Carotid Ultrasound

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Cardiovasc Ultrasound. 2006 Mar 24;4:16.
The impact of carotid plaque presence and morphology on mortality outcome in cardiological patients.
Petersen C, Pecanha PB, Venneri L, Pasanisi E, Pratali L, Picano E.
CNR, Institute of Clinical Physiology, Pisa, Italy. >P> BACKGROUND: Carotid plaque severity and morphology can affect cardiovascular prognosis. We evaluate both the importance of echographically assessed carotid artery plaque geometry and morphology as predictors of death in hospitalised cardiological patients. METHODS: 541 hospitalised patients admitted in a cardiological division (age = 66 +/- 11 years, 411 men), have been studied through ultrasound Duplex carotid scan and successively followed-up for a median of 34 months. Echo evaluation assessed plaque severity and morphology (presence of heterogeneity and profile). RESULTS: 361 patients showed carotid stenosis (67% with < 50% stenosis, 18% with 50-69% stenosis, 9% with > 70% stenosis, 4% with near occlusion and 2% with total occlusion). During the follow-up period, there were 83 all-cause deaths (15% of the total population). Using Cox's proportional hazard model, age (RR 1.06, 95% CI 1.03-1.09, p = 0.000), ejection fraction > 50% (RR = 0.62, 95% CI 0.4-0.96, p = 0.03), treatment with statins (RR = 0.52, 95% CI 0.29-0.95, p = 0.34) and the presence of a heterogeneous plaque (RR 1.6; 95% CI, 1.2 to 2.14, p = 0.002) were independent predictors of death. Kaplan-Meier survival estimates have shown the best outcome in patients without plaque, intermediate in patients with homogeneous plaques and the worst outcome in patients with heterogeneous plaques (90% vs 79% vs 73%, p = 0.0001). CONCLUSION: In hospitalised cardiological patients, carotid plaque presence and morphology assessed by ultrasound are independent predictors of death.

Minerva Cardioangiol. 2006 Feb;54(1):53-67.s
Ultrasound vascular screening for cardiovascular risk assessment. Why, when and how?
Naqvi TZ.
Division of Cardiology, Department of Medicine, Cedars-Sinai Medical Center, UCLA School of Medicine, Los Angeles, CA, USA.

Carotid artery vessel wall assessment in the form of intima-media thickness (IMT) has been identified since the late 1970's as a sensitive tool to detect atherosclerosis, predict its sequelae and detect its progression and regression. Unfortunately the technique has remained confined to large multicenter clinical research trials and no consensus has been developed regarding methodology, analysis and interpretation and no agreed upon clinical protocol that could be used in clinical practice exists. The need for an accepted clinical protocol has become acute especially since the technique has been recommended by writing groups such as American Heart Association as a useful tool for risk stratification in those with unclear or intermediate risk of cardiovascular (CV) disease. The advent of automated edge detection software and a reimbursement of this technique by insurers make it compelling that clinical consensus is reached soon. Accurate data collection methodology and measurement precision are essential; as such a method that is sensitive yet not cumbersome is required for clinical utility. This review will give a short introduction to the studies that confirm value of IMT in detecting atherosclerosis and predicting its sequelae, followed by a discussion on the appropriate clinical method of imaging and reporting. Other controversial areas in methodology such as difference between plaque vs IMT in CV risk prediction will be discussed. Finally tools and skill a clinician will need to be able to do this technique will be discussed.

Rev Med Chir Soc Med Nat Iasi. 2005 Apr-Jun;109(2):236-41.
Carotid atherosclerotic alterations revealed at ultrasonografic examination at patients with coronary heart disease
Mitu F, Mitu M, Turiceanu M, Tudorie C, Pandele GI.
Universitatea de Medicina si Farmacie Gr.T. Popa Iasi, Facultatea de Medicina, Clinica a VI-a Medicala, Spitalul Clinic de Recuperare Iasi.

Carotid ultrasound examination is a noninvasive method with large indications in the evaluation of atherosclerotic lesions at cardiac patients. The aims of the study were: the ultrasound assessment of extra cranial carotid system at patients with coronary heart disease; relationship with the cardiovascular risk factors, lipid profile and echocardiographic data. METHODS: There were studied 47 patients with coronary heart disease (angina, myocardial infarction, ischemic cardiomyopathy, CABG). The evaluation included cardiovascular risk factors, clinical examination, serum lipids and glucose, echocardiographic data. The ultrasound examination of the carotid arteries included the measurement of the diameter and intimae-media thickness (IMT) of the common carotid arteries, the presence and location of atherosclerotic plaques and the presence and severity of carotid stenosis. RESULTS: There was a significant increase of the diameter and IMT with age (p=0.009 respectively p=0.05). Males had a greater medium diameter than women (7.8 +/- 0.9 mm vs. 7.3 +/- 0.8 mm, p=0.04). There was no significant relationship between the cardiovascular risk factors (smoking, arterial hypertension, diabetes mellitus, dislipidemia) and IMT. The thickness of the interventricular septum (at the echocardiographic examination) correlated with the IMT (p=0.03). All the patients with myocardial infarction revealed carotid atherosclerotic plaques and most of the smokers had carotid plaques (88.9% vs. 44.8%, p=0.03). Patients with carotid plaques were older (60.9 +/- 10.1 vs. 54.8 +/- 6.1, p=0.02). CONCLUSIONS: The incidence of carotid atherosclerosis increases with age; the carotid diameter is greater at males and older patients; IMT is influenced mainly by age; carotid plaques are present mainly at older patients, at smokers and those with myocardial infarction and can be considered an additional risk factor for vascular

Diabetes Technol Ther. 2004 Feb;6(1):65-9.
Is carotid ultrasound a useful tool in assessing cardiovascular disease in individuals with diabetes?
Parikh A, Daneman D.
Division of Endocrinology, Department of Pediatrics, University of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada.

