Systemic Atherosclerotic Burden Research Articles

Association of multiple blood metals and systemic atherosclerosis: A cross-sectional study in the CAD population

BackgroundCoronary atherosclerotic disease (CAD) is often accompanied by peripheral atherosclerosis, resulting in a higher risk of ischemia and cardiovascular death. Exposure to metals is associated with atherosclerotic plaques at specific sites. However, less is known about the effects of mixed metals on systemic atherosclerotic burden in CAD patients. ObjectivesTo investigate the association of metal mixtures with systemic atherosclerotic burden in a CAD population. MethodsA cross-sectional study including 1562 CAD patients from Southwest China was conducted. The levels of 10 blood metals were measured via inductively coupled plasma spectrometry. More than one vessel with a stenosis ≥50% vessel diameter was defined as CAD. Carotid and lower limb atherosclerosis was assessed by using ultrasound, and coronary atherosclerosis was quantified via arterial angiography. Systemic atherosclerosis was scored according to the presence or absence of lesions at the three sites and the total number of lesions. To investigate the combined impacts and interaction effects of metals, Bayesian kernel machine regression was used. Weighted quantile regression was used to identify the contributions of the metals. ResultsSignificant overall associations of mixed metals with systemic atherosclerotic burden were found. These positive overall associations were mainly driven by Cd, Cu and Pb in systemic atherosclerosis. The main contributing factors were As and Cu for coronary atherosclerosis as well as Cd, Cu and Pb for carotid and lower limb atherosclerosis. Cd and Pb or Cr can interact, and Pb interacts with age, sex and alcohol. ConclusionsIn CAD patients, exposure to combinations of metals was highly positively associated with systemic atherosclerotic burden. These significant trends were more pronounced in the peripheral arteries and carotid arteries. Controlling environmental metal exposure can contribute to reducing systemic atherosclerosis in CAD patients.

A UK retrospective analysis of recurrent cardiovascular events following acute myocardial infarction in patients with multivessel disease and additional risk factors

Abstract Background Patients with multivessel disease (MVD) are at increased risk of recurrent cardiovascular (CV) events in the early period after acute myocardial infarction (AMI) compared to patients without MVD, possibly due to increased atherosclerotic burden. Moreover, many have additional risk factors such as older age, peripheral artery disease (PAD), prior AMI or diabetes that could further increase risk of recurrent events. Real-world evidence regarding the impact of additional CV risk factors on outcomes in patients with MVD remains sparse. Purpose To assess clinical outcomes in the early period after AMI in a UK cohort of patients with MVD and additional risk factors. Methods A retrospective analysis (January 1, 2008–December 31, 2018, inclusive) was conducted using the Clinical Practice Research Datalink database linked to Hospital Episode Statistics and Office of National Statistics databases to identify patients with a confirmed diagnosis of MVD within the study period and at least one non-fatal myocardial infarction (MI) diagnosis code on or after their first recorded MVD diagnosis. The effect of diabetes on clinical outcomes was assessed by comparing patients diagnosed with diabetes on or prior to their index AMI with those with no concurrent diabetes diagnosis (MVD+DM and MVD-DM cohorts, respectively). Clinical outcomes were also assessed in AMI patients without diabetes but with at least two additional risk factors including: age >65 years, PAD diagnosis or prior MI diagnosis (MVD2RF+ cohort), and those with a single or none of the aforementioned risk factors (MVD2RF- cohort). Major adverse CV events (MACE) was defined as a composite of non-fatal AMI, non-fatal stroke or CV death. Results Of the 78,128 patients with MVD identified, 19,768 and 52,197 were eligible for inclusion in the MVD+DM and MVD-DM cohorts respectively. Occurrence of MACE was similar between the MVD+DM and MVD-DM cohorts at both 90 days (15% vs. 14%) and 1 year (19% vs. 17%) post-AMI; however, all-cause and CV mortality were significantly higher in the MVD+DM cohort over the study period (p<0.001). In the subset of patients without diabetes, 7,531 and 44,666 patients met the criteria for the MVD2RF+ and MVD2RF- cohorts, respectively. A substantially higher proportion of patients in the MVD2RF+ cohort experienced a MACE within 90 days or 1 year post-MI compared with the MVD2RF- cohort (90 days: 45% vs. 9%; 1 year: 56% vs. 11%), with non-fatal MI accounting for the majority of recurrent events. Kaplan-Meier survival analysis revealed that both all-cause and CV mortality were significantly higher in the MVD2RF+ than the MVD2RF- cohort (p<0.001). Conclusions Having multiple risk factors including older age, PAD and a history of AMI substantially increases the risk of recurrent events in patients with MVD, particularly in the early period after AMI. Strategies to reduce the systemic atherosclerotic burden and risk of recurrent events in these patients are needed. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): CSL Behring

