二维超声检测冠心病患者颈动脉粥样硬化病变

对103例经选择性冠状动脉造影的患者作双侧颈动脉超声检查，探讨了颈动脉超声检查的方法学以及颈动脉粥样硬化斑块的好发部位和超声分型，发现颈动脉粥样硬化斑块好发于颈动脉分叉处，以左侧多见，且多为扁平斑；颈动脉粥样硬化与冠状动脉粥样硬化之间有着密切的相关关系，冠状动脉病变支数越多，其颈动脉粥样硬化斑块积分也越高，不同冠状动脉病变组之间有非常显著的差异（P＜0．001）。     

The prognostic importance of endothelial dysfunction and carotid atheroma burden in patients with coronary artery disease

OBJECTIVES: The goal of this study was to determine the relative prognostic importance of noninvasive measures of endothelial function and atheroma burden in patients with coronary artery disease (CAD). BACKGROUND: Direct measurement of atherosclerosis by carotid ultrasound and endothelial function assessment by brachial artery flow-mediated dilation (FMD) have both been shown to predict vascular events. The combined prognostic utility of carotid ultrasound and FMD relative to traditional risk markers and cardiovascular fitness has not been evaluated. METHODS: A total of 152 patients with CAD underwent metabolic testing, exercise stress tests, carotid ultrasound, and endothelial function measurements. RESULTS: Patients were followed for 34 +/- 10 months during which 22 vascular events occurred. Peak FMD (p = 0.012) and FMD/nitroglycerin-mediated dilation (NMD) ratio (p = 0.008) were lower in subjects with events. Univariate analysis with Cox proportional hazards modeling identified plaque area (p = 0.0047), total area (p = 0.0085), peak FMD (p = 0.01), FMD/NMD ratio (p = 0.008), stress test workload (p = 0.027), long-acting nitroglycerin (NTG) (p = 0.0071), and calcium blockers (p = 0.0057) as predictors of adverse events. Multivariate analysis showed that FMD/NMD ratio (p < 0.0001), carotid plaque area (p = 0.06), and NTG (p = 0.005) were independent predictors. Based on median values, subjects were divided into high and low "plaque burden" groups and into high and low FMD/NMD subgroups. Patients with high FMD/NMD had low event rates irrespective of the degree of carotid atheroma. Patients with low FMD/NMD and high "plaque burden" had the highest event rate (p < 0.05). CONCLUSIONS: The structural and functional status of the vasculature are independent predictors of coronary events as shown by noninvasive measurement of endothelial function and carotid atheroma burden in patients with CAD. Preserved endothelial function attenuates the risk of future events associated with a high plaque burden.     

Serum soluble Klotho is inversely related to coronary artery calcification assessed by intravascular ultrasound in patients with stable coronary artery disease

BackgroundAlthough the Klotho gene is recognized as an aging-suppressor gene, the clinical significance of its soluble product, soluble Klotho, in coronary artery disease (CAD) has not been completely determined. The relationship between soluble Klotho and coronary artery calcification (CAC) was investigated in patients with stable CAD.MethodsCAC in culprit lesions was analyzed in 75 non-dialysis patients with stable CAD who were scheduled for percutaneous coronary intervention (PCI) following intravascular ultrasound (IVUS). The main outcome measure was the calcium index (CalcIndex), a volumetric IVUS-derived measure of total calcification per culprit lesion. A low CalcIndex was defined as a first-quartile calcium index (<0.042). Patients were divided into two groups according to the median serum Klotho value: low Klotho (n = 37, ≤460 pg/mL) and high Klotho (n = 38, >460 pg/mL).ResultsThe CalcIndex was significantly lower in patients with high than with low Klotho. Patients with high Klotho had a significantly higher prevalence of a low CalcIndex than those with low Klotho. The number of angiographic moderate-severe CACs in whole coronary arteries was significantly decreased in patients with high Klotho compared to low Klotho. Serum Klotho levels correlated significantly and inversely with the CalcIndex. This relationship was pronounced in patients with estimated glomerular filtration rate <60 mL/min/1.73 m². Logistic regression analysis showed that high Klotho was associated with a low CalcIndex independent of classical coronary risk factors and markers of mineral metabolism.ConclusionsHigh serum soluble Klotho levels are associated with a low degree of CAC in non-dialysis, stable CAD patients treated by PCI.     

