Pre-existing Vascular Disease Research Articles

Dyslipidemia

Dyslipidemia

Subclinical Thyroid Dysfunction and Cognitive Decline in Old Age

BackgroundSubclinical thyroid dysfunction has been implicated as a risk factor for cognitive decline in old age, but results are inconsistent. We investigated the association between subclinical thyroid dysfunction and cognitive decline in the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER).MethodsProspective longitudinal study of men and women aged 70–82 years with pre-existing vascular disease or more than one risk factor to develop this condition (N = 5,154). Participants taking antithyroid medications, thyroid hormone supplementation and/or amiodarone were excluded. Thyroid function was measured at baseline: subclinical hyper- and hypothyroidism were defined as thyroid stimulating hormones (TSH) <0.45 mU/L or >4.50 mU/L respectively, with normal levels of free thyroxine (FT4). Cognitive performance was tested at baseline and at four subsequent time points during a mean follow-up of 3 years, using five neuropsychological performance tests.ResultsSubclinical hyperthyroidism and hypothyroidism were found in 65 and 161 participants, respectively. We found no consistent association of subclinical hyper- or hypothyroidism with altered cognitive performance compared to euthyroid participants on the individual cognitive tests. Similarly, there was no association with rate of cognitive decline during follow-up.ConclusionWe found no consistent evidence that subclinical hyper- or hypothyroidism contribute to cognitive impairment or decline in old age. Although our data are not in support of treatment of subclinical thyroid dysfunction to prevent cognitive dysfunction in later life, only large randomized controlled trials can provide definitive evidence.

Hepatic inflammation and fibrosis biomarkers are associated with cardiovascular risk factors but not cardiovascular disease in people with type 2 diabetes: the Edinburgh Type 2 Diabetes Study

BackgroundBoth cardiovascular disease and liver disease are particularly common in people with type 2 diabetes and it is possible that the two conditions are inter-related. Non-invasive biomarkers are increasingly used to estimate liver inflammation and fibrosis. In this study the association of these biomarkers with cardiovascular risk factors and disease was explored in a large, representative population of people with type 2 diabetes mellitus. MethodsCytokeratin 18 (CK18, biomarker of hepatic inflammation) and the European Liver Fibrosis panel (ELF, biomarker of hepatic fibrosis) were measured in a random subgroup of 564 adults, aged 60–75 years at recruitment, participating in the Edinburgh Type 2 Diabetes Study (ET2DS). Data on conventional CV risk factors (body-mass index [BMI], waist circumference, blood pressure, total cholesterol, triglycerides, smoking status) and prevalent cardiovascular disease (validated myocardial infarction, angina, stroke and transient ischaemic attack events) were also available. FindingsMedian CK18 was 102 U/L [IQR 76–137, range 29–993] and mean ELF was 8·9 U/L [SD 0·8, range 6·9–11·6]. After adjustment for age and sex, increased CK18 was significantly associated with higher triglyceride levels (r=0·157, p=0·002). Increased ELF score was associated with higher BMI (r=0·202, p<0·001), waist circumference (r=0·139, p=0·008), and diastolic blood pressure (r=–0·045, p=0·025). Despite these associations, neither biomarker was significantly associated with prevalent cardiovascular disease (prevalent cardiovascular disease vs no cardiovascular disease, mean CK18 108·1 U/L [SD 26·2] vs 105·5 [22·6], p=0·473 and mean ELF 8·94 [0·77] vs 8·89 [0·76], p=0·442). InterpretationIn people with type 2 diabetes, non-invasive biomarkers of hepatic inflammation and fibrosis are associated with a number of cardiovascular risk factors but do not appear to associate with pre-existing vascular disease. Further investigation is required to determine whether liver biomarkers predict incident cardiovascular disease in this high risk group. FundingDiabetes UK.

