Duplex Scanning Of Carotid Arteries Research Articles

INTERRELATION BETWEEN CARDIOVASCULAR RISK FACTORS AND TELOMERE BIOLOGY WITH THE SIGNS OF VASCULAR AGING

Aim.To study interrelationship between cardiovascular risk factors and cellular and vascular aging processes. Material and methods. Totally 136 patients were included having no signs of cardiovascular diseases, diabetes 2nd type and receiving no drug therapy, but with one or several risk factors for cardiovascular diseases (smoking, arterial hypertension, obesity, dyslipidemia, fasting hyperglycemia). The telomere length and telomerase activity was measured by polymerase chain reaction. The thickness of intima-media complex (TIMC) and presence of atherosclerotic plaques (ASP) were measured by duplex scanning of right and left carotid arteries. Pulse wave velocity (PWV) was measured by applanation tonometry. Biochemical tests done by standard.Results.PWV significantly correlated with age, body mass index, glycosilated hemoglobin level, fasting glycemia and telomere length. Presence of ASP and increased TIMC significantly correlated with age, body mass index, arterial hypertension, dyslipidemia.Conclusion.Increase of arterial wall stiffness and subclinical atherosclerotic disease have different causes. The level of PWV more linked with carbohydrate metabolism disorder, and TIMC and ASP are linked with lipid disorders.

Lipoprotein-associated phospholipase A2: relation to development of ischemic stroke in patients with essential hypertension

to investigate association of lipoprotein-associated phospholipase A2 (Lp-PLA2) level (mass) with ischemic stroke in patients with essential hypertension (EH) with or without dyslipidemia. We examined 60 patients with EH without complications and 90patients with EH and history of ischemic stroke. Examination included measurement of height, weight, waist, blood pressure and heart rate, determination of glucose, creatinine, lipid profile, Lp-PLA2 mass, and duplex scanning of carotid arteries. All patients were divided into 2groups: A) with high (n=70), and B) normal or mildly elevated (n=80) levels of low density lipoprotein cholesterol (LDLC). In group A (LDLC <3.4 mmol/L) Lp-PLA2 mass in patients with stroke was higher than in patients with uncomplicated EH; age and elevated Lp-PLA2 mass were independently associated with history of stroke. In group B (LDLC >3.4 mmol/L) Lp-PLA2 mass did not differ between patients with EH with or without stroke while low level of high density lipoprotein cholesterol was most significantly associated with history of stroke. These results suggest that the role of LP-PLA2 in the development of ischemic stroke is reduced in the presence of evident dyslipidemia and high level of traditional cardiovascular risk factors. However, in the presence of low level of traditional metabolic risk factors proinflammatory substances and LP-PLA2 in particular acquire dominant role in the processes of atherogenesis and plaque destabilization.

CAROTID ARTERY DUPLEX SCAN IN DIAGNOSING CORONARY ATHEROSCLEROSIS AND ASSESSING ITS SEVERITY

Aim. To assess the role of carotid artery duplex scan in diagnosing coronary atherosclerosis of varied severity. Material and methods. The study included 194 patients (126 men and 68 women) aged 33-85 years who were hospitalised to the State Research Centre for Preventive Medicine and underwent coronary artery angiography and carotid artery duplex scan. The severity of coronary atherosclerosis at coronary artery angiography was assessed by the Gensini score. Results. The combination of carotid and coronary artery atherosclerosis was observed in 74,7% of the patients. Among those with carotid atherosclerosis, coronary atherosclerosis was registered in 92,4%. This suggests that carotid artery duplex scan is highly sensitive in diagnosing coronary atherosclerosis, despite its low specificity (27,0% patients without carotid atherosclerosis had coronary atherosclerosis). Positive predictive value (likelihood of disease in those with positive test results) of carotid artery duplex scan was 84%. Patients with carotid atherosclerotic plaques had significantly higher Gensini scores than patients with atherosclerosis-free carotid arteries (32 vs. 3,5, respectively; p=0,012), which suggests more severe coronary atherosclerosis in the presence of carotid atherosclerotic plaques. The intima-media thickness values over 0,9 mm were associated with higher Gensini scores (11 vs. 32,5, respectively; p=0,003), confirming more severe coronary atherosclerosis in these patients. Participants with severe coronary atherosclerosis had 3 or more carotid atherosclerotic plaques (p&lt;0,01), typically of heterogeneous structure (p=0,03). The highest Gensini scores were observed in patients with atherosclerotic plaques in common carotid arteries. Conclusion. The results obtained suggest that carotid artery duplex scan is highly informative in diagnosing coronary atherosclerosis and assessing its severity.

