Prediction of cardiovascular events with traditional risk equations and total plaque area of carotid atherosclerosis: The Arteris Cardiovascular Outcome (ARCO) cohort study.

A large number of cardiovascular events occur in seemingly healthy individuals. Atherosclerosis imaging can improve the outcome and treatment regime of such subjects. We aim to assess the predictive value of atherosclerosis imaging beyond traditional risk calculators in subjects aged 40-65 years. We compared PROCAM, SCORE and FRAM with carotid ultrasound (total plaque area, TPA) and arterial age (AA) was calculated in subjects without known cardiovascular diseases. Follow-up was obtained by phone or mail. In 2842 subjects (age 50 ± 8, 38% women) 154 (5.4%) cardiovascular events occurred (ASCVD: 41 myocardial infarctions, 16 strokes or TIA, 21 CABG, 41 PTCA, 35 coronary artery disease defined by invasive angiography) during a mean follow-up time of 5.9 (1-12) years. PROCAM risk was 5 ± 6%, SCORE risk 1.3 ± 1.6% and FRAM 10 ± 6%. Both for the primary outcome (AMI, STROKE/TIA, CABG) and the secondary outcome (adding CAD and PTCA) hazards increased significantly for TPA tertiles and AA groups between 1.4 (0.1-16.1) and 21.4 (2.8-163.6) after adjustment for risk factors (age, smoke, sex, systolic BP, lipids, BMI, medication in Model 1) and after adjustment for results from PROCAM, SCORE and FRAM (Model 2). Model performance was statistically improved regarding model fit in all models using TPA and AA. Net reclassification improvement (NRI) for PROCAM and SCORE using TPA tertiles or AA age groups increased significantly between 30% to 48%. TPA and AA added prognostic information to conventional risk equations, supporting the assessment of ASCVD risk with carotid ultrasound in subjects aged 40-65 years.

Cost-effectiveness analysis of statins in primary care: results from the Arteris cohort study.

BACKGROUND: The Swiss Federal Office of Public Health performed a health technology assessment regarding statins in primary care. The chosen models may lead to a situation where a clinically indicated statin therapy is estimated not to be cost effective. METHODS: We performed a cohort study regarding cardiovascular events, comparing SCORE and AGLA risk categories with tertiles of carotid plaque burden and used two models for cost-effectiveness analysis of high-potency statins. RESULTS: Subjects (n = 2842) were followed up for 5.9 ± 2.9 years with the occurrence of 154 cardiovascular events (extrapolated 10-year risk was 9.2%). Carotid plaque imaging (total plaque area, TPA) significantly improved cardiovascular risk prediction compared with AGLA and SCORE for event-free survival prediction, test accuracy (discrimination) and calibration. Discrimination was significantly improved by about 4% with the inclusion of TPA. Cost-effectiveness analysis using quality-adjusted life years (QALYs) and sensitivity analyses (based on 16 models) ranged between CHF 144,496 and −128,328 per QALY. Cost-effectiveness analysis using direct and indirect costs showed that a treat-them-all strategy in the Swiss population would be cost effective with a return-on-investment per patient in 10 years of between CHF 4442 and 19,059, and the use of carotid imaging was also cost effective (incremental cost-efficiency ratio −2.97 to −7.86). CONCLUSIONS: Carotid ultrasound significantly improved cardiovascular risk stratification and is cost effective. The Swiss Medical Board QALY model presents several drawbacks, which are shown in our sensitivity analysis, where results vary considerably and are not useful for clinical decision making. A “treat them all” strategy with statins in the Swiss population aged 30–65 years may be cost effective, when indirect costs of avoidable cardiovascular events are included, even at an unacceptably low value of a statistical life year.

Open repair of abdominal aortic aneurysms in patients with horseshoe kidney / Nyitott hasi aortaaneurysma-mutétek patkóvese fennállása esetén.

Összefoglaló. A patkóvese a vese leggyakrabban eloforduló fejlodési rendellenességeinek egyike. Hasi aortaaneurysmával való együttes elofordulása kifejezetten ritka (a hasi aortaaneurysmás esetek 0,12%-a). Az elso esetben egy 64 éves férfi akut alsó végtagi panaszokkal került felvételre. A CT-angiográfia patkóvesét és thrombotizált infrarenalis aortaaneurysmát igazolt. Az akut mutét során a hasi aortaaneurysma resectióját és aortobifemoralis bypassmutétet végeztünk a patkóvese ishmusának megtartásával. A második esetben hasi panaszokat okozó, mindkét arteria iliaca communisra ráterjedo infrarenalis aortaaneurysma esetén végeztünk aortobiiliacalis rekonstrukciót. Az aneurysma elott elhelyezkedo isthmus tervezetten szétválasztásra került, a poláris veseartériát visszaültettük. A tünetes hasi aortaaneurysma abszolút mutéti indikációt képez. A preoperatív CT- vagy MR-angiográfia kulcsfontosságú mind a mutéti indikáció felállítása, mind pedig a mutét megtervezése szempontjából. A beavatkozás elott pontos képet kell kapnia az érsebésznek az aorta anatómiája mellett a patkóvese vérellátásáról és a húgyúti rendszerrol. Az érsebészeti rekonstrukció esetén a transperitonealis feltárás - foleg akut mutét esetén - több elonnyel rendelkezik, mint a retroperitonealis feltárás. Orv Hetil. 2020; 161(46): 1966-1971. Summary. Horseshoe kidney is one of the most common congenital disorders of the kidney. The simultaneous incidence of horseshoe kidney and abdominal aneurysm is very low (0.12% of all cases of abdominal aortic aneurysm). In the first case, a 64-year-old male patient was admitted with acute lower limb ischaemia. CT-angiography revealed an occluded aortic aneurysm. During the emergency operation, the abdominal aneurysm was resected and an aortobifemoral bypass procedure was performed sparing the kidney's isthmus. In the second case, the abdominal complaints were caused by an infrarenal abdominal aneurysm that involved both common iliac arteries. Aortobiiliac reconstruction was performed with planned separation of the kidney isthmus and reimplantation of the accessory renal artery. Symptomatic abdominal aortic aneurysm is an urgent indication for reconstruction. The preoperative CT- or MR-angiography play a key role in the indication and planning of the reconstruction. It is highly important for the vascular surgeon to have a clear picture of the blood supply of the horseshoe kidney and the urinary tract along with the anatomy of the aorta before the operation. The transperitoneal approach has several advantages over the retroperitoneal approach during vascular reconstruction surgery. Orv Hetil. 2020; 161(46): 1966-1971.