Reclassification of Cardiovascular Risk in Patients With Normal Myocardial Perfusion Imaging Using Heart Rate Response to Vasodilator Stress

Previous studies have shown that patients with normal vasodilator myocardial perfusion imaging (MPI) findings remain at a greater risk of future cardiac events than patients with normal exercise MPI findings. The aim was to assess improvement in risk classification provided by the heart rate response (HRR) in patients with normal vasodilator MPI findings when added to traditional risk stratification. We retrospectively studied 2,000 patients with normal regadenoson or adenosine MPI findings. Risk stratification was performed using Adult Treatment Panel III framework. Patients were stratified by HRR (percentage of increase from baseline) into tertiles specific to each vasodilator. All-cause mortality and cardiac death/nonfatal myocardial infarction (MI) ≤2 years from the index MPI were recorded. During follow-up, 11.8% patients died and 2.7% patients experienced cardiac death/nonfatal MI in the adenosine and regadenoson groups, respectively. The patients who died had a greater Framingham risk score (12 ± 4 vs 11 ± 4, p= 0.009) and lower HRR (22± 16 vs 32 ± 21, p <0.0001). In an adjusted Cox model, the lowest tertile HRR was associated with an increased risk of mortality (hazard ratio 2.1) and cardiac death/nonfatal MI (hazard ratio 2.9; p <0.01). Patients in the highest HRR tertile, irrespective of the Adult Treatment Panel III category, were at low risk. When added to the Adult Treatment Panel III categories, the HRR resulted in net reclassification improvement in mortality of 18% and cardiac death/nonfatal MI of 22%. In conclusion, a blunted HRR to vasodilator stress was independently associated with an increased risk of cardiac events and overall mortality in patients with normal vasodilator MPI findings. The HRR correctly reclassified a substantial proportion of these patients in addition to the traditional risk classification models and identified patients with normal vasodilator MPI findings, who had a truly low risk of events.

Delirium, dementia and senility

Delirium is a neuropsychiatric syndrome characterized by sudden onset and global effects on degrees of consciousness, attention and cognition. It is now widely recognized that delirium is associated with high morbidity and mortality. Increasing age appears the strongest risk factor for delirium (Table 1). It affects up to 40% of all medically ill older adults. Delirium subsequent to surgical procedures, particularly those involving major fractures, cardiovascular grafting or organ transplantation is unpredictable, ranging 9–87% with an average of 40%, depending on the age of the patient, type of intervention and pre-existing vascular disease risks or infections (Cerejeira and Mukaetova-Ladinska, 2011). The presence of delirium complicates outcomes in the majority of ill patients, as demonstrated by longer hospital admission, and impact on daily performance, frequently leading to costly institutional care. In all these situations, it is necessary to ensure that delirium is consistently and correctly diagnosed. Being well qualified to make the diagnosis—as psychiatrist, neurologist or geriatrician—is an important consideration when reporting on the nature or consequences of delirium in any particular study. View this table: Table 1 Predisposing and precipitating biological factors associated with delirium Over and above the established immediate consequences, there also appears to be a link between delirium and long-term cognitive impairment (MacLullich et al ., 2009; Witlox et al ., 2010; de Lange et al ., 2012). Despite varied sample sizes, study designs, screening methods and origin of patients being studied, there is remarkable consistency of evidence that even a single episode of delirium is detrimental to cognitive function and may more than double the risk of dementia (Witlox et al ., 2010). An increased risk of poor cognitive outcome and dementia is particularly noteworthy in older adults who have …

Asymptomatic Carotid Artery Stenosis and Cognitive Outcomes After Coronary Artery Bypass Grafting