Clinical and pathogenetic aspects of hypertensive crises in patients with early signs of chronic cerebrovascular diseases

The aim of the present retrospective study was the analysis of characteristics of early signs of chronic cerebrovascular diseases in patients with hypertension of grades 1 or 2 suffering from hypertensive crises of various severity. We developed uniform diagnostic criteria for hypertensive crises that allowed to identify them and to assess their rate and severity. We studied 109 men and women (age 50–69) with hypertension, who were divided into 2 groups: patients who suffered from hypertensive crises (n=65) and patients with no crises (n=44). Complex assessment included 24-hour blood pressure monitoring, echocardiography, duplex scan of carotid, vertebral and cerebral arteries, and MRI of the head. Clinical and pathogenetic features of the development and progression of chronic cerebrovascular diseases in patients with hypertension were disclosed, and profile characteristics of such a type of patients with hypertensive crisis were described. We plan to continue the prospective follow-up and to assess the efficacy of antihypertensive treatment for the prevention of recurrent crises.

There is No Benefit to Universal Carotid Artery Duplex Screening before a Major Cardiac Surgical Procedure

Perioperative stroke is a devastating complication after cardiac surgery. In an attempt to minimize this complication, many cardiac surgeons routinely preoperatively order carotid artery duplex scans to assess for significant carotid stenosis. We hypothesize that the routine screening of preoperative cardiac surgery patients with carotid artery duplex scans detects few patients who would benefit from carotid intervention or that a significant carotid stenosis reliably predicts stroke risk after cardiac surgery. A retrospective review identified 1,499 patients who underwent cardiac surgical procedures between July 1999 and September 2010. Data collected included patient demographics, comorbidities, history of previous stroke, preoperative carotid artery duplex scan results, location of postoperative stroke, and details of carotid endarterectomy (CEA) procedures before, in conjunction with, or after cardiac surgery. Statistical methods included univariate analysis and Fisher's exact test. Twenty-six perioperative strokes were identified (1.7%). In the 21 postoperative stroke patients for whom there is complete carotid artery duplex scan data, 3 patients had a hemodynamically significant lesion (>70%) and 1 patient underwent unilateral carotid CEA for bilateral disease. Postoperative strokes occurred in the anterior cerebral circulation (69.2%), posterior cerebral circulation (15.4%), or both (15.4%). Patient comorbidities, preoperative carotid artery duplex scan screening velocities, or types of cardiac surgical procedure were not predictive for stroke. Thirteen patients (0.86%) underwent CEA before, in conjunction with, or after cardiac surgery. Two of these patients had symptomatic disease, 1 of whom underwent CEA before and the other after his cardiac surgery. Of the 11 asymptomatic patients, 2 underwent CEA before, 3 concurrently, and 6 after cardiac surgery. Left main disease (≥50% stenosis), previous stroke, and peripheral vascular disease were found to be statistically significant predictors of carotid revascularization. A cost analysis of universal screening resulted in an estimated net cost of $378,918 during the study period. The majority of postoperative strokes after cardiac surgery are not related to extracranial carotid artery disease and they are not predicted by preoperative carotid artery duplex scan screening. Consequently, universal carotid artery duplex scan screening cannot be recommended and a selective approach should be adopted.

