Predicting vulnerable carotid plaques by detecting wall shear stress based on ultrasonic vector flow imaging.

OBJECTIVE: Carotid plaque vulnerability is a significant factor in the risk of cardiocerebrovascular events, with intraplaque neovascularization (IPN) being a crucial characteristic of plaque vulnerability. This study investigates the value of ultrasound vector flow imaging (V-flow) for measuring carotid plaque wall shear stress (WSS) in predicting the extent of IPN. METHODS: We enrolled 140 patients into three groups: 53 in the plaque group (72 plaques), 23 in the stenosis group (27 plaques), and 64 in the control group. V-flow was used to measure WSS parameters, including the average WSS (WSS mean) and the maximum WSS (WSS max), across three plaque locations: mid-upstream, maximum thickness, and mid-downstream. Contrast-enhanced ultrasound examination was used in 76 patients to analyze IPN and its correlation with WSS parameters. RESULTS: WSS max in the stenosis group was significantly higher than that in the control and plaque groups at the maximum thickness part (P < .05) and WSS mean in the stenosis group was significantly lower than that in the control group at the mid-upstream and mid-downstream segments (P < .05). WSS mean in the plaque group was significantly lower than that of the control group at all three locations (P < .05). Contrast-enhanced ultrasound examination revealed that plaques with neovascularization enhancement exhibited significantly higher WSS values (P < .05), with a positive correlation between WSS parameters and IPN enhancement grades, particularly WSS max at the thickest part (r = 0.508). Receiver operating characteristic curve analysis of WSS parameters for evaluating IPN showed that the efficacy of WSS max in evaluating IPN was better than that of WSS mean (P < .05), with an area under the curve of 0.7762 and 0.6973 (95% confidence intervals, 0.725-0.822 and 0.642-0.749, respectively). The cut-offs were 4.57 Pa and 1.12 Pa, sensitivities were 74.03% and 63.64%, and specificities were 75.00% and 68.18%. CONCLUSIONS: V-flow effectively measures WSS in carotid plaques. WSS max provides a promising metric for assessing IPN, offering potential insights into plaque characteristics and showing some potential in predicting plaque vulnerability.

Novel treatment from a botanical formulation Si-Miao-Yong-an decoction inhibits vasa vasorum angiogenesis and stabilizes atherosclerosis plaques via the Wnt1/ß-catenin signalling pathway.

CONTEXT: Si-Miao-Yong-An (SMYA) has been widely used for the clinical treatment of atherosclerosis (AS). Yet, its complete mechanism of action is not fully understood. OBJECTIVE: To investigate the mechanism by which SMYA stabilizes AS plaques from the perspective of inhibiting vasa vasorum (VV) angiogenesis. MATERIALS AND METHODS: We used male ApoE-/- mice to establish an AS model. The mice were divided into model, SMYA (11.7 mg/kg/d), and simvastatin (SVTT) (2.6 mg/kg/d) groups. Mice were given SMYA or SVTT by daily gavage for 8 weeks. HE staining, immunofluorescence double-labelling staining, and immunohistochemical staining were used to observe the pathological changes in the plaques. Finally, the protein and mRNA expression levels of the Wnt1/ß-catenin signalling pathway were detected by Western blot and qRT-PCR, respectively. RESULTS: SMYA significantly attenuated cholesterol crystallization, and lipid accumulation in AS plaques, resulting in smaller plaque size (0.25 mm2 vs. 0.46 mm2), and lowering ratio of plaque to lumen area (20.04% vs. 38.33%) and VV density (50.64/mm2 vs. 98.02/mm2). Meanwhile, SMYA suppressed both the positive area percentage of Wnt1 (2.53 vs. 3.56), ß-catenin (3.33 vs. 5.65) and Cyclin D1 (2.10 vs. 3.27) proteins in the aortic root plaques, and mRNA expression of Wnt1 (1.38 vs. 2.09), ß-catenin (2.05 vs. 3.25) and Cyclin D1 (1.39 vs. 2.57). DISCUSSION AND CONCLUSIONS: SMYA has a protective effect against AS, which may be related to its anti-VV angiogenesis in plaques, suggesting that SMYA has the potential as a novel botanical formulation in the treatment of AS.

PFKFB3 gene deletion in endothelial cells inhibits intraplaque angiogenesis and lesion formation in a murine model of venous bypass grafting.