The Proinflammatory Soluble CD40 Ligand Is Associated with the Systemic Extent of Stable Atherosclerosis.

Background and objectives: Polyvascular atherosclerosis is frequent and associated with a high cardiovascular risk, although the mechanisms regulating the atherosclerosis extent to single or multiple arterial territories are still poorly understood. Inflammation regulates atherogenesis and soluble CD40 ligand (sCD40L) is an inflammatory mediator associated with the presence of single-territorial atherosclerosis. We assessed whether the sCD40L expression is associated with the atherosclerosis extent to single or multiple arterial territories and with the atherosclerosis severity in different territories. Materials and Methods: We prospectively enrolled 94 participants with no atherosclerosis (controls, n = 26); isolated coronary atherosclerosis (group 1, n = 20); coronary and lower extremity (LE) atherosclerosis (group 2, n = 18); coronary and carotid atherosclerosis (group 3, n = 12); and coronary, LE, and carotid atherosclerosis (group 4, n = 18). Serum sCD40L levels were quantified. Results: The sCD40L levels (ng/mL, mean (standard deviation)) were 4.0 (1.5), 5.6 (2.6), 7.2 (4.2), 5.9 (3.7), and 5.1 (2.4) in controls and groups 1 to 4, respectively (ANOVA p = 0.012). In nonrevascularized patients, the sCD40L levels were significantly higher in group 2 than in group 1 and were correlated with the number of LE diseased segments. Prior LE bypass surgery was associated with lower sCD40L levels. Coexistence of coronary and LE atherosclerosis was independently associated with the sCD40L levels. Conclusions: The sCD40L levels were increased in stable atherosclerosis, particularly in polyvascular coronary and LE atherosclerosis. The number of LE diseased segments and prior LE revascularization were associated with sCD40L expression. To our knowledge, these are novel data, which provide insights into the mechanisms underlying multi-territorial atherosclerosis expression. sCD40L may be a promising noninvasive tool for refining the stratification of the systemic atherosclerotic burden.

Semi-quantitative ultrasound assessment of nonalcoholic fatty liver disease highlightens early subclinical atherosclerotic vascular damage: From risk factors to vascular damage