Co-Existence of Carotid Artery Disease, Renal Artery Stenosis, and Lower Extremity Peripheral Arterial Disease in Patients With Coronary Artery Disease

In atherosclerosis, carotid artery stenosis (CAS), renal artery stenosis (RAS), lower extremity peripheral arterial disease (PAD), and coronary artery disease (CAD) are common pathologic lesions; their interrelationship is, however, unclear. We studied concomitant multiple atherosclerotic lesions in patients with CAD to understand their prevalence and relations. A cross-sectional analysis was performed on data from consecutive patients who underwent nonemergent coronary angiography. Simultaneous carotid and renal artery Doppler studies and ankle-brachial systolic pressure measurements were reviewed to diagnose concomitant lesions and their severity. The study included 1,734 patients (aged 71 ± 9 years; 70% men), with prevalences of CAS, RAS, lower extremity PAD, and CAD of 6%, 7%, 13%, and 72%, respectively. In patients with CAD (n = 1,253), the prevalences of CAS, RAS, and lower extremity PAD were 7%, 9%, and 16%, respectively; 24% CAD patients had ≥1 additional atherosclerotic lesion. Significant interactions among the prevalences of these lesions were found. In addition, the extent of CAD and the prevalences of CAS, RAS, and lower extremity PAD were significantly correlated. Multivariate analysis supported these relationships. In conclusion, the prevalences of CAS, RAS, lower extremity PAD, and CAD were strongly interrelated in the study population; CAD severity was related to that of other atherosclerotic lesions. Additional systematic screening of other concomitant atherosclerotic lesions is recommended, especially in CAD patients having multivessel disease, left main disease, and/or already diagnosed with other concomitant atherosclerotic lesions.

Part Two: Against the Motion. Completion Angiography is Unnecessary Following Carotid Endarterectomy

Part Two: Against the Motion. Completion Angiography is Unnecessary Following Carotid Endarterectomy

Part One: For the Motion. Completion Angiography Should be Used Routinely Following Carotid Endarterectomy

Part One: For the Motion. Completion Angiography Should be Used Routinely Following Carotid Endarterectomy

The features of time characteristics of heart rate variability in chronic obstructive pulmonary disease

Aim. To study the features of time characteristics of heart rate variability during isolated chronic obstructive pulmonary disease, as well as in association with arterial hypertension and ischemic heart disease. Methods. The characteristics of heart rate variability using Holter electrocardiography monitoring, echocardiography and duplex scanning of carotid arteries were studied. The results of investigations of 298 individuals of both sexes aged 37-78 years were included into the analysis, including 79 patients with chronic obstructive pulmonary disease who were divided into three groups. The first group included 19 patients with isolated chronic obstructive pulmonary disease, the second group consisted of 25 patients with chronic obstructive pulmonary disease and arterial hypertension, the third group included 35 patients with chronic obstructive pulmonary disease and ischemic heart disease, who were divided into two subgroups: patients with (n=9) and without (n=26) a prior history of myocardial infarction. For comparison, examined were 48 patients with isolated hypertension, 132 patients with ischemic heart disease and 39 practically healthy individuals. Results. In patients with isolated chronic obstructive pulmonary disease an autonomic imbalance occurs in the form of a uniform decrease in the activity of the parasympathetic nervous system during the day and an increase of the night time heart rate, identifiable are the signs of subclinical cardiac pathology in the form of thickening of the «intima-media» complex and the formation of atherosclerotic plaques in the carotid arteries, hypertrophy of the myocardium and left ventricular diastolic dysfunction, reduced systolic velocity of the mitral valve fibrous annulus. If chronic obstructive pulmonary disease is combined with aerterial hypertension and ischemic heart disease, as opposed to isolated cardiac pathology, a monotonic tachycardia develops during the day. In cases of concomitant chronic obstructive pulmonary disease and arterial hypertension during a simultaneous decrease in all time characteristics of heart rate variability, in most patients hypertrophy of both ventricles can be visualized. Conclusion. In patients with chronic obstructive pulmonary disease the time characteristics of heart rate variability depend on the presence or absence of concomitant diseases of the cardiovascular system.