Vein grafting is a frequently used surgical intervention for cardiac revascularization. However, vein grafts display regions with intraplaque (IP) angiogenesis, which promotes atherogenesis and formation of unstable plaques. Graft neovessels are mainly composed of endothelial cells (ECs) that largely depend on glycolysis for migration and proliferation. In the present study, we aimed to investigate whether loss of the glycolytic flux enzyme phosphofructokinase-2/fructose-2,6-bisphosphatase 3 (PFKFB3) in ECs inhibits IP angiogenesis and as such prevents unstable plaque formation. To this end, apolipoprotein E deficient (ApoE-/-) mice were backcrossed to a previously generated PFKFB3fl/fl Cdh5iCre mouse strain. Animals were injected with either corn oil (ApoE-/-PFKFB3fl/fl) or tamoxifen (ApoE-/-PFKFB3ECKO), and were fed a western-type diet for 4 weeks prior to vein grafting. Hereafter, mice received a western diet for an additional 28 days and were then sacrificed for graft assessment. Size and thickness of vein graft lesions decreased by 35 and 32%, respectively, in ApoE-/-PFKFB3ECKO mice compared to controls, while stenosis diminished by 23%. Moreover, vein graft lesions in ApoE-/-PFKFB3ECKO mice showed a significant reduction in macrophage infiltration (29%), number of neovessels (62%), and hemorrhages (86%). EC-specific PFKFB3 deletion did not show obvious adverse effects or changes in general metabolism. Interestingly, RT-PCR showed an increased M2 macrophage signature in vein grafts from ApoE-/-PFKFB3ECKO mice. Altogether, EC-specific PFKFB3 gene deletion leads to a significant reduction in lesion size, IP angiogenesis, and hemorrhagic complications in vein grafts. This study demonstrates that inhibition of endothelial glycolysis is a promising therapeutic strategy to slow down plaque progression.

Neutrophil-to-lymphocyte ratio is associated with carotid intraplaque neovascularization in asymptomatic carotid stenosis patients.

BACKGROUND AND PURPOSE: Neutrophil-to-lymphocyte ratio (NLR) has been suggested as an available systemic inflammatory biomarker. This study aims to evaluate whether intraplaque neovascularization assessed by contrast-enhanced ultrasound (CEUS) is associated with NLR in asymptomatic carotid stenosis patients. MATERIALS AND METHODS: One hundred and forty-four asymptomatic patients with carotid luminal stenosis >30% were assessed using contrast-enhanced ultrasound imaging. The contrast enhancement within the plaque was classified on a visual semiquantitative grading scale. The data collected included the patient's risk factors, laboratory results, cardiovascular disease history, and drug use history. Univariate and multivariate analyses were assessed to identify independent factors related to intraplaque neovascularization with adjustment for potential confounders. RESULTS: Patients with CEUS grade 2 plaques had a higher level of LDL-C (p < .001), neutrophil count (p < .001), and blood glucose (p = .005), but lower level of lymphocyte count (p = .021). The presence of grade 2 plaques was significantly associated with high NLR values (OR 1.21, 95% CI 1.03-1.43, p = .017). Patients were divided into four groups according to the quartile of NLR values. Compared to the patients in the first quartile of NLR (<1.73), the patients in the fourth NLR quartile (≥3.38) were characterized by the most prevalence of CEUS grade 2 plaques (OR 4.55, 95% CI 1.69-12.25, p = .003). Multivariate logistic regression analysis after adjusting various variables demonstrated NLR remained an independent risk factor for the presence of CEUS grade 2 plaques. CONCLUSION: Intraplaque neovascularization is significantly associated with NLR in asymptomatic carotid stenosis patients.

The association of lipoprotein(a) and intraplaque neovascularization in patients with carotid stenosis: a retrospective study.

BACKGROUND: Lipoprotein(a) is genetically determined and increasingly recognized as a major risk factor for arteriosclerotic cardiovascular disease. We examined whether plasma lipoprotein(a) concentrations were associated with intraplaque neovascularization (IPN) grade in patients with carotid stenosis and in terms of increasing plaque susceptibility to haemorrhage and rupture. METHODS: We included 85 patients diagnosed with carotid stenosis as confirmed using carotid ultrasound who were treated at Guangdong General Hospital. Baseline data, including demographics, comorbid conditions and carotid ultrasonography, were recorded. The IPN grade was determined using contrast-enhanced ultrasound through the movement of the microbubbles. Univariate and multivariate binary logistic regression analyses were used to evaluate the association between lipoprotein(a) and IPN grade, with stepwise adjustment for covariates including age, sex, comorbid conditions and statin therapy (model 1), total cholesterol, triglyceride, low-density lipoprotein cholesterol calculated by Friedwald's formula, high-density lipoprotein cholesterol, apolipoprotein A and apolipoprotein B (model 2), maximum plaque thickness and total carotid maximum plaque thickness, degree of carotid stenosis and internal carotid artery (ICA) occlusion (model 3). RESULTS: Lipoprotein(a) was a significant predictor of higher IPN grade in binary logistic regression before adjusting for other risk factors (odds ratio [OR] 1.238, 95% confidence interval [CI] (1.020, 1.503), P = 0.031). After adjusting for other risk factors, lipoprotein(a) still remained statistically significant in predicting IPN grade in all model. (Model 1: OR 1.333, 95% CI 1.074, 1.655, P = 0.009; Model 2: OR 1.321, 95% CI 1.059, 1.648, P = 0.014; Model 3: OR 1.305, 95% CI 1.045, 1.628, P = 0.019). Lp(a) ≥ 300 mg/L is also significantly related to IPN compare to < 300 mg/L (OR 2.828, 95% CI 1.055, 7.580, P = 0.039) as well as in model 1, while in model 2 and model 3 there are not significant difference. CONCLUSIONS: Plasma lipoprotein(a) concentrations were found to be independently associated with higher IPN grade in patients with carotid stenosis. Lowering plasma lipoprotein(a) levels may result in plaque stabilization by avoiding IPN formation.

