Echolucency of carotid plaque is useful for assessment of residual cardiovascular risk in patients with chronic coronary artery disease who achieve LDL-C goals on statin therapy.

BACKGROUND: Ultrasound assessment of either intima-media thickness (IMT) or plaque echolucency of the carotid artery provides prognostic information on coronary events. This study examined the hypothesis that IMT and plaque echolucency of the carotid artery may remain useful for prediction of coronary events in patients with coronary artery disease (CAD) after achievement of LDL-C goals on statin therapy. METHODS AND RESULTS: Ultrasound assessment of carotid maximum IMT (maxIMT) and plaque echolucency with integrated backscatter (IBS) analysis was performed in 357 chronic CAD patients with LDL-C <100mg/dl on statin therapy. All patients were prospectively followed up until the occurrence of one of the following coronary events: cardiac death, non-fatal myocardial infarction, or unstable angina pectoris requiring unplanned revascularization. During a mean follow-up of 32±18 months, 33 coronary events occurred. On multivariate Cox proportional hazards analysis, plaque echolucency (lower IBS value) was a significant predictor of coronary events (HR, 0.44; 95% CI: 0.29-0.73; P=0.009), whereas maxIMT was not. The addition of plaque echolucency to traditional risk factors improved net reclassification improvement (NRI) and integrated discrimination improvement (IDI; NRI, 0.59; P=0.0013; and IDI, 0.075; P=0.0009). CONCLUSIONS: Measurement of echolucency of the carotid artery was useful for assessment of residual coronary risk in CAD patients after LDL-C goal attainment on statin treatment.

Combined assessment of flow-mediated dilation of the brachial artery and brachial-ankle pulse wave velocity improves the prediction of future coronary events in patients with chronic coronary artery disease.

BACKGROUND AND PURPOSE: Measurement of either flow-mediated endothelium-dependent dilatation (FMD) of the brachial artery, brachial-ankle pulse wave velocity (baPWV), or intima-media thickness (IMT) of the carotid artery is useful for risk assessment of future cardiovascular events. This study examined whether combination of these vascular parameters may have an additive effect on the ability of traditional risk factors to predict coronary events in patients with chronic coronary artery disease (CAD). METHODS: Patients (n=923) with stable CAD had measurements of FMD, baPWV, and maximum IMT (maxIMT), and were prospectively followed up for <8.5 years or until a coronary event - cardiac death, non-fatal myocardial infarction (MI) or unstable angina pectoris (uAP) requiring unplanned coronary revascularization. RESULTS: During the follow-up period, 116 events occurred (29 cardiac deaths, 46 non-fatal MIs and 41 cases of uAP). A multivariate Cox proportional hazards analysis showed that FMD (HR 0.50, 95% CI 0.38-0.66) and baPWV (HR 1.52, 95% CI 1.27-1.82) but not maxIMT were significant predictors of coronary events. Based on the concordance statistics, the predictive value of traditional risk factors [area under the receiver operating characteristic curve (AUC), 0.67] was increased more by the addition of FMD and baPWV combined (AUC, 0.75) compared with the addition of either maxIMT, FMD, or baPWV alone, or the combination of maxIMT and FMD or maxIMT and baPWV (AUC, 0.67, 0.71, 0.71, 0.71 and 0.71, respectively). CONCLUSIONS: The combined addition of FMD and baPWV to the risk assessment algorithms may be useful for risk stratification of chronic CAD patients.

Insulin resistance negatively affects long-term outcome in non-diabetic patients with coronary artery disease after therapies to reduce atherosclerotic risk factors.

BACKGROUND: Insulin resistance (IR) is a predictor of cardiovascular (CV) events even before the onset of diabetes. However, it is unclear whether changes in IR after a reduction of atherosclerotic burden may affect long-term outcome in patients with coronary artery disease (CAD). This study examined whether changes in IR after therapy to reduce atherosclerotic risk factors provides prognostic information on future CV events in non-diabetic patients with CAD. METHODS AND RESULTS: This study enrolled 175 non-diabetic patients with newly diagnosed CAD and IR. IR was defined as the homeostasis model assessment of IR (HOMA-IR)>/=2.5. Evaluation of HOMA-IR was repeated at entry (1st test) and 6 months after individualized, optimized therapy including medications and lifestyle changes (2nd test). After the 2nd test, all patients were prospectively followed-up for 3 years or until the occurrence of one of the following events: CV death, nonfatal myocardial infarction, unstable angina requiring coronary revascularization, or ischemic stroke. IR was improved (HOMA-IR<2.5) after 6 months in 71 (41%) patients, whereas IR persisted in 104 (59%) patients. During the follow-up period, events occurred in 21 (20%) of the 104 patients with persistent IR and 3 (4%) of the 71 patients with improved IR (p<0.01). In multivariate stepwise Cox proportional hazards analysis, persistent IR was an independent predictor of future CV events (HR 4.8, 95% CI 1.4-11.2, p<0.01). CONCLUSIONS: The presence of IR despite optimized therapies to reduce atherosclerotic risk factors represents an adverse outcome predictor in non-diabetic patients with CAD.

Ultrasound assessment of brachial endothelial vasomotor function in addition to carotid plaque echolucency for predicting cardiovascular events in patients with coronary artery disease.

BACKGROUND: Single assessment of either flow-mediated vasodilatation of the brachial artery (FMD) or carotid plaque echolucency provides prognostic information for both cerebrovascular and coronary events. OBJECTIVES: This study tested the hypothesis that combined assessment using carotid plaque echolucency and FMD may have an additive effect when predicting cardiovascular events in patients with coronary artery disease (CAD). METHODS: Ultrasound assessment of carotid plaque echolucency with integrated backscatter (IBS) analysis (calibrated IBS=intima-media IBS value-adventitia IBS) and FMD was performed in 547 consecutive patients with CAD. All the study patients were followed up prospectively for a period of ≤ 60 months until the occurrence of one of the following cardiovascular events: cardiac death, non-fatal myocardial infarction, unstable angina requiring coronary revascularization, or ischemic stroke. RESULTS: During a mean follow-up period of 52 ± 10 months, 69 cardiovascular events occurred. A multivariate Cox proportional hazard model after 1000 bootstrapped resampling demonstrated that calibrated IBS and FMD were significant, independent predictors of future cardiovascular events after adjustment for known risk factors (calibrated IBS, HR 0.88, 95% CI 0.83-0.93; FMD, HR 0.76, 95% CI 0.68-0.85). The c-statistics, net reclassification improvement (NRI), and integrated discrimination improvement (IDI) analyses showed that the combination of calibrated IBS and FMD values had a greater incremental effect on the predictive value of known risk factors for cardiovascular events. CONCLUSIONS: Combined assessment of brachial endothelial function and carotid plaque echolucency is an independent predictor of cardiovascular events and improves risk prediction when added to known risks.