HIGH HEART RATE AS A POTENTIAL RISK FACTOR FOR DEVELOPMENT OF CARDIOVASCULAR DISEASES IN WOMEN WITH RHEUMATOID ARTHRITIS

Aim. To study relationship between heart rate (HR) and traditional risk factors for cardiovascular diseases (TRF for CVD), subclinical structural and functional changes in the heart and vessels, as well as the activity and severity of rheumatoid inflammation in women with rheumatoid arthritis (RA). Material and methods. A total of 291 female patients less than 60 years of age with a definite diagnosis of RA were examined. The control group consisted of 125 women without rheumatic diseases. Aside from clinical symptoms, activity and severity level of RA, the presence of main TRF for CVD were assessed, 24 h Holter ECG monitoring (24-h ECG), duplex scanning of common carotid arteries, transthoracic echocardiography were performed and the serum levels of inflammatory markers were determined. Results. RA patients compared with the control group women had higher values of minimum (52.3±0.4 vs 47.5±0.4; p&lt;0.001) and mean (78.5±0.5 vs 75.5±0.5; p&lt;0.001) HR according to 24-h ECG, after adjustment for main TRF for CVD (age, arterial hypertension, menopause, levels of total cholesterol, triglycerides, high density lipoprotein cholesterol). Accelerated HR in RA directly correlated with an increased joint functional disability index - HAQ, RA severity index, the level of inflammatory markers and administration of leflunomide after adjustment for age (р&lt;0.05). Patients with HR≥86 beats per minute compared with RA patients with values of HR≤71 beats per min had lower total cholesterol (5.84±0.13 vs 5.11±0.17; p=0.001) and low density lipoprotein cholesterol levels (4.06±0.13 vs 3.28±0.18; p=0.001), longer duration, higher activity (Visual Analog Pain Scale, DAS28, extra-articular manifestations of RA, concentration of proinflammatory markers) and severity level of RA (severity index, HAQ, radiological stage III/IV), as well as higher percentage of left ventricular diastolic dysfunction (LVDD) after adjustment for age. Conclusion. According to 24-h ECG, an increase in mean HR values in women with RA is associated with activity , severity of rheumatoid inflammation and LVDD. Prospective studies are needed to determine the role of accelerated HR as a risk factor for development of CVD and the feasibility of preventive measures creation aimed to lower HR to prevent cardiovascular events in RA.

THE RELATIONSHIP OF CARDIOVASCULAR RISK FACTORS AND ARTERIAL WALL STIFFNESS IN WOMEN WITH A HIGH ACTIVITY OF RHEUMATOID ARTHRITIS

Aim. To study the relationship of arterial stiffness (determined by contour analysis of peripheral pulse wave) with cardiovascular risk factors in women with rheumatoid arthritis (RA). Material and methods. Women with high activity of RA (n=130) were examined. Women without rheumatic diseases (n=25) were included into control group. Assessment of the major traditional risk factors (TRF) of cardiovascular disease (CVD), duplex scanning of the common carotid arteries, transthoracic echocardiography (Echo-CG), and determination of serum inflammation marker levels were performed, in addition to evaluation of clinical symptoms, RA activity and severity. Indicators of digital pulse volume were determined by photoplethysmography. Results. Young and middle aged patients with RA after adjusting for the major TRF of CVD compared with women without RA have higher stiffness index (SI), reflecting increased stiffness of large arteries, and reflection index (RI), that shows raised tone of small arteries. The value SI&gt;9.6 m/s or RI&gt;70% is associated with a higher rate of diastolic dysfunction (DD), and left ventricular hypertrophy (LVH), while the more severe RA [high frequency III/IV radiographic stage, high levels of IgM rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP)] and the history of inefficacy of tumor necrosis factor-α (TNF-α) inhibitors in the absence of significant differences in TRF of CVD. SI and RI values in patients treated with methotrexate were significantly lower than in patients receiving other basic anti-inflammatory drugs or not treated patients. Conclusion. Increased arterial stiffness that is associated with the development of DD and LVH, irreversible joint damages, higher IgM RF and anti-CCP levels may be one of the possible mechanisms of the relationship of RA severity and increased risk of cardiovascular complications. RI determination can be used for screening of LVH in women with RA of high activity.