Mathematical modeling of intraplaque neovascularization and hemorrhage in a carotid atherosclerotic plaque.

BACKGROUND: Growing experimental evidence has identified neovascularization from the adventitial vasa vasorum and induced intraplaque hemorrhage (IPH) as critical indicators during the development of vulnerable atherosclerotic plaques. In this study, we propose a mathematical model incorporating intraplaque angiogenesis and hemodynamic calculation of the microcirculation, to obtain the quantitative evaluation of the influences of intraplaque neovascularization and hemorrhage on vulnerable plaque development. A two-dimensional nine-point model of angiogenic microvasculature is generated based on the histology of a patient's carotid plaque. The intraplaque angiogenesis model includes three key cells (endothelial cells, smooth muscle cells, and macrophages) and three key chemical factors (vascular endothelial growth factors, extracellular matrix, and matrix metalloproteinase), which densities and concentrations are described by a series of reaction-diffusion equations. The hemodynamic calculation by coupling the intravascular blood flow, the extravascular plasma flow, and the transvascular transport is carried out on the generated angiogenic microvessel network. We then define the IPH area by using the plasma concentration in the interstitial tissue, as well as the extravascular transport across the capillary wall. RESULTS: The simulational results reproduce a series of pathophysiological phenomena during the atherosclerotic plaque progression. It is found that the high microvessel density region at the shoulder areas and the extravascular flow across the leaky wall of the neovasculature contribute to the IPH observed widely in vulnerable plaques. The simulational results are validated by both the in vivo MR imaging data and in vitro experimental observations and show significant consistency in quantity ground. Moreover, the sensitivity analysis of model parameters reveals that the IPH area and extent can be reduced significantly by decreasing the MVD and the wall permeability of the neovasculature. CONCLUSIONS: The current quantitative model could help us to better understand the roles of microvascular and intraplaque hemorrhage during the carotid plaque progression.

Detection of Carotid Atherosclerotic Intraplaque Neovascularization Using Superb Microvascular Imaging: A Meta-Analysis.

OBJECTIVES: Although superb microvascular imaging (SMI) (Toshiba/Canon, Tokyo, Japan) has enabled routine characterization of intraplaque neovascularization (IPN) features in patients with carotid stenosis, no reports have been published on the multicenter and large sample size research in this aspect. The efficacy of SMI in detecting carotid IPN has not been concluded. This study aimed to assess the efficacy of SMI comparing with contrast-enhanced carotid ultrasonography (CEUS) in the detection of carotid IPN or pathologic evaluations of IPN correlated with a history of stroke or transient ischemic attack (TIA). METHODS: Web of Science, Cochrane Library, PubMed, Embase, and Scopus were searched up to August 2020 to identify peer-reviewed human studies on the diagnostic accuracy of SMI in detecting IPN. For the selected study, the correlation coefficient R and Kappa index between SMI and CEUS in detecting IPN were calculated. The correlation coefficient R between SMI in identifying IPN and pathologic evaluations of IPN and the odds ratio of IPN detected by SMI and history of stroke or TIA were also extracted. The subgroup analysis was performed to indicate the source of heterogeneity. RESULTS: Our search identified 11 reports enrolling a total of 605 carotid stenosis patients. Carotid IPN detected by SMI was significantly correlated with which detected by CEUS (R, 0.89; 95% CI, 0.80-0.94; P = .00, and Kappa index, 0.73; 95% CI, 0.67-0.80; P = .00). Notably, a significant correlation was observed in SMI in detecting IPN and pathologic evaluations of IPN (R, 0.52; 95% CI, 0.40-0.62; P = .00). The odds ratio of IPN detected by SMI and history of stroke or TIA was pooled summary with statistical significance (OR, 3.33; 95% CI, 1.78-6.23; P = .00). In subgroup analysis, lower heterogeneity was associated with the degree of carotid stenosis, patients from which country, and types of equipment. CONCLUSIONS: SMI and CEUS display an excellent agreement in detecting carotid IPN. IPN detected by SMI shows high consistency with pathologic evaluations of IPN. Individuals with carotid IPN are more likely to develop stroke or TIA than those without carotid IPN.