Introduction Nonalcoholic fatty liver disease (NAFLD) is an independent risk factor for coronary artery disease; moreover, it increases systemic atherosclerotic burden by inducing the overexpression of inflammatory mediators, promoting endothelial damage, and impairing blood pressure regulation. Aim Aim of this work was to evaluate whether a standardized evaluation of NAFLD improves cardiovascular risk assessment recognizing subclinical atherosclerosis in lower cardiovascular risk. Material and methods We investigated NAFLD occurrence and severity, carotid and femoral intima-media-thickness (IMT) and vascular stiffness by ultrasound technique, endothelial function by peripheral-arterial-tonometry, lipid profile and inflammatory markers in 220 subjects (100 men, 120 women; 45.42 ± 13.22 years old), without history of cardiovascular event, diabetes, liver infection, alcohol consumption, systemic diseases, and the use of drugs causing liver damage. NAFLD was evaluated, graded according to an eight-point scoring semi-quantitative severity score. Results and discussion At univariate logistic analysis, NAFLD ≥ 3 score was significantly associated with pathological IMT, augmentation index, pulsewave-velocity at carotids and femoral arteries, and endothelial dysfunction, and this association was confirmed after adjustment for European Society of Cardiology Systematic Coronary Risk Evaluation (ESC SCORE) at multivariate analyses. Moreover, high sensitivity C-reactive protein levels were significantly higher in patients with at least 3 point steatosis, in comparison to the others. Receiver operating characteristic (ROC) curve analysis for NAFLD showed a significant higher area under curve for the detection of both early atherosclerotic burden and vascular stiffness, in comparison to ROC curve of ESC SCORE. Conclusions According to our findings a NAFLD ≥ 3 score was able to screen a subgroup with widespread morphological vascular damage and endothelial dysfunction in a primary prevention population.

014 Patterns of early atherosclerosis formation and cardiac remodelling in healthy adults of south asian and european descent

Introduction South Asians (SAs) have a higher risk of cardiovascular disease (CVD) and stroke, but paradoxically lower prevalence of peripheral arterial disease (PAD) than Western Europeans (WEs). The aim of this study was to determine early changes in systemic atherosclerotic burden and cardiac remodelling as measured using whole body cardiovascular MRI (WB-CVMR). Methods 19 SA and 38 age, gender and BMI matched WE were recruited. All were ≥40 years, free from CVD and with a 10-year risk of CVD Results SAs exhibited a significantly lower iliofemoral atheroma burden (regional SAS 0.0 ± 0.0 vs 1.9 ± 6.9, p = 0.048) and a trend towards lower overall atheroma burden (WB SAS 0.7 ± 0.8 vs 1.8 ± 2.3, p = 0.1). They had significantly lower indexed left ventricular mass (46.9 ± 11.8 vs 56.9 ± 13.4ml/m 2 , p = 0.008), end diastolic volume (63.9 ± 10.4 vs 75.2 ± 11.4ml/m 2 , p = 0.001), end systolic volume (20.5 ± 6.1 vs 24.6 ± 6.8ml/m 2 , p = 0.03) and stroke volume (43.4 ± 6.6 vs 50.6 ± 7.9ml/m 2 , p = 0.001), but with no significant difference in functional indices. Conclusion South Asians have a lower peripheral atherosclerotic burden and smaller hearts than Western Europeans even in a healthy population. Thus the paradoxical high risk of CVD compared with PVD risk may be due to an adverse cardiac haemodynamic status incurred by the smaller heart rather than atherosclerosis.

Increased homocysteine and lipoprotein(a) levels highlight systemic atherosclerotic burden in patients with a history of acute coronary syndromes

Strong evidence supports an association between high levels of homocysteine (Hcy) and lipoprotein(a) [Lp(a)] and an increased rate of ischemic vascular events. The study population comprised 162 patients (50 women [30.9%]; age, 66.71± 12.76years) having a history of acute coronary syndrome within 1year who underwent fasting blood sampling, measurement of intima-media thickness and pulse wave velocity at the common carotid and femoral arteries by Doppler ultrasound, and ankle-brachial index measurement. Cutoff values were considered 0.9mm and 1.2mm for carotid and femoral intima-media thickness, respectively; 12m/s for pulse wave velocity; and<0.9 for ankle-brachial index. We included hypertension, dyslipidemia, diabetes, overweight/obesity, smoking, and family history of cardiovascular disease in the count of traditional risk factors (CRFs). Adding Hcy ≥15μmol/L and Lp(a) ≥500mg/L to CRFs, we obtained a new score, named TOTAL. On univariate analysis, Hcy and Lp(a) were significantly associated with presence of atherosclerotic extracoronary lesions (for Hcy: β= .934; standard error= 0.178; P< .0001; for Lp(a): β= .961; standard error= 0.177; P< .0001) and compliance alterations (for Hcy: odds ratio, 13.3; 95% confidence interval, 3.9-45.3; P< .0001; for Lp(a): odds ratio, 14.6; 95% confidence interval, 5.69-37.62; P< .0001). On multivariate analysis, Lp(a) and Hcy were significantly associated with extracoronary atherosclerosis, even after correction for CRFs. The area under the curve of the TOTAL score for both atherosclerosis and vascular compliance alterations was significantly higher than the area under the curve of traditional CRFs plus only Hcy ≥15μmol/L or plus Lp(a) ≥500mg/L, separately added. The addition of evaluation of Hcy ≥15μmol/L and Lp(a) ≥500mg/L to the traditional CRF count does improve detection of systemic atherosclerotic burden of patients with acute coronary syndrome and can offer a new opportunity to optimize secondary prevention.