Recurrent Amaurosis Fugax in a Patient after Stanford Type A Dissection Depending on Blood Pressure and Haemoglobin Level

Purpose. A transient painless monocular visual loss due to a decrease in retinal circulation—also known as “amaurosis fugax”—often precedes acute territorial cerebral ischaemia. The case we present underlines the importance of a comprehensive diagnostic workup in patients with amaurosis fugax. Case Report. A 44-year-old man who had suffered from a dissection of the ascending aorta (Stanford Type A) five months ago presented with recurrent monocular vision problems. Episodes with sectional vision loss mainly occurred in combination with low blood pressure levels. Furthermore, the haemoglobin level was chronically low (Hb 9.7 mg/dL), and the patient was by mistake on a simultaneous therapy with phenprocoumon and unfractionated heparin. Carotid artery duplex scanning revealed a high-grade stenosis of the proximal right common carotid artery. MR imaging corroborated hypoperfusion in brain area corresponding to the right MCA. Conclusion. Our patient is an example in whom transient retinal ischaemic attacks may originate from haemodynamic reasons.

Autonomic nervous system state, calcium channel activity and gene polymorphisms of angiotensin-converting enzyme inhibitor and β2-adrenergic receptor in patients with complicated essential arterial hypertension

Objective: to study the state of the autonomic nervous system (ANS), gene polymorphism of angiotensin-converting enzyme (ACE) and β 2 -adrenergic receptors, and intracellular calcium metabolism in patients with essential hypertension (EH) with a complicated course of the disease (left ventricular hypertrophy (LVH ) and ischemic stroke). Materials and methods: A total of 250 Kirgiz male with EH, among them 180 patients without stroke, 70 patients who had ischemic stroke and 35 patients with LVH were examined. Control group -19 healthy peoples. It were performed daily blood pressure monitoring, echocardiography, duplex scanning of carotid arteries, the activity of calcium channels, spectral analysis of heart rate variability (HRV) during active tilt-test and genotyping on ACE and the β 2 -adrenergic receptors. Results: It was observed a significant reduction of HRV and decreased response of LF (low frequency) component to tilt-test in hypertensive patients, compared to control. Tilt-test in patients with complications of EH had shown inverse response of LF to orthostatic test. It was found hyperactivity of ATP/ADP dependent calcium channels in platelets in patients with EH during the development of LVH. Patients with Gln27Gln genotype in compare to other variants of Gln27Glu polymorphism of β 2 -AR were characterized by increasing meanings of BP and its morning raises which possibly may cause increasing of left ventricular mass in these patients. 3. Our data support an association between I/D polymorphism and stroke in patients with EH. Presence of DD genotype may be considered as independent from daily profile of BP and intima-media thickness predictor of ischemic stroke in patients with EH. Conclusion: We propose several possible clinical and genetic predictors of complicated EH (rigid response of LF-component during tilt-test, the presence of hyperactivity calcium channel, carrier of Gln27Gln polymorphism of β 2 -adrenergic receptors and I/D polymorphism of ACE gene).

