Risk Stratification for Cardiovascular Disease in Women in the Primary Care Setting.

BACKGROUND: Traditional risk assessment tools classify the majority of middle-aged women at low risk despite cardiovascular (CV) disease's affecting >50% of women and remaining the leading cause of death. Ultrasound-determined carotid intima-media thickness (CIMT) and/or computed tomographic coronary artery calcium score (CACS) quantify subclinical atherosclerosis and add incremental prognostic value. The aim of this study was to assess the utility of CIMT and CACS to detect subclinical atherosclerosis in younger women. METHODS: Asymptomatic women aged 50 to 65 years with at least one CV risk factor and low Framingham risk scores were identified prospectively at primary care and cardiology clinics. Mean intimal thickness, plaque on CIMT, and Agatston calcium score for CACS were obtained. RESULTS: Of 86 women (mean age, 58 ± 4.6 years; mean Framingham risk score, 1.9 ± 1.2; mean low-density lipoprotein cholesterol level, 138.9 ± 37.0 mg/dL), 53 (62%) had high-risk CIMT (51% plaque, 11% CIMT > 75th percentile). In contrast, three women (3.5%) had CACS > 100, all of whom had plaque by CIMT. Of the 58 women with CACS of 0, 32 (55%) had high-risk CIMT (48% plaque, 7% CIMT > 75th percentile). CONCLUSIONS: In patients referred by their physicians for assessment of CV risk, CIMT in asymptomatic middle-aged women with at least one CV risk factor and low risk by the Framingham risk score identified a large number with advanced subclinical atherosclerosis despite low CACS. Our results suggest that CIMT may be a more sensitive method for CV risk assessment than CACS or traditional risk tools in this population. Further studies are needed to determine if earlier detection would be of clinical benefit.

Aneurysmal dilatation of the inferior vena cava.

AIM: Inferior vena cava aneurysms (IVCA) are rare, unlike aortic aneurysms. The diagnosis and treatment is challenging. This study defines clinical and echocardiographic findings in a prospective cohort of sixteen patients with fusiform IVCA. METHODS AND RESULTS: All patients referred to the Mayo Clinic between January 2006 and July 2009 for a clinically indicated echocardiogram (36,128 patients) were screened for a dilated IVC. Sixteen cases of fusiform IVCA were identified. Eleven cases (68.8%) were female. Mean age at presentation was 76 years (range 51-89). Eleven (68.8%) had structural heart disease: with right ventricular (RV) dysfunction in 45.5% (n = 5), moderate or greater tricuspid regurgitation (TR) was seen in 36.4% (n = 4) and RV enlargement was seen in 18.2% (n = 2). The most common clinical indication for echocardiography was dyspnea (25%; n = 4) and heart failure (18.8%; n = 3). The mean IVCA diameter was 4.1 cm (range 3.8-5 cm) and the mean length of the aneurysms was 6.2 cm (range 3.5-8.7 cm), with mean right ventricular systolic pressure of 55 mmHg (range 31-105 mmHg). Five (31.3%) had at least a moderate reduction in right ventricular ejection fraction and five (31.3%) had significant TR. Among these five patients with significant TR, severe TR was present in 80%; (n = 4) and moderate to severe TR was present in 20%; (n = 1). CONCLUSIONS: IVC aneurysms are more common in the elderly, and is associated with an increase in right sided heart pressures, significant TR, and RV dysfunction.

Two-dimensional speckle-tracking echocardiography of the left atrium: feasibility and regional contraction and relaxation differences in normal subjects.

BACKGROUND: Increased left atrial (LA) size and reduced global contractility are related to adverse cardiac events. The potential incremental value of assessing regional LA contractility is unknown. To assess the feasibility of measuring this variable angle, independent 2-dimensional speckle-tracking strain echocardiography (2D-SpTr) was used to measure regional LA strain (epsilon) and strain rate (SR) in normal individuals of various ages. METHODS: From standard apical views, 2D-SpTr was used on 84 normal subjects to measure longitudinal velocity, epsilon, and SR in 13 LA segmental regions. The values obtained from the different atrial regions were compared with each other and corresponding LA volumes before and after LA contraction. RESULTS: Regional LA epsilon and SR could be measured in 77 of 84 normal subjects (94%). A consistent pattern of differences in LA regional function was noted with the annular regions, and particularly the inferior wall having a larger average peak velocity and epsilon and SR values in comparison with the mid and superior LA segments. Peak epsilon and SR during LA contraction had only a modest correlation with LA volumes. CONCLUSION: The angle-independent technique of 2D-SpTr tracking can analyze regional LA epsilon and SR in 94% of normal subjects. Regional differences in LA contractility are consistently present. The annular regions, and especially the inferior wall have the highest values for LA epsilon and SR. The significance of these findings and their possible use in identifying disease states will require further study.