Correlation of Cerebral White Matter Lesions with Carotid Intraplaque Neovascularization assessed by Contrast-enhanced Ultrasound.

PURPOSE: Carotid atherosclerotic plaque is closely associated with cerebral white matter lesions (WMLs), while intraplaque neovascularization (IPN) contributes significantly to arterial remodeling and plaque vulnerability. In this study, we aim to evaluate the correlation of carotid IPN with cerebral WMLs. METHODS: The presence of IPN and WMLs were assessed by contrast-enhanced ultrasound (CEUS) and MRI respectively. IPN was evaluated utilizing semi-quantification visual grading scale and WMLs was divided according to Fazekas grading scale. We investigated the baseline data, Fazekas grades, and IPN grades among 269 participants. We explored the influences of each variable on Fazekas grades using ordinal logistic regression and evaluated the relationship between IPN grades and WMLs Fazekas grades. RESULTS: Increased age (OR: 1.06, P<0.001), hypertension (OR: 2.17, P=0.002), cerebral infarction (OR: 1.74, P=0.046), and elevated carotid IPN grading were significantly associated with aggravated Fazekas grades (grade 2 or 3). To be specific, people having grade 3, 2, and 1 carotid IPN were 25.84 (P<0.001), 10.64 (P<0.001), and 5.96 (P=0.010) times as likely to have elevated Fazekas grades compared with those who having grade 0 carotid IPN. CONCLUSION: Increased carotid IPN is independently correlated with aggravated cerebral WMLs.

Evaluating the Efficacy of Atorvastatin on Patients with Carotid Plaque by an Innovative Ultrasonography.

BACKGROUND: The present study aimed to explore the efficacy of atorvastatin on patients with carotid plaque, applying superb microvascular imaging (SMI), and contrast-enhanced ultrasound (CEUS) for evaluating carotid intraplaque neovascularization. METHODS: A total of 82 patients (82 carotid plaques) who were randomized into treatment group and control group underwent conventional ultrasound, CEUS, and SMI examinations. Patients in treatment group received a dose of 20 mg atorvastatin per day for 6 months while those in control group received placebo instead. Lipid parameters were assessed and intraplaque neovascularization were evaluated by CEUS and SMI before and 6 months after atorvastatin treatment. RESULTS: No significant differences were found between the 2 groups at the study entry. Patients with atorvastatin treatment received marked improvement in total cholesterol, triglyceride, and LDL-cholesterol compared with those in control group (P < .001). In treatment group, SMI-detected intraplaque neovascularization reduced from 69.23% to 48.72% while CEUS-detected ones reduced from 76.92% to 69.23%. By contrast, the percentage of intraplaque neovascularization in control group did not change too much either by SMI (65.12%, 67.44%) or CEUS (74.41%, 74.41%). The consistency between CEUS and SMI was above .75 at all assessments (P < .001). CONCLUSIONS: Atorvastatin treatment works for patients with carotid plaque by reducing LDL-cholesterol and improving plaque regression. Second, the consistency between SMI and CEUS in visualizing intraplaque neovascularization is good. That indicates a high possibility to identify carotid plaque instability by a safer and cheaper ultrasonography without contrast agent.

Evaluation of Intraplaque Neovascularization Using Superb Microvascular Imaging and Contrast-Enhanced Ultrasonography.

BACKGROUND: Several studies have shown a linkage between intraplaque neovascularization (IPN) and plaque instability. Although contrast-enhanced ultrasonography (CEUS) may help visualize IPN in the carotid artery, its benefits are limited in Japan, where there is no health insurance coverage for contrast agents in medical imaging. Superb microvascular imaging (SMI), however, enables the depiction of low-velocity blood flow. The current study compares the diagnostic accuracy of SMI and CEUS in the evaluation of IPN. METHODS: The SMI and CEUS video images were transferred to a workstation and then analyzed to determine whether intraplaque blood flow signals were detected with SMI and whether plaques were contrast-enhanced with carotid artery CEUS. The images generated were independently interpreted by 2 radiologic technologists and 1 neurologist. RESULTS: Intraplaque enhancement was observed in 19 patients using CEUS while intraplaque blood flow signals were observed in 12 patients using SMI. A 100% specificity was recorded for SMI (all 12 patients with SMI-detected intraplaque blood flow showed contrast-enhanced plaques), while its sensitivity was 63% (8 of the 15 patients with no SMI-detected intraplaque blood flow showed contrast-enhanced plaques on CEUS). CONCLUSIONS: The results of this study show that patients with SMI-detected blood flow will tend to have plaque enhancement using CEUS. This suggests that SMI, as a simpler, safer, and noninvasive technique, can facilitate the visualization of carotid artery IPN without the use of a contrast agent, as well as in the clinical evaluation of plaque instability.