Functional behavior and morphology of the coronary artery wall in patients with Kawasaki disease assessed by intravascular ultrasound

Objectives. To examine the development of coronary artery lesions in Kawasaki disease, we assessed the functional behavior and morphology of coronary arteries by intravascular ultrasound.Background. Long-term follow-up studies of patients with Kawasaki disease have demonstrated the development of localized coronary stenoses even after aneurysms have regressed. It is also possible that angiographically normal coronary segments in patients with this disease may retain histologic changes.Methods. Twenty-three patients followed up by serial coronary angiography were examined at a mean age ± SD of 14.9 ± 2.9 years. The thickness of the intima-media complex was measured by intravascular ultrasound (30 MHz; 3.5 or 4.3F; 1,800 rpm). Coronary reactivity to nitroglycerin was determined by measuring percent changes in cross-sectional coronary artery area after intracoronary injection (7 μg/kg body weight) of this agent.Results. A remarkably thickened intima-media complex was observed at the sites with persisting (0.54 ± 0.20 mm, n = 19) and regressed (0.84 ± 0.40 mm, n = 23) aneurysms. Mild thickening of the intima-media complex was often observed even in angiographically normal segments (0.22 ± 0.05 mm, n = 31), in the left main coronary artery (0.47 ± 0.15 mm, n = 20) and at normal branches (0.36 ± 0.09 mm, n = 13). Coronary reactivity to nitroglycerin was significantly lower at the sites of regressed aneurysms (12.8 ± 6.6%, n = 9) than in normal segments (32.8 ± 10.9%, n = 13, p < 0.01), indicating the presence of functional impairment at the sites with regressed aneurysms. Decreased nitroglycerin reactivity was also observed in some segments without evidence of aneurysm.Conclusions. These results indicate that in patients with Kawasaki disease the coronary disease accompanying impaired reactivity to nitroglycerin is present at the sites of regressed aneurysms as well as in angiographically normal coronary segments. We suggest that these sites with morphologic and functional abnormalities are related to the development of significant stenosis.     

Decreased carotid intima-media thickness in patients with coronary artery ectasia compared with patients with coronary artery disease

BACKGROUND: Although atherosclerosis is supposed to be responsible for more than 50% of coronary artery ectasia, the precise pathology of coronary artery ectasia is not clearly understood. A histopathological examination of ectatic segments has revealed mainly destruction of the media layer of the artery. In the present study, we assessed carotid intima-media thickness and common carotid artery diameter in patients with and without coronary artery ectasia. MATERIALS AND METHODS: Thirty-five consecutive patients with coronary artery ectasia and coronary artery disease and 35 age and sex-matched patients with coronary artery disease alone were included in the study. The common carotid artery was studied as the longitudinal plane within 10 mm from the bifurcation of the common carotid artery. The intima-media thickness was measured in the far wall at end-diastole from the B-mode screen to a point within the 10-mm segment proximal to the bifurcation by one investigator blinded to clinical data. RESULTS: No significant differences with respect to age, body mass index, hypertension, diabetes mellitus, hypercholesterolemia and smoking habits were observed between the two groups studied. Intima-media thickness of the common carotid artery of the patients with coronary artery ectasia was significantly lower than that of the patients with coronary artery disease alone (0.71 +/- 0.13 vs. 0.77 +/- 0.09 mm, respectively, P = 0.04). CONCLUSION: Decreased intima-media thickness of the carotid artery in patients with coronary artery ectasia and coronary artery disease may have pathogenic mechanisms different from coronary artery disease per se.     

