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Cardiovascular Risk Profile, Cardiac and Cervical Artery Ultrasound in Patients with Peripheral Artery Disease
Abstract
Patients with peripheral arterial present different hemodynamic significance of atherosclerotic lesions in the coronary and cervical arterial territories also, which are responsible for increased vital cardiovascular risk. The aim of this study was to assess the role of clinic and imagistic cardiac and carotid evaluation of PAD patients to estimate the cardiovascular risk in the perspective of perioperative therapeutic strategy revascularization. After clinical and imagistic evaluation we found that proving the polyarterial profile changes the medical and interventional therapy, prioritizing coronary and carotid arterial revascularization.
... The prevalence of CVRF (smoking, DM, dyslipidemia, HT) in PAD patients causes, in addition to peripheral arterial lesions, coronary arteries and myocardial involvement with ischemic, hypertensive and/or diabetic heart disease, aortic and mitral valve calcifications and sometimes myophatic evolution through dilated cardiac disease [44][45][46]. In PAD patients were found high prevalence of clinically significant cardiac US changes (61.6% vs. 35.3%), ...
... US evaluation is useful in defining the group of patients with low CV risk, in which can be performed with relative safety the revascularization of the limb by interventional/surgery procedures. In the case of the intermediate risk group, additional CV risk assessment tests are required [44][45][46][47][48][49][50]. ...
... PAD patients had advanced cervical arterial ATS lesions expressed both by a higher IMT and an increased prevalence of ATS plaques. Stenotic and occlusive ATS is a systemic phenomenon commonly coexisting in several arterial territories (coronary, carotid, peripheral arteries), often symptomatic in one of the arterial areas and asymptomatic in other affected arterial areas [44][45][46]. There are fewer studies that investigated the lesions in the cervical arterial system in patients with PAD, compared to the large number of studies investigating the coronary-carotid relationship [65]. ...
In the peripheral arteries, a thrombus superimposed on atherosclerosis contributes to the progression of peripheral artery disease (PAD), producing intermittent claudication (IC), ischemic necrosis, and, potentially, loss of the limb. PAD with IC is often undiagnosed and, in turn, undertreated. The low percentage of diagnosis (∼30%) in this setting of PAD is of particular concern because of the potential worsening of PAD (amputation) and the high risk of adverse vascular outcomes (vascular death, coronary artery disease, stroke). A Medline literature search of the highest-quality systematic reviews and meta-analyses of randomized controlled trials documents that, due to risk of bias, imprecision, and indirectness, the overall quality of the evidence concerning diagnostic tools and antithrombotic interventions in PAD is generally low. Areas of research emerge from the information collected. Appropriate treatments for PAD patients will only derive from ad-hoc studies. Innovative imaging techniques are needed to identify PAD subjects at the highest vascular risk. Whether IC unresponsive to physical exercise and smoking cessation identifies those with a heritable predisposition to more severe vascular events deserves to be addressed. Devising ways to improve prevention of vascular events in patients with PAD implies a co-ordinated approach in vascular medicine.
The evidence that measurement of the common carotid intima-media thickness (CIMT) improves the risk scores in prediction of the absolute risk of cardiovascular events is inconsistent.
To determine whether common CIMT has added value in 10-year risk prediction of first-time myocardial infarctions or strokes, above that of the Framingham Risk Score.
Relevant studies were identified through literature searches of databases (PubMed from 1950 to June 2012 and EMBASE from 1980 to June 2012) and expert opinion.
Studies were included if participants were drawn from the general population, common CIMT was measured at baseline, and individuals were followed up for first-time myocardial infarction or stroke.
Individual data were combined into 1 data set and an individual participant data meta-analysis was performed on individuals without existing cardiovascular disease.
We included 14 population-based cohorts contributing data for 45,828 individuals. During a median follow-up of 11 years, 4007 first-time myocardial infarctions or strokes occurred. We first refitted the risk factors of the Framingham Risk Score and then extended the model with common CIMT measurements to estimate the absolute 10-year risks to develop a first-time myocardial infarction or stroke in both models. The C statistic of both models was similar (0.757; 95% CI, 0.749-0.764; and 0.759; 95% CI, 0.752-0.766). The net reclassification improvement with the addition of common CIMT was small (0.8%; 95% CI, 0.1%-1.6%). In those at intermediate risk, the net reclassification improvement was 3.6% in all individuals (95% CI, 2.7%-4.6%) and no differences between men and women.
The addition of common CIMT measurements to the Framingham Risk Score was associated with small improvement in 10-year risk prediction of first-time myocardial infarction or stroke, but this improvement is unlikely to be of clinical importance.
Objectives:
The goal of this study was to compare the performance of several measures of carotid intima-media thickness (C-IMT) as predictors of cardiovascular events (CVEs), and to investigate whether they add to the predictive accuracy of Framingham risk factors (FRFs).
Background:
Various markers of subclinical atherosclerosis have been identified as predictors of CVEs, but the most powerful variable is still under debate.
Methods:
A cohort study was carried out in 5 European countries. A total of 3,703 subjects (median age 64.4 years; 48% men) were followed-up for a median of 36.2 months, and 215 suffered a first CVE (incidence: 19.9/1,000 person-years).
