[Optimization of organizational approaches to management of patients with atherosclerosis].

Despite undoubted achievements of modern cardiology in prevention and treatment of atherosclerosis, cardiologists, neurologists, and vascular surgeons are still facing severe stenotic atherosclerotic lesions in different vascular regions, both symptomatic and asymptomatic. As a rule hemodynamically significant stenoses of different locations are found after development of acute vascular events. In this regard, active detection of arterial stenoses localized in different areas just at primary contact of patients presenting with symptoms of ischemia of various locations with care providers appears to be crucial. Further monitoring of these stenoses is also important. The article is dedicated to innovative organizational approaches to provision of healthcare to patients suffering from circulatory system diseases that have contributed to improvement of demographic situation in Kuzbass.

Surgical aspects of the diabetic foot.

A comprehensive review of the literature relating to the pathology and management of the diabetic foot is presented. This should provide a guide for the treatment of ulcers, Charcot neuro-arthropathy and fractures involving the foot and ankle in diabetic patients.

Carotid atherosclerosis and cardiovascular risk stratification: role and cost-effectiveness of echo-Doppler examination in untreated essential hypertensives.

OBJECTIVE: To investigate the impact and cost-effectiveness of carotid ultrasonographic examination on total risk stratification in low-medium risk hypertensive patients in relation to age (< 50 and > 50 years) and gender. METHODS: Five hundred and eighty untreated hypertensives classified at low-medium risk, after the routine work-up recommended by the 2003 ESH/ ESC guidelines, were included in the study and total risk was reassessed by adding the results of carotid ultrasonography. RESULTS: According to the stratification based on routine work-up 16.3% of the whole population was considered at low added risk and 83.7% at medium added risk. Carotid subclinical damage was found in 158 patients (27.0%), who were then reclassified in the high-risk stratum. Prevalence rates of patients reclassified in the high-risk stratum as a consequence of carotid damage were as follows: 12.6% in men < 50 years, 14.1% in women < 50 years, 53.0% in men > or = 50 years and 40.1% in women > or = 50 years. The cost per detected case of carotid atherosclerosis was 473 euro in patients < 50 years and 133 euro in those > or = 50 years. CONCLUSIONS: Our results show that: (i) the use of carotid ultrasonography allows a much more accurate identification of high-risk individuals; (ii) its impact and cost-effectiveness on the risk stratification process differs markedly according to the age and gender; (iii) the selective use of this procedure in subjects at high risk of target organ damage may substantially improve the cost of primary prevention.

Noninvasive assessment of arterial stiffness and risk of atherosclerotic events in children.

Noninvasive assessment of vascular dysfunction in the pediatric population has taken advantage of the development of high-resolution ultrasound techniques. The most frequently used methods are the quantification of flow-mediated endothelium-dependent dilation of the brachial artery and measurement of the intima-media thickening of the carotid artery. Both reduced flow-mediated dilation and increased intima-media thickness have been proven to correlate with late cardiovascular events and/or mortality in adults. As these noninvasive methods can easily be applied in children, there have been recent investigations in high-risk pediatric patients harboring classical cardiovascular risk factors. Endothelial dysfunction and increased thickness of the intima media are currently observed in children with familial hypercholesterolemia, obesity, and type 1 diabetes mellitus. The association of early vascular dysfunction with a known risk factor is an important issue as these anomalies precede the formation of atherosclerotic plaques. Therefore, they may help in stratification of the risk for cardiovascular event and to better tailor therapeutic interventions in at risk children. Finally, these methods have been applied in specific pediatric populations, such as children with end-stage renal disease, chronic parenteral nutrition, HIV infection, and coarctation of the aorta. In these conditions, endothelial dysfunction and vascular remodeling are also present early in life and these data raise new possibilities in the understanding of the pathogenesis of atherosclerosis in these populations.

Direct medical costs attributable to acute myocardial infarction and ischemic stroke in cohorts with atherosclerotic conditions.

