Treatment of cardiac insufficiency: does treatment depend on whether its cause is ischemic or idiopathic?]

Angiotensin converting enzyme (ACE) inhibitors are associated with a greater reduction in mortality in non-ischaemic cardiomyopathy than in ischaemic cardiomyopathy after the results of the V-HeFT-II and SOLVD trials in symptomatic patients. However, a recent analysis of the global, symptomatic and therapeutic, results of the SOLVD trials, demonstrated a similar reduction in mortality with ACE inhibitors in ischaemic and non-ischaemic cardiomyopathies. Moreover, after myocardial infarction, the beneficial effects of ACE inhibitors have been well established in patients with left ventricular dysfunction. Betablockers, especially bisoprolol in the CIBIS-I trial, also seem to be more effective in non-ischaemic cardiomyopathy. However, CIBIS-II and the US Carvedilol Heart Failure Trial Program clearly showed that the benefits of betablockade were identical whether ischaemic or not. The beneficial effects of betablockers in the post-infarction period are more marked when left ventricular dysfunction is severe. The PROVED and RADIANCE trials suggest that digitalis is more effective in non-ischaemic cardiomyopathy. These results were not confirmed by the DIG trial which showed a significant reduction in the combined criterion, mortality and hospital admission for aggravation of cardiac failure, both in ischaemic and in non-ischaemic cardiomyopathy. However, the use of digitalis should be prudent during ischaemic cardiomyopathy, the neutral effect on global mortality in the DIG trial masking divergent results with a tendency to reducing mortality due to aggravation of cardiac failure and a significant increase of other causes of cardiac death, especially from myocardial infarction and arrhythmias. Amiodarone could also be useful in non-ischaemic cardiomyopathy. The reduction in risk of death in the GESICA study, which comprised 60% of patients with non-ischaemic cardiomyopathy, contrasting with the absence of an effect with this molecule in the STAT-CHF trial which only comprised 29% of patients with non-ischaemic cardiomyopathy. The new generation of calcium antagonists could also be more effective in non-ischaemic cardiomyopathy. Although amlodipine significantly reduced mortality in the PRAISE trial in non-ischaemic cardiomyopathy, there was no favourable effect with felodipine in the V-HeFT-III tria. Finally, if in the earlier studies oral anticoagulants were more effective in non-ischaemic cardiomyopathy, the recent results of the SOLVD trial showed that warfarin decreased the mortality in both ischaemic and non-ischaemic cardiomyopathy. The value of anti-aggregant therapy is not questioned in coronary artery disease, but its role in dilated cardiomyopathy has not yet been established. In conclusion, apart from the use of digitalis which must be prudent in post-infarction cardiomyopathy or in patients with ventricular arrhythmias, the treatment of cardiac failure differs little with respect to its ischaemic or non-ischaemic aetiology, and should be based on the NYHA (New York Heart Association) classification.     

Dobutamine stress echocardiography and thallium-201 SPECT for detecting ischaemic dilated cardiomyopathy in patients with heart failure.

AIMS: A diagnosis of ischaemic aetiology of a dilated cardiomyopathy has important therapeutic and prognostic implications. In such patients, abnormal ECG and atypical symptoms limit the usefulness of standard ECG-ergometry in detecting myocardial ischaemia. To assess the values of high-dose dobutamine stress echocardiography and of Thallium-201 SPECT (exercise-reinjection-rest protocol) in differentiating between ischaemic and non-ischaemic dilated cardiomyopathy, 37 patients with suspected myocardial ischemia, low ventricular ejection fraction (23 +/- 5%) and heart failure were studied. METHODS AND RESULTS: Coronary artery disease was defined as >50% coronary stenosis in at least one coronary artery. By dobutamine stress echocardiography, ischaemic dilated cardiomyopathy was considered present when either an ischaemic response (biphasic response or direct deterioration) or a scar (fixed dyssynergy) was documented in at least two segments. By Thallium-201 SPECT, severe perfusion defects, either reversible (ischaemia) or fixed (scar), in at least two segments were considered markers of ischaemic dilated cardiomyopathy. Twenty-three patients had ischaemic dilated cardiomyopathy, while 14 had normal coronary arteries. The presence of myocardial ischaemia and/or scar by dobutamine stress echocardiography identified patients with ischaemic dilated cardiomyopathy with a sensitivity of 100% and a specificity of 86%. The sensitivity of Thallium-201 SPECT was 92%, its specificity was 69%. Three of the four false positive results occurred in patients with left bundle branch block. Thirty-two patients were concordantly classified by the two techniques (agreement=86%, k=0.73). CONCLUSION: Both dobutamine stress echocardiography and Thallium-201 SPECT are sensitive techniques for detecting the ischaemic aetiology of dilated cardiomyopathy. The specificity is lower, particularly by SPECT, when left ventricular branch block is present.     

