Clinical significance of lipoprotein(a) in carotid plaque types and ischemic stroke in the elderly

Background:   The relationship between lipoprotein(a) (Lp(a)) and ischemic stroke is still controversial in the elderly. The purpose of the present paper was to evaluate the significance of Lp(a) in the development of extracranial carotid lesions and ischemic stroke.
Methods:   A total of 371 elderly subjects, studied with carotid ultrasonography (US) and brain computed tomography (CT), was stratified into two groups according to serum Lp(a) levels: the normal Lp(a) and high Lp(a) (>40 mg/dL) groups. Carotid plaques were divided into three types based on the US echogenicity: hypoechoic, hyperechoic, and heterogeneous plaques. Low-density areas (LDA) on brain CT images were classified into three groups depending on their distribution: basal ganglionic, cortical and only leuko-araiosis types.
Results:   The incidence of bilateral carotid lesions and the ratios of hypoechoic and heterogeneous plaques were significantly higher in the high Lp(a) group than in the normal Lp(a) group. Both the mean height and length of plaque were also greater in the high Lp(a) group. Mean Lp(a) levels were significantly elevated in cases with hypoechoic and heterogeneous types, compared to the cases without lesions. Higher mean Lp(a) levels were seen in cases with any kind of LDA than in normal subjects on CT, but there was no significant difference in the incidence of each LDA between the two groups.
Conclusions   These findings indicate that serum Lp(a) is strongly related to carotid lesions, especially hypoechoic and heterogeneous plaque types, in Japanese elderly patients. This suggests that Lp(a) could promote the formation of lipid-rich atheromatous plaque with intraplaque hemorrhage or superimposed thrombi. Serum Lp(a) also seemed to be a risk for all types of LDA.     

踝臂指数和颈动脉斑块积分预测冠脉病变的价值

目的 探讨踝臂指数(ABI)和颈动脉斑块积分(Crouse积分)预测冠状动脉病变的价值.方法 选择2013年12月～2014年5月在解放军总医院心内科住院并首次行冠状动脉造影的194例患者,根据冠状动脉造影结果按病变狭窄程度(Gensini积分)分为严重病变组(64例)和非严重病变组(130例),分析ABI及颈动脉Crouse积分与冠脉病变的关系.结果 严重病变组和非严重病变组的ABI和颈动脉Crouse积分差异均有统计学意义(P＜ 0.05或P＜ 0.01);相关性分析结果,ABI与冠脉病变情况呈负相关(r=-0.518,P＜0.01),颈动脉Crouse积分与冠脉病变情况呈正相关(r=0.616,P＜0.01).ABI诊断严重冠脉病变的受试者工作特征曲线(ROC曲线)下面积为0.278,以ABI≤0.9为截断值,其预测冠脉严重病变的敏感性为23.4％,特异性为95.4％;颈动脉Crouse积分诊断严重冠脉病变的ROC曲线下面积为0.627,以颈动脉Crouse积分≥1.9为截断值,其预测冠脉严重病变的敏感性为70.3％,特异性为41.5％.结论 ABI和颈动脉Crouse积分与冠状动脉的病变程度密切相关,对于预测严重病变的冠状动脉,二者具有很高的应用价值.     

Assessment of lesion-associated myocardial ischemia based on fusion coronary CT imaging – the FUSE-HEART study: A protocol for non-randomized clinical trial

Introduction:Multimodality assessment of coronary artery lesions has demonstrated superior effectiveness compared to the conventional approach, for assessing both anatomical and functional significance of a coronary stenosis. Multiple imaging modalities can be integrated into a fusion imaging tool to better assess myocardial ischemia.Material and methods:The FUSE-HEART trial is a single center, prospective, cohort study that will assess the impact of a coronary artery stenosis on myocardial function and viability, based on advanced fusion imaging technics derived from Cardiac Computed Tomography Angiography (CCTA). Moreover, the study will investigate the correlation between morphology and composition of the coronary plaques and myocardial ischemia in the territory irrigated by the same coronary artery. At the same time, imaging parameters will be correlated with inflammatory status of the subjects. The trial will include 100 subjects with coronary lesions found on CCTA examination. The study population will be divided into 2 groups: first group will consist of subjects with anatomically significant coronary lesions on native coronary arteries and the second one will include subjects surviving an acute myocardial infarction. The vulnerability score of the subjects will be calculated based on presence of CCTA vulnerability markers of the coronary plaques: napkin ring sign, positive remodeling, spotty calcifications, necrotic core, and low-density plaques. 3D fusion images of the coronary tree will be generated, integrating the images reflecting wall motion with the ones of coronary circulation. The fusion models will establish the correspondence between plaque composition and wall motion in the subtended myocardium of the coronary artery. The study primary outcome will be represented by the rate of major adverse cardiac events related to myocardial ischemia at 1-year post assessment, in correlation with the degree of coronary artery stenosis and myocardial ischemia or viability.The secondary outcomes are represented by the rate of re-hospitalization, rate of survival and rate of major adverse cardiovascular events (including cardiovascular death or stroke), in correlation with the morphology and composition of atheromatous plaques located in a coronary artery, and myocardial ischemia in the territory irrigated by the same coronary artery.Conclusion:In conclusion, FUSE-HEART will be a study based on modern imaging tools that will investigate the impact of a coronary artery stenosis on myocardial function and viability, using advanced fusion imaging technics derived from CCTA, sighting to validate plaque composition and morphology, together with inflammatory biomarkers, as predictors to myocardial viability.     

