Automatic segmentation of the vessel wall in three-dimensional (3D) carotid artery (CA) ultrasound (US) images can significantly advance the development of cardiovascular disease risk prediction and therapy assessments. Unsupervised domain adaptation segmentation (UDASeg) mitigates the domain shift problem and outputs robust results when the target images are acquired by US machines and imaging parameters different from the training images. Current UDASeg methods focus on target images with domain labels, but domain-agnostic target datasets (DaTD) present more severe domain shift and degrade the effectiveness of UDASeg. To overcome the domain shift induced by the DaTD in 3D CA US image segmentation, we proposed a Domain-agnostic UDASeg (DaUDASeg) method, comprising a Domain-agnostic Target Domain Aligning Module (DaTDAM) and a Cross Pseudo Labeled Supervision (CPLS) in the training stage. Specifically, the DaTDAM decreases domain shift in image appearances and is constructed by a proposed Domain agnostic Style Transfer Model, which adopts a shared network structure and is trained with a Structure Anchor Learning to improve the domain alignment capability in DaTD. The proposed CPLS mitigates overfitting to the source dataset by adding a Pseudo Labeled Target Dataset. This dataset is constructed via similarity filtering and is then used for the final supervised training, providing additional semantic supervision from the target data. The experimental results in a domain-agnostic 3D CA US image dataset showed that our method outperformed the competing methods with 3.0%, 0.09 mm, and 0.57 mm in the DSC, ASSD, and HD95 metrics, respectively. These gains demonstrate improved segmentation performance.

BACKGROUND:Some studies report that certain blood groups are associated with vascular disease. However, only a few studies have assessed the association between atherosclerosis and ABO blood groups. We investigated whether ABO blood groups are associated with carotid atherosclerosis. METHODS:A retrospective cohort study of 3855 patients from 1985 to 2021 at the Stroke Prevention and Atherosclerosis Research Center (SPARC). The database included patients with a history of vascular disease and those referred to SPARC for primary prevention. Carotid plaque burden was measured as total plaque area; percent stenosis was calculated from peak systolic velocity. Total plaque area and stenosis are compared in blood groups, using unadjusted comparisons. Quantile regression analyses were performed adjusting for risk factors including age, sex, blood pressure and smoking status. The association between carotid stenosis and blood groups was analyzed using logistic regression models. Subgroup analysis was stratified by presence or absence of vascular disease at baseline and the burden of atherosclerosis. RESULTS:In quantile regression analysis, we found no significant associations between total plaque area and ABO blood groups. Carotid stenosis as a categorical and binary variable (defined as cases with stenosis ≥50% vs. < 50%) and total plaque area as a binary variable (TPA ≥ 1.19 cm2 vs. <1.19 cm2) had no association with ABO blood groups. In patients with cardiovascular disease (CVD), there was no association between blood groups and total plaque area. CONCLUSION:Blood groups are not associated with carotid atherosclerosis. Prevention efforts should focus on controlling risk factors and living a healthy lifestyle.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors represent a novel approach for reducing cholesterol and, accordingly, the burden of atherosclerosis. However, limited data are available regarding the possible effects of PCSK9 inhibitors on atherosclerotic plaque. To evaluate the efficacy of PCSK9 inhibitors in reducing carotid plaque progression in individuals with high-risk carotid atherosclerotic disease. We used carotid total plaque area (TPA) to assess the burden of atherosclerosis. Ultrasound imaging of the carotid was acquired before and after the initiation of PCSK9 inhibitor therapy. We selected high-risk cases with atherosclerosis with a minimum of three ultrasound examinations, 1 year before, one at the time of initiation of a PCSK9 inhibitor, and 1 year after initiating a PCSK9 inhibitor. Statistical analysis was conducted using the mixed-effects model with Restricted Maximum Likelihood (REML). We reviewed data from 131 patients with a mean follow-up of 6 (±4) years. Patients were high-risk, with the majority having diabetes or hypertension. There was a decrease in TPA, particularly during the first 3 years after initiating PCSK9 inhibitor therapy ( p  < 0.05). Furthermore, we observed that individuals with higher baseline serum low-density lipoprotein cholesterol (LDL-C) levels experienced a greater decline in TPA ( p  < 0.05). PCSK9 inhibitors are effective in achieving plaque regression in high-risk patients with atherosclerosis. This is important, as plaque regression is associated with a lower risk of stroke, myocardial infarction, or vascular death.