Carotid Sinus Hypersensitivity in Patients Undergoing Coronary Arteriography:

Carotid Sinus Hypersensitivity and Atherosclerosis. Introduction: The purpose of the present investigation was to study the precise relationship between carotid sinus hypersensitivity (CSH) and both the severity of carotid atherosclerosis and the extent of coronary artery disease in patients who were referred for evaluation for suspected ischemic heart disease.
Methods and Results: Duplex echocardiography and coronary angiography were used to assess carotid and coronary artery atherosclerosis in 130 consecutive patients. Carotid sinus stimulation was performed before coronary arteriography with simultaneous recordings of the ECG and aortic pressure. Coronary artery disease was present in 103 patients (79%). Thirty patients (23.08%) had one-vessel disease (1-VD), 31 (23.85%) had 2-VD, 29 (22.31%) had 3-VD, and 13 patients (10%) had left main coronary artery disease. Carotid artery atherosclerosis was present in 100 patients (76.92%) and carotid disease (diameter stenosis ≥ 50%) was present in 24 patients (18.46%). CSH was found in 33 patients (25%). The incidence of CSH was 9% in patients with carotid stenosis 1%-15%, 17% in patients with stenosis 16%-49%, 85% in patients with stenosis 50%-79%, and 100% in patients with stenosis ≥ 80%. The incidence of CSH was 11%, 17%, 23%, 34%, and 62% in patients with no VD, 1-VD, 2-VD, 3-VD, and left main coronary artery disease, respectively. Stepwise multiple logistic regression analysis revealed that carotid disease and left main coronary artery disease were the most significant determinants of CSH (P < 0.001 and P = 0.013, respectively).
Conclusion: The incidence of CSH increased in proportion to the severity of carotid and coronary atherosclerosis. These data provide evidence that CSH is closely related to severe carotid atherosclerosis or left main coronary artery disease in patients being evaluated for suspected ischemic heart disease.     

Quantification of carotid atheroma, by vascular ultrasonics and spectral analysis, after myocardial infarction. Apropos of 80 cases

A prospective study of carotid artery atheroma by vascular echotomography and spectral analysis was performed in 40 patients with myocardial infarction and 40 control subjects. Carotid artery atheroma was commoner in the group of patients with myocardial infarction (72.5% +/- 6.8%), earlier (9 years), more commonly bilateral (37.5% +/- 7.6%) and more stenotic (32.5% +/- 7.4%) than in the control group (p less than 0.000a, p less than 0.0001 and p less than 0.002, respectively). The severity of carotid artery atheroma correlated with the site of coronary artery disease; the following significant relationships were found: stenosing 40% and/or bilateral carotid atherosclerosis and left anterior descending disease (p less than 0.02); carotid atherosclerosis and double or triple vessel disease (p less than 0.05). The authors conclude that detection of carotid artery atheroma after myocardial infarction is valuable for two reasons: it gives an indication as to the severity of the coronary disease; carotid endarterectomy may be considered at the same time as coronary artery bypass surgery.     

Pilot Results of the Early Detection by Ultrasound of Carotid Artery Intima-Media Thickness Evaluation (EDUCATE) study