BACKGROUND: The cost of acute ischemic events in persons with established atherosclerotic conditions is unknown. METHODS: The direct medical costs attributable to secondary acute myocardial infarction (AMI) or ischemic stroke among persons with established atherosclerotic conditions were estimated from 1995-1998 data on 1,143 patients enrolled in US managed care plans. RESULTS: The average 180-day costs attributable to secondary AMI or stroke were estimated as USD 19,056 in the AMI cohort having a private insurance (commercial; n = 344), USD 16,845 in the AMI cohort having government insurance (Medicare, age >/=65 years; n = 200), USD 10,267 for stroke commercial (n = 108), USD 16,280 for stroke Medicare (n = 113), USD 15,224 for peripheral arterial disease commercial (n = 170), and USD 15,182 for peripheral arterial disease Medicare (n = 208). CONCLUSION: These estimates can be used to study the cost-effectiveness of interventions proven to reduce these secondary events.

The variability and accurate assessment of microinflammation in haemodialysis patients.

BACKGROUND: Systemic microinflammation is correlated with atherosclerosis. It needs a reliable assessment. This study explores the temporal variations of three inflammatory indexes [C-reactive protein (CRP), serum amyloid A (SAA) and interleukin-6 (IL-6)] in a period free of clinical events and tests the reliability of their multiple measurements for the assessment of microinflammation in haemodialysis (HD) patients, a population at high risk of atherosclerotic cardiovascular disease. METHODS: For 4 months, serum CRP, SAA and IL-6 were measured in 29 HD patients during the weeks they were free of inflammatory clinical events (> or =12 measurements for each index in every patient). The components of the variance as well as the reliability of two to five measurements for each index, aimed at assessing microinflammation precisely, were computed. RESULTS: The median (interquartile range) of CRP was 2.3 (0.9-4.9) mg/l, of SAA 3.7 (2.1-9.3) mg/l and of IL-6 4.4 (2.2-7.7) pg/ml. Patients were approximately equally distributed between three groups of low, intermediate and high variability for each index. The contribution of intraindividual (biological) variation to the total of variance was 71.3%, 69.3% and 86.7% for CRP, SAA and IL-6, respectively (higher than in all other similar studies in healthy populations). Using two measurements, the estimated reliability was 57-68% for CRP in two-thirds of the patients (comparable with that found in healthy subjects) and 57% for SAA and IL-6 in only one-third of the patients. Increasing the number of measurements up to five did not change the reliability. CONCLUSIONS: Individual factors significantly influence the levels of inflammatory indexes in HD patients in periods free of inflammatory clinical events. The mean of two weekly CRP measurements, but not of SAA or IL-6, seems to assess microinflammation in most patients with a sufficient reliability.

Penetrating atherosclerotic ulcers of the descending thoracic aorta may be managed expectantly.

The natural history of penetrating atherosclerotic ulcers (PAUs) of the descending thoracic aorta remains unclear. Between January 1996 and June 2000, PAU was diagnosed in 36 patients (16 men, 20 women; mean age 74.9 +/- 1.5 years) at Washington University. Imaging studies and hospital records were reviewed. Late follow-up was by search of the Social Security Death Index and telephone interview. None of 16 asymptomatic patients underwent operation. At follow-up (median 457 days), 6 patients had died of unrelated and 2 of unknown causes. Among 20 symptomatic patients, 10 had associated intramural hematoma (5) or dissection (5), of whom 3 underwent operation. At median follow-up (448 days), the 7 unoperated patients remained alive without an aortic operation. Among the remaining 10 symptomatic patients, 3 had an aortic operation and 2 died of unknown causes during follow-up (median 586 days). These data suggest that, in selected cases, PAU may be managed expectantly with careful observation.

Scintigraphic and ultrasonographic assessment of the effect of lumbar sympathectomy upon chronic arteriosclerotic ischaemia of lower extremities.