The vessel-wall-volume (VWV) measured based on three-dimensional (3D) carotid artery (CA) ultrasound (US) images can help to assess carotid atherosclerosis and manage patients at risk for stroke. Manual involvement for measurement work is subjective and requires well-trained operators, and fully automatic measurement tools are not yet available. Thereby, we proposed a fully automatic VWV measurement framework (Auto-VWV) using a CA prior-knowledge embedded U-Net (CAP-UNet) to measure the VWV from 3D CA US images without manual intervention. The Auto-VWV framework is designed to improve the repeated VWV measuring consistency, which resulted in the first fully automatic framework for VWV measurement. CAP-UNet is developed to improve segmentation accuracy on the whole CA, which composed of a U-Net type backbone and three additional prior-knowledge learning modules. Specifically, a continuity learning module is used to learn the spatial continuity of the arteries in a sequence of image slices. A voxel evolution learning module was designed to learn the evolution of the artery in adjacent slices, and a topology learning module was used to learn the unique topology of the carotid artery. In two 3D CA US datasets, CAP-UNet architecture achieved state-of-the-art performance compared to eight competing models. Furthermore, CAP-UNet-based Auto-VWV achieved better accuracy and consistency than Auto-VWV based on competing models in the simulated repeated measurement. Finally, using 10 pairs of real repeatedly scanned samples, Auto-VWV achieved better VWV measurement reproducibility than intra- and inter-operator manual measurements. The code is available at https://github.com/Yue9603/Auto-VWV.

Understanding cerebral circulation is crucial for early diagnosis and patient-oriented therapies for brain conditions. However, blood flow simulations at the organ scale have been limited. This work introduces a framework for modeling extensive vascular networks in the human cerebral cortex and conducting pulsatile blood flow simulations. Using a patient-specific cerebral geometry, we applied a parallelized adaptive constrained constructive optimization algorithm to create a comprehensive pial vascular network in the left hemisphere, starting from the main cerebral arteries. The resulting network included over 75 000, 103 000, and 55 000 vessels for the anterior, middle, and posterior territories, respectively. Pial vessel diameters featured a median [interquartile range, IQR] value of [Formula: see text]. We integrated the pial vascular network model with the Anatomically-Detailed Arterial Network (ADAN) model to conduct one-dimensional (1D) blood flow simulations under normotensive and hypertensive conditions. Viscoelastic dissipation proved to be a key ingredient in the characterization of the hemodynamic environments in the pial circulation. In the normotensive scenario, mean blood pressure in the pial vessels resulted in a median [IQR] value of [Formula: see text]. The flow pulsatility index and its corresponding damping factor were effective descriptors of the hypertensive state. The median [IQR] pulsatility index in the normotensive state was [Formula: see text], and in hypertension it increased up to [Formula: see text], while its corresponding damping factor in the normotensive state was [Formula: see text], and in the hypertensive state it was reduced to [Formula: see text]. We observed large regional pressure gradients in terminal vessels, with pressure levels ranging from [Formula: see text] in normotension to [Formula: see text] in hypertension. Additionally, the pulsatility index at terminal vessels increased with distance from the Circle of Willis in the hypertensive case, contrasting with the decreasing pattern seen in normotension. This approach provides a unique characterization of hemodynamics in the pial vascular network of the human cerebral cortex, paving the way for research into microcirculatory environments, the link between hemodynamics and neural function, and their roles in conditions like stroke and dementia.