BACKGROUND: Limitations of current models for risk stratification are known. Noninvasive imaging is being advocated as an adjunct to improve risk prediction; however, studies documenting outcomes are rare. Therefore, we aimed to evaluate the negative and positive predictive values of carotid atherosclerosis for future cardiovascular events. METHODS: The Early Detection by Ultrasound of Carotid Artery intima media Thickness Evaluation (EDUCATE) study prospectively enrolled 253 consecutive young to middle-aged adults undergoing elective coronary angiography. Bilateral carotid ultrasound and lipid profiles were performed. Carotid atherosclerosis was defined as intima media thickness >/=1.0 mm in the main body, or focal plaque within the body, bulb, or proximal branch. Future events included major (death, myocardial infarction, stroke) and minor (revascularization and new onset heart failure). RESULTS: Of the enrolled patients 236 completed all tests; mean age was 51 +/- 8 years; 58% women. Sensitivity, specificity, and negative predictive values for carotid atherosclerosis in predicting severe coronary artery disease were 72%, 49% and 79%, with an odds ratio (OR) of 2.2 (95% confidence interval [CI] 1.2-4.0). Of patients suffering major events, 90% had carotid atherosclerosis. Only 1 of 95 without carotid atherosclerosis experienced a major event. Kaplan-Meier analysis revealed differences in event-free survival in favor of subjects without carotid atherosclerosis for major (P = .051) and any event (P = .015). Cox analysis revealed a hazard ratio (HR) of 2.7 (95% CI 1.2-6.2; P = .020) for predicting future events. The relationship remained significant after adjusting for traditional risk factors (HR 2.5, 95% CI 1.1-5.9; P = .034). CONCLUSIONS: Carotid atherosclerosis is associated with severe coronary artery disease and future events. Negative carotid ultrasound is associated with excellent prognosis.     

颈动脉粥样硬化与冠状动脉狭窄程度的关系

探讨颈动脉粥样硬化病变的性质、程度及其与冠状动脉狭窄程度的关系。选择200例冠状动脉造影患者，并经颈动脉DSA及B超检查。根据造影结果分为冠心病组和非冠心病组(对照组)。根据冠状动脉狭窄直径，冠心病组再分成三个亚组。结果发现，颈动脉粥样硬化与冠状动脉狭窄之间呈线性正相关，颈动脉狭窄较冠状动脉狭窄发生率低，但随着冠状动脉狭窄程度加重，颈动脉粥样斑块的发生率明显增加，且颈动脉狭窄亦有加重趋势。结果提示，颈动脉粥样硬化与冠状动脉狭窄密切相关。对中年以上人群，尤其是有多种危险因素者，常规进行颈动脉超声检查，可为早期发现和筛选心脑血管疾病高危患者提供依据。     

Carotid intima-media thickness as an independent predictor of coronary artery disease.

BACKGROUND: A noninvasive technique of measuring carotid artery intima-media thickness has recently generated considerable interest as a marker of atherosclerosis and in the prediction of clinical coronary events and coronary artery disease. The present study evaluated the association of carotid artery intima-media thickness in the prediction of coronary artery disease in a western Indian population. METHODS AND RESULTS: Carotid artery intima-media thickness was measured with a B-mode scan in an ongoing study of 266 patients, who were further subdivided into 4 subgroups: those with non-insulin dependent diabetes mellitus; hypertension; diabetes mellitus with hypertension; and those without diabetes or hypertension (labeled as controls). The maximal intima-media thickness greater than 0.8 mm at the far wall of the common carotid artery, excluding raised lesions and plaques, was selected as the highest value for comparison. The subgroups were further divided into those with and without apparent coronary artery disease. A statistically significant intima-media thickness greater than 0.8 mm was observed in 59.2% of the subjects with coronary artery disease as against 40.8% in those without the disease on univariate analysis. A higher incidence of intima-media thickness of more than 0.8 mm was observed in all subgroups with coronary artery disease as against those without the disease, which was most marked in the hypertensive group (22.2% v. 3.6%) and contributed to the increased arterial thickness in diabetics with concomitant hypertension. Multivariate regression analysis revealed carotid artery intima-media thickness to be associated with coronary artery disease with an odds ratio of 2.40. CONCLUSIONS: Carotid artery intima-media thickness is a simple, noninvasive and reproducible clinical tool to evaluate atherosclerosis and predict coronary artery disease in Indian subjects. Prospective studies in a larger number of subjects, particularly in those undergoing coronary angiography, will help in establishing the role of this technique.     