Kararlı Koroner Arter Hastalığı Olan Hastalarda Nitratların Oluşturduğu Baş Ağrısının Aterosklerotik Yükü Öngörmedeki Değeri

Introduction: Nitrates, which lead to vasodilation in vessels, is one of the cornerstone drugs of antianginal therapy. The most frequently encountered side effect of nitrates is headache, which is linked to vasodilation of the cerebral arteries. Vasodilator response to nitrates is significantly reduced in patients with atherosclerosis. The aim of present study was to assess the relationship between nitrate-induced headache (NIH) and systemic and coronary atherosclerotic burden in patients with stable coronary artery disease. Patients and Methods: Overall, 40 patients with NIH (group I: 61.2 ± 8.56 years, 32 males) and 62 patients without headache (group II: 63.5 ± 8.45 years, 41 males) were included in the study. Systemic atherosclerotic burden was evaluated by carotid intima-media thickness (CIMT) and cardio-ankle vascular index (CAVI). Coronary atherosclerotic burden was assessed by the Gensini score. Results: CIMT and CAVI were significantly greater in group II than in group I (0.8 ± 0.20 vs. 0.6 ± 0.20 and 9.5 ± 1.0 vs. 8.4 ± 1.2, respectively; p< 0.001). The Gensini score was also higher in group II than in group I [median 32 (16.7-45.2) vs 12.5 (5.2-19.2); p< 0.001]. In multivariate analysis, headache was found as an independent determinant of CIMT, CAVI, and Gensini score (p< 0.001). Conclusion: Patients with NIH had a low level systemic and coronary atherosclerotic burden, evaluated by CIMT, CAVI, and Gensini score, compared with those without NIH.

Renal Ultrasound (and Doppler Sonography) in Hypertension: An Update.