Noninvasive coronary flow reserve assessed by transthoracic coronary Doppler ultrasound in patients with left anterior descending coronary artery stents

Noninvasive measurement of coronary flow reserve (CFR) (hyperemic/flow velocity ratio at rest) by transthoracic Doppler echocardiography showed normalization of flow in the left anterior descending (LAD) coronary artery early after stenting. We hypothesized that noninvasive CFR may reveal in-stent restenosis at follow-up. Therefore, we studied 134 patients, 0 to 72 months after successful proximal-middle LAD stenting, and 38 controls. LAD flow velocity was measured by transthoracic Doppler echocardiography during 90 seconds venous adenosine infusion (140 microg/kg/min). CFR was measured in diastole. According to angiography, patients who received stents were divided into 3 groups: group I, <50% LAD in-stent restenosis (n = 83); group II, nonsignificant (50% to 69%) LAD in-stent restenosis (n = 17); and group III, significant (> or = 70%) LAD in-stent restenosis (n = 34). LAD CFR was similar in group I and controls (2.90 +/- 0.58 vs 3.05 +/- 0.81; p = NS), it was slightly lower in group II (2.42 +/- 0.33) compared with controls and group I (p <0.001 vs both), and clearly abnormal (<2) in group III (1.38 +/- 0.48) compared with controls, and groups I and II (p <0.001). A CFR <2 had 91% sensitivity, 95% specificity, and 96% positive and 97% negative predictive values to detect significant stenosis in patients with LAD stents. Our data show that noninvasive Doppler assessment of CFR allows identification of significant LAD in-stent restenosis, based on a cut-off value of <2.     

Sex differences in coronary artery size assessed by intravascular ultrasound

BACKGROUND: Women have worse outcomes after myocardial infarction and coronary revascularization. The explanations are likely multifactorial but may include smaller coronary artery size. Smaller luminal diameter has been confirmed angiographically; however, because of possible confounding effects of coronary remodeling, angiographically silent atherosclerosis, and body size, it is unclear if there is a true sex influence on arterial size. METHODS: We performed intravascular ultrasound on left main (LM) and proximal left anterior descending (LAD) coronary artery segments that were free of significant atherosclerosis in 50 men and 25 women. Arterial and luminal areas were measured by planimetry and corrected for body surface area. We evaluated associations between sex and coronary dimensions with univariate and then multiple linear regression analyses. RESULTS: Mean uncorrected LM and LAD arterial areas were smaller in women than in men (21.53 vs 26.95 mm(2), P <.001, and 14. 68 vs 19.94 mm(2), P =.002, respectively), as were mean LM and LAD luminal areas (15.94 vs 18.79 mm(2), P =.020, and 10.13 vs 12.71 mm(2), P =.036, respectively). In multivariate models accounting for body surface area and controlling for other factors, sex independently predicted corrected LM and LAD arterial area. In analyses that additionally controlled for plaque area, sex independently predicted corrected LAD luminal area. CONCLUSIONS: LM and LAD arteries are smaller in women, independent of body size. This suggests an intrinsic sex effect on coronary dimensions. Future studies should investigate underlying mechanisms because they may lead to novel therapeutic strategies and improved outcomes for women with coronary artery disease.     

Low prevalence of significant carotid artery disease on ultrasound in patients proceeding to coronary artery bypass surgery

Background: Cardiothoracic surgery is associated with an increased risk of perioperative stroke. Preoperative carotid ultrasonography can identify significant stenosis, but there is debate about the value of screening. The aims of this study were to (i) determine the prevalence of significant carotid artery disease in screened patients undergoing cardiothoracic surgery and (ii) correlate their ultrasonographic findings with perioperative strokes. Methods: Retrospective analysis of 166 patients (118 men, 48 women) who underwent a preoperative carotid ultrasound and coronary artery bypass graft surgery (CABG) from 2004 to 2007. Perioperative strokes were recorded and compared with ultrasonographic and clinical data. A separate cohort of 1423 patients (1064 men, 359 women) who underwent CABG over the same period was also evaluated. Results: Only 11 screened patients (6.6%) had significant (>70%) carotid artery disease and two of these underwent simultaneous carotid endarterectomy. There were five perioperative strokes in screened patients, four of which occurred in individuals with <50% disease. Compared with the non‐screened cohort, ultrasound screened patients were older and more likely to have a prior stroke or transient ischaemic attack, hypertension, hypercholesterolaemia, peripheral vascular disease and/or renal impairment than non‐screened patients. There was no significant difference in perioperative strokes compared with non‐screened patients (3% vs 1.2% respectively, P= NS). Conclusion: There is a low prevalence of significant carotid artery disease in ultrasound screened patients. The risk of perioperative strokes in screened patients is low and not significantly different from non‐screened patients.     

