Myron R. Schoenfeld

Forty-five-month follow-up of extracranial carotid arterial disease for new coronary events in elderly patients

BackgroundA prospective study evaluated the prevalence of 40% to 100% extracranial carotid arterial disease (ECD) by carotid duplex ultrasonograms and its association with coronary artery disease (CAD) and incidence of new coronary events in 949 patients with a mean age of 82 ± 8 years. MethodsTechnically adequate bilateral carotid duplex ultrasonograms were obtained in 949 unselected patients, mean age 82 ± 8 years, in a chronic care facility. The prevalence of CAD and incidence of coronary events were determined in patients with and without ECD. Follow-up was 45 ± 22 months. Data were analyzed by chi-square analyses. ResultsCAD was present in 87 of 150 patients (58%) with ECD and in 314 of 799 patients (39%) without ECD (P < 0.001). Coronary events occurred in 70 of 87 patients (80%) with ECD and CAD (group A), in 188 of 314 patients (60%) with CAD and no ECD (group B), in 28 of 63 patients (44%) with ECD and no CAD (group C), and in 133 of 485 patients (27%) with no ECD and no CAD (group D). Significant P values were P < 0.001 comparing A with B, A with C, A with D, and B with D; P < 0.01 comparing C with D; and P < 0.025 comparing B with C. ConclusionsPatients with ECD have a higher prevalence of CAD and a higher incidence of coronary events than patients without ECD. Patients with CAD and ECD have a higher incidence of coronary events than patients with CAD and no ECD. Patients with ECD and no CAD have a higher incidence of coronary events than patients with no ECD and no CAD.

Frequency of thromboembolic stroke in persons ≥60 years of age with extracranial carotid arterial disease and/or mitral annular calcium

Abstract Patients with extracranial internal or common carotid arterial disease have an increased incidence of ischemic stroke. 1–4 Patients with mitral annular calcium (MAC) have an increased incidence of thromboembolic stroke. 5–7 We are reporting the results from our prospective study associating extracranial internal or common carotid arterial disease and MAC with the incidence of new thromboembolic stroke at 45-month follow-up.

Association of extracranial carotid arterial disease and chronic atrial fibrillation with the incidence of new thromboembolic stroke in 1,846 older persons

In a prospective study of 1,846 persons, mean age 81 +/- 8 years, 281 persons (15%) had 40% to 100% extracranial carotid arterial disease and 253 persons (14%) had chronic atrial fibrillation. The Cox regression model showed that significant independent risk factors for new thromboembolic stroke were atrial fibrillation (p = 0.0001, risk ratio 3.3), 40% to 100% extracranial carotid arterial disease (p = 0.0001, risk ratio 2.5), prior stroke (p = 0.0001, risk ratio 2.1), and male gender (p = 0.045, risk ratio 1.2).

Left ventricular hypertrophy is more prevalent in patients with systemic hypertension with extracranial carotid arterial disease than in patients with systemic hypertension without extracranial carotid arterial disease

The mechanism of the association between LV hypertrophy and ECAD is unknown and needs to be investigated. Whether LV hypertrophy in patients with systemic hypertension is a marker for ECAD or contributes to ECAD needs to be investigated. The association between LV hypertrophy and significant ECAD was independent of the level of blood pressure in our patients. Coronary atherosclerosis in our patients with signifciant ECAD may have contributed to the increased prevalence of LV hypertrophy. The association between LV hypertrophy and significant ECAD may contribute to the high incidence of stroke in patients with LV hypertrophy. This is currently under investigation by our group.

Risk factors for extracranial internal or common carotid arterial disease in persons aged 60 years and older

Abstract Systolic and diastolic hypertension, diabetes mellitus and cigarette smoking are risk factors for atherothrombotic brain infarction. 1–6 The relation of abnormal serum lipids and obesity to atherothrombotic brain infarction is unclear. 1,2,5–7 We reported in a retrospective study of 535 elderly patients that risk factors for atherothrombotic brain infarction were systolic or diastolic hypertension and diabetes mellitus in both elderly men and women and cigarette smoking in elderly men. 5 We demonstrated in a prospective study of 708 elderly patients that at 3-year follow-up, risk factors for new atherothrombotic brain infarction were systolic or diastolic hypertension and diabetes mellitus in both elderly men and women, cigarette smoking in elderly men and obesity in elderly women. 6 We also reported that 64 of 478 unselected elderly patients ( 13%) in a long-term health care facility had 40 to 100% luminal diameter narrowing of an extracranial internal or common carotid artery diagnosed by carotid duplex ultrasonography. 8 We now report correlations of coronary risk factors with significant extracranial carotid disease (ECD) diagnosed by carotid duplex ultrasonography.

