Testing for carotid atherosclerosis

BACKGROUND: Optometrists frequently examine patients with the signs and symptoms of carotid artery disease. Referral for appropriate testing is mandatory in such patients. METHODS: A review of the noninvasive tests which an optometrist can perform in the office is presented. The paper also describes the noninvasive tests which are performed in vascular clinics on patients in whom carotid atherosclerosis is to be ruled out. Arteriography, both conventional and digital subtraction studies, is also described. RESULTS: A discussion of the appropriate medical and surgical treatment of patients with carotid atherosclerosis and the ocular manifestations of it is included in the paper. CONCLUSIONS: With the increasing expansion of the scope of practice for optometrists, it is imperative that the signs and symptoms of carotid atherosclerosis be understood and managed appropriately. Preliminary tests for carotid arterial disease can be performed in the office, and referral for more extensive testing is better accomplished when those tests are understood by the referring optometrist.     

Relation of systemic arterial pulse pressure to coronary atherosclerosis in patients with mitral stenosis

The relation of a wide systemic arterial pulse pressure to coronary atherosclerosis has not been fully defined. One hundred fifty-nine patients > 40 years old with symptomatic mitral stenosis (MS) who received routine coronary angiography were classified into 2 groups according to the presence of > or = 50% diameter narrowing of > or = 1 coronary artery (n = 48) or no significant disease (n = 111). Pulse pressure was determined both by noninvasive sphygmomanometer and invasive catheterization methods. There were no significant differences in risk factors of coronary artery disease (CAD) or the severity of MS between the 2 groups. From multivariate logistic regression analysis, independent predictors of development of CAD in MS were age (standardized coefficient beta = 1.3437, p = 0.0025), gender (beta = 0.0107, p = 0.0105), mean blood pressure (beta = 1.1839, p = 0.0105), and pulse pressure (beta = 1.3157, p = 0.0008). A wide pulse pressure (> or = 60 mm Hg) correlated with the presence of angiographically significant CAD with a sensitivity and specificity of 88% and 77%. The negative predictive value was 93%. Pulse pressure assessed by sphygmomanometry provided important clinical information. A wide pulse pressure in patients with MS was associated with a high incidence of CAD.     

Multimodal approach to carotid bifurcation in atherosclerosis

The cost of treatment of ischemic stroke (second cause of death for elderly patients) is increasing. carotid bifurcation surgery can change the prognosis (as proven by NASCET and ECST studies) for symptomatic patients with over 70% of carotid narrowing. Exploration of the carotid bifurcation is an important step in the diagnosis and must assess the degree of stenosis, the smoothness of the plaque and describe the collateral vessels. Duplex sonography is used to analyze the plaque and to measure the hemodynamic consequences beyond the stenosis. Transcranial Doppler is used to study the hemodynamic consequences at the circle of Willis. 3D TOF MR Angiography visualizes vessels using MIP but with a risk of overestimation of the degree of stenosis. A good morphological study of the circle of Willis can be achieved. With spiral CT, 3D data bases can be acquired with a single injection of contrast medium. Analysis is based on native, reformatted and MIP images. The image quality is generally good, but decreases in the case of huge calcifications. Brain examination can be performed in the same session, looking for rupture of the blood-brain barrier. Angiography remains the gold standard with a high complication rate. It allows excellent analysis from the aortic arch to distal cortical vessels. Isotope studies are only performed in difficult cases (vertebro-basilar lesions, differential diagnosis). Duplex ultrasound is performed first in all protocols. Until recently, angiography was performed before surgery, but the current tendency is to use a less invasive examination (MR angiography or CT angiography) and angiography is then only performed when necessary. A knowledge of the respective advantages of each technique is essential in order to adapt the protocols to each local team.     

