Carotid artery examination, an important tool in patient evaluation.

Examination of the arteries is an age old medical tradition. Examination of the carotid artery is of unique importance because it is an easily accessible large artery. Through the methods of inspection, palpation, and auscultation, carotid artery examination gives clinicians important diagnostic clues about the health and disease of the patient. Inspection and palpation of the carotid give insight into left ventricular systolic function and distinguish types of valvular heart disease. Auscultation identifies patients with high-risk atherosclerosis. In most cases carotid examination is neither sensitive nor specific, but in the correct clinical context it offers important evidence leading to specific diagnoses and treatment. In this review, we discuss the examination of the carotid artery under normal conditions and describe how abnormalities in the carotid artery examination are indicators of disease.

Carotid bruits and cerebrovascular disease risk: a meta-analysis.

BACKGROUND AND PURPOSE: Current guidelines recommend against routine auscultation of carotid arteries, believing that carotid bruits are poor predictors of either underlying carotid stenosis or stroke risk in asymptomatic patients. We investigated whether the presence of a carotid bruit is associated with increased risk for transient ischemic attack, stroke, or death by stroke (stroke death). METHODS: We searched Medline (1966 to December 2009) and EMBASE (1974 to December 2009) with the terms "carotid" and "bruit." Bibliographies of all retrieved articles were also searched. Articles were included if they prospectively reported the incidence of transient ischemic attack, stroke, or stroke death in asymptomatic adults. Two authors independently reviewed and extracted data. RESULTS: We included 28 prospective cohort articles that followed a total of 17 913 patients for 67 708 patient-years. Among studies that directly compared patients with and without bruits, the rate ratio for transient ischemic attack was 4.00 (95% CI, 1.8 to 9.0, P<0.0005, n=5 studies), stroke was 2.5 (95% CI, 1.8 to 3.5, P<0.0005, n=6 studies), and stroke death was 2.7 (95% CI, 1.33 to 5.53, P=0.002, n=3 studies). Among the larger pool of studies that provided data on rates, transient ischemic attack rates were 2.6 per 100 patient-years (95% CI, 2.0 to 3.2, P<0.0005, n=24 studies) for those with bruits compared with 0.9 per 100 patient-years (95% CI, 0.2 to 1.6, P=0.02, n=5 studies) for those without carotid bruits. Stroke rates were 1.6 per 100 patient-years (95% CI, 1.3 to 1.9, P<0.0005, n=26 studies) for those with bruits compared with 1.3 per 100 patient-years (95% CI, 0.8 to 1.7, P<0.0005, n=6) without carotid bruits, and death rates were 0.32 (95% CI, 0.20 to 0.44, P<0.005, n=13 studies) for those with bruits compared with 0.35 (95% CI, 0.00 to 0.81, P=0.17, n=3 studies) for those without carotid bruits. CONCLUSIONS: The presence of a carotid bruit may increase the risk of cerebrovascular disease.

Assessment of Semi-automated Computed Tomographic Measures of Segmental Perfusion Defects in a Swine Model (Sus scrofa) of Intermediate Coronary Lesions.

Computed tomographic myocardial perfusion (CTP) imaging is a tool that shows promise in emergent settings for defining the hemodynamic significance of coronary artery disease. In this study, we examined the accuracy with which the transmural perfusion ratio (TPR) derived through semiautomated CTP analysis reflected segmental perfusion defects associated with intermediate coronary artery lesions in swine. Lesions (diameter stenosis, 65% ± 11%) of the left anterior descending coronary artery (LAD) were created in 10 anesthetized female swine (weight, 47.5 ± 1.9 kg) by using a pneumatic occlusion device implanted on the LAD. Occluder inflation pressures were adjusted to maintain fractional flow reserve (FFR, 74.3 ± 1.7) during adenosine infusion (140ug/kg/min). Static CTP imaging using a stress-rest protocol and segmental TPR derived from semiautomated CT perfusion software was compared with microsphere-derived TPR (mTPR) by using a 16-segment model and polar mapping. Intermediate LAD stenosis was verified through multiplanar coronary CT angiography. Receiver operating characteristic analysis identified an optimal threshold for segmental perfusion defects for intermediate lesions (TPR threshold, ≤0.80); however, the area under the receiver operating characteristic curve was 0.58, and the overall accuracy was 63%. At this threshold, the sensitivity and specificity were 65% and 61%, and the positive and negative predictive values were 61% and 65%, respectively. Although CTP-TPR illustrated segmental perfusion defects with intermediate lesions, the disparity between CTP-TPR and mTPR measures of segmental perfusion suggests that further advances in analysis software may be necessary to improve the localization of segmental defects for intermediated lesions.