Association of extracranial carotid arterial disease, prior atherothrombotic brain infarction, systemic hypertension, and left ventricular hypertrophy with the incidence of new atherothrombotic brain infarction at 45-month follow-up in 1,482 older patients

Comparison of 239 older patients with 40% to 100% extracranial carotid arterial disease (ECAD) with 1,243 older patients with no significant ECAD showed a higher prevalence of systemic hypertension, left ventricular (LV) hypertrophy, and prior atherothrombotic brain infarction (ABI) and a higher incidence of new ABI in patients with ECAD than in patients without ECAD. A multivariate Cox regression model showed that independent predictors of new ABI were ECAD (risk ratio = 2.5), systemic hypertension (risk ratio = 2.3), prior ABI (risk ratio = 2.3), LV hypertrophy (risk ratio = 2.3), and male sex (risk ratio = 1.3).

Are Strokes More Likely to Result from Severe Carotid Atherosclerotic Stenoses? If Not, Why Not?

The authors studied by carotid duplex ultrasonography 478 unselected el derly patients (age sixty to one hundred one years, mean 82±8), in their long- term health care facility. Of these, 108 had previously experienced strokes owing to atherothrombotic brain infarcts, documented by a neurologist, and 370 had not. The degree of extracranial internal or common carotid narrowing in these patients was classified by standard Vmax Doppler criteria as 0-40%, 40- 80%, and 80-100% luminal diameter reduction. The authors found that 87% of the patients had little or no carotid stenosis (0-40% luminal diameter reduction). Nevertheless, 79% of the previous strokes had occurred in these patients, and the incidence of strokes in this group was 21%. Severe, but not mild or moderate, degrees of carotid obstruction (80- 100% luminal diameter reduction) were associated with a 100% stroke inci dence. The authors conclude that strokes most commonly result from causes other than ischemia due to in situ severe extracranial internal or common carotid stenosis or occlusion.

TRENDS IN CARDIOLOGY

Speaker: SEYMOUR H. RINZLER, M.D., F.A.C.P., New York, N.Y., Cardiologist to the Anti-Coronary Club of the New York City Department of Health; Chief of the Day Cardiac Clinic, Beth Israel Hospital, New York City. Moderator: NATHANIEL T . KWIT, M.D., New York, N.Y. Guests: HYMAN H. ARENBERG, M.D., New York, N.Y. ARGYRIOS GOLFINOS, M.D., New York, N.Y. LESLIE L. HAYOS, M.D., Valley Stream, N.Y. STANLEY REICHMAN, M.D., New York, N.Y. MYRON R. SCHOENFELD, M.D., Yonkers, N.Y. WILLIAM N. ZAHM, M.D., New York, N.Y.

ELECTROCARDIOGRAPHIC MANIFESTATIONS OF RIGHT VENTRICULAR HYPERTROPHY DUE TO RHEUMATIC MITRO‐TRICUSPID HEART DISEASE

Frank right ventricular hypertrophy often cannot be detected electrocardiographically, particularly in patients with acquired heart disease. Some of these cases may be caused by a counter-balancing left ventricular hypertrophy or other complicating factors but, even so, the impression remains that the commonly accepted criteria for electrocardiographic diagnosis are deficient. Ideally, a satisfactory set of criteria would detect even the mildest case of right ventricular hypertrophy; a t the very least, it should identify the severe cases. Amongst the severest cases of right ventricular hypertrophy in acquired heart disease are those due to rheumatic mitral stenosis with tricuspid insufficiency. There are only a few reports on the electrocardiographic findings in such patients (1-4), and in only one of these reports are the electrocardiographic details presented (I). We therefore undertook a study to test the adequacy of the criteria for right ventricular hypertrophy and right ventricular diastolic overload in a group of patients with rheumatic mitro-tricuspid disease. The results of this study are presented here.

TRENDS IN CARDIOLOGY*: THE RELATION OF DIETARY FATS TO SERUM CHOLESTEROL AND ARTERIOSCLEROTIC HEART DISEASE

Speaker: SEYMOUR H. RINZLER, M.D., F.A.C.P., New York, N.Y., Cardiologist to the Anti-Coronary Club of the New York City Department of Health; Chief of the Day Cardiac Clinic, Beth Israel Hospital, New York City. Moderator: NATHANIEL T . KWIT, M.D., New York, N.Y. Guests: HYMAN H. ARENBERG, M.D., New York, N.Y. ARGYRIOS GOLFINOS, M.D., New York, N.Y. LESLIE L. HAYOS, M.D., Valley Stream, N.Y. STANLEY REICHMAN, M.D., New York, N.Y. MYRON R. SCHOENFELD, M.D., Yonkers, N.Y. WILLIAM N. ZAHM, M.D., New York, N.Y.