of 171 patients with subclinical atherosclerosis (45% vs. 63.15%; P=0.01). Among 98 total events occurred in patients without MetS, 27 developed in the subgroup of 118 patients with normal carotid arteries and 71 occurred in the subgroup of 160 patients with subclinical atherosclerosis (22.9% vs. 44.4%; P=0.0003). In addition among 63 total events occurred in patients without atherosclerotic lesions, 36 events happened in the subgroup of 80 patients with MetS and 27 events occurred in the subgroup of 118 patients without MetS (45% vs. 22.9%; P=0.0018). Finally, among 179 total events recorded in patients with atherosclerotic lesions 108 events happened in the subgroup of 171 patients with MetS and 71 events happened in the subgroup of 160 patients without MetS (63.15% vs. 44.4%; P=0.0009). The Kaplan-Meier function showed an improved survival in patients without atherosclerotic lesions compared with patients with carotid ultrasound alterations (P=0.0159, HR: 0.7366, CI: 0.5479 to 0.9904). Conclusions: Subclinical atherosclerosis lead to an increased risk of cardiovascular events, especially if it is associated with MetS. Therefore we suggest to investigate the presence of subclinical atherosclerosis in all patients with more than 45 years with cardiovascular risk factors for a better stratification of the global cardiovascular risk.

Progression of Carotid Plaque Volume Predicts Cardiovascular Events

Carotid ultrasound evaluation of intima-media thickness (IMT) and plaque burden has been used for risk stratification and for evaluation of antiatherosclerotic therapies. Increasing evidence indicates that measuring plaque burden is superior to measuring IMT for both purposes. We compared progression/regression of IMT, total plaque area (TPA), and total plaque volume (TPV) as predictors of cardiovascular outcomes. IMT, TPA, and TPV were measured at baseline in 349 patients attending vascular prevention clinics; they had TPA of 40 to 600 mm(2) at baseline to qualify for enrollment. Participants were followed up for ≤5 years (median, 3.17 years) to ascertain vascular death, myocardial infarction, stroke, and transient ischemic attacks. Follow-up measurements 1 year later were available in 323 cases for IMT and TPA, and in 306 for TPV. Progression of TPV predicted stroke, death or TIA (Kaplan-Meier logrank P=0.001), stroke/death/MI (P=0.008) and Stroke/Death/TIA/Myocardial infarction (any Cardiovascular event) (P=0.001). Progression of TPA weakly predicted Stroke/Death/TIA (P=0.097) but not stroke/death/MI (P=0.59) or any CV event (P=0.143); likewise change in IMT did not predict Stroke/Death/MI (P=0.13) or any CV event (P=0.455 ). In Cox regression, TPV progression remained a significant predictor of events after adjustment for coronary risk factors (P=0.001) but change in TPA did not. IMT change predicted events in an inverse manner; regression of IMT predicted events (P=0.004). For assessment of response to antiatherosclerotic therapy, measurement of TPV is superior to both IMT and TPA.