Biomarkers of Asymptomatic Carotid Stenosis in Patients Undergoing Coronary Artery Bypass Grafting

Carotid artery stenosis is an important etiologic factor of stroke related to coronary artery bypass surgery. We evaluated clinical and laboratory factors to identify biomarkers for pre-existing carotid artery stenosis in patients undergoing coronary artery bypass surgery. Between June 2006 and September 2008, 811 patients aged ≥50 years underwent preoperative carotid artery duplex scanning as part of a preoperative assessment for nonemergency cardiac procedures. Of these, 54 patients with previous stroke or transient ischemic attack were excluded. The association between various biomarkers and carotid artery stenosis was analyzed by multiple logistic regression analysis. The receiver operating characteristic curves were generated and analyzed to compare diagnostic performance and optimum diagnostic cutoff levels of biomarkers. A total of 757 patients was included in the study. The prevalence of asymptomatic carotid stenosis of ≥50% and ≥70% was 26.4% and 8.6%, respectively. In multivariate analysis, plasma levels of apolipoprotein B (apoB):apoA-I, lipoprotein(a), and homocysteine were independently associated with carotid stenosis of ≥50%: the OR (95% CI) for apoB/apoA-I, lipoprotein(a), and homocysteine in the highest versus lowest quartile was 2.07 (1.18 to 3.66), 2.17 (1.16 to 4.05), and 2.13 (1.20 to 3.79), respectively. Receiver operating characteristic curve analysis indicated area under the curve values of 0.708 (apoB:apoA-I), 0.678 (lipoprotein[a]), and 0.689 (homocysteine). The sensitivity, specificity, positive and negative predictive values (%) for diagnosis of carotid stenosis ≥50% were 80.0, 50.4, 38.0, and 86.9 for apoB:apoA-I; 47.0, 78.9, 46.1, and 79.5 for lipoprotein(a); and 69.3, 62.1, 41.2, and 84.1 for homocysteine, respectively. Our findings indicated that plasma levels of apoB/apoA-I, lipoprotein(a), and homocysteine can predict asymptomatic carotid stenosis in patients undergoing coronary artery bypass surgery.

Risk factors of stroke and delirium after off-pump coronary artery bypass surgery

Off-pump coronary artery bypass surgery (CABG) has not abolished the risk of postoperative stroke and delirium seen for on-pump CABG. Advanced arteriosclerotic changes are common in both on-pump and off-pump CABG. We sought to analyze if advanced arteriosclerotic changes are risk factors of stroke or transient ischemic attack (TIA), and delirium after off-pump CABG. Patients undergoing off-pump CABG between 2001 and 2005 were reviewed using medical records (n=685). Potential risk factors of postoperative stroke and delirium were identified from previous studies. Further, variables retrieved from carotid artery duplex scanning as indices of advanced arteriosclerosis, were examined. The incidences of postoperative stroke/TIA and delirium after off-pump CABG were 2.6% (n=18) and 16.4% (n=112), respectively. Carotid artery stenosis >50% was a significant risk factor of stroke or TIA (P=0.02) as well as delirium (P=0.04) after off-pump CABG. A history of atrial fibrillation (AF) (P=0.037) or diabetes mellitus (P=0.041) was a risk factors of postoperative stroke or TIA. In contrast, age over 75 years (P=0.006), creatinine >1.3 mg/dl (99 μmol/l) (P=0.011), a history of hypertension (P=0.001), past history of AF (P=0.024), and smoking (P=0.048) were significant risk factors of postoperative delirium.

Part One: For the Motion Carotid Disease is Rarely Responsible for Stroke after Coronary Bypass Surgery

Part One: For the Motion Carotid Disease is Rarely Responsible for Stroke after Coronary Bypass Surgery

Prospective evaluation of the relationship between C-reactive protein, D-dimer and progression of peripheral arterial disease