颈动脉粥样硬化与冠心病的相关性研究

目的:探讨颈动脉粥样硬化与冠心病的相关性。方法:对84例拟诊冠心病的患者,行颈动脉超声和冠状动脉造影检查。结果:发现心绞痛组和心肌梗死组的颈动脉粥样硬化(AS)等级积分、Crouse积分和斑块数均明显高于非冠心病组(P<0.01和P<0.001),冠脉单支和多支病变组与非冠心病组的颈动脉粥样硬化指标亦有明显差异(<0.001和P<0.0001);冠脉造影积分和冠脉病变支数与颈动脉粥样硬化的等级积分、Crouse积分和斑块数均呈显著的正相关。颈动脉超声的敏感性为86.4％,特异性为64.0％,总的诊断符合率为79.8％。结论:测定颈动脉粥样硬化斑块的超声病理分型对冠心病的预测具有临床意义。     

Newly diagnosed carotid atherosclerosis in patients with coronary artery disease admitted for cardiac rehabilitation.

BACKGROUND: The association of coronary artery disease (CAD) with carotid artery disease has been well documented. However, data focusing on CAD patients participating in cardiac rehabilitation programs are lacking. We studied the prevalence of newly diagnosed carotid artery disease in CAD patients admitted for cardiac rehabilitation. METHODS: We performed carotid ultrasonography in 168 angiographically confirmed CAD patients admitted to two facilities. Patients with previous cerebrovascular episodes or carotid imaging were excluded. RESULTS: Out of 168 patients considered (mean age 65 +/- 8 years; males 76%; chronic stable angina as the reason for cardiac rehabilitation 34%, silent ischemia 14%, and acute coronary syndrome 52%), 149 (89%) were found to have carotid atherosclerosis. Carotid atherosclerosis was present in 83, 87, 89, and 93% of patients with one-, two- and three-vessel disease and left main stem CAD respectively. Patients with severe CAD (i.e. three-vessel or left main stem) had a higher prevalence of > or = 50% carotid stenosis as compared to patients without severe CAD (26 vs 8%, p < 0.05). Severe CAD had a high negative (92%) and a low positive (26%) predictive value for the presence of > or = 50% carotid stenosis. CONCLUSIONS: Silent and previously undetected carotid atherosclerosis is frequent in CAD patients admitted for cardiac rehabilitation. The absence of severe CAD reflects the absence of > or = 50% carotid stenosis.     

颈动脉粥样硬化对冠状动脉病变的预测分析

目的探讨颈动脉粥样硬化对冠状动脉病变的预测价值.方法对191例确诊为冠心病的患者及175例正常对照者行颈动脉超声检查,依冠状动脉造影结果分为对照组与冠心病单支病变组、双支病变组及多支病变组,比较各组间颈动脉内膜-中膜厚度及粥样硬化程度;并根据颈动脉粥样硬化的程度预测冠心病的发生、发展情况.结果对照组与冠心病各组在左侧内膜-中膜厚度、斑块发生率和狭窄率上存在差并(P＜0.05),而且冠状动脉病变支数越多颈动脉粥样硬化的程度也越重.以颈动脉斑块分级计分大于1、2和3分为标准预测冠心病的阳性预测值分别是68.5%、73.2%和74.6%.结论以上提示颈动脉粥样硬化是冠状动脉粥样硬化有价值的预测因素,通过颈动脉粥样硬化程度可预测冠状动脉病变的存在及其严重程度.     

Exploratory hierarchy and surgical indications for carotid surgery in patients with coronary disease

The major cause of death from carotid artery surgery (1.2% in 1984 in this series) is still coronary disease and myocardial infarct. A series of 50 patients were randomly selected for detailed study of post-operative cardiologic complications and the following sequelae were noted: mortality = 1 myocardial infarct; morbidity = 1 myocardial infarct, 3 documented anginal pains, 8 repolarization disorders, 4 benign ventricular arrhythmias. Analysis of these complications and a literature review demonstrated: the high frequency of combined carotid artery and coronary artery stenosis even in asymptomatic patients (25 to 40% of cases); the elevated percentage of complications in patients with symptomatic coronary disease (mortality risk multiplied by ten), hypertension or arterial disease; the low effect of age taken alone as risk factor. Pre-operative explorations to detect angina, particularly when latent and asymptomatic, should include a questionnaire, strict patient clinical examination and detailed reading of electrocardiogram tracings. An effort test should be performed as a function of results and patients' medical history and when positive should lead to coronarography in patients under 70 in good general condition, and when doubt persists after the effort tests. The indication for surgical treatment is dependent on results of these explorations: Carotid artery surgery (stenosis with high cerebral risk) should be performed under pre- and post-operative myocardial protection in patients with coronary artery disease who are too old or inoperable for cardiac reasons. Simultaneous myocardial and cerebral revascularization in the presence of severe lesions and at equivalent risk of progression. First intention carotid artery surgery for bilateral stable lesions with subsequent simultaneous myocardial and cerebral revascularization. First intention carotid artery surgery in case of cerebral ischemia with coronary artery shunt surgery at a later stage. Improved exploration of patients and close cooperation between cardiologists, anaesthetists and surgeons should allow patients at high risk to be operated upon under improved conditions of safety.     