Hostility and the progression of carotid atherosclerosis

We studied prospectively the association of hostility and anger suppression by the use of ultrasonographically assessed 2-year progression of carotid atherosclerosis (PCA) in a sample of 119 middle-aged men from eastern Finland. Based on measures of cynical distrust, impatience-irritability, anger-in, and anger-control, four variants of hostility-by-anger suppression model were tested with multiple regression analysis. In addition to the previously established risk factors (i.e., serum low-density lipoprotein cholesterol concentration, smoking, and old age), cynical distrust and anger-control significantly predicted PCA. There was about a two-fold accelerated PCA in the group with high cynical distrust and high anger-control even after we controlled for the established biological risk factors and possible confounding background variables. The impact of the independent variables on PCA seemed to be additive rather than synergistic. These results, based on a relatively small, but nonselected population sample, extend previous results of angiographic studies.     

颈动脉粥样硬化与脑梗死关系探讨

目的 研究颈动脉粥样硬化病变特点和颈动脉内膜中层厚度(IMT)与脑梗死的关系.方法 对观察组100例急性脑梗死患者和对照组100例同期体检的健康者进行颈动脉彩色多普勒超声检查,检测双侧颈总动脉、颈动脉分叉和颈内动脉IMT和颈动脉粥样硬化斑块情况.结果 观察组颈动脉粥样硬化检出率为76.1%,以软斑、溃疡斑和混合斑为主;对照组颈动脉粥样硬化检出率为37.8%,以硬斑和扁平斑为主,两组差异有统计学意义(P<0.05).观察组颈总动脉、颈动脉分叉和颈内动脉IMT均显著大于对照组(P<0.05).结论 颈动脉粥样硬化斑块的形成是造成脑梗死的主要原因,颈动脉超声检查能准确显示斑块的形态、大小、位置及管腔狭窄程度,对脑梗死的早期预防和治疗具有重要的临床价值.     

Competence of health professionals to check the carotid pulse

During the last 25 years there has been a substantial caries decline among children and adolescents in many Western societies. Recent epidemiologic data show a reduced caries prevalence also in young adult cohorts, indicating that the caries reduction is maintained into adulthood.     

Prevalence and determinants of carotid atherosclerosis in healthy postmenopausal women

Fecal incontinence is an under-reported complication of scleroderma. Ten incontinent patients with scleroderma were evaluated through anorectal manometry and compared with 20 incontinent patients without scleroderma who were matched for age and sex as controls. The scleroderma patients had a higher voluntary external anal squeeze pressure, whereas the resting internal anal sphincter pressure was similar to that of the control group. The threshold for rectal sensation in the scleroderma group was significantly less than that in controls. Episodes of fecal incontinence, anal canal length, and maximal tolerable volume were not significantly different between the study groups. The rectoanal inhibitory response was abnormal in 80% of patients with systemic sclerosis but was normal in 70% of the controls. Stool consistency was significantly looser in the scleroderma patients. Treatment of fecal incontinence in scleroderma patients may be successful in many patients using a combination of dietary and pharmacologic manipulation because diarrhea is an important etiologic cofactor superimposed on reduced internal anal sphincter pressure.     

LDL-unbound apolipoprotein(a) and carotid atherosclerosis in hemodialysis patients