心脏直视手术前颈动脉支架术的初步探讨

目的 评估心脏疾病合并严重颈动脉狭窄患者于心脏直视手术前行颈动脉支架术预防围手术期缺血性卒中的有效性和安全性.方法 前瞻性队列研究,对心脏疾病合并严重颈动脉狭窄患者于心脏直视手术前行颈动脉支架术,评估颈动脉支架术至心脏直视术后30 d的终点事件(卒中、心肌梗死和死亡).结果 自2005年1月至2007年12月,本研究共连续入选42例患者.颈动脉支架技术成功率100%.远端栓塞防护装置使用率为97.6%(41/42).心脏直视手术包括:冠状动脉旁路移植术36例(85.7%),冠状动脉旁路移植术加瓣膜置换术5例(11.9%),瓣膜置换术1例(2.4%).自颈动脉支架术至心脏直视术后30 d的卒中率为2.4%(1/42),心肌梗死率为0%,死亡率为0%.结论 这一小样本前瞻性队列研究表明,心脏直视手术前行颈动脉支架术预防围手术期缺血性卒中安全有效,优于文献报告的分期颈动脉内膜剥脱术的结果,但由于本研究样本量小,需进一步研究验证.     

Elective stenting of carotid artery stenosis in patients with severe coronary artery disease

Aims To evaluate the feasibility and safety of elective carotid stentimplantation in patients with carotid stenoses and concomitantcoronary artery disease, as an alternative to combined carotidand coronary surgery. Methods We treated 50 patients with >70% stenoses in 53 carotid arterieswith balloon angioplasty followed by elective stent implantation.All patients had severe coronary artery disease, and/or mitralinsufficiency, aortic stenosis, rhythm disorders or generalizedarteriosclerosis. In three patients the opposite carotid arterywas occluded; nine patients had bilateral stenoses of whichtwo received stents bilaterally. Results Fifty-six successful stent implantations (42 Wallstents, eightBeStents, two AVE-Microstents, one Palmaz Schatz stent, threeSito stents) were performed, reducing the baseline percent stenosisfrom 78±18% to 13±11%. Complications includedthree transient ischaemic attacks, one minor and one major stroke.Follow-up was available for 46 patients over a mean of 10 months.Three asymptomatic restenoses and one deformation of a BeStentoccurred. Conclusion Our preliminary results indicate that carotid artery stentingin patients with concomitant severe coronary artery diseaseis feasible, safe, and may be an alternative to combined carotidand coronary surgery. ^f1 Correspondence:Jürgen Waigand, M.D. Franz Volhard Clinic,Wiltberg Strasse 50, 13122 Berlin, Germany.     

Progression of carotid atherosclerosis in Japanese patients with coronary artery disease

The authors investigated the relationship between the progression of carotid atherosclerosis and the severity of coronary artery disease (CAD). The two-year follow-ups of extracranial carotid atherosclerosis in 50 patients with CAD were evaluated by B-mode high-resolution ultrasonography. The summed maximal thickness of carotid plaques increased by 3.2 to 10.1 mm (mean 1.06 mm, SD 2.42 mm). The extent of coronary atherosclerosis (p<0.02) and the serum total cholesterol level (p<0.01) were different between the progressing group (n=20) and the nonprogressing group (n=25) with carotid atherosclerosis. Carotid disease progression was significantly higher in patients with three-vessel coronary disease than in those without significant coronary disease (p<0.005). Age, serum triglyceride, high-density lipoprotein-cholesterol, pack-years of smoking, % smokers, % hypertensives, and % diabetics were not different between the two groups. It was concluded that the severity of CAD was one of the strong predictors for carotid disease progression in patients with CAD.     