Spatio-temporal Quantification of Carotid Plaque Neovascularization on Contrast Enhanced Ultrasound: Correlation with Visual Grading and Histopathology.

OBJECTIVE/BACKGROUND: To evaluate whether carotid intraplaque neovascularization (IPN) can be accurately assessed by two types of quantitative analysis on contrast enhanced ultrasound (CEUS), the time intensity curve analysis and the analysis of contrast agent spatial distributions, and whether the quantitative analysis correlates with semiquantitative visual interpretation and histopathology. METHODS: Forty-four plaques in 34 patients were included for CEUS examination. A three point score system (absent, moderate, and extensive) was used for semiquantitative grading of IPN. Eight spatial quantitative parameters were derived, including the IPN area ratio in plaque (AR) and the AR in plaque core (AR13). Two temporal quantitative parameters were obtained, namely the enhanced intensity in plaque (EI) and the enhanced intensity ratio (EIR). Histopathology with CD34 staining for quantification of microvessel density (MVD) was performed on 12 plaques excised by carotid endarterectomy. RESULTS: Both spatial and temporal parameters were correlated with MVD on histology (AR: r = .854; AR13: r = .858; EI: r = .767; EIR: r = .750 [p < .01]), as well as with semiquantitative grading (p < .01). Five mutually independent factors were condensed from 10 interrelated parameters by using factor analysis, and they significantly predicted MVD with an radj value as high as .932 (p = .01). CONCLUSION: Both spatial and temporal analysis on CEUS can accurately assess IPN. Combining them provides better IPN assessment and may be useful for plaque vulnerability evaluation and risk stratification.

Mast cells in human carotid atherosclerotic plaques are associated with intraplaque microvessel density and the occurrence of future cardiovascular events.

AIMS: Human autopsy, animal, and cell culture studies together have merged in a concept suggesting participation of mast cells (MCs) in the generation of atherosclerotic plaques. More specifically, these studies have suggested MC-induced intraplaque neovascularization as one mechanism by which MCs may render the plaques vulnerable. The present study was designed to assess the association between MC numbers and neovascularization in human atherosclerotic plaques, and to relate the abundance of plaque MCs to the occurrence of adverse cardiovascular events during the follow-up. METHODS AND RESULTS: Atherosclerotic plaques of 270 patients suffering from carotid artery stenosis were stained for the presence of MCs (MC tryptase). Furthermore, during a follow-up of 3 years, cardiovascular-related endpoints were assessed in 253 patients. On average a high number of MCs were observed per plaque cross-section [median 108 (55-233) cells per section]. Plaques with high MC numbers revealed an unstable lipid-rich inflammatory phenotype and were associated with symptomatic patients. In addition, MC numbers were positively associated with microvessel density (r = 0.416, P < 0.001). Patients with high intraplaque MC numbers showed significantly more cardiovascular events during the follow-up (58/142 vs. 31/111 events, P = 0.029). In a multivariate analysis with correction for the main risk factors of cardiovascular diseases, MCs remained independently associated with adverse cardiovascular events (P = 0.025). CONCLUSION: Mast cells are highly prevalent in human carotid atherosclerotic lesions and associated with plaque microvessel density. Furthermore, intraplaque MC numbers associate with future cardiovascular events.

Pharmacological interventions for intraplaque neovascularization in atherosclerosis.

Advanced atherosclerosis is linked to plaque instability, which can result in rupture and the onset of a heart attack. Evidence gathered from human atheroma plaques indicates that intraplaque neovascularization poses a risk to plaque stability and may lead to plaque hemorrhage. Hence, targeting the neovascularization within the atheroma plaque has the potential to mitigate the plaque's vulnerability. While neovascularization has been extensively explored in the context of cancer, research on pharmacological inhibition of this phenomenon in atherosclerosis remains limited. This systematic review aimed to comprehensively assess current and emerging pharmacological interventions for inhibiting intraplaque neovascularization in preclinical settings. Electronic databases (Web of Science, PubMed, Scopus, and Ovid) were searched from January 2013 until February 1, 2024. Preclinical studies reporting the effect of any pharmacological interventions targeting intraplaque neovascularization were included. A total of 10 articles involving in vivo animal studies were eligible for inclusion, with five of them incorporating in vitro experiments to complement their in vivo findings. The pharmacological interventions studied were axitinib, ghrelin, K5, rosuvastatin, atorvastatin, 3PO, everolimus, melatonin, Si-Miao-Yong-A, and protocatechuic aldehyde. All the interventions showed a positive impact in inhibiting intraplaque neovascularization in various atherosclerotic animal models through various signaling pathways. This review provides valuable insights into pharmacological approaches to attenuate intraplaque neovascularization that could serve as a promising therapeutic avenue to enhance plaque stability.