High lipoprotein(a) [Lp(a)] plasma concentrations, which are genetically determined by apo(a) size polymorphism, are directly associated with an increased risk for atherosclerosis. Patients with end-stage renal disease (ESRD), who show an enormous prevalence of cardiovascular disease, have elevated plasma concentrations of Lp(a). In recent studies we were able to show that apo(a) size polymorphism is a better predictor for carotid atherosclerosis and coronary artery disease in hemodialysis patients than concentrations of Lp(a) and other lipoproteins. Less than 5% of apo(a) in plasma exists in a low-density lipoprotein (LDL)-unbound form. This "free" apo(a) consists mainly of disintegrated apo(a) molecules of different molecular weight, ranging from about 125 to 360 kDa. LDL-unbound apo(a) molecules are elevated in patients with ESRD. The aim of this study was therefore to investigate whether the LDL-unbound form of apo(a) contributes to the prediction of carotid atherosclerosis in a group of 153 hemodialysis patients. The absolute amount of LDL-unbound apo(a) showed a trend to increasing values with the degree of carotid atherosclerosis, but the correlation of Lp(a) plasma concentrations with atherosclerosis was more pronounced. In multivariate analysis the two variables were related to neither the presence nor the degree of atherosclerosis. Instead, the apo(a) phenotype took the place of Lp(a) and LDL-unbound apo(a). After adjustment for other variables, the odds ratio for carotid atherosclerosis in patients with a low molecular weight apo(a) phenotype was about 5 (p<0.01). This indicates a strong association between the apo(a) phenotype and the prevalence of carotid atherosclerosis. Finally, multivariate regression analysis revealed age, angina pectoris and the apo(a) phenotype as the only significant predictors of the degree of atherosclerosis in these patients. In summary, it seems that LDL-unbound apo(a) levels do not contribute to the prediction of carotid atherosclerosis in hemodialysis patients. However, this does not mean that "free", mainly disintegrated, apo(a) has no atherogenic potential.     

Use of the transtheoretical model for behavioral change in women's health

Application of stage-based counseling approaches using the transtheoretical model can help providers of primary care to women take full advantage of windows of opportunity for promoting women's health. The transtheoretical model enables the counselor or clinician to individualize the message provided to patients based on their stage. This matching of stage of change with the appropriate principles and processes of change will enable primary care providers to more effectively bring about behavioral change and improve the health status of our patients.     

Alliance predicts patients' outcome beyond in-treatment change in symptoms.

The authors examined the relations among therapeutic alliance, outcome, and early-in-treatment symptomatic improvement in a group of 86 patients with generalized anxiety disorders, chronic depression, or avoidant or obsessive–compulsive personality disorder who received supportive–expressive dynamic psychotherapy. Although alliance at Sessions 5 and 10, but not at Session 2, was associated with prior change in depression, alliance at all sessions significantly predicted subsequent change in depression when prior change in depression was partialed out. The results are discussed in terms of the causal role of the alliance in therapeutic outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Circulating cell adhesion molecules are correlated with ultrasound-based assessment of carotid atherosclerosis

Although cellular adhesion molecules (CAMs) are hypothesized to play an important role in atherogenesis, the relationship between CAMs and systemic atherosclerosis is uncertain. Among 92 outpatients (48 men; mean+/-SD age, 65+/-9 years), we evaluated the association of soluble vascular CAM-1 (sVCAM-1) and intercellular adhesion molecule-1 (sICAM-1) with carotid intimal-medial thickness (IMT), an index of early atherosclerosis. All subjects underwent a 2-dimensional ultrasound examination of both carotid arteries at the distal common carotid arteries and bifurcation. sVCAM-1 and sICAM-1 levels measured by enzyme-linked immunosorbent assay were significantly correlated with mean IMT of the common carotid artery (r=0.34 and r=0.30, respectively; P<0.01) and carotid bifurcation (r=0.31 and r=0.26, respectively; P<0.05), whereas sVCAM-1 was also positively associated with maximal carotid IMT (r=0.35, P<0.01). Adjustment for age attenuated the association between sVCAM-1 and common (r=0.16, P=0.13) and bifurcation (r=0.18, P=0.07) carotid IMT but had minimal effect on the associations between sICAM-1 and carotid measurements (r=0.32, P<0.01; r=0.23, P<0.05; for common and bifurcation IMT, respectively). Age-adjusted sICAM-1 levels increased in a stepwise fashion across common carotid IMT tertiles (253+/-27 versus 275+/-24 versus 384+/-26 pg/mL for the lowest, intermediate, and highest IMT tertiles, respectively; P<0.01). A similar trend was also found between sVCAM-1 levels and common carotid IMT tertiles (625+/-60 versus 650+/-53 versus 714+/-58 pg/mL; P<0.15). These associations were minimally affected in analyses adjusting for hypertension, diabetes, smoking, low and high density lipoprotein cholesterol, lipoprotein(a), and homocysteine, or in a subgroup analysis limited to those with no prior history of atherothrombotic disease. These data demonstrate a positive association between serum CAMs with carotid IMT and further support the hypothesis that systemic inflammation may have a role in atherosclerotic lesion development.     

