Reduced progression of carotid intima media thickness by personalised pictorial presentation of subclinical atherosclerosis in VIPVIZA-A randomised controlled trial.

OBJECTIVES: Reduced progression of atherosclerosis can decrease the risk of cardiovascular disease (CVD). This study aimed at evaluating the effect of a pictorial intervention showing atherosclerotic severity on the progression of carotid atherosclerosis. METHODS: A prospective randomised open-label blinded end-point trial with participants aged 40-60 years enroled from a routine CVD prevention programme. The intervention group (n: 1575) and their treating physicians received an image based presentation of subclinical atherosclerotic severity measured by carotid ultrasound. The control group (n: 1579) did not receive any information about ultrasound results. Carotid ultrasound at baseline and at 3-year follow-up contained plaque detection and measurements of carotid intima media thickness (cIMT). The left, right and bilateral-mean-cIMT, plaque prevalence and total plaque area (TPA) at 3-year follow-up were compared between groups. Significance level was set to p = 0.01 to adjust for multiple comparisons. RESULTS: The intervention group revealed reduced cIMT progression in the left-mean-cIMT of -0.011 mm (p = 0.001) compared with the control group. The intervention effect on cIMT progression was most prominent in individuals with increased cIMT and plaque prevalence at baseline (-0.021 mm, p = 0.005). There were no differences in progression between groups for the right-and bilateral-mean-cIMT (-0.005 mm, p = 0.223 and -0.005 mm, p = 0.036, respectively), nor any differences between groups for plaque prevalence or TPA (odds ratio 0.88, p = 0.09 and 0.89, p = 0.21, respectively). CONCLUSION: Pictorial presentation of subclinical atherosclerotic severity sent to both the individual and their treating physician resulted in significantly reduced left cIMT progression. Pictorial presentation has the potential to increase adherence in CVD prevention.

A novel echocardiographic estimate of pulmonary vascular resistance employing the hydraulic analogy to Ohm's law.

Background: Assessment of pulmonary vascular resistance (PVR) is critical for accurate diagnosis and optimal pharmacotherapy in pulmonary hypertension. We aimed to test the diagnostic performance of a novel, Doppler-based method to evaluate PVR based on Ohm's law (PVRecho) using pragmatic estimates of pulmonary capillary wedge pressure (PCWP). Methods and results: Simultaneous right heart catheterization (RHC) and echocardiography was performed in a derivation cohort of 111 patients in sinus rhythm referred for PH evaluation and PVRecho independently validated in 238 patients. PVRecho was calculated using pulmonary artery mean pressure estimates (PAMPecho) obtained from peak tricuspid gradient employing a fixed right atrial pressure estimate, PCWPecho was estimated as 10 or 20 mmHg using age-related mitral E/A cut-offs and cardiac output from left ventricular outflow. In the derivation cohort, both PAMPecho and PCWPecho estimates demonstrated excellent agreement with catheterization measurements. PVRecho was highly feasible, demonstrated negligible bias and excellent agreement with PVRRHC (Bias = -0.58, SD 2.2 mmHg) and outperformed the Abbas method to identify PVRRHC > 3WU (AUC = 0.85 vs. 0.70; p = 0.02). In the validation cohort, PVRecho preserved good invasive agreement with negligible bias, displayed strong diagnostic performance (AUC = 0.84) and significant ability to distinguish isolated post-capillary from combined post- and pre-capillary pulmonary hypertension (PH) subgroups (AUC = 0.77). Conclusion: PVRecho based on Ohm's law employing pragmatic estimates of PCWPecho demonstrates excellent agreement with invasive reference standard measurements and strong diagnostic ability to identify elevated PVRRHC. This novel approach may be useful during therapy selection to distinguish PH hemodynamic subgroups.

Near-occlusion is difficult to diagnose with common carotid ultrasound methods.

PURPOSE: To assess the sensitivity and specificity of common carotid ultrasound method for carotid near-occlusion diagnosis. METHODS: Five hundred forty-eight patients examined with both ultrasound and CTA within 30 days of each other were analyzed. CTA graded by near-occlusion experts was used as reference standard. Low flow velocity, unusual findings, and commonly used flow velocity parameters were analyzed. RESULTS: One hundred three near-occlusions, 272 conventional ≥50% stenosis, 162 <50% stenosis, and 11 occlusions were included. Carotid ultrasound was 22% (95%CI 14-30%; 23/103) sensitive and 99% (95%CI 99-100%; 442/445) specific for near-occlusion diagnosis. Near-occlusions overlooked on ultrasound were found misdiagnosed as occlusions (n = 13, 13%), conventional ≥50% stenosis (n = 65, 63%) and < 50% stenosis (n = 2, 2%). No velocity parameter or combination of parameters could identify the 65 near-occlusions mistaken for conventional ≥50% stenoses with >75% sensitivity and specificity. CONCLUSION: Near-occlusion is difficult to diagnose with commonly used carotid ultrasound methods. Improved carotid ultrasound methods are needed if ultrasound is to retain its position as sole preoperative modality.