The aim of the study was an evaluation of the effect of onesided lumbar sympathectomy in patients with peripheral vascular disease of lower extremity(ies), using perfusion scintigraphy with (99)mTc-MIBI and ultrasound Doppler blood flow-rate measurements. A secondary aim was a comparison of the diagnostic efficacy of the two techniques applied. The study was performed on 30 patients, studied prior to and early after one-sided lumbar sympathectomy. The scintigraphy yielded results indicating a statistically significant increase in perfusion of femoral and calf muscles (p < 0.001). Ultrasound investigation demonstrated significant (p < 0.001) increase of the maximal blood flow rate in the popliteal artery. Scintigraphic perfusion study yielded better agreement with the clinical evaluation than the ultrasound Doppler technique (83 v. 47 per cent, p < 0.01) and higher sensitivity in demonstration of improved blood supply (88 v. 36 per cent, p < 0.001).

Intravascular ultrasound assessment of ulcerated ruptured plaques: a comparison of culprit and nonculprit lesions of patients with acute coronary syndromes and lesions in patients without acute coronary syndromes.

BACKGROUND: It is not clear why some plaque ruptures lead to acute coronary syndromes (ACS) but others do not. METHODS AND RESULTS: We analyzed 80 plaque ruptures in 74 patients and compared culprit lesions of ACS patients with nonculprit lesions of ACS patients and lesions of non-ACS patients; both culprit and nonculprit plaque ruptures were studied in 6 of 54 ACS patients. Intravascular ultrasound findings suggesting thrombus were observed more frequently in culprit lesions of ACS patients (n=35) compared with nonculprit lesions of ACS patients (n=19) and lesions of non-ACS patients (n=26): 60% versus 32% versus 8% (P<0.001). At the minimal lumen site, smaller lumen areas (3.3+/-1.5 versus 5.4+/-2.6 versus 6.1+/-2.0 mm2, P<0.001) and greater area stenosis (61+/-15% versus 50+/-14% versus 46+/-18%, P=0.002) and plaque burden (80+/-8% versus 71+/-8% versus 69+/-10%, P<0.001) were observed in culprit lesions of ACS patients compared with nonculprit lesions of ACS patients and lesions of non-ACS patients. Lesions were longer (18.7+/-6.4 versus 154.9+/-6.1 versus 12.0+/-4.9 mm, P<0.001) and rupture site remodeling indices were greater (1.26+/-0.21 versus 1.24+/-0.21 versus 1.09+/-0.05, P=0.002). Independent predictors of culprit plaque ruptures in ACS patients were smaller minimum lumen areas (P=0.02) and presence of thrombus (P=0.01). CONCLUSIONS: Ruptured plaques in culprit lesions of ACS patients have smaller lumens; greater plaque burdens, area stenosis, and remodeling indices; and more thrombus. Plaque rupture itself does not lead to symptoms. The association of plaque rupture with a smaller lumen area and/or thrombus formation causes lumen compromise and leads to symptoms.

From vulnerable plaque to vulnerable patient: a call for new definitions and risk assessment strategies: Part I.

Atherosclerotic cardiovascular disease results in >19 million deaths annually, and coronary heart disease accounts for the majority of this toll. Despite major advances in treatment of coronary heart disease patients, a large number of victims of the disease who are apparently healthy die suddenly without prior symptoms. Available screening and diagnostic methods are insufficient to identify the victims before the event occurs. The recognition of the role of the vulnerable plaque has opened new avenues of opportunity in the field of cardiovascular medicine. This consensus document concludes the following. (1) Rupture-prone plaques are not the only vulnerable plaques. All types of atherosclerotic plaques with high likelihood of thrombotic complications and rapid progression should be considered as vulnerable plaques. We propose a classification for clinical as well as pathological evaluation of vulnerable plaques. (2) Vulnerable plaques are not the only culprit factors for the development of acute coronary syndromes, myocardial infarction, and sudden cardiac death. Vulnerable blood (prone to thrombosis) and vulnerable myocardium (prone to fatal arrhythmia) play an important role in the outcome. Therefore, the term "vulnerable patient" may be more appropriate and is proposed now for the identification of subjects with high likelihood of developing cardiac events in the near future. (3) A quantitative method for cumulative risk assessment of vulnerable patients needs to be developed that may include variables based on plaque, blood, and myocardial vulnerability. In Part I of this consensus document, we cover the new definition of vulnerable plaque and its relationship with vulnerable patients. Part II of this consensus document focuses on vulnerable blood and vulnerable myocardium and provide an outline of overall risk assessment of vulnerable patients. Parts I and II are meant to provide a general consensus and overviews the new field of vulnerable patient. Recently developed assays (eg, C-reactive protein), imaging techniques (eg, CT and MRI), noninvasive electrophysiological tests (for vulnerable myocardium), and emerging catheters (to localize and characterize vulnerable plaque) in combination with future genomic and proteomic techniques will guide us in the search for vulnerable patients. It will also lead to the development and deployment of new therapies and ultimately to reduce the incidence of acute coronary syndromes and sudden cardiac death. We encourage healthcare policy makers to promote translational research for screening and treatment of vulnerable patients.