Right Ventricular Failure Following Patent Foramen Ovale Closure on Venovenous-Extracorporeal Membrane Oxygenation.

We present a patient with pulmonary arterial hypertension requiring venovenous-extracorporeal membrane oxygenation for acute respiratory distress syndrome. Refractory hypoxemia secondary to right-to-left interatrial shunting via a patent foramen ovale was discovered. Right heart catheterization with invasive occlusion test heralded worsening right heart failure so closure was aborted. (Level of Difficulty: Intermediate.).

Carotid bruits as a prognostic indicator of cardiovascular death and myocardial infarction: a meta-analysis.

BACKGROUND: Although carotid bruits are deemed to be markers of generalised atherosclerosis, they are poor predictors of cerebrovascular events. We investigated whether a carotid bruit predicts myocardial infarction and cardiovascular death. METHODS: In this meta-analysis, we searched Medline (1966 to August, 2007) and Embase (1974 to August, 2007) with the terms "carotid" and "bruit". Bibliographies of all the retrieved articles were also searched. Articles were included if they reported the incidence of myocardial infarction or cardiovascular death in adults. Outcome variables were extracted in duplicate and included the rate of myocardial infarction and cardiovascular mortality. Quality of the articles was independently assessed with the Hayden rating scheme. Data were pooled with a random effects model. FINDINGS: Of the 22 articles included, 20 (91%) used prospective cohorts. Our analysis included 17,295 patients with 62 413.5 patient-years of follow-up, with a median sample size of 273 patients (range 38-4736) followed up for 4 years (2-7). The rate of myocardial infarction in patients with carotid bruits was 3.69 (95% CI 2.97-5.40) per 100 patient-years (eight studies) compared with 1.86 (0.24-3.48) per 100 patient-years in those without bruits (two studies). Yearly rates of cardiovascular death were also higher in patients with bruits (16 studies) than in those without (four studies) (2.85 [2.16-3.54] per 100 patient-years vs 1.11 [0.45-1.76] per 100 patient-years). In the four trials in which direct comparisons of patients with and without bruits were possible, the odds ratio for myocardial infarction was 2.15 (1.67-2.78) and for cardiovascular death 2.27 (1.49-3.49). INTERPRETATION: Auscultation for carotid bruits in patients at risk for heart disease could help select those who might benefit the most from an aggressive modification strategy for cardiovascular risk.

Cost effectiveness and clinical efficacy of patent foramen ovale closure as compared to medical therapy in cryptogenic stroke patients: A detailed cost analysis and meta-analysis of randomized controlled trials.

