A combined "in vivo" noninvasive evaluation of carotid plaques using ultrasonography and high-resolution magnetic resonance - new insight into plaque burden and vulnerability.

BACKGROUND: Qualitative change in carotid plaques was prospectively evaluated by Gray Scale Median (GSM) analysis at repeated examinations "in vivo", in relation to quantitative change in carotid arterial geometry, as assessed by high-resolution magnetic resonance imaging (HR-MRI). PATIENTS AND METHODS: Duplex ultrasound with GSM analysis and HR-MRI at the carotid level were performed at baseline and 1- and 2-year follow up in 30 patients with < 70% carotid stenosis. Changes in GSM values (ΔGSM) were evaluated as the intra-individual difference between 2-year and baseline values. HR-MRI studies were evaluated for lumen area (LA), total vessel area (TVA), vessel wall area (VWA = TVA-LA) and normalized wall index (NWI = VWA/TVA). RESULTS: ΔGSM value distribution was divided into quartiles. Predominantly echolucent plaques with ΔGSM value in the lowest quartile (ΔGSM ≤- 8) showed a significantly greater mean 2-year LA (28.62 ± 10.9 mm2 vs. 17.88 ± 4.8 mm2, p = 0.04) and a greater mean 2-year TVA (83.64 ± 19.4 mm2 vs. 63.26 ± 9.2 mm2, p = 0.02) than predominantly echogenic plaques with ΔGSM value in the highest quartile (ΔGSM ≥8). CONCLUSIONS: Increasing echolucency during the 2-year follow up was associated with a 2-year lower degree of stenosis and higher tendency toward lumen preservation. By corroborating that plaque vulnerability is highly independent of stenosis severity, our study provided a possible new combined "in vivo" noninvasive approach for the assessment of carotid plaque vulnerability.

Cardiovascular evaluation of middle-aged individuals engaged in high-intensity sport activities: implications for workload, yield and economic costs.

BACKGROUND: The European Association of Cardiovascular Prevention and Rehabilitation (EACPR) recommends cardiovascular evaluation of middle-aged individuals engaged in sport activities. However, very few data exist concerning the impact of such position stand. We assessed the implications on workload, yield and economic costs of this preventive strategy. METHODS: Individuals aged 35-65 years engaged in high-intensity sports were examined following the EACPR protocol. Athletes with abnormal findings or considered at high-cardiovascular risk underwent additional examinations. The costs of the overall evaluation until diagnosis were calculated according to Swiss medical rates. RESULTS: 785 athletes (73% males, 46.8±7.3 years) were enrolled over a 13-month period. Among them, 14.3% required additional examinations: 5.1% because of abnormal ECG, 4.7% due to physical examination, 4.1% because of high-cardiovascular risk and 1.6% due to medical history. A new cardiovascular abnormality was established in 2.8% of athletes, severe hypercholesterolaemia in 1% and type 2 diabetes in 0.1%. Three (0.4%) athletes were considered ineligible for high-intensity sports, all of them discovered through an abnormal ECG. No athlete was diagnosed with significant coronary artery disease on the basis of a high-risk profile or an exercise ECG. The cost was US$199 per athlete and US$5052 per new finding. CONCLUSIONS: Cardiovascular evaluation of middle-aged athletes detected a new cardiovascular abnormality in about 3% of participants and a high-cardiovascular risk profile in about 4%. Some of these warranted exclusion of the athlete from high-intensity sport. The overall evaluation seems to be feasible at reasonable costs.

Costs and yield of a 15-month preparticipation cardiovascular examination with ECG in 1070 young athletes in Switzerland: implications for routine ECG screening.

BACKGROUND: The usefulness and modalities of cardiovascular screening in young athletes remain controversial, particularly concerning the role of 12-lead ECG. One of the reasons refers to the presumed false-positive ECGs requiring additional examinations and higher costs. Our study aimed to assess the total costs and yield of a preparticipation cardiovascular examination with ECG in young athletes in Switzerland. METHODS: Athletes aged 14-35 years were examined according to the 2005 European Society of Cardiology (ESC) protocol. ECGs were interpreted based on the 2010 ESC-adapted recommendations. The costs of the overall screening programme until diagnosis were calculated according to Swiss medical rates. RESULTS: A total of 1070 athletes were examined (75% men, 19.7±6.3 years) over a 15-month period. Among them, 67 (6.3%) required further examinations: 14 (1.3%) due to medical history, 15 (1.4%) due to physical examination and 42 (3.9%) because of abnormal ECG findings. A previously unknown cardiac abnormality was established in 11 athletes (1.0%). In four athletes (0.4%), the abnormality may potentially lead to sudden cardiac death and all of them were identified by ECG alone. The cost was 157,464 Swiss francs (CHF) for the overall programme, CHF147 per athlete and CHF14,315  per finding. CONCLUSIONS: Cardiovascular preparticipation examination in young athletes using modern and athlete-specific criteria for interpreting ECG is feasible in Switzerland at reasonable cost. ECG alone is used to detect all potentially lethal cardiac diseases. The results of our study support the inclusion of ECG in routine preparticipation screening.