Noninvasive assessment of arterial stiffness and risk of atherosclerotic events.

Investigation of arterial stiffness, especially of the large arteries, has gathered pace in recent years with the development of readily available noninvasive assessment techniques. These include the measurement of pulse wave velocity, the use of ultrasound to relate the change in diameter or area of an artery to distending pressure, and analysis of arterial waveforms obtained by applanation tonometry. Here, we describe each of these techniques and their limitations and discuss how the measured parameters relate to established cardiovascular risk factors and clinical outcome. We also consider which techniques might be most appropriate for wider clinical application. Finally, the effects of current and future cardiovascular drugs on arterial stiffness are also discussed, as is the relationship between arterial elasticity and endothelial function.

Diffusion and perfusion MRI for the assessment of carotid atherosclerosis.

Atherosclerotic disease of the extracranial vessels is a frequent cause of cerebral ischemia and stroke. Many natural history studies and prospective treatment trials with large patient samples have focused on optimal patient assessment in regard to medical or interventional measures. Clinical decision making nowadays is largely based on the identification, visualization, and grading of the local stenosis, and the identification of neurologic symptoms related to carotid artery stenosis. MRI already has contributed considerably as many surgeons no longer require preoperative conventional contrast angiography but may use the combination of duplex ultrasound studies and MRA for visualization of the pathology. Besides MRA improvements, DWI and PWI are increasingly used in addition to conventional MR contrasts (PD, T2-, T1-weighted MRI) in attempts to gather information on tissue status and the pathophysiology of hemodynamic compromise and cerebral ischemia in patients with carotid artery stenosis. Obtaining background information using this array of MR data may eventually become a basis for optimal risk-benefit assessment in patients with carotid artery stenosis.

B-mode ultrasound and spiral CT for the assessment of carotid atherosclerosis.

