Maureen J. van der Vlugt

Long-term risk of recurrent vascular events after young stroke: The FUTURE study

Long‐term data on recurrent vascular events after young stroke are limited. Our objective was to examine the long‐term risk of recurrent vascular events after young stroke.

High incidence of diabetes after stroke in young adults and risk of recurrent vascular events: the FUTURE study

Background Diabetes diagnosed prior to stroke in young adults is strongly associated with recurrent vascular events. The relevance of impaired fasting glucose (IFG) and incidence of diabetes after young stroke is unknown. We investigated the long-term incidence of diabetes after young stroke and evaluated the association of diabetes and impaired fasting glucose with recurrent vascular events. Methods This study was part of the FUTURE study. All consecutive patients between January 1, 1980, and November 1, 2010 with TIA or ischemic stroke, aged 18–50, were recruited. A follow-up assessment was performed in survivors between November 1, 2009 and January 1, 2012 and included an evaluation for diabetes, fasting venous plasma glucose and recurrent vascular events. The association of diabetes and IFG with recurrent vascular events was assessed by logistic regression analysis, adjusted for age, sex and follow-up duration. Results 427 survivors without a medical history of diabetes were included in the present analysis (mean follow-up of 10.1 (SD 8.4) years; age 40.3 (SD 7.9) years). The incidence rate of diabetes was 7.9 per 1000 person-years and the prevalence of IFG was 21.1%. Patients with diabetes and IFG were more likely to have experienced any vascular event than those with normal fasting glucose values (OR 3.5 (95%CI 1.5–8.4) for diabetes and OR 2.5 (95%CI 1.3–4.8) for IFG). Conclusions Diabetes or IFG in young stroke survivors is frequent and is associated with recurrent vascular events. Regular screening for IFG and diabetes in this population, yields potential for secondary prevention.

The very long-term risk and predictors of recurrent ischaemic events after a stroke at a young age: The FUTURE study

Introduction Patients who suffer a stroke at a young age, remain at a substantial risk of developing recurrent vascular events and information on very long-term prognosis and its risk factors is indispensable. Our aim is to investigate this very long-term risk and associated risk factors up to 35 years after stroke. Patients and methods Prospective cohort study among 656 patients with a first-ever ischaemic stroke or transient ischaemic stroke (TIA), aged 18–50, who visited our hospital (1980–2010). Outcomes assessed at follow-up (2014–2015) included TIA or ischaemic stroke and other arterial events, whichever occurred first. Kaplan–Meier analysis quantified cumulative risks. A prediction model was constructed to assess risk factors independently associated with any ischaemic event using Cox proportional hazard analyses followed by bootstrap validation procedure to avoid overestimation. Results Mean follow-up was 12.4 (SD 8.2) years (8105 person-years). Twenty-five years cumulative risk was 45.4% (95%CI: 39.4–51.5) for any ischaemic event, 30.1% (95%CI: 24.8–35.4) for cerebral ischaemia and 27.0% (95%CI: 21.1–33.0) for other arterial events. Risk factors retained in the prediction model were smoking (HR 1.35, 95%CI: 1.04–1.74), poor kidney function (HR 2.10, 95%CI: 1.32–3.35), history of peripheral arterial disease (HR 2.10, 95%CI: 1.08–3.76) and cardiac disease (HR 1.84, 95%CI: 1.06–3.18) (C-statistic 0.59 (95%CI: 0.55–0.64)). Discussion and conclusion Young stroke patients remain at a substantial risk for recurrent events; almost 1 of 2 develops a recurrent ischaemic event and 1 of 3 develops a recurrent stroke or TIA during 25 years of follow-up. Risk factors independently associated with recurrent events were poor kidney function, smoking, history of peripheral arterial disease and cardiac disease.

A high prevalence of carotid artery stenosis in male patients older than 65 years, irrespective of presenting clinical manifestation of atherosclerotic diseases

This study investigated the prevalence of carotid artery stenosis (CS) and the association with various risk factors in male patients (>65 years) diagnosed with cardiovascular diseases. Duplex sonography of the carotid arteries was performed in 434 of 473 eligible patients of whom 118 (27.8%) patients had significant CS ≥50%. The prevalence and severity of CS did not differ between patients who presented with neurological symptoms or acute coronary syndrome/peripheral artery disease (30.8% vs 25.9%, respectively). Among patients with CS, a higher rate of current smoking, a higher systolic blood pressure, and a lower glomerular filtration rate were observed compared with patients without CS. A history of coronary artery bypass graft was a significant predictor of the presence of CS (P = .003, odds ratio [OR] = 2.70 [1.40-5.19]). The prevalence of CS in elderly males with manifest atherosclerotic disease is high, irrespective of presenting clinical manifestation.

Improving the diagnostic performance of 18F-FDG PET/CT in prosthetic heart valve endocarditis