Inter-sonographer reproducibility of carotid ultrasound plaque detection using Mannheim consensus in subclinical atherosclerosis.

AIMS: To determine the inter-sonographer reproducibility of carotid ultrasound plaque detection using Mannheim consensus in a subclinical population and evaluate associations related to the reproducibility. METHODS AND RESULTS: Bilateral ultrasound screening for carotid plaques defined by Mannheim consensus was performed on 106 subclinical participants. Two different sonographers scanned the same participant, and reproducibility of plaque detection was measured by Cohens kappa. Associations with reproducibility were evaluated by comparing wall, and plaque characteristics between subjects with plaques identified in one and both scans. In general, the inter-sonographer reproducibility of plaque detection was substantial with a kappa value of 0·70 (95% CI 0·60-0·80). Plaques detected in only one scan had significantly lower plaque area and plaque thickness (6·82 mm2 and 1·45 mm) as compared to plaques detected in both scans (11·65 mm2 and 1·96 mm, P<0·001). CONCLUSION: Minor carotid plaques contribute to decreased reproducibility as compared to large plaques when screening for subclinical atherosclerosis using Mannheim consensus. Using an alternative plaque definition based on plaque thickness >1.5 mm and plaque area >10 mm2 could increase the reproducibility of plaque detection in subclinical atherosclerosis.

Health literacy is independently and inversely associated with carotid artery plaques and cardiovascular risk.

AIMS: Health literacy, the degree to which individuals understand and act upon health information, may have a pivotal role in the prevention of cardiovascular disease (CVD), with low health literacy potentially explaining poorer adherence to prevention guidelines. We investigated the associations between health literacy, ultrasound-detected carotid atherosclerosis and cardiovascular risk factors. METHODS: Baseline data (cross-sectional analysis) from a randomized controlled trial, integrated within the Västerbotten Intervention Program, Northern Sweden, was used. We included 3459 individuals, aged 40 or 50 years with ≥1 conventional risk factor or aged 60 years old. The participants underwent clinical examination, blood sampling, carotid ultrasound assessment of intima-media wall thickness (CIMT) and plaque formation, and answered a questionnaire on health literacy - the Brief Health Literacy Screen. The European Systematic Coronary Risk Evaluation and Framingham Risk Score were calculated. RESULTS: About 20% of the participants had low health literacy. Low health literacy was independently associated with the presence of ultrasound-detected carotid artery plaques after adjustment for age and education, odds ratio (95% confidence interval) 1.54 (1.28-1.85), demonstrating a similar level of risk as for smoking. Health literacy was associated with CIMT in men. Low health literacy was associated with higher CVD risk scores. Sensitivity analyses with low health literacy set to 9% or 30% of the study sample, respectively, yielded essentially the same results. CONCLUSIONS: Low health literacy was independently associated with carotid artery plaques and a high level of CVD risk scores. Presenting health information in a fashion that is understood by all patients may improve preventive efforts.

Tissue oxygen saturation changes and postoperative complications in cardiac surgery: a prospective observational study.

BACKGROUND: Cardiac surgery with extracorporeal circulation (ECC) can induce microvascular dysfunction and tissue hypoperfusion. We hypothesized that the alterations in near-infrared spectroscopy (NIRS)-derived parameters would be associated with post-operative complications in cardiac surgery patients. METHODS: Prospective observational study performed at two University Hospitals. Ninety patients undergoing cardiac surgery with ECC were enrolled. The NIRS sensor was applied on the thenar eminence. A vascular occlusion test (VOT, 3-min ischemia) was performed at baseline (t0), at Intensive Care Unit (ICU) admission (t1), 3 (t2) and 6 (t3) hours later. Baseline tissue oxygen saturation (StO2), oxygen extraction rate and microvascular reactivity indices were calculated. RESULTS: In the first hours after cardiac surgery, StO2 tended to increase (86% [80-89] at T3 versus 82% [79-86] at T0, p = ns), while both tissue oxygen extraction and microvascular reactivity tended to decrease, as indicated by increasing occlusion slope (- 8.1%/min [- 11.2 to - 7] at T3 versus - 11.2%/min [- 13.9 to - 7.9] at T0, p = ns) and decreasing recovery slope (1.9%/sec [1.1-2.9] at T3 versus 3.1%/sec [2.3-3.9] at T0, p = ns). No substantial differences were found in NIRS-derived variables and their changes over time between patients with complications and those without complications. CONCLUSIONS: Peripheral tissue oxygen extraction and microvascular reactivity were reduced during the first hours after cardiac surgery. NIRS-derived parameters were not able to predict complications in this population of cardiac surgery patients.

Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA): a pragmatic, open-label, randomised controlled trial.

BACKGROUND: Primary prevention of cardiovascular disease often fails because of poor adherence among practitioners and individuals to prevention guidelines. We aimed to investigate whether ultrasound-based pictorial information about subclinical carotid atherosclerosis, targeting both primary care physicians and individuals, improves prevention. METHODS: Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA) is a pragmatic, open-label, randomised controlled trial that was integrated within the Västerbotten Intervention Programme, an ongoing population-based cardiovascular disease prevention programme in northern Sweden. Individuals aged 40, 50, or 60 years with one or more conventional risk factors were eligible to participate. Participants underwent clinical examination, blood sampling, and ultrasound assessment of carotid intima media wall thickness and plaque formation. Participants were randomly assigned 1:1 with a computer-generated randomisation list to an intervention group (pictorial representation of carotid ultrasound plus a nurse phone call to confirm understanding) or a control group (not informed). The primary outcomes, Framingham risk score (FRS) and European systematic coronary risk evaluation (SCORE), were assessed after 1 year among participants who were followed up. This study is registered with ClinicalTrials.gov, number NCT01849575. FINDINGS: 3532 individuals were enrolled between April 29, 2013, and June 7, 2016, of which 1783 were randomly assigned to the control group and 1749 were assigned to the intervention group. 3175 participants completed the 1-year follow-up. At the 1-year follow-up, FRS and SCORE differed significantly between groups (FRS 1·07 [95% CI 0·11 to 2·03, p=0·0017] and SCORE 0·16 [0·02 to 0·30, p=0·0010]). FRS decreased from baseline to the 1-year follow-up in the intervention group and increased in the control group (-0·58 [95% CI -0·86 to -0·30] vs 0·35 [0·08 to 0·63]). SCORE increased in both groups (0·13 [95% CI 0·09 to 0·18] vs 0·27 [0·23 to 0·30]). INTERPRETATION: This study provides evidence of the contributory role of pictorial presentation of silent atherosclerosis for prevention of cardiovascular disease. It supports further development of methods to reduce the major problem of low adherence to medication and lifestyle modification. FUNDING: Västerbotten County Council, the Swedish Research Council, the Heart and Lung Foundation, the Swedish Society of Medicine, and Carl Bennet Ltd, Sweden.

Successful novice's training in obtaining accurate assessment of carotid IMT using an automated ultrasound system.

AIMS: The aim of this study was to assess the feasibility and learning curve of training novice operators in using automated ultrasound to achieve satisfactory carotid intima-media thickness (CIMT) measurements. METHODS AND RESULTS: Four novices underwent 4 weeks carotid ultrasound training using a newly developed automated ultrasonograph. A longitudinal B-mode image of the distal right common carotid artery (CCA) was acquired in 96 patients. The interoperator CIMT reproducibility was analysed by the coefficient of variation (CV) and intraclass correlation coefficient (ICC) for every week and compared with that from an expert operator. The weekly mean CV of the measurements on the 24 patients made by all novices was consistently reduced: 0.06, 0.05, 0.03, and 0.02, respectively. For the expert, the mean CV was 0.02, 0.02, 0.03, and 0.02, respectively. The novices' standard deviation (SD) of CVs also reduced weekly from 0.04 in the first week to 0.01 in the last week (P < 0.05). The corresponding weekly variation in the SD for the expert was 0.02 for the first week to 0.01 in the last week (P = 0.27). The agreement between measurements made by the novices was expressed by the ICC being 0.97 (P < 0.001) in the first week and increased to 0.99 (P < 0.001) in the fourth week. CONCLUSION: CIMT assessment by novices using an automated ultrasound could be reliably achievable after a short training period. These results may have encouraging implications when designing screening programmes for primary prevention in community health service.