Progression of human carotid and femoral atherosclerosis: a prospective follow-up study by magnetic resonance vessel wall imaging.

AIMS: The time course of atherosclerosis burden in distinct vascular territories remains poorly understood. We longitudinally evaluated the natural history of atherosclerotic progression in two different arterial territories using high spatial resolution magnetic resonance imaging (HR-MRI), a powerful, safe, and non-invasive tool. METHODS AND RESULTS: We prospectively studied a cohort of 30 patients (mean age 68.3, n = 9 females) with high Framingham general cardiovascular disease 10-year risk score (29.5%) and standard medical therapy with mild-to-moderate atherosclerosis intra-individually at the level of both carotid and femoral arteries. A total of 178 HR-MRI studies of carotid and femoral arteries performed at baseline and at 1- and 2-year follow-up were evaluated in consensus reading by two experienced readers for lumen area (LA), total vessel area (TVA), vessel wall area (VWA = TVA - LA), and normalized wall area index (NWI = VWA/TVA). At the carotid level, LA decreased (-3.19%/year, P = 0.018), VWA increased (+3.83%/year, P = 0.019), and TVA remained unchanged. At the femoral level, LA remained unchanged, VWA and TVA increased (+5.23%/year and +3.11%/year, both P < 0.01), and NWI increased for both carotid and femoral arteries (+2.28%/year, P = 0.01, and +1.8%/year, P = 0.033). CONCLUSION: The atherosclerotic burden increased significantly in both carotid and femoral arteries. However, carotid plaque progression was associated with negative remodelling, whereas the increase in femoral plaque burden was compensated by positive remodelling. This finding could be related to anatomic and flow differences and/or to the distinct degree of obstruction in the two arterial territories.

Late acute thrombotic occlusion after endovascular brachytherapy and stenting of femoropopliteal arteries.

OBJECTIVES: The aim of this article is to underline the importance of this complication after endovascular brachytherapy (EVBT) and intravascular stenting of the femoropopliteal arteries occurring in a running randomized trial. BACKGROUND: Endovascular brachytherapy has been proposed as a promising treatment modality to reduce restenosis after angioplasty. However, the phenomenon of late acute thrombotic occlusion (LATO) in patients receiving EVBT after stenting is of major concern. METHODS: In an ongoing prospective multicenter trial, patients were randomized to undergo EVBT (iridium 192; 14 Gy at a depth of the radius of the vessel +2 mm) after percutaneous recanalization of femoropopliteal obstructions. Of the 204 patients who completed the six months follow-up, 94 were randomized to EVBT. RESULTS: Late acute thrombotic occlusion occurred exclusively in 6 of 22 patients (27%) receiving EVBT after intravascular stenting and always in concomitance with reduction of antithrombotic drug prevention (clopidogrel). Conversely, none of the 13 patients with stents and without EVBT (0%; p < 0.05) and none of the 72 patients (0%; p < 0.01) undergoing EVBT after simple balloon angioplasty presented LATO. CONCLUSIONS: Late thrombotic occlusion occurs not only in patients undergoing EVBT after percutaneous coronary recanalization but also after stenting of the femoropopliteal arteries and may compromise the benefits of endovascular radiation. The fact that all our cases with LATO occurred concomitantly with stopping clopidogrel may indicate a possible rebound mechanism. An intensive and prolonged antithrombotic prevention is probably indicated in these patients.

Effects of probucol versus aspirin and versus brachytherapy on restenosis after femoropopliteal angioplasty: the PAB randomized multicenter trial.

PURPOSE: To evaluate the effect of probucol and/or of endovascular brachytherapy (EVBT) on restenosis after percutaneous transluminal angioplasty (PTA) of femoropopliteal arteries. METHODS: A total of 335 patients (206 men; mean age 72+/-9 years) with intermittent claudication were randomized according to a 2x2 factorial design to 1 of the 4 groups: probucol, placebo, EVBT, and EVBT+probucol. Probucol (1 g/d) or placebo were given in double-blinded fashion 1 month before and for 6 months after PTA. Gamma irradiation (192Iridium, 14 Gy, 5-mm reference depth) was randomly applied in an unblinded manner from a noncentered endoluminal catheter. All patients received aspirin (100 mg/d). Primary endpoint was restenosis (>50% diameter reduction) detected by duplex ultrasound 6 months after PTA. Secondary endpoints included clinical and hemodynamic assessment. RESULTS: Restenosis in patients undergoing EVBT was 17% (23/133) versus 35% (50/142) in patients without EVBT (p<0.001); in patients treated with probucol versus placebo, the rates were 23% (31/135) and 30% (43/140, p<0.001). Three quarters (77%, 102/133) of patients were free of claudication after EVBT therapy versus 61% (87/142) without EVBT (p<0.05). Need for target vessel revascularization was 6% (8/133) with EVBT versus 14% (20/142) without EVBT (p<0.01). Late thrombotic occlusions occurred in 4% (6/133), exclusively in patients treated with EVBT after stent implantation. CONCLUSIONS: Endovascular brachytherapy significantly reduces restenosis, improves symptoms, and reduces reinterventions after PTA of femoropopliteal arteries. Probucol reduces restenosis but has no additive effect when combined with brachytherapy.