Lipoprotein(a) in patients with carotid atherosclerosis and ischemic cerebrovascular disorders

Two novel peptides, named PACAP (pituitary adenylate cyclase activating polypeptide) containing 38 (PACAP38) and 27 residues (PACAP27) were recently isolated from ovine hypothalami. In order to investigate the pituitary cell type(s) that bear a receptor for PACAP, PACAP38 was biotinylated and used for cytochemical examination of binding. The cells were also identified by immunocytochemical methods using the antisera against each of the rat anterior pituitary hormones or an antiserum against S-100 protein, a marker for pituitary folliculo-stellate (FS) cells. Biotinylated PACAP38 (biot-PACAP) exhibited adenylate cyclase stimulating activity (ACSA) comparable to PACAP38 in rat pituitary cell cultures, and displaced the bound 125I-PACAP27 to the rat pituitary membrane preparation to the same extent as PACAP38. After 2-4 days of culture, dispersed rat pituitary cells were incubated with varying concentrations of biot-PACAP at room temperature or 4 degrees C. The bound biot-PACAP38 was visualized by avidin-biotin-peroxidase complex (ABC) method with nickel intensification. Biot-PACAP-positive and pituitary hormone or S-100-positive cells were counted. More than 90% of S-100-positive cells bound biot-PACAP38. A considerable number of GH and PRL cells and a lesser number of ACTH cells also bound biot-PACAP38, whereas only a few identified LH, FSH, or TSH cells bound biot-PACAP38. These results suggest that FS cells are a major target cell type for PACAP. A recent study from our laboratory demonstrated that PACAP stimulated the release of interleukin (IL)-6 in rat pituitary cell cultures. FS cells are known to produce IL-6.     

Ultrasonographic manifestations of carotid atherosclerosis and glucose intolerance in elderly eastern Finnish men

OBJECTIVE: To study the association of ultrasonographic manifestations of common carotid atherosclerosis with glucose intolerance in survivors of the cohort of men born in 1900-1919 in eastern Finland. RESEARCH DESIGN AND METHODS: Carotid ultrasonography was carried out for 182 men in 1989. Glucose tolerance status classified based on an oral glucose tolerance test in 1984 and 1989 surveys was used in both prospective and cross-sectional analyses. RESULTS: Carotid atherosclerosis was common in men aged 70-89 years. There was no significant difference in the maximal carotid intimal-medial thickness between diabetic and nondiabetic men and over different age-groups; it was 1.28, 1.33, and 1.36 mm in subjects with diabetes, impaired glucose tolerance, and normal glucose tolerance, respectively (P = 0.69). No association between the presence of a nonmineralized or a mineralized atherosclerotic lesion with diabetes was found. Fasting plasma insulin did not relate to ultrasonographically detectable atherosclerotic lesions. CONCLUSIONS: Hyperglycemia and hyperinsulinemia may not be main contributors to atherosclerosis in elderly men, partly because smoking is less common and total and LDL cholesterol concentrations are lower in diabetic men than in men with normal glucose tolerance.     

Tension measurement of pulse pressure of herniation in children

Nine patients were operated on in Department of Neurosurgery in Poznań throughout 1990-1993 because of the insufficient carotid blood circulation. In patients measurements of the pulsation pressure of the carotid artery were carried out with a tensometric sensor of pressure during surgery. Neurological symptoms, EEG, evoked potentials and other examinations were conducted before an after operation and correlated with results of pulsation pressure.     