Risk factors in the combination of myocardial infarction and carotid atheroma

This study compares two groups of patients: Group I with 44 patients who suffered recent acute myocardial infarction and Group II: 40 control subjects. In both groups, 2D Doppler echocardiography was performed to detect carotid atheroma, to determine the respective roles of vascular risk factors for two sites of atherosclerosis. Carotid atheroma affected 73 p. 100 of subjects in Group I and 22.5 p. 100 in Group II. Carotid stenosis of more than 40 p. 100 was found mainly in hypertensive patients who presented with acute myocardial infarction, and in patients with left ventricular hypertrophy. Smoking was more frequent in Group I than in Group II (p less than 0.001) irrespective of the frequency of carotid atheroma (p less than 0.05). Hypercholesterolaemia only favoured carotid atherosclerosis after acute myocardial infarction (p = 0.01). We did not find any difference in the incidence of diabetes mellitus in the two groups of patients. Age analysis indicated that carotid atheroma occurred earlier in Group I than in Group II. An association between a dominant risk factor for coronary disease (smoking or hypercholesterolemia) was found in 9 patients, all of whom had severe bipolar atherosclerosis with multivessel coronary lesions and carotid stenosis.     

颈动脉粥样硬化与冠状动脉粥样硬化的关系

目的　探讨颈动脉粥样硬化与冠状动脉粥样硬化的关系。方法　对 94例老年患者进行了冠状动脉造影和颈动脉超声检查。颈动脉粥样硬化斑块积分采用Sutton法。结果　单支组及多支组内膜中膜厚度、斑块积分显著高于正常组 ,多支组显著高于单支组 (P<0 .0 5 )。斑块指数与年龄、吸烟、低密度脂蛋白胆固醇与高密度脂蛋白胆固醇的比值、收缩压以及高血压病程的程度呈正相关。结论　颈动脉粥样硬化与冠状动脉粥样硬化的病变是平行的     

Management of Combined Severe Carotid and Coronary Artery Disease

Patients with severe carotid and coronary disease—especially if they require coronary artery bypass grafting (CABG)—are at high risk of cardiac events and stroke. Carotid revascularization should be considered for patients with symptomatic carotid disease and bilateral severe asymptomatic carotid stenosis. In patients with unilateral asymptomatic carotid stenosis, decision to proceed to revascularization should be based more on a perspective of long-term stroke prevention than of perioperative stroke reduction. Compared with endarterectomy, carotid artery stenting is associated with a lower incidence of periprocedural myocardial infarction, an event linked to long-term mortality. This observation may be particularly relevant for patients with advanced coronary artery disease such as those undergoing CABG. Irrespective of the carotid revascularization strategy, a broad disease management approach based on lifestyle modification and pharmacologic cardiovascular prevention is more likely to affect both the quality and duration of life than revascularization itself.     

Segmental quantitative analysis of digital thallium-201 myocardial scintigrams in diagnosis of coronary artery disease. Comparison with rest and exercise electrocardiography and coronary arteriography.