Livedo and ischemic strokes: diagnostic hints of a rare condition

Sneddon’s syndrome (SS) is a rare condition characterized by the combination of ischemic strokes and cutaneous livedo [1, 2], defined as the ‘‘persistent, not reversible with rewarming, violaceous, reticular or mottled pattern of the skin of trunk, arms or legs, consisting of regular unbroken circles (livedo reticularis) or irregular-broken circles (livedo racemosa)’’. Other well-defined neurological manifestations of SS include headache, seizures, and vascular dementia. Here, we report two cases with clinical and imaging features suggestive of SS. In both patients skin biopsy was performed and sections were stained with hematoxylin and eosin (HE general examination revealed diffused livedo racemosa (Fig. 1a). An extensive cardiological evaluation including an electrocardiogram, an echocardiogram and carotid ultrasound evaluation ruled out cardiovascular causes of stroke. Coagulation parameters (including fibrinogen and D-dimer), inflammatory indexes, syphilis serology, and autoimmune antibody panels including, ANA, ENA, ANCA, lupus anti-coagulants (LAC) and antiphospholipid antibodies (IgM and IgG anti-cardiolipin and anti-b2-microglobulin) were negative. A heterozygous mutation of factor V Leiden was detected. Brain MRI showed cortical atrophy and multiple ischemic lesions involving both the superficial and deep territories of posterior and middle cerebral artery (Fig. 1b). Skin biopsy showed intra-capillary and parietal widespread thrombosis (Fig. 1c). Oral anticoagulants and antipsychotic were added to therapy. A 65-year-old man (Case 2) presented with a 3-year history of progressive lower limbs weakness and mixed dysphagia. He had been having recurrent ischemic strokes since he was 55. He had history of myocardial infarcts, hypertension, and smoking. His neurological examination revealed dysphagia, ataxic and spastic gait, limbs hyperreflexia, right extensor plantar response. General examination revealed diffused livedo racemosa at the trunk and lower limbs (Fig. 1a). A cardiological evaluation and electrocardiogram ruled out the presence of heart arrhythmia; echocardiography demonstrated mild hypokinesia of apical and distal septum of lateral ventricle, as consequence of previous myocardial infarcts. Coagulation parameters and thrombophilic screening were normal. Brain MRI showed diffused cortical atrophy and multiple ischemic lesions (Fig. 1b) in both medium-sized superficial and deep, posterior and middle cerebral artery territories. Skin biopsy revealed intra-capillary and parietal widespread thrombosis (Fig. 1c). As for the first patient, oral anticoagulants were added to therapy. G. Cirillo A. Tessitore (&) F. Salemi S. Liguori S. Esposito G. Tedeschi Department of Neurology, Second University of Naples, 80138 Naples, Italy e-mail: alessandro.tessitore@unina2.it

Preclinical atherosclerosis and metabolic syndrome increase cardio- and cerebrovascular events rate: a 20-year follow up

BackgroundIntima-media thickness (IMT) is a validated marker of preclinical atherosclerosis and a predictor of cardiovascular events.PatientsWe studied a population of 529 asymptomatic patients (age 62 ± 12.8 years), divided into two groups of subjects with and without Metabolic Syndrome (MetS).MethodsAll patients, at baseline, have had a carotid ultrasound evaluation and classified in two subgroups: the first one without atherosclerotic lesions and the second one with preclinical atherosclerosis (increased IMT or asymptomatic carotid plaque). Cardiovascular endpoints were investigated in a 20-years follow-up.ResultsThere were 242 cardiovascular events: 144 among patients with MetS and 98 among in healthy controls (57.4% vs. 35.2%; P < 0.0001). 63 events occurred in patients with normal carotid arteries, while 179 events occurred in patients with preclinical atherosclerosis (31.8% vs. 54.1%; P < 0.0001). Of the 144 total events occurred in patients with MetS, 36 happened in the subgroup with normal carotid arteries and 108 in the subgroup with preclinical atherosclerosis (45% vs. 63.15%; P = 0.009). 98 events occurred in patients without MetS, of which 27 in the subgroup with normal carotid arteries and 71 in the subgroup with preclinical atherosclerosis (22.88% vs. 44.37%; P = 0.0003). In addition, considering the 63 total events occurred in patients without atherosclerotic lesions, 36 events were recorded in the subgroup with MetS and 27 events in the subgroup without MetS (45% vs. 22.88%; P = 0.0019). Finally, in 179 total events recorded in patients with preclinical carotid atherosclerosis, 108 happened in the subgroup with MetS and 71 happened in the subgroup without MetS (63.15% vs. 44.37%; P = 0.0009). The Kaplan-Meier function showed an improved survival in patients without atherosclerotic lesions compared with patients with carotid ultrasound alterations (P = 0.01, HR: 0.7366, CI: 0.5479 to 0.9904).ConclusionsPreclinical atherosclerosis leads to an increased risk of cardiovascular events, especially if it is associated with MetS.