Carotid artery disease and stroke in patients with peripheral arterial disease. The role of inflammation.

Although during the last decade there have been great advances in our knowledge of the epidemiology and pathophysiology of multi-district atherosclerotic disease, little is known about the association between peripheral arterial disease and carotid artery disease. This review was conceived to cast some light on this topic, paying special attention to inflammation which plays a pivotal role in atherosclerosis. An aspect of pathophysiologic and clinical relevance is that the coexistence of carotid disease is more frequent in peripheral arterial disease than in coronary artery disease, not only in terms of carotid stenosis, but also with respect to the presence of hypoechoic unstable plaque. These latter plaques present a large infiltration of macrophages and are associated to high levels of inflammatory markers. In particular, the greater prevalence of hypoechoic carotid plaques in peripheral arterial disease compared to patients with carotid artery disease was poorly related to classic risk factors, but showed an independent association with an increased number of leukocyte and neutrophil cells, which are reliable markers of inflammation. The greater prevalence of hypoechoic unstable carotid plaques could explain why peripheral arterial disease portends higher risk of stroke than coronary artery disease

Femoral Plaque Echogenicity and Cardiovascular Risk in Claudicants

OBJECTIVES: The present study was designed to verify whether the evaluation of femoral plaque echogenicity might be a useful tool for cardiovascular risk assessment in patients affected by lower extremity peripheral arterial disease. BACKGROUND: Lower extremity peripheral arterial disease is a common manifestation of atherosclerosis and is associated with a high risk of developing major cardiovascular events. Vulnerable atherosclerotic plaque plays a central role in the occurrence of acute ischemic events in different vascular territories. Furthermore, atherosclerosis is a systemic disease, and the presence of an unstable atherosclerotic plaque in a certain vascular district, characterized by low echogenicity at B-mode ultrasound, is associated to a greater prevalence of unstable plaques in other vascular beds. METHODS: Femoral plaque echogenicity of 246 claudicants with ankle/brachial index ≤0.90 was evaluated at B-mode ultrasound by visual analysis and by calculating the grayscale median (GSM) value. In these patients, the occurrence of myocardial infarction and stroke was prospectively assessed. RESULTS: Femoral GSM values and plaque types assessed by visual analysis were highly correlated by Spearman analysis (rho = 0.905, p < 0.001). During a median follow-up of 30 months, 32 patients (13%) had a major cardiovascular event. Compared with patients without events, those who experienced an event during the follow-up had a lower femoral plaque GSM value (42.9 ± 26.2 vs. 58.8 ± 19.3, p = 0.002) and a higher prevalence of hypoechoic femoral plaque at visual analysis (68.8% vs. 19.6%, p < 0.001). At Cox analysis, femoral GSM showed an inverse relationship with cardiovascular risk, even after adjustment for possible confounders (hazard ratio: 0.96, 95% confidence interval [CI]: 0.95 to 0.98, p < 0.001). Furthermore, patients with hypoechoic femoral plaques at visual analysis had a 7.24-fold increased cardiovascular risk compared with patients with hyperechoic plaques after adjustment for possible confounders (95% CI: 3.23 to 16.22, p < 0.001). CONCLUSIONS: This study demonstrates that the presence of hypoechoic atherosclerotic femoral plaques is associated with higher cardiovascular risk in lower extremity peripheral arterial disease patients

Effetto della rivascolarizzazione percutanea periferica sull’incidenza di eventi cardiovascolari nei pazienti diabetici affetti da Arteriopatia Obliterante degli Arti Inferiori