Ultrasound (US) allows the non-invasive evaluation of morphological changes of kidney structure (by means of B-Mode) and patterns of renal and extrarenal vascularization (by means of color-Doppler and contrast-enhanced US). In hypertensive subjects it offers a relevant contribution to the diagnosis of early renal damage, acute or chronic nephropathies and nephrovascular disease. However, morphological changes are often detected late and non-specific and in recent years evidence has increased regarding the clinical relevance of renal resistive index (RRI) for the study of vascular and renal parenchymal renal abnormalities. RRI is measured by Doppler sonography in an intrarenal artery, as the difference between the peak systolic and end-diastolic blood velocities divided by the peak systolic velocity. At first RRI was proved to be a marker of renal disease onset and progression; later the influence of systemic vascular properties on RRI was shown and authors claimed its use as an independent predictor of cardiovascular risk rather than of renal damage. Indeed, renal vascular resistance is only one of several renal (vascular compliance, interstitial and venous pressure), and extrarenal (heart rate, pulse pressure) determinants that concur to determine RRI individual values but not the most important one. The clinical relevance of RRI measurement as a surrogate endpoint of specific renal damage or/and as surrogate endpoint of atherosclerotic diffuse vascular damage is still debated.To summarize, from the literature: (a) In hypertensives with normal renal function and no albuminuria, especially in younger people, RRI is an early marker of renal damage that is especially useful when hypertension and diabetes concur in the same subjects. In these subjects RRI could improve current clinical scores used to stratify early renal damage. In older subjects RRI increases in accordance with the increase in systemic vascular stiffness and, because of this close relationship, RRI is also a marker of systemic atherosclerotic burden and the role of renal determinants can weaken. The clinical relevance was not specifically investigated. (b) In transplant kidney and in chronic renal disease high (>0.80) RRI values can independently predict renal failure. The recent claim that systemic (pulse pressure) rather than renal hemodynamic determinants sustain this predictive role of RRI, does not significantly reduce this predictive role of RRI. (c) Doppler ultrasound allows diagnosis and grading of renal stenosis in both fibromuscolar dysplastic and atherosclerotic diseases. Moreover, by RRI assay Doppler ultrasound can indirectly measure the hemodynamic impact of renal artery stenosis on the homolateral kidney, by virtue of the stenosis-related decrease in pulse pressure. However, in elderly subjects with atherosclerotic renal artery stenosis coexisting renal diseases can independently increase RRI by the augmentation in renal vascular stiffness and tubulo-interstitial pressure and hidden changes due to renal artery stenosis.

The internist and the renal resistive index: truths and doubts.

The renal resistive index (RRI) is measured by Doppler sonography in an intrarenal artery, and is the difference between the peak systolic and end-diastolic blood velocities divided by the peak systolic velocity. The RRI is used for the study of vascular and renal parenchymal renal abnormalities, but growing evidence indicates that it is also a dynamic marker of systemic vascular properties. Renal vascular resistance is only one of several renal (vascular compliance, interstitial and venous pressure), and extrarenal (heart rate, aortic stiffness, pulse pressure) determinants that combine to determine the RRI values, and not the most important one. RRI cannot always be considered a specific marker of renal disease. To summarize from the literature: (1) hydronephrosis, abdominal hypertension, renal vein thrombosis and acute kidney injury are all associated with an acute increase in interstitial and venous pressure that determine RRI values. In all these conditions, RRI is a reliable marker of the severity of renal damage. (2) The hemodynamic impact of renal artery stenosis can be assayed by the RRI decrease in the homolateral kidney by virtue of decreasing pulse pressure. However, renal diseases that often coexist, increase renal vascular stiffness and hide the hemodynamic effect of renal stenosis. (3) In transplant kidney and in chronic renal disease, high RRI values (>0.80) can independently predict renal and clinical outcomes, but systemic (pulse pressure) rather than renal hemodynamic determinants sustain the predictive role of RRI. (4) Higher RRI detects target renal organ damage in hypertension and diabetes when renal function is still preserved, as a marker of systemic atherosclerotic burden. Is this the fact? We attempt to answer.

Visit-to-visit blood pressure variability as a prognostic marker in patients with cardiovascular and cerebrovascular diseases – Relationships and comparisons with vascular markers of atherosclerosis

BackgroundVisit-to-visit blood pressure variability (BPV) is a simple surrogate marker for the development of atherosclerotic diseases, cardiovascular and all-cause mortality. Nevertheless, the relative prognostic value of BPV in comparison with other established vascular assessments remain uncertain. MethodsWe prospectively followed-up 656 high-risk patients with diabetes or established cardiovascular or cerebrovascular diseases for the occurrence of major adverse cardiovascular events (MACEs). Baseline brachial endothelial function, carotid intima-media thickness (IMT) and plaque burden, ankle-brachial index and arterial stiffness were determined. Visit-to-visit BPV were recorded during a mean 18±9 outpatient clinic visits. ResultsAfter a mean 81±12 month's follow-up, 123 patients (19%) developed MACEs. Patients who developed a MACE had significantly higher systolic BPV, more severe endothelial function, arterial stiffness and systemic atherosclerotic burden compared to patients who did not develop a MACE (all P<0.01). BPV significantly correlated with all of the vascular assessments (P<0.01). A high carotid IMT had the greatest prognostic value in predicting development of a MACE (area under receiver operating characteristic curve (AUC) 0.69±0.03, P<0.01). A high BPV also had moderate prognostic value in prediction of MACE (AUC 0.65±0.03, P<0.01). After adjustment of confounding factors, a high BPV remained a significant independent predictor of MACE (hazards ratio 1.67, 95% confidence interval 1.14-2.43, P<0.01). ConclusionsCompared with established surrogate markers of atherosclerosis, visit-to-visit BPV provides similar prognostic information and may represent a new and simple marker for adverse outcomes in patients with vascular diseases.