More studies on the natural history of carotid artery plaques are needed to predict more reliably which plaque types or features are the most dangerous (see Table 2). Studies on carotid and coronary endarterectomy specimens indicate a dynamic process of rupture, thrombus formation, healing, and remodeling of the plaque. A plaque from a symptomatic patient may not show any signs of plaque rupture if the plaque has healed or evolved since the debut of symptoms. Selection of high-risk symptomatic patients with carotid atherosclerosis for medical or surgical treatment requires reliable, noninvasive, and cost-effective imaging methods. B-mode ultrasonography can be used for detection of early (IMT) as well as late (plaque morphology) atherosclerotic disease. Plaque morphology evaluation on spiral CT imaging is only for research and not yet for clinical use. Asymptomatic patients with carotid atherosclerosis hardly benefit from surgical treatment, as the minimal decrease in ischemic stroke risk is almost equal to the risk of perioperative stroke or death. A high degree of carotid stenosis measured using conventional angiography is an accepted risk factor for stroke but does not identify all vulnerable plaques. Echolucency on ultrasound B-mode imaging can be included as an important parameter in this risk stratification, as it appears to predict rupture-prone, lipid-rich plaques in the mild to severely stenotic carotid artery of a symptomatic patient. The subjective evaluation of plaque morphology on B-mode ultrasound should be complemented or substituted with objective evaluation such as videodensitometric analysis. This method is commercially available and is a relatively cheap and investigator-independent solution, but more studies are required to determine the exact contribution of echolucency to stroke risk. Furthermore, the evaluation of plaque morphology using ultrasound B-mode is still subject to large variations and observer-dependence, limiting its clinical use. In contrast, carotid IMT measurements are reliable to monitor progression and regression of early carotid disease as well as the impact of interventions. This method, however, suffers when used in severely diseased vessels where the boundaries of the IMT complex are hard to distinguish in all segments of the artery. Spiral CT imaging is a preliminary test for plaque characterization, as it primarily identifies calcification but not the more relevant lipid component. Moreover, it is time and resource demanding and involves use of both contrast and radiation, increasing the risk of allergic events and cancer. Standardization and continuous quality control are important, as are consensus agreements on how to quantify lesions (especially IMT), calibrate and standardize B-mode images and outline the plaque, and analyze data. The development of imaging methods for atherosclerotic research is currently fast and promising. This progress is most necessary, considering the very high demands for surrogate endpoints and risk markers in clinical intervention studies. Whether ultrasonic plaque characterization can be implemented in broad general clinical practice, for example, in screening of individuals at high risk of developing atherosclerosis and ischemic events, has to be based upon data from large prospective studies with long-term follow-up. IMT is already used in population screening, as in the ARIC study [9,101].

Epiaortic ultrasound and intraoperative transesophageal ecocardiography for the thoracic aorta atherosclerosis assessment in patient undergoing CABG. Surgical technique modification to avoid cerebral stroke.

BACKGROUND: Cerebral complication during coronary artery bypass surgery (CABG), still occurs in spite of cardiopulmonary bypass (CPB) technology advances. Our study sought to assess the role of epiaortic ultrasound (EAS) and intraoperative transesophagial ecocardiography (TEE) in detection of patients with atherosclerosis of the thoracic aorta and high risk for cerebral embolisation. Consequently our surgical strategies modification for a better cerebral protection. METHODS: Our lot study comprise 352 patients undergoing EAS and TEE, during CABG. EAS was performed before opening of the pericardium using a 7.5 MHz ultrasonic probe packed in a sterile bag. In the presence of moderate aortic atherosclerosis (maximum aortic wall thickness of 3 mm) primarily single aortic cross-clamping and choose of aortic cannulation place was carried out. In cases of severe aortic atheroma (maximum aortic wall thickness > 5 mm or mobile plaque), aortic no touch technique, off-pump were used. From 34 patients with severe ascending aortic atherosclerosis 22 of these patients (18 male, 4 female, age 72(57-79), Parsonet Score 11(0-8), Euroscore 8(2-13), McSPI Stroke Risk Index 6 (1-30%) were managed on "no touch technique", Off-pump. All patients received at least one left internal mammary artery (LIMA) in situ graft and additional extraanatomical bypass conduits: venous Y-graft from IMA (n = 14), arterial Y-graft from LIMA (n = 3), vein graft from axillary artery (n = 3), vein graft from the RIMA stump (n = 3). Median operative time was 240 (115-435) min. RESULTS: We found a mild aortic atherosclerosis in 151 patients (43%), moderate in 167 (47%) and severe in 34 patients (8.8%).. Operative mortality was 2/22 in a group with high risk index, from another cause than cerebral stroke. No cerebral stroke occurred. The rate of perioperative myocardial infarction (CKMB > 50U/l) was 5/22. Median stay in ICU, 54 hours (15-1245 hours). After a median follow up period of 8 months one death occurred from cerebral stroke and no myocardial infarction. CONCLUSION: Accurate detection of atheroma on ascending aorta and aortic arch by a combination between EAS and TEE and in special surgical technique modification using off-pump revascularization and extraanatomical bypass for the management of a heavily calcified aorta can result in a very low stroke rate despite a considerable stroke risk. The hospital mortality and morbidity can be lower than predicted by Euroscore and Parsonet Score.