BACKGROUND: Up to half the patients with cryptogenic stroke under the age of 55 years have been found to have a PFO. Observational studies have demonstrated a benefit from closure of PFO and several RCTs have shown a trend toward benefit. The cost and clinical effectiveness of PFO closure is unclear. METHODS AND RESULTS: We searched for RCTs of PFO closure in patients with cryptogenic stroke and performed a detailed cost analysis and meta-analysis of treatment outcomes based on the results of the meta-analysis. Five RCTs containing 3404 patients with cryptogenic stroke were included. Of these 1829 underwent PFO closure and 1611 received medical therapy. Mean follow-up was 4.0 years. PFO closure achieved cost effectiveness (<$50,000/Quality-adjusted life-year gained) 2.7 years (95% Confidence Interval (CI) 2.2-3.4) after closure. The incremental cost to prevent one combined end point (CEP, combined transient ischemic attack (TIA), stroke, and death) by PFO closure was $535,655(95% CI $458,329-$642,674). After 55.4 years (95%CI 51.1-60.5) of follow-up, the per patient total cost of medical therapy exceeded that of PFO closure. PFO closure demonstrated clinical efficacy with a decreased risk of CEP (pooled hazard ratio (HR = 0.43(95%CI 0.27-0.59))) and a decreased risk of stroke (HR = 0.29(95%CI 0.02-0.57)). CONCLUSIONS: In comparison to medical therapy alone, PFO closure appears to be cost-effective and clinically efficacious.

Accuracy of cardiac CT, radionucleotide and invasive ventriculography, two- and three-dimensional echocardiography, and SPECT for left and right ventricular ejection fraction compared with cardiac MRI: a meta-analysis.

AIMS: Left ventricular ejection fraction (LVEF) and right ventricular ejection fraction (RVEF) are important tools in clinical decision-making. We hypothesized that two-dimensional echocardiography (2DE), three-dimensional echocardiography (3DE), radionucleotide ventriculography (RNV), cardiac computed tomography (CT), gated single-photon emission CT (SPECT), and invasive cardiac cine ventriculography (ICV) provide variable accuracy for LVEF and RVEF when using cardiac magnetic resonance imaging (MRI) as a gold standard. METHODS AND RESULTS: We systematically searched published databases for studies comparing LVEF and RVEF measured by CT, 3DE, 2DE, RNV, ICV, and SPECT compared with MRI. We utilized meta-analytic methods to determine the pooled bias (mean weighted difference), limits of agreement (LOA), and correlation coefficient for each modality. For LVEF, 174 studies (7047 patients) were included. For RVEF, 46 studies (1720 patients) were included. Pooled LOA for LVEF were different between modalities: CT and 3DE had smaller LOA than 2DE, SPECT, ICV, and RNV. 2DE showed the largest LOA and a weaker correlation for LVEF (-13.3 to 12.1%, r = 0.660). For RVEF, CT and 3DE have the best data to support their use with a bias <5% and tight LOA and correlation coefficients with (r) >0.75. CONCLUSION: For LVEF, CT and 3DE had the lowest bias and the best agreement with MRI. Compared with MRI, CT and 3DE comparably estimate RVEF and have the most evidence to support their use.

Cost effectiveness of percutaneous closure versus medical therapy for cryptogenic stroke in patients with a patent foramen ovale.

In patients with patent foramen ovales (PFOs) and cryptogenic stroke, observational studies have demonstrated reductions in recurrent neurologic events with transcatheter PFO closure compared with medical therapy. Randomized controlled trials and meta-analyses have shown a trend toward benefit with device closure. The cost-effectiveness of PFO closure has not been described. Therefore, a detailed cost analysis was performed using pooled weighted outcome and complication rates from published randomized controlled trials, Medicare cost tables, and wholesale medication prices. Incremental cost per life-year gained and per quality-adjusted life-year (QALY) gained by PFO closure was calculated. The commonly accepted cost-effectiveness threshold of <$50,000/quality-adjusted life-year gained was used. At 2.6 years (the mean duration of randomized controlled trial follow-up), PFO closure was more costly ($16,213, 95% confidence interval [CI] $15,753 to $16,749) per patient, with a cost of $103,607 (95% CI $5,826 to $2,544,750) per life-year gained. The expenditure to prevent 1 combined end point (transient ischemic attack, stroke, and death) at 2.6 years was $1.09 million (95% CI $1.04 million to $1.20 million). Modeling the costs of medical treatment prospectively, PFO closure reached cost-effectiveness (<$50,000/quality-adjusted life-year gained) at 2.6 years (95% CI 1.5 to 44.2). At 30.2 years (95% CI 28.2 to 36.2), the per patient mean cost of medical therapy exceeded that of PFO closure. In conclusion, PFO closure is associated with higher expenditures related to procedural costs; however, this increase may be offset over time by reduced event rates and costs of long-term medical treatment in patients who undergo transcatheter PFO closure. In younger patients typical of cryptogenic stroke, PFO closure may be cost effective in the long term.