Peripheral Arterial Disease

Peripheral arterial disease (PAD) affects a considerable percentage of the population. The manifestations of this disease are not always clinically overt. As a result, PAD remains underdiagnosed and undertreated. PAD is not just a disease of the peripheral arteries, but also an indication of generalized vascular atherosclerosis. PAD patients also have a high prevalence of other arterial diseases, such as coronary/carotid artery disease and abdominal aortic aneurysms. PAD is also a predictor of increased risk of lung and other cancers. The most often used examination for the establishment of the diagnosis of PAD, the ankle-brachial pressure index (ABPI), is also a predictor of generalized atherosclerosis, future cardiovascular events and cardiovascular mortality. Several markers that have been linked with PAD (e.g. C-reactive protein, serum bilirubin levels) may also have predictive value for other conditions besides PAD (e.g. kidney dysfunction). The management of PAD should therefore not be restricted to the peripheral circulation but should include measurements to manage and decrease the systemic atherosclerotic burden of the patient.

Criticial limb ischemia: epidemiology.

Critical limb ischemia is found in 12% of the U.S. adult population. Its clinical presentation varies from no symptoms to intermittent claudication, atypical leg pain, rest pain, ischemic ulcers, or gangrene. Those with critical limb ischemia have a high incidence of cardiovascular comorbidities that reflect a significant systemic atherosclerotic burden; they have increased functional impairment and increased rates of functional decline compared with persons without critical limb ischemia. Interventions for critical limb ischemia and the impact of major amputation have a significant social and economic impact. At 1 year, 25% of patients will be dead, 30% will have undergone amputation, and only 45% will remain alive with both limbs. At 5 years, more than 60% of patients with critical limb ischemia will be dead.

Risk factors and peripheral arterial disease; a plea for objective measurements

In the general population the prevalence of peripheral arterial disease (PAD) varies between 7 and 21% [1–3]. The prevalence is strongly related to age, gender and the definition of PAD, defined by the ankle-brachial index (ABI) cut-off and/or the presence of symptoms. Before progressing to clinical stages such as intermittent claudication or even critical limb ischemia, PAD is typically asymptomatic during several years [4]. The ABI, as a screening tool, has emerged as an accurate and reliable marker of (a)symptomatic PAD and as a measure of systemic atherosclerotic burden.

Prevalence of (A)Symptomatic Peripheral Arterial Disease; the Additional Value of Ankle–Brachial Index on Cardiovascular Risk Stratification

The prevalence of peripheral arterial disease (PAD) in the general population varies between 7% and 21%. This is strongly related to age, gender and the definition of PAD, defined by the ankleebrachial index (ABI) cut-off and/or the presence of intermittent claudication (IC). PAD is typically asymptomatic before progressing to clinical stages such as IC or even critical limb ischaemia. The ABI, as a screening tool, has emerged as an accurate and reliable marker of (a)symptomatic PAD and as a measure of systemic atherosclerotic burden. The getABI study detected a PAD prevalence of 18% in the primary-care setting, while only 2.8% of the patients were symptomatic. In this issue of the Journal, Ramos et al. identified the prevalence of symptomatic and asymptomatic PAD in a population-based, cross-sectional study including 6262 participants aged 35e79 years. Furthermore, they evaluated the value of ABI measurement in addition to coronary heart disease (CHD) risk estimation. PAD, defined as an ABI< 0.9, was present in 4.5% of the study population, of which only 0.62% presented with IC assessed by the Edinburgh questionnaire. Prevalence increased up to 14% in