Effect of combining evolocumab with statin on carotid intraplaque neovascularization in patients with premature coronary artery disease (EPOCH).

BACKGROUND AND AIMS: We aimed to explore the effect of PCSK9 inhibitor based on the background of statin on carotid intraplaque neovascularization (IPN) assessed by serial contrast-enhanced ultrasound (CEUS) analysis in Chinese patients with premature coronary artery disease (PCAD). METHODS: 41 patients were included to receive treatments with biweekly evolocumab (n = 22) or placebo (n = 19) in addition to statin therapy for 52 weeks. All patients were newly diagnosed with PCAD and treatments were initiated at baseline of the observations. Baseline and 52-week CEUS were acquired to measure the max plaque height (MPH) and IPN. The primary outcome was the 52-week IPN changes, the secondary endpoints included the 52-week MPH changes and major adverse cardiovascular events. RESULTS: The mean ± SD age of the participants was 46.76 ± 8.56 years, and 61% (25/41) of patients were on statins before the start of the study. There was no statistically significant difference in the history of statins treatment and the initiated lipid-lowering therapy of atorvastatin and rosuvastatin between groups (p > 0.05). At 52 weeks, the evolocumab group showed a lower LDL level (0.84 ± 0.45 mmol/L vs. 1.58 ± 0.51 mmol/L, p < 0.001) and a greater decrease in percent reduction of LDL-C level (-65% vs. -32%) and a higher percent of achieving lipid-lowering target (95% vs. 53%, p < 0.05) compared with the placebo group. At 52 weeks, IPN (evolocumab group: 0.50 ± 0.60 vs. 1.50 ± 0.80, p < 0.001; placebo group: 0.79 ± 0.54 vs. 1.26 ± 0.65, p < 0.05) and MPH (evolocumab group: 2.01 ± 0.44 mm vs. 2.57 ± 0.90 mm, p < 0.05, placebo group: 2.21 ± 0.58 mm vs. 2.92 ± 0.86 mm, p < 0.05) reduced significantly in both groups from baseline to 52-week follow-up. IPN and MPH were decreased by both treatments. Still, there was no significant difference in delta (52 weeks - baseline) MPH by an ANOVA analysis between the two groups [evolocumab group: -0.56 mm (2.01 mm-2.57 mm); placebo group: -0.71 mm (2.21 mm-2.92 mm), p > 0.05]. In the evolocumab group, the change in the mean reduction of IPN from baseline [-1.00 (0.50-1.50) vs. -0.47 (0.79-1.26), p < 0.05] and the incidence of patients with carotid IPN decrease were significantly greater reduction (90% vs. 58%, p < 0.05). CONCLUSIONS: If compared to placebo, the PCSK9 inhibitor evolocumab combined with statins resulted in a greater decrease in LDL-C and plaque neovascularization in Chinese patients with PCAD.

Deep learning approach for cardiovascular disease risk stratification and survival analysis on a Canadian cohort.

The quantification of carotid plaque has been routinely used to predict cardiovascular risk in cardiovascular disease (CVD) and coronary artery disease (CAD). To determine how well carotid plaque features predict the likelihood of CAD and cardiovascular (CV) events using deep learning (DL) and compare against the machine learning (ML) paradigm. The participants in this study consisted of 459 individuals who had undergone coronary angiography, contrast-enhanced ultrasonography, and focused carotid B-mode ultrasound. Each patient was tracked for thirty days. The measurements on these patients consisted of maximum plaque height (MPH), total plaque area (TPA), carotid intima-media thickness (cIMT), and intraplaque neovascularization (IPN). CAD risk and CV event stratification were performed by applying eight types of DL-based models. Univariate and multivariate analysis was also conducted to predict the most significant risk predictors. The DL's model effectiveness was evaluated by the area-under-the-curve measurement while the CV event prediction was evaluated using the Cox proportional hazard model (CPHM) and compared against the DL-based concordance index (c-index). IPN showed a substantial ability to predict CV events (p < 0.0001). The best DL system improved by 21% (0.929 vs. 0.762) over the best ML system. DL-based CV event prediction showed a ~ 17% increase in DL-based c-index compared to the CPHM (0.86 vs. 0.73). CAD and CV incidents were linked to IPN and carotid imaging characteristics. For survival analysis and CAD prediction, the DL-based system performs superior to ML-based models.

