Simulaatio ja potilasturvallisuus

Teema : potilasturvallisuus

Vauhtia rupturoituneen vatsa-aortan aneurysman endovaskulaariseen hoitoon simulaation keinoin

Teema : simulaatio

Aorta of young and middle-aged heterozygous familial hypercholesterolemia patients shows no functional or morphological impairment assessed by MRI

In familial hypercholesterolemia (FH) the level of LDL cholesterol is 2–3 times that of the normal population and leads to accelerated atherosclerosis. Improved care for risk factors has decreased cardiovascular mortality of these patients. We studied subclinical atherosclerotic changes with morphologic and functional aortic magnetic resonance imaging (MRI) in FH patients under the age of 50. 39 DNA test-verified heterozygous FH-North Karelia patients, aged 6–48, 28 of them treated with statins, and 25 healthy controls, aged 12 to 50, underwent aortic MRI, carotid ultrasound (US), and risk-factor assessment. No differences in any of the morphologic or functional aortic parameters appeared between patients and controls. Age and gender were independent predictors of the majority of the morphologic and functional measures. Carotid intima-media thickness assessed by US was greater in patients (0.57 mm ± 0.13 vs 0.48 ± 0.13 mm, p = 0.005) as was cholesterol-years score (243 ± 122 vs 137 ± 74, p < 0.001). Patients had thicker intima-media of the common carotid artery and higher cholesterol burden as indicated by their cholesterol-years score. Despite this, no differences existed in morphologic or functional aortic parameters assessed with MRI. The improved care of cardiovascular risk factors, especially statin treatment, may protect the aorta of FH patients. However, larger confirmatory studies are needed

Magnetic Resonance Imaging of Atherosclerotic Manifestations in Familial Hypercholesterolemia

Cardiovascular diseases (CVD) are, in developed countries, the leading cause of mortality. The majority of premature deaths and disability caused by CVD are due to atherosclerosis, a degenerating inflammatory disease affecting arterial walls. Early identification of lesions and initiation of treatment is crucial because the first manifestations quite often are major disabling cardiovascular events. Methods of finding individuals at high risk for these events are under development. Because magnetic resonance imaging (MRI) is an excellent non-invasive tool to study the structure and function of vascular system, we sought to discover whether existing MRI methods are able to show any difference in aortic and intracranial atherosclerotic lesions between patients at high risk for atherosclerosis and healthy controls. Our younger group (age 6-48) comprised 39 symptomless familial hypercholesterolemia (FH) patients and 25 healthy controls. Our older group (age 48-64) comprised 19 FH patients and 18 type 2 diabetes mellitus (DM) patients with coronary heart disease (CHD) and 29 healthy controls. Intracranial and aortic MRI was compared with carotid and femoral ultrasound (US). In neither age-group did MRI reveal any difference in the number of ischemic brain lesions or white matter hyperintensities (WMHIs) - possible signs of intracranial atherosclerosis - between patients and controls. Furthermore, MRI showed no difference in the structure or function of the aorta between FH patients and controls in either group. DM patients had lower compliance of the aorta than did controls, while no difference appeared between DM and FH patients. However, ultrasound showed greater plaque burden and increased thickness of carotid arterial walls in FH and DM patients in both age-groups, suggesting a more advanced atherosclerosis. The mortality of FH patients has decreased substantially after the late 1980´s when statin treatment became available. With statins, the progression of atherosclerotic lesions slows. We think that this, in concert with improvements in treatment of other risk factors, is one reason for the lack of differences between FH patients and controls in MRI measurements of the aorta and brain despite the more advanced disease of the carotid arteries assessed with US. Furthermore, whereas atherosclerotic lesions between different vascular territories correlate, differences might still exist in the extent and location of these lesions among different diseases. Small (<5 mm in diameter) WMHIs are more likely a phenomenon related to aging, but the larger ones may be the ones related to CVD and may be intermediate surrogates of stroke. The image quality in aortic imaging, although constantly improving, is not yet optimal and thus is a source of bias.Sydän- ja verisuonitaudit ovat yleisin kuolinsyy länsimaissa. Ateroskleroosi eli valtimokovettumatauti aiheuttaa suurimman osan sydän- ja verisuonitautikuolemista. Sen riskitekijöitä ovat muun muassa familiaarinen hyperkolesterolemia ja diabetes. Koska ateroskleroosi ilmenee usein vasta vakavina komplikaatioita kuten sydän- ja aivoinfarkteina, on sen varhainen toteaminen tärkeää. Käytössä olevien menetelmien, verikokeiden ja ulkoisten mittausten avulla voidaan epäsuorasti arvioida henkilön komplikaatioriski. Kuitenkaan valtimoiden kuntoa ei nykymenetelmin pystytä arvioimaan. Erityisesti riskiryhmiä varten on tavoiteltavaa löytää keino ateroskleroosin etenemisen arvioimiseksi, jotta hoitoa voitaisiin ajoissa tehostaa. Väitöskirjatyössä selvitettiin löytyykö nykyisillä magneettikuvausmenetelmillä eroja aivojen rakenteessa tai verisuonten rakenteessa ja toiminnassa korkean ateroskleroosiriskin omaavien potilaiden ja terveiden verrokkien välillä. Tutkimuksessa tarkastetiin kahta ikäryhmää. Nuoremmassa ryhmässä (ikä 6–48 vuotta) oli 39 familiaalista hyperkolesterolemiaa (FH) sairastavaa potilasta sekä 25 tervettä verrokia. Vanhemmassa ryhmässä (ikä 48–64 vuotta) oli 19 FH potilasta ja 18 tyypin 2 diabeetikkoa, joilla molemmilla oli todettu sepelvaltimotauti sekä 29 tervettä verrokkia. Tutkittavien pään ja aortan magneettikuvaustuloksia verrattiin kaula- ja nivusvaltimoiden ultraäänilöydöksiin. Aivojen magneettikuvauksessa ateroskleroottisiksi oletetuissa muutoksissa ei havaittu eroja potilaiden ja verrokkien välillä. Myöskään aortan venyvyydessä tai rakenteessa ei havaittu eroja FH-potilaiden ja verrokkien välillä. Sen sijaan diabetes-potilaiden aortan venyvyys oli heikompi kuin verrokeilla. Kaulasuonten ultraäänellä mitattu intima-media-kerros oli molemmilla potilasryhmillä selvästi paksumpi kuin verrokeilla. FH-potilaiden kuolleisuus on laskenut merkittävästi 1980-luvun taitteesta, jolloin kolesteroliarvoja laskevat statiini-lääkkeet tulivat markkinoille. Tämä yhdessä muiden riskitekijöiden parantuneen hoidon kanssa lienee merkittävä syy siihen, ettei eroja FH-potilaiden ja verrokkien välillä aortan tai aivojen osalta havaittu. Toisaalta ultraäänellä arvioiden kaulavaltimoiden ateroskleroosi oli potilasryhmissä selvästi pitemmälle edennyt kuin verrokeilla. Ateroskleroottiset muutokset eivät välttämättä ilmene tasaisesti läpi valtimopuuston, mikä voi selittää eroja tautien ja kuvantamismenetelmien välillä. Magneettikuvauksen rajoitteet varsinkin syvällä olevia kohteita, kuten aortaa, kuvattaessa tulee kuitenkin pitää mielessä ja mahdollisena virhelähteenä