Screening of ruptured plaques in patients with coronary artery disease by intravascular ultrasound

AIM: To visualise the characteristics of ruptured plaques by intravascular ultrasound (IVUS) and to correlate plaque characteristics with clinical symptoms to establish a quantitative index of plaque vulnerability. METHODS: 144 consecutive patients with angina were examined using IVUS. Ruptured plaques, characterised by a plaque cavity and a tear on the thin fibrous cap, were identified in 31 patients (group A), of whom 23 (74%) presented with unstable angina. Plaque rupture was confirmed by injecting contrast medium filling the plaque cavity during IVUS examination. Of the patients without plaque rupture (group B, n = 108), only 19 (18%) had unstable angina. RESULTS: No significant differences were found between groups A and B in relation to plaque and vessel area (p > 0.05). Mean (SD) per cent stenosis in group A was less than in group B, at 56.2 (16.5)% v 67.9 (13.4)%; p < 0.001. Area of the emptied plaque cavity in group A (4.1 (3.2) mm2) was larger than the echolucent zone in group B (1.32 (0.79) mm2) (p < 0.001). The plaque cavity to plaque ratio in group A (38.5 (17.1)%) was larger than the echolucent area to plaque ratio in group B (11.2 (8.9)%) (p < 0.001). The thickness of the fibrous cap in group A was less than in group B, at 0.47 (0.20) mm v 0.96 (0.94) mm; p < 0.001. CONCLUSIONS: Plaques seem to be prone to rupture when the echolucent area is larger than 4.1 (3.2) mm2, when the echolucent area to plaque ratio is greater than 38.5 (17.1)%, and when the fibrous cap is thinner than 0.7 mm. IVUS can identify plaque rupture and vulnerable plaques. This may influence patient management and treatment.     

冠心病患者颈动脉超声检查的特征

目的：观察冠心病患者的颈动脉超声检查的特征,探索冠心病病情严重程度与颈动脉超声检查的关系。方法：选择在心内科同期住院的102例冠心病患者,其中心肌梗死（MI）患者37例,非MI患者65例,另选58例非冠心病患者作为正常对照组。测定颈动脉超声图像,血流动力学指标,血脂、血糖等生化指标,并进行统计学分析。结果：颈动脉超声显示,颈动脉内膜中层厚度在冠心病非MI组[（0.99±0.18）mm],MI组[（0.99±0.22）mm]明显大于正常对照组[（0.78±0.11）mm],P〈0.05,颈总动脉最大流速冠心病非MI组[（71.34±19.76）cm/s],MI组[（78.92±20.61）cm/s]明显高于正常对照组[（67.38±14.35）cm/s],P〈0.05。冠心病非MI组斑块发生率为69.2%,MI组为62.2%,明显高于正常对照组（36.2%,P均〈0.01）。Pearson相关分析显示颈动脉内膜中层厚度与总胆固醇、低密度脂蛋白-胆固醇、甘油三酯水平呈显著正相关（标准化回归系数0.460～0.862,P均〈0.001）。结论：颈动脉超声不仅可间接评价冠心病患者,且颈动脉内膜中层的厚度与血脂异常显著相关。     

Echolucent carotid plaques predict future coronary events in patients with coronary artery disease

OBJECTIVES: The purpose of this study was to examine whether echolucent carotid plaques predict future coronary events in patients with clinically stable coronary artery disease (CAD). BACKGROUND: Although rupture of coronary plaques is considered a major cause of acute coronary syndromes (ACS), the clinical estimation of coronary vulnerability still remains inconclusive. Ultrasound evaluation of carotid plaques with integrated backscatter (IBS) analysis can indicate the consistency/structure of the plaques. Lipid-rich lesions known as "unstable plaques" appear as echolucent plaques with low IBS values using this technique. METHODS: We investigated the echogenicity of carotid plaques using ultrasound with IBS in 286 consecutive CAD patients (71 with ACS and 215 with stable CAD). Coronary plaque complexity was also determined angiographically in stable CAD patients followed up for 30 months or until the occurrence of coronary events. RESULTS: The calibrated IBS values of carotid plaques in ACS patients were significantly lower than those in stable CAD patients (p < 0.01). Echolucent carotid plaques accurately predicted the existence of complex coronary plaques (predictive power of 83%). Kaplan-Meier analysis demonstrated a significantly higher probability of coronary events developing in patients with echolucent carotid plaques than in patients without this type of plaque (p < 0.001). The presence of echolucent carotid plaques in stable CAD patients predicted future coronary events independent of other risk factors (odds ratio 7.0, 95% confidence interval 2.3 to 21.4; p < 0.001). CONCLUSIONS: Echolucent carotid plaques with low IBS values predicted coronary plaque complexity and the development of future coronary complications in patients with stable CAD. Qualitative evaluation of carotid plaques using ultrasound with IBS is a clinically useful procedure for risk assessment of CAD patients.     