Background: 18F-Fluorodeoxyglucose (FDG) positron-emission tomography/computed tomography (PET/CT) was recently introduced as a new tool for the diagnosis of prosthetic heart valve endocarditis (PVE). Previous studies reporting a modest diagnostic accuracy may have been hampered by unstandardized image acquisition and assessment, and several confounders, as well. The aim of this study was to improve the diagnostic performance of FDG PET/CT in patients in whom PVE was suspected by identifying and excluding possible confounders, using both visual and standardized quantitative assessments. Methods: In this multicenter study, 160 patients with a prosthetic heart valve (median age, 62 years [43–73]; 68% male; 82 mechanical valves; 62 biological; 9 transcatheter aortic valve replacements; 7 other) who underwent FDG PET/CT for suspicion of PVE, and 77 patients with a PV (median age, 73 years [65–77]; 71% male; 26 mechanical valves; 45 biological; 6 transcatheter aortic valve replacements) who underwent FDG PET/CT for other indications (negative control group), were retrospectively included. Their scans were reassessed by 2 independent observers blinded to all clinical data, both visually and quantitatively on available European Association of Nuclear Medicine Research Ltd–standardized reconstructions. Confounders were identified by use of a logistic regression model and subsequently excluded. Results: Visual assessment of FDG PET/CT had a sensitivity/specificity/positive predictive value/negative predictive value for PVE of 74%/91%/89%/78%, respectively. Low inflammatory activity (C-reactive protein <40 mg/L) at the time of imaging and use of surgical adhesives during prosthetic heart valve implantation were significant confounders, whereas recent valve implantation was not. After the exclusion of patients with significant confounders, diagnostic performance values of the visual assessment increased to 91%/95%/95%/91%. As a semiquantitative measure of FDG uptake, a European Association of Nuclear Medicine Research Ltd–standardized uptake value ratio of ≥2.0 was a 100% sensitive and 91% specific predictor of PVE. Conclusions: Both visual and quantitative assessments of FDG PET/CT have a high diagnostic accuracy in patients in whom PVE is suspected. FDG PET/CT should be implemented early in the diagnostic workup to prevent the negative confounding effects of low inflammatory activity (eg, attributable to prolonged antibiotic therapy). Recent valve implantation was not a significant predictor of false-positive interpretations, but surgical adhesives used during implantation were.Laurens E. Swart, MD; Anna Gomes, MD, PhD; Asbjørn M. Scholtens, MD; Bhanu Sinha, MD, PhD; Wilco Tanis, MD, PhD; Marnix G.E.H. Lam, MD, PhD; Maureen J. van der Vlugt, MD, PhD; Sebastian A.F. Streukens, MD; Erik H.J.G. Aarntzen, PhD; Jan Bucerius, MD, PhD; Sander van Assen, MD, PhD; Chantal P. Bleeker-Rovers, MD, PhD; Peter Paul van Geel, MD, PhD; Gabriel P. Krestin, MD, PhD; Joost P. van Melle, MD, PhD, Jolien W. Roos-Hesselink, MD, PhD; Riemer H.J.A. Slart, MD, PhD; Andor W.J.M. Glaudemans, MD, PhD; Ricardo P.J. Budde MD PhD

Intermodality variation of aortic dimensions: How, where and when to measure the ascending aorta

BACKGROUND No established reference-standard technique is available for ascending aortic diameter measurements. The aim of this study was to determine agreement between modalities and techniques. METHODS In patients with aortic pathology transthoracic echocardiography, computed tomography angiography (CTA) and magnetic resonance angiography (MRA) were performed. Aortic diameters were measured at the sinus of Valsalva (SoV), sinotubular junction (STJ) and tubular ascending aorta (TAA) during mid-systole and end-diastole. In echocardiography both the inner edge-to-inner edge (I-I edge) and leading edge-to‑leading edge (L-L edge) methods were applied, and the length of the aortic annulus to the most cranial visible part of the ascending aorta was measured. In CTA and MRA the I-I method was used. RESULTS Fifty patients with bicuspid aortic valve (36 ± 13 years, 26% female) and 50 Turner patients (35 ± 13 years) were included. Comparison of all aortic measurements showed a mean difference of 5.4 ± 2.7 mm for the SoV, 5.1 ± 2.0 mm for the STJ and 4.8 ± 2.1 mm for the TAA. The maximum difference was 18 mm. The best agreement was found between echocardiography L-L edge and CTA during mid-systole. CTA and MRA showed good agreement. A mean difference of 1.5 ± 1.3 mm and 1.8 ± 1.5 mm was demonstrated at the level of the STJ and TAA comparing mid-systolic with end-diastolic diameters. The visible length of the aorta increased on average 5.3 ± 5.1 mmW during mid-systole. CONCLUSIONS MRA and CTA showed best agreement with L-L edge method by echocardiography. In individual patients large differences in ascending aortic diameter were demonstrated, warranting measurement standardization. The use of CTA or MRA is advised at least once.

Coronary anatomy in Turner syndrome versus patients with isolated bicuspid aortic valves

Objective Variations in coronary anatomy, like absent left main stem and left dominant coronary system, have been described in patients with Turner syndrome (TS) and in patients with bicuspid aortic valves (BAV). It is unknown whether coronary variations in TS are related to BAV and to specific BAV subtypes. Aim To compare coronary anatomy in patients with TS with/without BAV versus isolated BAV and to study BAV morphology subtypes in these groups. Methods Coronary anatomy and BAV morphology were studied in 86 patients with TS (20 TS-BAV, 66 TS-tricuspid aortic valve) and 86 patients with isolated BAV (37±13 years vs 42±15 years, respectively) by CT. Results There was no significant difference in coronary dominance between patients with TS with and without BAV (25% vs 21%, p=0.933). BAVs with fusion of right and left coronary leaflets (RL BAV) without raphe showed a high prevalence of left coronary dominance in both TS-BAV and isolated BAV (both 38%). Absent left main stem was more often seen in TS-BAV as compared with isolated BAV (10% vs 0%). All patients with TS-BAV with absent left main stem had RL BAV without raphe. Conclusion The equal distribution of left dominance in RL BAV without raphe in TS-BAV and isolated BAV suggests that presence of left dominance is a feature of BAVs without raphe, independent of TS. Both TS and RL BAV without raphe seem independently associated with absent left main stems. Awareness of the higher incidence of particularly absent left main stems is important to avoid complications during hypothermic perfusion.