Introduzione. L’Arteriopatia Ostruttiva degli Arti Inferiori (AOAI), una delle principali espressioni cliniche della patologia aterosclerotica, è una condizione molto frequente nei pazienti diabetici e si associa ad una ridotta capacità deambulatoria e ad un’alta incidenza di eventi ischemici cardiovascolari (CV). La rivascolarizzazione percutanea degli arti inferiori (PTA) migliora la qualità di vita e la distanza di marcia nei pazienti diabetici. Lo scopo del presente studio è dimostrare che la PTA possa migliorare anche la prognosi CV in questa categoria di pazienti ad alto rischio. Metodi. 236 pazienti diabetici affetti da AOAI allo stadio II di Fontaine furono arruolati nello studio. Sulla base delle raccomandazioni del Trans-Atlantic Inter Society Consensus II, 123 (52,1%) pazienti furono sottoposti a PTA (gruppo PTA) e 113 (47,9%) furono trattati con sola terapia medica (gruppo MT). L’incidenza di eventi CV maggiori e le curve di sopravvivenza al follow up furono valutate con l’analisi Cox e le curve di Kaplan-Meier, rispettivamente. Risultati. Non si osservarono differenze statisticamente significative nei fattori di rischio CV tra gruppo PTA e gruppo MT. Una prevalenza minore di uomini (74.8% vs. 85.8%, p=0.034) e una peggiore distanza di marcia (108.7 ± 300.9 vs 378.4 ± 552.3 meters, p<0.001) fu rilevata nel gruppo PTA. Durante una mediana di follow up di 20 mesi (12.0-29.0), l’incidenza di eventi cardiovascolari fu significativamente inferiore nel gruppo PTA rispetto al gruppo MT (7.3% vs. 22.1%, p=0.001) e i pazienti del gruppo MT avevano all’analisi Cox un rischio 3,9 volte superiore di sviluppare eventi CV rispetto al gruppo PTA dopo correzione per possibili fattori confondenti. Conclusioni. Il presente studio mostra che la PTA degli arti inferiori nei pazienti diabetici affetti da AOAI non solo migliora lo stato funzionale ma è anche associata ad un miglioramento della prognosi cardiovascolare rispetto alla sola terapia medica

Metabolic syndrome in peripheral arterial disease: Relationship with severity of peripheral circulatory insufficiency, inflammatory status, and cardiovascular comorbidity

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Functional status measured by walking impairment questionnaire and cardiovascular risk prediction in peripheral arterial disease: results of the Peripheral Arteriopathy and Cardiovascular Events (PACE) study

International audienceThe prognostic impact of the functional status of patients with intermittent claudication is still obscure. From the lists of seven general practitioners, we identified all subjects aged 40-80 years (n = 4352). Of those reporting leg symptoms while walking on the Rose questionnaire (n = 760), 60 had a qualifying diagnosis of peripheral arterial disease (PAD). All of them received the Walking Impairment Questionnaire (WIQ). For each patient affected by PAD, three sex- and age-matched controls were selected randomly. After a 24-month follow-up, survival curves showed that PAD patients with WIQ scores > median had a higher cardiovascular risk than controls, and patients with WIQ scores median for at least three WIQ domains was intermediate versus the risk of controls and PAD patients with a WIQ score < median, also when adjusted for the covariates indicated above (RR = 3.26, p = 0.019). In intermittent claudication, a worse functional status entails a greater risk of ischemic events versus low functional impairment

Femoral Plaque Echogenicity and Cardiovascular Risk in Claudicants

ObjectivesThe present study was designed to verify whether the evaluation of femoral plaque echogenicity might be a useful tool for cardiovascular risk assessment in patients affected by lower extremity peripheral arterial disease.BackgroundLower extremity peripheral arterial disease is a common manifestation of atherosclerosis and is associated with a high risk of developing major cardiovascular events. Vulnerable atherosclerotic plaque plays a central role in the occurrence of acute ischemic events in different vascular territories. Furthermore, atherosclerosis is a systemic disease, and the presence of an unstable atherosclerotic plaque in a certain vascular district, characterized by low echogenicity at B-mode ultrasound, is associated to a greater prevalence of unstable plaques in other vascular beds.MethodsFemoral plaque echogenicity of 246 claudicants with ankle/brachial index ≤0.90 was evaluated at B-mode ultrasound by visual analysis and by calculating the grayscale median (GSM) value. In these patients, the occurrence of myocardial infarction and stroke was prospectively assessed.ResultsFemoral GSM values and plaque types assessed by visual analysis were highly correlated by Spearman analysis (rho = 0.905, p < 0.001). During a median follow-up of 30 months, 32 patients (13%) had a major cardiovascular event. Compared with patients without events, those who experienced an event during the follow-up had a lower femoral plaque GSM value (42.9 ± 26.2 vs. 58.8 ± 19.3, p = 0.002) and a higher prevalence of hypoechoic femoral plaque at visual analysis (68.8% vs. 19.6%, p < 0.001). At Cox analysis, femoral GSM showed an inverse relationship with cardiovascular risk, even after adjustment for possible confounders (hazard ratio: 0.96, 95% confidence interval [CI]: 0.95 to 0.98, p < 0.001). Furthermore, patients with hypoechoic femoral plaques at visual analysis had a 7.24-fold increased cardiovascular risk compared with patients with hyperechoic plaques after adjustment for possible confounders (95% CI: 3.23 to 16.22, p < 0.001).ConclusionsThis study demonstrates that the presence of hypoechoic atherosclerotic femoral plaques is associated with higher cardiovascular risk in lower extremity peripheral arterial disease patients