Assessment of Carotid Plaque Enhancement on Contrast-Enhanced Ultrasound as a Predictor for Severe Coronary Artery Disease.

Background and Aim Contrast-enhanced ultrasound (CEUS) can reliably identify vulnerable plaques. As atherosclerosis is a systemic disease, we evaluated whether contrast enhancement of carotid plaque (CECP) can predict severe coronary artery disease (CAD) by comparing CECP in patients who have had acute coronary syndromes (ACS) recently with asymptomatic individuals. Settings and Design This case-control study was done at a tertiary care center during 2022. Materials and Methods Fourteen participants were recruited in each group, after screening in-patients for carotid plaques and inclusion and exclusion criteria. Those who had history of ACS were enrolled as cases, while those who did not were enrolled as controls. All these patients underwent grayscale, Doppler, and CEUS examination for characterization of the carotid plaque. For cases, findings on CEUS were also compared with the severity of CAD on catheter coronary angiography. Statistical Analysis Diagnostic parameters including sensitivity, specificity, and diagnostic accuracy were calculated and proportions were compared by using Fisher's exact test. Results Eight out of 28 patients showed CECP. CECP and CAD were positively associated with p -Value of 0.033. Eighty-three percent patients with triple vessel disease and 50% patients with double vessel disease on coronary angiography showed CECP. Sensitivity and specificity of CECP for prediction of CAD were 50 and 92.9%, respectively. Conclusion CECP on CEUS can predict CAD and is a more reliable indicator of severe CAD than plaque characteristics on grayscale and Doppler imaging; making it useful for screening of patients at risk of having CAD.

The Monocyte-to-Lymphocyte Ratio Was Associated With Intraplaque Neovascularization of the Carotid Artery on AngioPLUS.

BACKGROUND: The monocyte-lymphocyte ratio (MLR) is a hematological test parameter that reflects the status of both monocytes and lymphocytes as inflammatory cells. This study aims to investigate the relationship between MLR and carotid intraplaque neovascularization (IPN) in patients with asymptomatic carotid stenosis. METHODS: We performed the Angio Planewave Ultrasensitive (AngioPLUS) screening for patients with carotid plaques. The carotid plaque stability was evaluated by semiquantitative visual grading of carotid IPN. Binary logistic regression models were performed to determine the associations between different clinical and laboratory indicators and the presence of high IPN. RESULTS: A total of 160 patients were eventually enrolled with 99 in the low IPN group (Scores 0-1) and 61 in the high IPN group (Score 2). Univariate logistic regression showed that age, monocytes, lymphocytes, glycated hemoglobin (HbA1c), fibrinogen, d-dimmer, and MLR were significantly associated with the presence of high IPN (all p < 0.05). Multivariate logistic regression models showed that MLR was significantly associated with the presence of high IPN after adjusting for other covariates. An MLR value of 32.9 was the optimal cutoff value to differentiate high and low IPN. High MLR was also significantly correlated with the presence of high IPN (odds ratio [OR] = 4.08, 95% confidence interval [CI]: 1.69-9.88, p = 0.002) when included in the above multivariate logistic regression model. CONCLUSION: Elevated MLR is closely associated with the presence of high IPN and may serve as a surrogate biomarker for carotid IPN.

Relationship between fibroblast growth factor in plasma and carotid plaque neovascularization: a pilot study.

Background: Unstable atherosclerotic carotid plaques with intraplaque neovascularization (IPN) carry a substantial risk for ischemic stroke. Conventional ultrasound methods fall short in detecting IPN, where superb microvascular imaging (SMI) has emerged as a promising tool for both visualizing and quantification. High levels of fibroblast growth factor 23 (FGF-23) have, in observational studies, been suggested as related to cardiovascular morbidity and mortality. The association of FGF-23 to atherosclerotic carotid plaque instability remains relatively unexplored. Methods: A cohort of twenty-nine patients with ≥50% atherosclerotic carotid stenosis underwent conventional carotid ultrasound, SMI, and blood tests, including measurement of FGF-23 in plasma. Nineteen patients were characterized as symptomatic and ten as asymptomatic. Results: Our major findings were: i) Higher FGF-23 levels were strongly correlated with increased SMI-assessed IPN. ii) Neo-vessel count recorded by quantitative SMI was positively correlated to increased FGF-23 levels, but not with basic FGF levels. (iii) In contrast, traditional risk factors for plaque instability exhibited no noteworthy associations with SMI-assessed IPN or with FGF-23 levels. Conclusion: This pilot study suggest the potential of FGF-23 as a valuable marker for neovascularization and atherosclerotic carotid plaque instability as a risk factor for ischemic stroke. Further research involving larger cohorts and prospective data is necessary to understand FGF-23's role in this context comprehensively.