Whole blood viscosity and haematocrit are associated with internal carotid atherosclerosis in men

BACKGROUND: Alterations in blood viscosity and haematocrit have been described in patients with coronary and cerebrovascular diseases. The results have not been conclusive, as modifications of these parameters are often associated with the presence of coronary heart disease (CHD) risk factors. The aim of this study was to verify whether blood viscosity and haematocrit are increased in patients with carotid atherosclerosis, independently of the presence of CHD risk factors. METHODS: Male patients with internal carotid atherosclerosis (ICA+, n = 28) were selected from participants in a cardiovascular disease prevention campaign. Controls (ICA-, n = 28), also participating in the prevention campaign, were matched for age and all the classical CHD risk factors. Plasma lipids, glucose and fibrinogen were determined by routine methods. Cigarette smoking and current drug therapy was established by questionnaire. Whole blood viscosity was measured at shear rates of 450 and 225/s, using a cone-plate viscometer. Echo-Doppler of carotid arteries was performed with an ATL Ultramark 9 HDI using a 5-10 MHz multifrequency probe. RESULTS: Blood pressure, plasma lipids, glucose, body mass index, fibrinogen and plasma viscosity were similar in the two groups. ICA+ patients, compared with the ICA- group, had significantly greater values of blood viscosity (4.52 +/- 0.37 cP compared with 4.18 +/- 0.45 cP, P < 0.005 respectively; shear rate 450/s) and haematocrit (48.57 +/- 3.19% compared with 45.57 +/- 4.81%, P < 0.008 respectively). CONCLUSIONS: Our findings demonstrate that blood viscosity and haematocrit are increased in men with internal carotid atherosclerosis, independently of the presence of risk factors for atherosclerosis.     

Assessment of autopsic samples of carotid atherosclerosis in the aged by intravascular ultrasound

To assess the value of intravascular ultrasound in detecting carotid atherosclerosis, we compared the ultrasound images of 48 carotid artery segments from autopsies with their histological findings. The results showed that by intravascular ultrasonography one could distinguish between elastic and muscular tissues of arteries, determine the lesions of fibroelastosis and calcified plaques on arterial wall, and precisely measure the wall thickness, inner and outer diameter, luminal area and cross-sectional area of arteries with a high correlation between the data measured from ultrasonography and histological study (r values were 0.98, 0.97, 0.97, 0.96 and 0.96, respectively). This study suggests that intravascular ultrasound might be effectively used for morphological study and detection of atherosclerotic lesions in vivo.     

Effect of xuefuzhuyu pill on patients with carotid atherosclerosis by colour Doppler ultrasonography

OBJECTIVE: To observe the effect of Xuefuzhuyu Pill (XFZYP) on carotid atherosclerosis. METHODS: The patients were randomly divided into XFZYP group and aspirin control group. The status of the carotid plaque vessel wall and blood flow were observed by colored Doppler ultrasonography. RESULTS: (1) Plaque of 6 cases regressed, of 6 cases unchanged, of 1 case progressed after treatment of XFZYP. The area of plaques between baseline and after treatment decreased 0.11 +/- 0.05 cm and that of thickness reduced for 0.09 +/- 0.04 cm2 (P < 0.05) in XFZYP group. While plaque of 3 cases regressed, of 6 unchanged, of 2 cases progressed after treatment of aspirin. The area and thickness of plaque were reduced to 0.05 +/- 0.04 cm and 0.04 +/- 0.03 cm respectively. There were no statistic difference in aspirin group. (2) The intima-media thickness of common carotid artery decreased 0.13 +/- 0.03 mm in XFZYP group (P < 0.001 versus baseline), but there were no significant change after treatment of aspirin (P > 0.05). (3) There were no distinct change about peak systole, minimal diastole time average peak, pulsative index, resistive index in common carotid artery and internal carotid artery after treatment of XFZYP and aspirin. CONCLUSION: Colour Doppler ultrasonography of carotid artery provide a noninvasive, safe and valid opportunities for clinical trail. XFZYP can be useful for the treatment of carotid atherosclerosis.