Conclusion: Asymptomatic >50% carotid stenosis is a risk factor for cognitive decline after coronary artery bypass grafting (CABG). Summary: Patients anticipate CABG will improve their quality of life (Koch CG et al, Semin Cardiothorac Vasc Anesth 2008;12:203-17). Preservation and improvement of psychologic emotional well-being enhances quality of life. Neuropsychologic disorders are being more frequently addressed in the care of the postoperative patient. Cerebrovascular disease and coronary artery disease potentially put patients at risk for cognitive decline. In this report, the authors correlate asymptomatic carotid stenosis with cognitive decline after coronary artery bypass grafting (CABG). They sought to detect the incidence of cognitive decline after CABG, identify risk factors associated with such cognitive decline, and investigate a possible link between cognitive performance and asymptomatic carotid stenosis. The authors studied 127 patients who underwent CABG. The patients underwent a neuropsychologic examination that included seven cognitive tests and two scales for evaluation of mood disorders. The patients were tested the day before surgery and before discharge from the hospital. Testing revealed that early postoperative decline was common and was detected in 46% of patients. Postoperative cognitive decline was associated with low cardiac output syndrome perioperatively (P < .05), postoperative bleeding (P = .03), longer duration of surgery (P = .02), and longer intensive care unit stay and postoperative mechanical ventilation time (P < .05). Multivariate regression analysis indicated carotid artery stenosis of >50% was a strong independent predictor of postoperative cognitive decline (odds ratio, 26.9; 95% confidence interval, 6.44-112.34). Comment: The authors' data indicate an association between cognitive decline after CABG and the presence of >50% carotid stenosis. One cannot, however, derive from this data that the carotid stenosis itself leads to cognitive decline after CABG. Indeed, we know that repair of asymptomatic carotid stenosis before CABG has minimal, if any, impact on more obvious clinical end points such as stroke and death after CABG. This study did not have cerebral imaging before and after CABG to correlate with the neurophysiologic testing. At this time, it seems more likely the carotid stenosis is more of a marker for more advanced preexisting intracranial vascular disease potentially associated with cognitive decline after CABG than a potential target for intervention to decrease cognitive decline after CABG.

Intima-media thickness predicts stroke risk in the Heinz Nixdorf Recall study in association with vascular risk factors, age and gender

Background and purposeIndividual risk stratification requires reliable information on preexisting vascular disease. The intima-media thickness of the common carotid artery (CIMT) is a non-invasively accessible marker of atherosclerosis, which can be used for risk evaluation. MethodsIn a sample of 3669 initially stroke-free subjects aged 45–75 years belonging to the population-based Heinz Nixdorf Recall cohort, the predictive value of CIMT for incident stroke was evaluated over 85.3 ± 17.4 months in addition to established risk factors. ResultsIn a multivariable Cox regression analysis with traditional cardiovascular risk factors including age, gender, systolic blood pressure, LDL and HDL, diabetes, body mass index, smoking and CIMT, CIMT was a moderate stroke predictor (hazard ratio = 1.20 per 0.1 mm, 95% confidence interval = 1.01–1.44; p = 0.043), additional to e.g. age (1.46 per 5 years, 1.21–1.75; p < 0.001), systolic blood pressure (1.16 per 10 mm Hg, 1.04–1.30; p = 0.008) and current smoking (1.93, 1.12–3.31; p = 0.014). CIMT was associated with stroke risk in subjects above but not below 65 years. CIMT predicted stroke events in men, but not women. CIMT discriminated stroke incidence specifically in subjects belonging to the highest Framingham risk score tercile. ConclusionsCIMT is a moderate independent stroke predictor, which discriminates stroke incidence in subjects at high vascular risk.

Microvascular dysfunction and pulse wave reflection characterize different vascular pathologies in patients at cardiovascular risk

Endothelial function and arterial pulse wave reflections play a crucial role in the pathogenesis of atherosclerosis. While the endothelium-dependent reactive hyperemia index (RHI) of the digital arteries is considered as a marker of microvascular function, an increased augmentation index (AI) may indicate beginning macrovascular damage. In this study we assessed the interrelationships among these noninvasive measures of vascular function. In 178 all-comer patients with documented cardiovascular risk factors (22 % female; 65 % coronary artery disease, CAD), we measured radial AI (rAI) by radial applanation tonometry and digital AI (dAI) as well as RHI by using fingertip peripheral arterial tonometry. A modified SMART risk score was calculated in all participants based on cardiovascular risk factors and preexisting vascular disease. dAI and rAI demonstrated a significant and robust overall correlation (Pearson rank coefficient r = 0.63, p < 0.01), which was not affected by age, sex, diabetes mellitus and CAD. In contrast, both parameters demonstrated at most a weak correlation (dAI: r = 0.26, p < 0.01 and rAI: r = 0.12, p = 0.10) with microvascular function (RHI). While dAI and rAI were significantly correlated to female sex, age, low body height, low heart rate and the presence of CAD, RHI was associated with the presence of diabetes mellitus and nicotine use. Finally, only microvascular function was associated with the modified SMART risk score, but not augmentation indices. RHI and increased pulse wave reflection appear to represent two distinct vascular pathologies in patients with cardiovascular risk. In contrast, RHI might be useful to identify patients at highest cardiovascular risk once atherosclerotic disease has been diagnosed.