Effect of moderate-intensity statin on carotid intraplaque neovascularization of coronary artery disease: a retrospective cohort study.

Background: Statin treatment can reduce atherosclerotic plaque as detected via invasive intracoronary methods. However, few studies have evaluated the effect of moderate-intensity statin therapy on carotid intraplaque neovascularization (IPN) using semiquantitative indices. This study thus aimed to assess the effect of statin on the carotid IPN of coronary artery disease with contrast-enhanced ultrasound (CEUS). Methods: In this noncontrol, retrospective, cohort study, 35 inpatients who underwent coronary angiography, serial CEUS, and laboratory evaluations were consecutively enrolled from June 2020 to December 2022 at the Department of Cardiology, Chinese PLA General Hospital. All patients were administered moderate-intensity statin during serial CEUS, and continuous and categorical assessment of IPN and maximum plaque height (MPH) of carotid plaque was performed. Patients with a target low-density lipoprotein cholesterol (LDL-C) <1.8 mmol/L at 12-month follow-up were compared with those who did not reach the LDL-C 1.8 mmol/L target. Results: From baseline to 12-month follow-up, there were significant differences in the LDL-C levels between patients (2.71±1.29 vs. 1.35±0.83 mmol/L), those with 12-month follow-up LDL-C <1.8 mmol/L (2.58±1.24 vs. 1.08±0.52 mmol/L), and those with 12-month follow-up LDL-C ≥1.8 mmol/L (3.24±1.44 vs. 2.56±0.85 mmol/L) all P values <0.05, with decreases of 41%, 49%, and 11% from baseline, respectively. The mean MPH (12 months to baseline) decreased from 2.47±0.63 to 2.22±0.60 mm (P<0.05), and the IPN also decreased from 1.15±0.62 to 0.58±0.56, representing a reduction of 0.57±0.59 from baseline (P<0.001). In the LDL-C <1.8 mmol/L patients, there were significant differences between baseline and 12 months in MPH (2.37±0.56 vs. 2.03±0.52 mm; P<0.05) and IPN (1.32±0.77 vs. 0.54±0.63; P<0.05) compared with those with a follow-up LDL-C ≥1.8 mmol/L. Patients with a follow-up LDL-C <1.8 mmol/L, compared with those with a follow-up LDL-C ≥1.8 mmol/L, showed a significantly greater reduction in MPH (-0.34±0.46 vs. -0.13±0.39; P<0.05) and IPN (-0.79±0.63 vs. -0.57±0.79; P<0.05). Additionally, patients with carotid IPN regression showed a higher percent change in LDL-C compared with those without carotid IPN regression (-53.31±23.20 vs. -29.55±19.47; P<0.05). Conclusions: Controlling the LDL-C to <1.8 mmol/L under moderate-intensity statin can stabilize and reduce carotid IPN as detected by the semiquantitative noninvasive CEUS.

Intraplaque Neovascularization, CD68+ and iNOS2+ Macrophage Infiltrate Intensity Are Associated with Atherothrombosis and Intraplaque Hemorrhage in Severe Carotid Atherosclerosis.

BACKGROUND: Atherosclerosis is a progressive disease that results from endothelial dysfunction, inflammatory arterial wall disorder and the formation of the atheromatous plaque. This results in carotid artery stenosis and is responsible for atherothrombotic stroke and ischemic injury. Low-grade plaque inflammation determines biological stability and lesion progression. METHODS: Sixty-seven cases with active perilesional inflammatory cell infiltrate were selected from a larger cohort of patients undergoing carotid endarterectomy. CD68+, iNOS2+ and Arg1+ macrophages and CD31+ endothelial cells were quantified around the atheroma lipid core using digital morphometry, and expression levels were correlated with determinants of instability: ulceration, thrombosis, plaque hemorrhage, calcification patterns and neovessel formation. RESULTS: Patients with intraplaque hemorrhage had greater CD68+ macrophage infiltration (p = 0.003). In 12 cases where iNOS2 predominated over Arg1 positivity, the occurrence of atherothrombotic events was significantly more frequent (p = 0.046). CD31 expression, representing neovessel formation, correlated positively with atherothrombosis (p = 0.020). CONCLUSIONS: Intraplaque hemorrhage is often described against the background of an intense inflammatory cell infiltrate. Atherothrombosis is associated with the presence of neovessels and pro-inflammatory macrophages expressing iNOS2. Modulating macrophage polarization may be a successful therapeutic approach to prevent plaque destabilization.