One hundred and forty-nine patients with suspected ischaemic heart disease were evaluated by exercise thallium-201 myocardial scintigraphy (201Tl SMS), single lead exercise electrocardiography, and coronary arteriography. Myocardial distribution of tracer was assessed semi-quantitatively from digital 201Tl scintigrams and compared with tracer distribution in subjects with normal hearts. Fifty-two of 54 (96%) patients with normal coronary arteries had normal myocardial scintigrams whereas three patients had a positive ischaemic exercise electrocardiogram and were scan normal. Conversely, 36 of 95 (38%) patients with coronary artery disease had a positive ischaemic electrocardiogram compared with 94 of 95 (99%) patients who had a positive myocardial scintigram. Disease in specific coronary arteries could be deduced from the topography of myocardial tracer deficit. Disease was predicted correctly in 76 out of 80 (95%) of left anterior descending coronary stenoses, in 48 out of 64 (75%) of right coronary artery stenoses, and in 55 out of 64 (85%) of left circumflex coronary artery stenosis, despite the presence of infarcted myocardium in other territories. Similarly, single vessel disease was predicted correctly in 14 out of 17 (82%) patients and multiple vessel disease in 64 out of 77 (83%) patients. 201Tl SMS with segmental quantitative analysis is a highly sensitive and specific technique in the diagnosis of coronary artery disease and may be useful screening procedure to select patients for further investigation, particularly those with evidence of life-threatening severe left coronary artery disease.     

颈动脉粥样硬化与冠状动脉旁路移植术后神经系统并发症相关性研究

目的:探讨颈动脉粥样硬化程度与非体外循环下冠状动脉旁路移植术后,神经系统并发症的关系。方法:连续选择择期行非体外循环下冠状动脉旁路移植术的患者475例,根据颈动脉超声结果分为四组:无狭窄、轻度、中度及重度狭窄,分析狭窄程度与术后神经系统并发症的关系及影响因素。结果:①四组患者之间年龄、脑卒中病史、糖尿病史及神经系统并发症比较,差异有统计学意义(P<0.05);②颈动脉狭窄患者术后神经系统并发症的发生率高于无颈动脉狭窄患者(χ2=3.851,P=0.050);③脑卒中病史(OR=1.835,95%CI:1.023～3.289,P<0.05)、颈动脉重度狭窄(OR=2.793,95%CI:1.296～6.018,P<0.05)与术后神经系统并发症相关(P<0.05)。结论:脑卒中病史、颈动脉重度狭窄是旁路移植术后神经系统并发症的危险因素。颈动脉不论狭窄程度,均可导致术后神经系统并发症发生率增高,低灌注可能为主要原因。     

Association of common carotid intima-media thickness and lipoprotein(a) with coronary artery disease

BACKGROUND: Carotid artery intimal medial thickness is a simple, non-invasive and reproducible clinical tool to evaluate atherosclerosis and predict coronary artery disease. Lipoprotein(a) levels are related to both atherogenesis and thrombogenesis and may be a key link between lipid and coronary artery disease. This study evaluated the association of carotid intimal medial thickness and lipoprotein(a) with coronary artery disease. METHODS AND RESULTS: We studied 185 randomly selected patients hospitalized for coronary angiogram in our institute. There were 110 angiographically proven patients of coronary artery disease with mean age of 55.8 +/- 9 years (range 34-72 years) and 75 subjects with normal coronary artery anatomy with mean age of 54.8 +/- 8 years (range 34-68 years). The mean carotid intimal medial thickness of subjects with coronary artery disease was significantly higher than in subjects without coronary artery disease (0.84 +/- 0.16 mm v. 0.65 +/- 0.15 mm, p<0.001). The mean carotid intimal medial thicknesses in patients with triple vessel, double vessel and single vessel disease were 0.96 +/- 0.12 mm, 0.84 +/- 0.11 mm and 0.78 +/- 0.13 mm, respectively (p=0.05). The mean lipoprotein(a) of subjects with coronary artery disease was significantly higher than in subjects without coronary artery disease (35.9 +/- 22.3 mg/dl v. 19.1 +/- 21.2 mg/dl, p<0.001). Mean lipoprotein(a) levels in subjects with carotid intimal medial thickness <0.80 was 26.4 +/- 24.2 mg/dl and in subjects with carotid intimal medial thickness > or = 0.80 was 32.1 +/- 22.1 mg/dl (p=0.05). CONCLUSIONS: There is a strong correlation between carotid and coronary atherosclerosis and carotid intimal medial thickness is a good predictor of presence and extent of coronary artery disease. Lipoprotein(a) level is a powerful independent risk factor for atherosclerosis. Carotid intimal medial thickness and lipoprotein(a) in conjoint can predict coronary artery disease reliably.     