Diagnosis by ultrasound of severe carotid artery disease in patients undergoing cardiopulmonary bypass operations.

A non-invasive method using continuous wave Doppler shift ultrasound and spectral analysis was used as a screening test for severe carotid artery disease in patients undergoing cardiopulmonary bypass operations. One hundred and eighty-eight patients were examined before cardiac surgery (91 for ischaemic heart disease, 17 for ischaemic heart disease and valve replacement, 66 for valve replacement alone, and 14 for congenital abnormalities). The mean age of the 108 patients suffering from ischaemic heart disease was 54 years (+/- 8) and that of the 80 patients admitted either for valve replacement alone or for congenital abnormalities was 52 years (+/- 12). Five of the 108 patients suffering from ischaemic heart disease were found to have severe occlusive disease of the internal carotid artery by the ultrasound test, while the test was normal in the other two groups. Patients with severe carotid artery disease proceeded to carotid arteriography and endarterectomy before the planned heart operation.     

Aortic atheroma: not a sensitive indicators for coronary artery disease in patients with mitral valve disease

Aortic atheroma detected by transoesophageal echocardiography has been reported to be a good prognostic marker for coronary disease on angiography. The value of this detection in valvular heart disease would be to avoid preoperative coronary angiography in asymptomatic patients. The aim of this study was to assess the prognostic value of aortic atheroma in a population with a low prevalence of coronary artery disease in whom transoesophageal echocardiography was systematically performed. In addition, calcification of the aortic knuckle, a marker of atherosclerosis, was analysed by simple chest X-ray. One hundred and ninety two patients (103 men, 89 women; mean age: 63.1 +/- 15 years), operated for mitral valve replacement, underwent transoesophageal echocardiography, angiography, within 6 months, and chest X-ray. The cardiovascular risk factors, presence of aortic atherome, angiographic coronary artery disease and aortic calcification were studied. Aortic atheroma was observed in 72 patients (37.5%), usually in the descending thoracic aorta (73.6%). Coronary stenosis was observed in 36 patients (18.7%). On univariate analysis, aortic atherome predicted coronary stenosis with a sensitivity of 53%, specificity of 66% and positive predictive value of 26% and negative predictive value of 86%, compared with chest X-ray: 71%, 65%, 33% and 90%, respectively. In multivariate analysis, only hypercholesterolaemia, smoking and age predicted the presence of coronary artery disease. The presence of aortic atheroma was not predictive (p = 0.3). The authors conclude that aortic atheroma does not predict the presence of coronary artery disease in a patient population with mitral valve disease and a low prevalence of coronary artery disease. Simple chest X-ray has almost the same diagnostic value. The association of these two investigations does not give sufficient negative predictive values to avoid coronary angiography.     

冠心病患者颈部动脉粥样硬化病变高频超声体表标识表现分析

目的：分析冠心病患者颈动脉粥样硬化（CAS）病变高频超声体表标识表现。方法：连续选择521例接受冠状动脉造影的住院患者,造影后同时进行颈部动脉体表血管彩色多普勒超声检查。结果：521例人选对象中．冠状动脉正常者81例（对照组）。确诊冠心病患者440例,其中轻度狭窄组36例、中度狭窄组90例和重度狭窄组314例。冠心病各组的内膜一中层厚度（IMT）、IMT增厚率、斑块总面积和斑块发生率均明显高于对照组,冠心病中、重度狭窄组的IMT和斑块总面积也显著多于轻度狭窄组（P〈0．05～0．01）。冠心病各组各种斑块明显多于对照组（P〈0．05～0．01）．中及重度狭窄组软斑、硬斑数显著多于轻度狭窄组（P均〈0．05）。在CAS超声分级比较中．冠心病各组狭窄超声级别均明显多于对照组．同时重度狭窄组c、D级例数明显多于后者（P〈0．05～0．01）。结论：冠心病患者颈部动脉病灶超声体表标识可作为冠状动脉粥样硬化严重程度的间接判定指标。