Optimisation of a high-resolution whole-body MR angiography protocol with parallel imaging and biphasic administration of a single bolus of Gd-BOPTA: preliminary experience in the systemic evaluation of atherosclerotic burden in patients referred for endovascular procedures

This study was performed to validate a high-resolution whole-body magnetic resonance angiography (MRA) protocol with parallel imaging and biphasic administration of a single bolus of contrast agent in the preliminary assessment of systemic atherosclerotic burden in patients referred for endovascular procedures. Forty patients referred for endovascular treatment of atherosclerotic disease of the carotid arteries (n=23), peripheral vessels (n=14) or aorta (n=3) on the basis of previous clinical and diagnostic examinations underwent high-resolution whole-body MRA at 1.5 T with 3D spoiled gradient recalled echo (GRE) sequences, featuring parallel imaging acquisition technique with x2 acceleration factor. Sixty-eight surface coil elements and a four-station imaging protocol were employed. Biphasic intravenous administration of a paramagnetic contrast agent [gadolinium benzyloxyproprionic-tetraacetic acid (Gd-BOPTA)] was performed with the following protocol: 10 ml at a speed of 1 ml/s followed by further 10 ml at a speed of 0.5 ml/s. For image analysis, the arterial system was divided into 42 segments for evaluation. The presence or absence of atherosclerotic lesions was evaluated by two observers in consensus; segments were classified as having clinically significant disease (>or=50% stenosis or an aneurysmal dilatation) or no significant disease (<50% stenosis). The presence of stenoocclusive disease, determined at all segments, was compared with findings on digital subtraction angiography (DSA), which were interpreted by a third independent reader. Sensitivity, specificity and concordance of whole-body MRA findings with DSA were calculated, and receiver operating characteristic (ROC) analysis was performed for all vascular territories. A total of 1,680 arterial segments was evaluated; 138 (8.3%) were affected by atherosclerotic alterations. Carotid lesions were confirmed in 23 patients (34 segments), involvement of peripheral vessels in 14 (57 segments) and abdominal aneurysms in three. Sensitivity and specificity of whole-body MRA were, respectively, 95%-97% for head and neck vessels, 100%-100% for thoracoabdominal vessels, 98%-97% for thigh vessels and 84%-88% for calf vessels; concordance with the DSA findings was significant (p<0.05). Subclinical atherosclerotic lesions were evidenced in 25 patients, involving carotid arteries (12 segments), peripheral vessels (21 segments) and abdominal aorta (one segment). All these lesions were confirmed by a second modality, and ten of these patients required further care. High-resolution whole-body MRA with Gd-BOPTA may be considered a reliable modality for imaging systemic atherosclerosis in candidates for endovascular procedures. The subclinical detection of the total atherosclerotic burden has potential implications for secondary care in this population.

Abstract 3118: Combined Assessment of Intima-Media Thickness and Echolucency of an Atherosclerotic Plaque in Carotid Artery has an Additive Value on Prediction of Future Coronary Events in Patients with Coronary Artery Disease and Carotid Atherosclerosis