Carotid ultrasound for risk clarification in young to middle-aged adults undergoing elective coronary angiography

BACKGROUND: An important aspect of risk prediction is the apparent difference between calculated risk and true risk. Current risk predictor models are not sensitive enough to identify many subjects at risk for future events or to prevent overuse of expensive tests. The aim of this study was to determine the usefulness of carotid ultrasound for risk stratification in subjects undergoing elective coronary angiography. METHODS: A total of 253 individuals (men < or =55 years of age and women < or =65 years of age) who were scheduled for elective coronary angiography underwent carotid ultrasonography. Noncoronary atherosclerosis was defined based on a maximal intima-media thickness of > or =1.0 mm or the presence of focal plaque. RESULTS: Of the subjects, 236 completed all of the tests. The mean age was 51 +/- 8 years, and 58% were women and 42% men. Severe angiographic disease (> or =50%) was present in 72 subjects. Carotid atherosclerosis was present in 141 subjects. Use of the Framingham risk score classified 172 subjects as low risk. Carotid atherosclerosis was diagnosed in 57% of the low-risk group compared with 70% of the high-risk group (P = .122). Carotid atherosclerosis was associated with severe coronary angiographic disease (OR = 2.2, CI = 1.2 to 4.0). CONCLUSION: Noncoronary atherosclerosis was associated with severe coronary disease as determined by angiography. Carotid atherosclerosis had a high negative predictive value in subjects with negative stress test results or risk-stratified as low risk. Noninvasive imaging by carotid ultrasonography for noncoronary atherosclerosis may be a good adjunct to clinical risk stratification for premature coronary heart disease.     

老年人颈动脉粥样硬化与冠状动脉粥样硬化的关系

为探讨老年人颈动脉粥样硬化与冠状动脉粥样硬化的关系,对94例进行冠状动脉造影的老年患者进行颈动脉超声检查。颈动脉粥样硬化斑块积分采用Sutton法,结果发现,冠状动脉病变单支组和多支组内膜一中膜厚度,斑块积分显著高于正常组,冠状动脉病变多支组显著高于单支组（P均＜0．05）,斑块指数与年龄,吸烟,低密度脂蛋白胆固醇／高密度脂蛋白胆固醇比值,收缩压以及高血压病程及程度密切相关,结果提示,颈动脉粥样硬化与冠状动脉粥样硬化的病变是平行的。     

The stress echo prognostic gender gap.

AIMS: To investigate whether myocardial ischaemia elicitable during pharmacological stress echocardiography portends different prognosis in men and women.METHODS AND RESULTS: The study group was made by 1733 patients (941 men, 792 women) who underwent dipyridamole (n=1008) or dobutamine (n=725) stress echo for evaluation of known or suspected coronary artery disease. An ischaemic response was found in 460 patients (308 men, 152 women). Considering the whole ischaemic population, women were older (P<0.0001) and more likely to have hypertension (P=0.02) and hypercholesterolaemia (P=0.04) than men. No difference in age and risk factors was evidenced between the two sexes in the subset of 203 patients with ischaemia and suspected coronary artery disease. During follow-up (25 +/- 24 months for the ischaemic and 37 +/- 25 months for the non-ischaemic sample), there were 113 cardiac events (45 deaths and 68 infarctions) and 232 revascularizations. Revascularization rate in ischaemic population was similar in both sexes (P=0.36). Multivariate predictors of cardiac events in the whole ischaemic group were resting WMSI (HR=2.7, 95% CI 1.3--3.3;P=0.0050), female gender (HR=2.2, 95% CI 1.2--3.7;P=0.0062), age > or = l65 years (HR=1.9, 95% CI=1.0--3.6;P=0.0427), and Delta WMSI (HR=2.1, 95% CI=1.0--3.7;P=0.0447). Female gender (HR=2.7, 95% CI 1.1--6.3;P=0.0233) was the only independent prognostic predictor in patients with ischaemia and suspected coronary artery disease. Five-year infarction-free survival was 82% in men and 71% in women in the whole ischaemic population (P=0.0041) as well as in the ischaemic group with suspected coronary artery disease (CAD) (P=0.0175). In the non-ischaemic sample resting WMSI (HR=4.8), history of myocardial infarction (HR=2.5), and hypercholesterolaemia (HR=1.8) were independent predictors of outcome at multivariate analysis, whilst the gender had no prognostic importance.Conclusions: Our results show that female gender is an independent predictor of cardiac events in patients with myocardial ischaemia induced by pharmacological stress echocardiography.