Protruding atherosclerotic aortic plaques and dyslipidaemia: correlation to subtypes of ischaemic stroke.

AIMS: To evaluate whether thoracic aortic plaques together with dyslipidaemia are related to ischaemic stroke, and if so, to which of the subtypes of stroke. METHODS AND RESULTS: We performed transoesophageal echocardiography in 50 patients with acute ischaemic stroke and in 401 controls. The aorta was divided into two segments: (1) the proximal, proximal to the left subclavian artery, and (2) the distal aorta. Protruding plaques (Intima > or =4 mm in thickness) in the proximal aorta were detected in 14 of the 50 patients (28%) with stroke, and in 53 of the 401 controls (13%) (P<0.01). Plaque score in the proximal aorta (2.1 +/- 1.8 vs 0.9 +/- 0.7; P<0.05), low-density lipoprotein cholesterol level (3.60 +/- 0.85 vs 2.87 +/- 0.72 mmol/l; P<0.05), and apolipoprotein B/A-I ratio (0.98 +/-0.17 vs 0.73 +/- 0.16; P<0.005) were higher in patients with athero-thrombotic than in cardioembolic stroke. The score in the proximal aorta correlated with low-density lipoprotein cholesterol level (r=0.44, P<0.005) and apolipoprotein B/A-I ratio (r=0.40, P<0.01). CONCLUSION: Severe plaques in the proximal aorta together with dyslipidaemia are seen more frequently in patients with atherothrombotic stroke. Lipid analysis may contribute to the prediction and the treatment of the patients who are at high risk for atherothrombotic stroke.     

脑络通与绞股蓝总皂甙对动脉粥样硬化性疾病的疗效比较

脑络通是用来治疗动脉粥样硬化性疾病的中药复方制剂,具有滋肾养肝、消痰祛瘀作用。为明确其治疗效果,周脑络通与绞股蓝总甙对103例动脉粥样硬化性疾病患者进行两盲临床对比观察,时间5个月以上。采用美国ATL公司彩色超声多谱勒血流声象系统在用药前后探测患者两侧颈动脉粥样硬化斑块及内中膜厚度,检测患者血脂、超氧化物歧化酶、脂过氧化物和血液流变学指标,部分病人检测血小板聚集率和心功能,并检测患者的血、尿常规和肝、肾功能,观察患者临床症状。结果发现脑络通组57块颈动脉粥样硬化斑块中15.8%(9/57)的斑块消除,47.4%(27/57)的斑块减轻,29.8%(17/57)的斑块不发展,总有效率为93%(53/57);绞股蓝组分别为0%,2.8%(1/36)和47.2%(17/36),总有效率为50%(18/36).脑络通组对斑块的消除、减轻、总有效率及斑块载面积减少方面皆明显优于绞股蓝组(p<0.01或0.05)。脑络通可使增厚的内中膜减薄。在降低血总胆固醇、甘油三酯、低密度脂蛋白、升高血超氧化物歧化酶活性,降低脂过氧化物,降低全血低切粘度、纤维蛋白原、红细胞压积、血小板最大聚集率等方面皆优于绞股蓝组。提示脑络通在调血脂、抗氧化、抗血栓和改善血液流变学等方面均有作用.在临床症状和患者心脏舒缩功能的改善方面亦优于绞股蓝组.本药长期服用对患者血、尿常规,肝、肾功能无异常影响,未见明显毒副反应.说明脑络通治疗动脉粥样硬化性疾病方面疗效优于绞股蓝总皂甙,脑络通可能阻止患者动脉粥样硬化病变的发展,甚至可能使动脉粥样硬化斑块消除。     

Gender differences in acute coronary syndromes: focus on the women with ACS without an obstructing culprit lesion

Introduction: The etiologies of acute coronary syndromes (ACS) in women expand beyond the traditional paradigm of obstructive epicardial atherosclerotic disease and plaque rupture. Fundamental differences in pathobiology and presentation can partially explain the gender disparity in ACS diagnosis and management, but there is also much we do not know about the spectrum of coronary artery disease in women.

Areas covered: This review seeks to explain some key differences between men and women in terms of risk factors, pathophysiology, and clinical presentations, as well as identify areas where more data are needed, focusing on women presenting with ACS but without a culprit lesion to explain their presentation. Literature search was undertaken with PubMed and Google Scholar.

Expert commentary: Women with acute coronary syndromes but without plaque rupture or obstructive epicardial atherosclerosis can be difficult to diagnose and manage. Improving care in this underdiagnosed and undertreated population will require early identification of at risk patients, development of better diagnostic strategies, and standardized implementation of guideline-based therapies.     

化痰逐瘀通脉颗粒联合辛伐他汀治疗颈动脉斑块

目的 探讨中药化痰逐瘀通脉颗粒联合辛伐他汀治疗颈动脉斑块的临床疗效.方法 选择符合颈动脉斑块和中医痰瘀互结诊断标准患者60例,随机分为治疗组和对照组,各30例,治疗组采用化痰逐瘀通脉颗粒(半夏、陈皮、茯苓等,1剂/d)联合辛伐他汀(10 mg/次,1次/d)口服;对照组仅采用辛伐他汀口服,治疗6周后比较2组临床疗效、IMT、血脂变化及不良反应.结果 治疗组中IMT和血脂变化均较治疗前有明显改善,且治疗组比对照组改善更为明显;治疗组总有效率93.33％明显高于对照组的70.0％(P＜0.05).结论 中药联合小剂量辛伐他汀治疗颈动脉斑块,能够起到消除或减缓动脉斑块形成的作用,降低不良反应发生率.