Reduced EPO receptor expression may contribute to limited pleiotropic effects of EPO during critical illness

We showed neuroprotective and renoprotective effects of recombinant human erythropoietin (rhEPO) after kidney and spinal cord ischemia/reperfusion (I/R) injury [1,2], but clinical studies using rhEPO to prevent acute kidney injury yielded equivocal results [3,4]. Increased cytokine release and/or oxidative stress can cause EPO resistance due to receptor modification and/or downregulation [5]. Since we recently failed to confirm rhEPO-related kidney protection in atherosclerotic swine [6], we compared kidney EPO receptor expression in swine strains with and without pre-existing vascular disease and kidney dysfunction.

Carotid plaque and intima-media thickness and the incidence of ischemic events in patients with atherosclerotic vascular disease

We aimed to evaluate whether carotid intima-media thickness (CIMT) or the presence of plaque can confer additional predictive value of future cardiovascular (CV) ischemic events in patients with pre-existing atherosclerotic vascular disease. We identified 2317 patients enrolled in the REduction of Atherothrombosis for Continued Health (REACH) registry who had atherosclerotic vascular disease and baseline CIMT measurements. The entire range of CIMT was divided into quartiles and the fourth quartile (≥ 1.5 mm) was defined as carotid plaque. Mean ± standard deviation baseline CIMT was 1.31 ± 0.65 mm. Associated CV ischemic events and vascular-related hospitalizations were evaluated over a 2-year follow-up. There was a positive increase in adjusted hazard ratios (HRs) for all-cause mortality (p = 0.04 for trend) and the quadruple endpoint (CV death, myocardial infarction (MI), stroke, hospitalization for CV events) with increasing quartiles of CIMT (p = 0.0008 for trend), which was mainly driven by the fourth quartile (carotid plaque). HRs for all-cause mortality, CV death, CV death/MI/stroke and the quadruple endpoint comparing the highest (carotid plaque) with the lowest CIMT quartile were 2.09 (95% CI, 1.07-4.10; p = 0.03); 2.49 (1.10-5.67; p = 0.03); 1.71 (1.10-2.67; p = 0.02); and 1.73 (1.31-2.27; p = 0.0001). In conclusion, our analyses suggest that the presence of carotid plaque, rather than the thickness of intima-media, appears to be associated with increased risk of CV morbidity and mortality, but confirmation of these findings in other population and prospective studies is required.

235 Treatment and outcomes of acute coronary syndromes in relation to burden of pre-existing vascular disease

235 Treatment and outcomes of acute coronary syndromes in relation to burden of pre-existing vascular disease

Risk Factors for Anastomotic Leakage after Rectal Cancer Resection and Reconstruction with Colorectostomy. A Retrospective Study with Bootstrap Analysis

This study was designed to apply modern statistical methods to evaluate risk factors for anastomotic leakage after rectal cancer resection in a retrospective cohort of patients who received a colorectostomy. Whereas a diverting stoma and tumor height are considered proven risk factors for anastomotic leakage, a lack of evidence about additional risk factors persists. In a single-center study, 527 consecutive patients who received a colorectostomy after rectal cancer resection between 1991 and 2008 were retrospectively assessed. In addition to traditional uni- and multivariate regression, locally weighted scatterplot smoothing (LOWESS) regression and bootstrap analysis were applied to increase internal validity. Anastomotic leakage occurred in 70 patients (13.3%; 95% confidence interval (CI), 10.5-16.5%) and mortality was 2.5% (95% CI, 1.4-4.2%). Diverting stoma (odds ratio (OR), 0.4; 95% CI, 0.17-0.61) and tumor height (OR, 0.88; 95% CI, 0.8-0.94) were proven to be protective. Neoadjuvant radiotherapy (OR, 2.15; 95% CI, 1.58-4.24) and intraoperative blood loss (OR, 1.05; 95% CI, 1.02-1.09) had a derogatory effect. Bootstrap analysis identified pre-existing vascular disease (95.5%), more advanced UICC stage III or IV tumors (95.7% or 91.5%, respectively), and intraoperative (96.1%) and postoperative (99.4%) blood substitution as harmful. Both intraoperative and postoperative blood substitution caused a dose-dependent increase in risk. Applying statistical resampling methods identified intraoperative blood loss, blood substitution, vascular disease, and advanced UICC stage as risk factors for anastomotic leakage. Greater distances between the tumor and the anal verge and performance of a diverting stoma were associated with a decreased risk of anastomotic leakage.