Coronary heart disease is a major cause of morbidity and mortality in North America. Its prevention is therefore an important clinical goal. Individuals with both Type 1 and Type 2 diabetes mellitus are at increased risk of developing heart disease as compared with those without diabetes. Carotid ultrasound is now a well-validated tool to study the presence and progression of cardiovascular disease. Using ultrasound one can determine elastic properties of the vessel wall (distensibility and compliance) as well as intima-media thickness (IMT). Several large studies have shown that IMT is a useful predictor of future cardiovascular events such as myocardial infarction and stroke, and is well correlated with other traditional risk factors such as blood pressure, lipids, level of glycemic control, and smoking. For this reason, carotid ultrasound may add valuable clinical information above and beyond that provided by traditional risk factors. The use of carotid ultrasound in the pediatric and adolescent population is increasing, and one study has shown decreased distensibility in adolescents with Type 1 diabetes mellitus versus controls. However, IMT measurements in the children and teens with Type 1 diabetes have yielded conflicting results, and larger, longitudinal studies are needed in this area.

Circulation. 2001 Feb 20;103(7):919-25.
Effects of ramipril and vitamin E on atherosclerosis: the study to evaluate carotid ultrasound changes in patients treated with ramipril and vitamin E (SECURE).
Lonn E, Yusuf S, Dzavik V, Doris C, Yi Q, Smith S, Moore-Cox A, Bosch J, Riley W, Teo K; SECURE Investigators.
Departments of Medicine, McMaster University, Hamilton, Ontario, Canada.

BACKGROUND: Activation of the renin-angiotensin-aldosterone system and oxidative modification of LDL cholesterol play important roles in atherosclerosis. The Study to Evaluate Carotid Ultrasound changes in patients treated with Ramipril and vitamin E (SECURE), a substudy of the Heart Outcomes Prevention Evaluation (HOPE) trial, was a prospective, double-blind, 3x2 factorial design trial that evaluated the effects of long-term treatment with the angiotensin-converting enzyme inhibitor ramipril and vitamin E on atherosclerosis progression in high-risk patients. METHODS AND RESULTS: A total of 732 patients >/=55 years of age who had vascular disease or diabetes and at least one other risk factor and who did not have heart failure or a low left ventricular ejection fraction were randomly assigned to receive ramipril 2.5 mg/d or 10 mg/d and vitamin E (RRR-alpha-tocopheryl acetate) 400 IU/d or their matching placebos. Average follow-up was 4.5 years. Atherosclerosis progression was evaluated by B-mode carotid ultrasound. The progression slope of the mean maximum carotid intimal medial thickness was 0.0217 mm/year in the placebo group, 0.0180 mm/year in the ramipril 2.5 mg/d group, and 0.0137 mm/year in the ramipril 10 mg/d group (P=0.033). There were no differences in atherosclerosis progression rates between patients on vitamin E and those on placebo. CONCLUSIONS: Long-term treatment with ramipril had a beneficial effect on atherosclerosis progression. Vitamin E had a neutral effect on atherosclerosis progression.

Australas Radiol. 2000 Aug;44(3):253-60.
Value of a contrast agent in equivocal carotid ultrasound studies: pictorial essay.
Holden A, Hope JK, Osborne M, Moriarty M, Lee K.
Department of Radiology, Auckland Hospital, New Zealand.

The aim of the present study was to assess the use of an echo-enhancing agent (Levovist; Schering AG) in equivocal carotid bifurcation ultrasound studies and compare the information obtained with digital subtraction angiography (DSA). Contrast-enhanced carotid ultrasound studies were performed on 30 carotid bifurcations in 28 patients. The standard carotid ultrasound examinations were considered equivocal for two reasons: apparent acute internal carotid artery occlusions (n = 10), and possibly patent but critically stenosed internal carotid arteries with the residual flow lumen being incompletely visualized (n = 20). All patients underwent subsequent carotid digital subtraction angiography. All patients with apparent acute carotid occlusions (n = 10) were correctly characterized on contrast-enhanced ultrasound when compared with DSA. The majority were complete occlusions (n = 8) although in two cases there were critical carotid stenoses requiring surgical endarterectomy. In the 'incompletely visualized lumen' group (n = 20), the majority (n = 16) were correctly characterized on contrast enhanced ultrasound: 13 cases of critically stenotic but patent internal carotid arteries, two cases without a haemodynamically significant stenosis and one case of a carotid occlusion with patent vasa vasorum. One of the critical carotid stenoses was prospectively reported as occluded on the 'gold standard' angiography. In three cases the flow lumen was still incompletely visualized due to calcified plaque despite an echo-enhancing agent; angiography revealed no significant stenosis in all cases. There was one false negative for internal carotid occlusion. This occurred early in the series and could be considered to be a technical error. Importantly, there were no false positives for carotid occlusion. Contrast-enhanced carotid ultrasound significantly improves diagnostic confidence in equivocal carotid ultrasound studies. In appropriate clinical settings this may reduce the need for subsequent carotid angiography.

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