Elevated levels of C-reactive protein (CRP) and D-dimer (DD) have been associated with the presence and progression of various forms of atherosclerotic disease, particularly coronary heart disease. We hypothesize that there is a relationship between elevated levels of baseline CRP and DD and progression of peripheral arterial disease (PAD) in patients with symptomatic PAD. The current study is a prospective evaluation of this hypothesis. Between 1996 and 2003, 384 subjects were enrolled in a National Institutes of Health-sponsored blinded, prospective trial evaluating the effects of multiple atherosclerotic risk factors on progression of symptomatic PAD. Baseline levels of CRP and D-dimer were obtained in 332 subjects. Subjects were followed every 6 months with clinical history and exam, ankle-brachial pressure index (ABI), and carotid artery duplex scanning (CDS). The primary study end point was a composite of ABI progression, CDS progression, stroke, myocardial infarction, amputation, and death from cardiovascular disease. Secondary end points included each of the components of the primary end point. The relationship between time to the various endpoints and baseline CRP and DD levels was examined by life-table analysis and Cox proportional hazards analysis. Adequate baseline samples for CRP and DD were available in 332 subjects (mean age, 67 years; 57.8% men) with mean follow-up of 38.4 months (range, 1 to 99 months). Mean baseline levels (+/- SD) for CRP were 0.8 +/- 1.14 (range, 0.03 to 13.0), and mean DD levels were 227.4 +/- 303.3 (range, 1.9 to 2744.8). Progression, as defined by the primary end point, occurred in 48.5% of subjects. Subjects with elevated CRP (highest tertile) were no more likely to have any of the progression end points than those with the lowest values (lowest tertile) (P = NS, log-rank test, for all comparisons). By univariate analysis, subjects with elevated DD (highest tertile) were significantly more likely to die from any cause compared with subjects with the lowest DD values (lowest tertile) (P = .03, log-rank test). They were, however, no more likely to reach any of the other progression end points, including the primary end point (P = NS, log-rank test for all other comparisons). Multivariate analysis showed that DD level was a significant independent variable associated with occurrence of myocardial infarction (hazard ratio, 2.3; P = .02). In subjects with symptomatic PAD, elevated baseline DD, a marker of thrombotic activity, was significantly associated with the occurrence of myocardial infarction. This study did not confirm a relationship between progression of PAD and baseline DD or CRP during the first 3 years. Baseline DD and CRP do not provide useful risk stratification in patients at high risk for progression of symptomatic PAD. Future studies should evaluate serial levels of these markers to assess their utility in predicting progression of symptomatic PAD.

Acute phenytoin toxicity mimicking stroke following cardiopulmonary bypass

A 55-year-old diabetic, hypertensive and dyslipidemic male with functional class III angina was admitted for coronary revascularization. Patient had a history of stroke with left hemiparesis five years ago, with complete recovery within a year. He had one episode of seizure three years back but did not seek any medical advice. Cardiac evaluation revealed triple vessel disease with fair left ventricular function without any intracardiac clots. Liver function test revealed SGOT of 48 u/L and SGPT of 56 u/L (normal range up to 40 u/l). Ultrasonography of abdomen showed fatty liver. Carotid artery duplex scanning showed 30% stenosis of right and 45% stenosis of left internal carotid artery. Computerised tomography (CT) of brain revealed chronic infarct in right frontal and gangliocapsular region. Electroencephalogram three weeks prior to surgery showed a spike and wave discharge over temporal areas consistent with seizure disorder, and patient was started on oral Phenytoin 100 mg thrice daily. He underwent coronary artery bypass grafting under CPB. Postoperatively hemodynamics remained stable. Oral aspirin and Phenytoin were restarted on first postoperative day. He was initially in a state of confusion, and, on the 3rd postoperative day, developed pronounced ataxia, nystagmus, dysarthria and vomiting. A likely clinical diagnosis of posterior circulation stroke was considered. CT scan ruled out a hemorrhagic stroke but could not rule out new embolic phenomena. Heparin infusion was thus started empirically. The neurological status was slowly deteriorating. MRI done on the fifth postoperative day revealed no fresh structural lesions in the brain. At this stage a likely possibility of Phenytoin toxicity was considered. Serum total Phenytoin concentration estimation revealed a toxic level of 40 microgram/ deciliter. (Therapeutic range 10-20 mcg/dl) which clinched the diagnosis. Patient also had hyponatremia requiring frequent corrections, however levels of urinary sodium were low. Phenytoin was stopped and patient showed good recovery with no residual neurological deficit within 15 days. At discharge his serum Phenytoin level was within normal range and he was advised to remain under a neurologist follow up.