Percutaneous closure versus medical therapy alone for cryptogenic stroke patients with a patent foramen ovale: meta-analysis of randomized controlled trials.

Of cryptogenic stroke patients younger than 55 years of age, up to 61% have had a patent foramen ovale (PFO). Observational studies have revealed reductions in recurrent neurologic events through PFO closure versus medical therapy, and randomized controlled trials have shown nonsignificant trends toward benefit. We systematically searched for randomized controlled trials of percutaneous PFO closure with medical therapy versus medical therapy alone in patients with cryptogenic stroke and performed a meta-analysis of treatment outcomes. The primary endpoint was combined death, stroke, and transient ischemic attack. We included 3 trials. Of 2,303 total patients, 1,150 underwent PFO closure and 1,153 received medical therapy (median follow-up period, 2.6 yr). The pooled incidence of the primary endpoint was 1.2 events per 100 patient-years in the closure group (95% confidence interval [CI], 0.2-2.3) and 1.8 in the therapy group (95% CI, 0.7-2.9) (P=0.32); the number needed to treat was 167 (range, 100-500). The corresponding pooled hazard ratio was 0.67 (95% CI, 0.44-1.01; P=0.054) in favor of closure. Closure was associated with an increased risk of atrial fibrillation: relative risk=3.51 (95% CI, 1.44-8.55; P=0.006). When stratified by device, use of the Amplatzer™ PFO Occluder resulted in significant stroke-prevention benefit over medical therapy alone: hazard ratio=0.44 (95% CI, 0.21-0.95; P=0.037). When compared with medical therapy alone, PFO closure with medical therapy showed a trend toward a decreased hazard of combined events, although the absolute event reduction was small and the number needed to treat was high.

Accuracy of traditional age, gender and symptom based pre-test estimation of angiographically significant coronary artery disease in patients referred for coronary computed tomographic angiography.

Determining the pretest probability of angiographically significant (≥50% stenosis) coronary artery disease (CAD) in symptomatic patients relies on the Diamond and Forrester (DF) classification, which was derived from a cohort referred for invasive coronary angiography. The accuracy of this approach in patients referred for noninvasive coronary angiography is not fully known. Consecutive patients without known CAD referred for coronary computed tomographic angiography (CCTA) were evaluated. Chest pain was prospectively categorized as nonanginal, atypical angina, typical angina, or asymptomatic. The pretest likelihood of angiographically significant CAD was estimated using DF classification and compared with observed rates of angiographically significant CAD on CCTA. Among 1,027 patients (41% women; mean age 50 ± 12 years), 38 (4%) had nonanginal symptoms, 643 (63%) had atypical angina, 72 (7%) had typical angina, and 274 (26%) were asymptomatic. The prevalence of angiographically significant CAD in patients with nonanginal chest pain, atypical angina, typical angina, and no symptoms was 1 (3%), 55 (9%), 14 (19%), and 25 (9%), respectively (p <0.001). DF classification significantly overestimated angiographically significant CAD prevalence across all symptom classifications, genders, and ages despite adjustment for risk factors (p <0.001 for all comparisons). DF classification had an area under the receiver-operating characteristic curve of 0.72 (95% confidence interval 0.66 to 0.78), which was not significantly different from age alone (0.69) or age, symptoms, and risk factors (0.68). In conclusion, in a low- to intermediate-risk cohort referred for CCTA, DF classification significantly overestimated angiographically significant CAD prevalence across all age, gender, and symptom strata. The DF classification may overestimate the pretest probability of angiographically significant CAD in contemporary patients referred for CCTA.