Temporary axillobifemoral bypass as an adjunct to endovascular aneurysm repair using fenestrated stent grafts

Prolonged endovascular procedures requiring a large diameter sheath in each groin can be associated with significant intraoperative lower limb ischemia, particularly in those with pre-existing peripheral vascular disease. We report the case of a patient who suffered severe ischemia-reperfusion injury following endovascular repair of a pararenal aortic aneurysm using a fenestrated stent graft and describe the use of temporary axillobifemoral bypass in a patient with similar comorbidities undergoing the same procedure. We propose this adjunctive technique as a means of maintaining antegrade limb perfusion and avoiding the peripheral and central metabolic consequences of ischemia-reperfusion injury.

Is carotid intima media thickness useful for individual prediction of cardiovascular risk? Ten-year results from the Carotid Atherosclerosis Progression Study (CAPS)

Carotid intima media thickness (cIMT) is an intermediate phenotype of early atherosclerosis that independently predicts vascular events. It is often suggested that cIMT be used as a screening tool to select subjects with an elevated event risk. Whether cIMT adds information to traditional risk models has so far received little investigation. The 10-year follow-up of 4904 subjects from the Carotid Atherosclerosis Progression Study (CAPS) without pre-existing vascular disease included cardiovascular events and total mortality. Using Cox models and reclassification statistics, we investigated the usefulness of cIMT in individual risk prediction beyond the Framingham and the SCORE models, using risk strata of 0-5, 5-10, 10-20, and >or=20% over 10 years. Carotid intima media thickness was significantly and independently predictive for cardiovascular events. Compared with a model using the Framingham risk factors, a second model that included the common carotid-IMT led to the reclassification of 357 subjects (8.1%). In 107 subjects (30.0%), this reclassification was correct as confirmed with the actual outcome over 10 years. Net reclassification improvement was -1.41% (P = NS); integrated discrimination improvement was 0.04% (P = NS). More subjects were shifted to lower than to higher risk categories by the inclusion of cIMT. Analyses including other endpoint definitions, other carotid segments, and the SCORE risk model for baseline prediction did not result in consistently better risk prediction with cIMT. Despite cIMT being predictive for cardiovascular endpoints, it did not consistently improve the risk classification of individuals. Carotid intima media thickness may not be useful for the risk stratification of individuals in the general population.

Cocaine and the Heart

The use of cocaine may be associated with either acute or chronic toxicity, and approximately 5% to 10% of emergency department visits in the United States are believed to be secondary to cocaine usage. Chest pain is the most common cocaine-related medical problem, leading to the evaluation of approximately 64,000 patients annually for possible myocardial infarction, of which approximately 57% are admitted to the hospital, resulting in an annual cost greater than $83 million. There is a plethora of cocaine-related cardiovascular complications, including acute myocardial ischemia and infarction, arrhythmias, sudden death, myocarditis, cardiomyopathy, hypertension, aortic ruptures, and endocarditis. There is no evidence to suggest that preexisting vascular disease is a prerequisite for the development of a cocaine-related cardiovascular event, although it may be a potentiating factor, as may be nicotine and alcohol.

Dysrhythmias associated with cocaine overdose

Dysrhythmias associated with cocaine overdose

Spontaneous celiac artery dissection and its management.