Single ultrasound assessment of either intima-media thickness (IMT) or plaque echolucency of carotid artery is considered a surrogate for systemic atherosclerotic burden and provides prognostic information for coronary events. The assessment of IMT and plaque echolucency of carotid artery has the advantage of obtaining structural and compositional information on atherosclerotic plaques in a single session. This study examined the hypothesis that the combined ultrasound assessment of IMT and echolucency in a carotid artery may have an additive effect on the prediction of coronary events in patients with coronary artery disease (CAD). Ultrasound assessment of carotid IMT and plaque echolucency with integrated backscatter (IBS) analysis (intima-media IBS value minus adventitia IBS) was performed in 411 patients with CAD and carotid plaques (IMT ≥ 1.1 mm). The plaque with the greatest axial thickness in carotid arteries was the target for measurement of maximum IMT (plaque-IMTmax) and echolucency (lower IBS reflects echolucent plaque). All patients were prospectively followed up for 70 months or until the occurrence of one of the following coronary events: cardiac death, nonfatal myocardial infarction, or unstable angina pectoris requiring revascularization. During follow-up, 49 coronary events occurred (cardiac death in 2, myocardial infarction in 10, unstable angina in 37). In a multivariate Cox hazards analysis, plaque-IMTmax and plaque echolucency (lower IBS value) were significant predictors of coronary events (HR; 1.82 and 0.85, 95% CI 1.2 – 2.9 and 0.80 – 0.91, respectively, both p &lt; 0.01) independently of age, LDL-C levels, and diabetes. When outcomes were stratified according to plaque-IMTmax and plaque echolucency in combination or alone, the combination of plaque-IMTmax and plaque echolucency was the strongest predictor of events, followed by plaque echolucency and plaque-IMTmax, on the basis of the c -statistic (area under the ROC curve; 0.80, 0.73, and 0.71, respectively). Combined ultrasound assessment of IMT and echolucency of carotid plaque had an additive value on the prediction of coronary events, and these simultaneous ultrasound measurements may be useful for risk stratification in CAD.

Risk assessment in the patient with established peripheral arterial disease

Office-based cardiovascular risk prediction continues to challenge practitioners in primary and secondary risk stratification settings. In patients with established peripheral arterial disease (PAD), the risk of cardiovascular events (i.e. death or morbidity due to coronary heart disease and/or cerebrovascular disease) is high, yet traditional risk factors and the ankle-brachial index (ABI) do not provide a complete secondary risk prediction. In this population, office-based cardiovascular risk stratification may be improved by surrogate markers of the systemic atherosclerotic burden, as well as markers of systemic inflammation. This review will evaluate the utility of the ABI, clinical stage of disease, and the emerging role of C-reactive protein (CRP) and other inflammatory markers in secondary risk prediction in PAD. Defining which patients are in the highest category of risk may direct health care providers to emphasize secondary preventive measures, and facilitate patient adherence to recommended medical therapies and smoking cessation.

Atherosclerotic disease is increased in recent-onset rheumatoid arthritis: a critical role for inflammation

Rheumatoid arthritis (RA) patients have increased mortality and morbidity as a result of cardiovascular and cerebrovascular disease. What is not clear, however, is either how early accelerated atherosclerosis begins in RA or how soon risk factors must be rigorously controlled. Furthermore, given the strong relationship of vascular disease to RA mortality and of inflammation to the accelerated atherosclerosis associated with RA, it is important to evaluate indices that could serially and noninvasively quantify atherosclerotic disease in RA patients. The carotid intima-media thickness (cIMT) and plaque, measured by ultrasound, correlate closely with direct measurement of the local and systemic atherosclerotic burden. To investigate the presence of subclinical atherosclerosis in the early stages of RA, the cIMT and plaque were measured using carotid duplex scanning in 40 RA patients with disease duration < 12 months and in 40 control subjects matched for age, sex and established cardiovascular risk factors. Patients with RA had significantly higher average cIMT values and more plaque than the control group (cIMT 0.64 ± 0.13 mm versus 0.58 ± 0.09 mm, respectively; P = 0.03). In RA patients, the cIMT was predicted by age and C-reactive protein level at first presentation to the clinic (R2 = 0.64). C-reactive protein was associated with age of disease onset and history of smoking. Since inflammation has been shown to predate onset of clinical RA, the accelerated atherogenic process related to inflammation may precede RA symptom onset.