Results:
All measures of C-IMT and the interadventitia common carotid artery diameter (ICCAD) were associated with the risk of CVEs, after adjustment for FRFs and therapies (all p < 0.005). The average of 8 maximal IMT measurements (IMT(mean-max)), alone or combined with ICCAD, classified events and non-events better than the common carotid mean IMT (net reclassification improvement [NRI]: +11.6% and +19.9%, respectively; both p < 0.01). Compared with classification based on FRFs alone, the NRI resulting from the combination of FRFs+ICCAD+IMT(mean-max) was +12.1% (p < 0.01). The presence of at least 1 plaque (maximum IMT >1.5 mm) performed significantly worse than composite IMTs that incorporated plaques (p < 0.001). Adjusted Kaplan-Meier curves showed that individuals with a FRS = 22.6% (cohort average), and both IMT(mean-max) and ICCAD above the median, had a 6.5% risk to develop a CVE over 3 years versus a 3.4% risk for those with the same FRS, and both IMT(mean-max) and ICCAD below the median.
Conclusions:
A risk stratification strategy based on C-IMT and ICCAD as an adjunct to FRFs is a rational approach to prevention of cardiovascular disease.
-Elevated blood pressure is the leading modifiable risk factor for cardiovascular disease (CVD) and premature death. The blood pressure waveform consists of discrete hemodynamic components, derived from measured central pressure and flow, which may contribute separately to risk for an adverse outcome. However, pressure-flow measures have not been studied in a large, community-based sample.
-We used proportional hazards models to examine association of incident CVD with forward pressure wave amplitude, mean arterial pressure, and global reflection coefficient derived from wave separation analysis and echocardiography in 2492 participants (mean age 66 ± 9 years, 56% women) in the Framingham Heart Study. During follow up (0.04 - 6.8 years), 149 participants (6%) had a CVD event. In multivariable models adjusting for age, sex, antihypertensive therapy, body mass index, heart rate, total and high density lipoprotein cholesterol concentrations, smoking, and presence of diabetes, forward pressure wave amplitude (HR=1.40; 95% CI: 1.16, 1.67; P=0.0003) was associated with incident CVD whereas mean arterial pressure (HR=1.10; 95% CI: 0.94, 1.29; P=0.25) and global wave reflection (HR=0.93; 95% CI: 0.78, 1.12; P=0.58) were not. After adding systolic blood pressure and carotid-femoral pulse wave velocity to the model, forward pressure wave amplitude persisted as a correlate of events (HR=1.33; 95% CI, 1.05, 1.68; P=0.02).
-Higher forward pressure wave amplitude (a measure of proximal aortic geometry and stiffness) was whereas mean arterial pressure and relative wave reflection (correlates of resistance vessel structure and function) were not associated with increased risk for incident CVD.
For over two decades the measurement of carotid intima-media thickness (CIMT) has been applied in cardiovascular research. There is a wealth of evidence supporting its value. A thickened CIMT measurement does not lead directly to the occurrence of a myocardial infarction or stroke, but merely reflects what is going on in the vasculature of an individual. Similarly, the rate of change in CIMT over time is a reflection of how the development of atherosclerosis is altered over time. Both these CIMT measurements are reflections of cardiovascular risk (1,2).
Carotid intima-media thickness (CIMT) measurements have been used in cardiovascular research for more than 2 decades. There is a wealth of evidence showing that CIMT can be assessed in a reproducible manner and that increased CIMT relates to unfavorable risk factor levels and atherosclerosis elsewhere in the arterial system and to the risk of vascular events. Change in CIMT over time can be readily assessed, and trials showed that the rate of change is modifiable by treatment. Several issues important for the cardiovascular research community and its application in clinical practice are still outstanding. Promising future areas for CIMT measurements are: 1) application in studies among children and adolescents; 2) use of CIMT trials positioned decisively before the start of a morbidity and mortality trial; and 3) the use of CIMT measurement in risk stratification in those with an intermediate 10-year risk estimate.
Among patients with atherothrombosis, including coronary artery disease (CAD), cerebrovascular disease (CVD), and peripheral arterial disease (PAD), patients with PAD generally have the worse prognosis. The Reduction of Atherothrombosis for Continued Health (REACH) Registry characterized the atherothrombotic risk factor profile, and evaluated treatment intensity and cardiovascular events among different atherothrombotic patient populations worldwide. Two thirds of PAD patients had polyvascular disease, defined as symptomatic involvement of more than one vascular bed. The risk factor profile in patients with CAD, CVD and PAD was very much similar. However, optimal risk factor control by medical treatment and lifestyle interventions was least accomplished in PAD patients. Furthermore, PAD patients and patients with polyvascular disease showed the highest cardiovascular event rates. Of note, therapeutic strategies are similar for all atherothrombotic disease categories, irrespective of the presence of polyvascular disease. Therefore, it is of the utmost importance to achieve optimal risk factor control, particularly for PAD patients and for those with polyvascular disease, in order to prevent future cardiovascular events.