Asymptomatic carotid murmur: ultrasonic factors influencing outcome.

Sixty consecutive patients with an asymptomatic mid-cervical murmur on auscultation were identified amongst 1000 patients who underwent duplex scanning of the extracranial carotid arteries during 1981-83. They were classified according to the scan results into 12 high risk subjects with greater than 75 per cent stenosis of an internal carotid artery, 37 low risk subjects with a less than 75 per cent stenosis and 6 with no detectable stenosis. The mean duration of follow-up was 3 years (minimum 2 years) or until stroke or death. One was lost to follow-up and four were excluded having undergone carotid endarterectomy during the study. Six of twelve subjects with greater than 75 per cent stenosis suffered a stroke (five fatal and one non-fatal). There were no premonitory signs except in one patient with non-focal cerebral ischaemia for 2 months before an hemispheric stroke. There was one fatal stroke in the less than 75 per cent stenosis group and none in the control group. In all, 17 (28 per cent) patients died (myocardial infarction, 8; stroke, 6; malignant disease, 3). These results confirm that asymptomatic carotid murmurs are associated with increased mortality with most having non-severe carotid disease on duplex scanning and few strokes during follow-up. There is an important minority with tight carotid stenosis who carry a worrying risk of stroke if left untreated.

Predictive value of asymptomatic cervical bruit for carotid artery disease in coronary artery surgery revisited

Objective To investigate the predictive value of asymptomatic cervical bruit for detecting internal carotid artery disease in consecutive patients undergoing coronary artery bypass grafting (CABG). Design A prospective cohort study. Setting Tertiary referral university hospitals. Patients 153 consecutive patients (mean age 57 years) undergoing CABG, without previous history of cerebrovascular events. Interventions Patients underwent detailed pre-operative work-up, including coronary angiography and carotid artery duplex scanning. Internal carotid artery diameter stenosis was graded as A: normal; B: < 15%; C: 15%–50%; D: 50–80%; D+: > 80–99% and E = complete occlusion. Results 72 patients (47.1%) (95% CI: 39%, 55%) had no evidence of internal carotid artery stenosis; 81 (52.9%) (95% CI: 44.9%, 60.9%) had varying grades of disease, unilateral or bilateral. Cervical bruit was detected in 12 / 153 patients (7.8%) (95% CI: 3.5%, 12.1%) of whom all but one (0.7%) had varying grades of internal carotid artery disease; of these, 4 patients had bilateral cervical bruit (2.6%) (95% CI: 0.06%, 5.2%). The sensitivity, specificity, positive and negative predictive values and overall accuracy of cervical bruit for detection of ≥ 50% internal carotid artery stenosis were 23.5%, 95.8%, 25%, 95.5% and 91.8%, respectively. The relative risk of ≥ 50% stenosis ipsilateral to cervical bruit in 306 sides was 5.58 (95% CI: 2.0, 15.0) and the odds ratio 7.1 (95% CI: 2.0, 25.0). Conclusions Asymptomatic cervical bruit proved a highly specific clinical sign for detection of internal carotid artery stenosis, whether haemodynamically significant (≥ 50%) or otherwise, in patients undergoing myocardial revascularisation. This was matched by a high negative predictive value and overall accuracy for flow limiting atheroma (≥ 50% stenosis). Yet, steering carotid investigations on the basis of cervical bruit alone would result in ≥ 80% internal carotid artery stenosis remaining undetected in 3% of overall patients, in whom cervical bruit is absent.