Fully automated on-screen carotid intima-media thickness measurement: a screening tool for subclinical atherosclerosis.

PURPOSE: Carotid intima-media thickness (CIMT) is generally considered an appropriate direct vascular method for cardiovascular risk assessment. The objective of this study was to evaluate the feasibility and reproducibility of a newly developed automated on-screen carotid ultrasound with respect to manual measurement with a conventional system. METHODS: We assessed CIMT in 50 consecutive patients (age 62 ± 5 years, range 21-79 years, 36 men) twice, using a newly developed automated ultrasound (CardioHealth Station) and a conventional system with manual measurement (Acuson, Sequoia). For each patient, three frozen frames of the distal 10 mm of the right and left common carotid arteries were acquired on the two systems, by operators blinded to each other. The average of the mean value of three readings of each system was calculated. RESULTS: The intraclass correlation coefficient of the interoperator variability was 0.95 and 0.94 for the automated and manual measurements, respectively. The comparative coefficient of variation of the interoperator variability was 8.2 and 8.7% for the automated and manual measurements, respectively. There was no clinically relevant difference between measurements obtained by the two systems (intraclass correlation coefficient = 0.98). The acquisition time of the automated system was significantly shorter than the conventional system (p < 0.01). CONCLUSIONS: Fully automated on-screen measurements of CIMT are feasible, faster, and as reproducible as conventional manual measurements and may be suitable and cost-effective for screening application in community medicine.

Transthoracic echocardiography is adequate for the diagnosis of right coronary artery aneurysms.

Coronary artery aneurysms (CAA) are rare but potentially fatal pathologies. This case was referred to our Unit after occasional echocardiographic finding of an intracardiac mass. A new detailed transthoracic echocardiogram was decisive for a diagnosis of a large CAA of the right coronary artery, compressing and dislocating the right atrium. Transesophageal echocardiography was not performed because of the data obtained. The diagnosis was confirmed by cardiac catheterization. The patient was managed with a surgical procedure.

Observational study on the beneficial effect of preoperative statins in reducing atrial fibrillation after coronary surgery.

BACKGROUND: Recent evidence supports the important role of inflammation in atrial fibrillation (AF) after coronary artery bypass grafting (CABG) and there is growing evidence that statin has cardiac antiarrhythmic effects. The aim of this study was to assess the efficacy of preoperative statins in preventing AF after CABG in a longitudinal observational study. METHODS: Over a two-year period, 405 consecutive patients underwent isolated CABG procedures. Univariate analysis was performed exploring the relationship regarding statin use and AF development. A propensity score for treatment with statins was obtained from core patient characteristics. The role of statin therapy on postoperative AF was assessed by means of a conditional logistic model, while stratifying on the quintiles of the propensity score. All analysis was performed retrospectively. RESULTS: Postoperative AF occurred in 29.5% of the patients with preoperative statin therapy compared with 40.9% of those patients without it (p = 0.021). No statistical differences among development of AF and type, dose, or duration of preoperative statin therapy were observed. Preoperative statins were associated with a 42% reduction in risk of AF development after CABG surgery (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.37 to 0.91, p = 0.017, while stratifying on the propensity score). No different effect of statins on AF was observed with respect to age groups (< or = 70 and > 70 years) (interaction p = 0.711). CONCLUSIONS: Preoperative statins may reduce postoperative AF after CABG. Patients undergoing elective revascularization may benefit from a preventive statin approach.

Post-infarction cardiac rupture: surgical treatment.

OBJECTIVE: Rupture of ventricular free wall (VFWR) may complicate acute myocardial infarction and accounts for high mortality. Surgical repair is the only therapeutic option. A review of our surgical experience is presented. METHODS: Seventeen patients (11 men, mean age 68 years) underwent surgery for VFWR. Patch covering technique was used in 13 patients, infarctectomy with patch reconstruction in three patients, direct suture without patch in one patient. Coronary artery bypass grafting was performed in eleven patients. RESULTS: Hospital mortality was 17.6% (three patients). Three patients died of cancer during the follow-up. The remaining 11 patients are in good condition after a mean follow-up of 45.8 months (range 7.5-84.2). CONCLUSIONS: Postinfarction rupture of ventricular free wall treated surgically gives excellent long-term results. Our first choice for repair is the covering technique with a large pericardial patch anchored with biological glue and epicardial sutures.