Compliance of the aorta in two diseases affecting vascular elasticity, familial hypercholesterolemia and diabetes: a MRI study

Sami Soljanlahti1, Taina Autti1, Laura Hyttinen2, Alpo F Vuorio3, Pekka Keto1, Kirsi Lauerma11Helsinki Medical Imaging Center, Helsinki University Central Hospital, Helsinki, Finland; 2Department of Internal Medicine, North Karelia Central Hospital, Joensuu, Finland; 3Division of Internal Medicine, Department of Medicine, University of Helsinki, Helsinki, FinlandAbstract: Arterial elasticity changes in familial hypercholesterolemia (FH) and diabetes mellitus (DM) with different but overlapping mechanisms. We compared aortic elasticity between 19 FH patients with the same mutation, 18 type 2 DM patients, and 30 controls, all aged 48 to 64. They underwent aortic magnetic resonance imaging, risk-factor assessment, and carotid and femoral ultrasound measurements. All patients were on adequate cardiovascular medication including statins and had established coronary heart disease (CHD). FH patients had longer-duration CHD (13.3 &plusmn; 7.7 years) than did DM patients (5.0 &plusmn; 3.1). Aortic compliance in the descending thoracic (DM 0.38 &plusmn; 0.14 vs control 0.53 &plusmn; 0.19, P = 0.032) and abdominal aorta (DM 0.45 &plusmn; 0.20 vs control 0.66 &plusmn; 0.25, P = 0.011) was lower in DM patients than in controls, whereas no significant difference existed between FH patients and controls. Carotid and femoral intima-media thickness was greater in FH and DM patients than in controls with no difference between patient groups. Carotid or femoral plaques appeared in 15 (79%) FH and in 10 (56%) DM patients. One control had a femoral plaque. Five FH patients showed stenosis, occlusion or both in carotid arteries. In our opinion, DM patients&rsquo; lower compliance reflect mainly arterial media affecting arteriosclerosis, while FH patients&rsquo; plaque status and longer duration of CHD suggest more advanced atherosclerosis. The FH patients may therefore be at increased risk for atherothrombotic events. However, due to small patient material, larger confirmatory studies are needed.Keywords: MRI, ultrasound, familial hypercholesterolemia, diabetes mellitus, elasticity, intima-media thicknes