Spontaneous visceral artery dissection is an uncommon event with an unpredictable natural history with superior mesenteric artery being the most common affected artery. It is most often asymptomatic and usually diagnosed at autopsy. Pre-disposing factors are not specific but have been suggested to be pre-existing vascular disease, hypertension and pregnancy. Spontaneous resolution, definitive occlusion of the artery, and formation of an aneurysm with associated complications are some other possible outcomes. Isolated dissection of the celiac artery (CA) is rare and there are only a few cases reported in the literature. We present a case of a 65 year old male with spontaneous celiac artery dissection and provide a review of the current literature about imaging findings and management of this entity.

Framingham Risk Score Inadequately Predicts Cardiac Risk in Young Patients Presenting with a First Myocardial Infarction

Introduction: The Framingham Risk Score (FRS) is a well-validated epidemiologic tool used to assess the risk for a first cardiac event. Because young patients presenting with a first myocardial infarction (MI) tend to have less significant risk profiles compared with older patients, we hypothesized that FRS may underestimate cardiac risk in these patients. Materials and Methods: We studied 1267 patients between January 2002 and November 2007 presenting with a first MI. Patients with pre-existing diabetes mellitus and vascular disease were excluded. FRS was calculated for each patient. Patients were divided based on their age: group A (&lt;40 years), group B (40 to 64 years) and group C (≥65 years). Results: The mean age was 54.7 ± 11 years, 88.4% of the patients were males. Younger patients were more likely to be assigned with lower scores. Based on FRS, 63.0%, 29.3% and 14.2% of group A, B and C patients were classified as low risk (10-year risk for cardiac events&lt;10%) respectively, P &lt;0.001. The sensitivity of FRS in identifying at least intermediate risk subjects (10-year risk for cardiac events &gt;10%) was 37.0% in group A vs 85.8% in group C (P &lt;0.001). The incidence of newly diagnosed diabetes mellitus was higher in younger patients (12.0% vs 13.2% vs 7.1 % in groups A, B and C respectively, P = 0.027). Conclusions: FRS inadequately predicts cardiac risk in young patients presenting with a first MI. This could be because a significant proportion of these young patients have undiagnosed diabetes mellitus, a coronary artery disease risk equivalent. Key words: Diabetes mellitus, Young myocardial infarction

Effect of homocysteine interventions on the risk of cardiocerebrovascular events: a meta-analysis of randomised controlled trials

To evaluate the effects of homocysteine lowering intervention on the risk of cardiocerebrovascular events and all-cause mortality in randomised controlled trials among people with preexisting cardiocerebrovascular or renal disease. Studies were retrieved by searching MEDLINE and OVID (from January 1966 to December 2008) using the following keywords: homocysteine, hyperhomocysteinaemia, cardiovascular disease, coronary disease, cerebrovascular disease, B vitamins, folic acid, randomised controlled trial. References of all retrieved articles were also searched. Randomised controlled trials which compared folic acid or plus B vitamins supplementation with either placebo or usual care were evaluated with cardiocerebrovascular disease events or all-cause mortality reported as an end-point. Data on study design, characteristics of participants, changes in homocysteine levels, and cardiocerebrovascular events and all-cause mortality were independently abstracted by two investigators using a standardised protocol. Seventeen trials involving 39,107 patients with preexisting cardiocerebrovascular or renal disease were included. Results of meta-analyses showed that no significant differences were identified between the intervention group and the control group. The overall relative risks (95% confidence intervals) of outcomes for patients treated with folic acid or plus B vitamins supplementation compared with controls were 1.01 (0.97-1.05) for cardiovascular events, 1.01 (0.94-1.07) for coronary heart disease, 0.94 (0.85-1.04) for stroke and 1.00 (0.95-1.05) for all-cause mortality. In the exclusion of low-quality trials and seven trials in grain fortification countries respectively, sensitivity analyses did not change the overall results. There is no sufficient evidence to show that homocysteine lowering intervention can reduce the risk of cardiocerebrovascular diseases or all-cause mortality among people with preexisting vascular disease. Folic acid supplementation should not be recommended for the secondary prevention of cardiocerebrovascular diseases. More evidence from large-scale randomised controlled trials is needed to confirm this.

Cannulation of the impalpable section of radial artery: preliminary clinical and ultrasound observations

Cannulation of the impalpable section of radial artery: preliminary clinical and ultrasound observations