BACKGROUND AND AIMS:Whether hypertensive patients with elevated arterial stiffness and central systolic blood pressure (cSBP) are exposed to higher stroke risk is unclear. METHODS:A total of 6663 participants without a history of cardiovascular disease were enrolled in this study. cSBP was measured noninvasively using the A-Pulse CASPro device; carotid-femoral pulse wave velocity (cfPWV) was collected using a Pulse Pen device. The primary outcome was incident stroke. RESULTS:Over 4.4 years (median), 454 incident strokes occurred (15.92 per 1000 person-years). Compared to the reference group (cSBP < 137 mmHg and cfPWV < 10 m/s), patients with elevated cSBP and cfPWV had a significantly increased risk of incident stroke (HR 1.78 [95% CI 1.39, 2.27]), and were the only group showing statistical significance versus those with solely increased cSBP (HR 1.13 [95% CI 0.87, 1.48]) or cfPWV (HR 1.15 [95% CI 0.87, 1.52]) after adjusting for covariates; p for trend < 0.001. Consistent findings were identified in multiple sensitivity and exploratory analyses. The additive interaction between elevated cSBP and cfPWV was significant, with a relative excess risk due to interaction of 0.55 [95% CI 0.05-1.03]. The association between elevated cSBP and cfPWV with incident stroke risk was more robust among patients who were taking non-guideline recommended antihypertensive medication at baseline (HR 3.03) than among those who took recommended regimens (HR 1.58). CONCLUSIONS:Hypertensive patients with elevated cSBP and cfPWV have a significantly higher risk of incident stroke than those with lower or solely increased cSBP and cfPWV. Greater clinical attention and tailored treatment strategies are needed.

BACKGROUND/OBJECTIVE:the determination of the carotid total plaque area (TPA) is an indicator of subclinical atherosclerosis and a useful tool in early cardiovascular prevention. Classically, diabetes has been considered the most atherogenic disease, even more so than hypertension, but the incidence of stroke and heart attack is higher in patients with hypertension than in patients with diabetes alone. Therefore, in this study, we compared hypertension and diabetes with regard to the burden of atherosclerosis. METHODS:a cross-sectional observational study was carried out on adults (n = 606). Those with a history of a cardiovascular event were excluded. RESULTS:median age was 65 years (IQR 17), 58.6% women. People with diabetes and hypertension had the highest TPA (β exponent: 1.64; 95% CI 1.20-2.26), followed by people with hypertension alone (β exponent: 1.39; 95% CI 1.05-1.86), while people with diabetes alone had no differences (P = .379) with respect to the control group. CONCLUSION:This cross-sectional study, though limited, emphasizes the need for larger prospective studies to validate the clinical significance of these findings and highlights the importance of routine monitoring of subclinical atherosclerosis in hypertensive patients to assess the effectiveness of preventive therapy.

The report by Chang et al, comparing patients with recently asymptomatic ipsilateral carotid stenosis who had carotid endarterectomy (CEA) vs those who did not,1 is an excellent attempt to use real-world data to simulate a clinical trial. However, the much lower risk difference (RD) for ipsilateral stroke alone, vs the RD for stroke or all-cause mortality, suggests strongly that patients in whom CEA was performed were healthier (as might be expected).

In an excellent review of plant-based meat alternatives in this issue of the Canadian Journal of Cardiology, Nagra et al.1Nagra M. Tsam F. Ward S. Ur E. The potential of plant-based meat alternatives for reducing cardiovascular disease risk.Can J Cardiol. 2024; XXXXX-XXGoogle Scholar focus on reduction of cardiovascular risk factors, and the effects of various individual dietary factors on cardiovascular risk. For example, "Soy consumption may reduce risk of CVD, CHD, and stroke by 16%, 17%, and 18% respectively, while also reducing risk of several cancers, including breast cancer." And, "Canola oil significantly reduced TC, LDL-C, and apoB compared with other oils." They found improvement in cardiometabolic risk profiles with plant-based meat alternatives, but no reduction of blood pressure. However, what really matters is not the effect of individual components of a diet, nor the effect of diet on cardiovascular risk factors; what matters is the effect of diet on the actual risk of cardiovascular events such as myocardial infarction and stroke. Most physicians markedly underestimate the cardiovascular benefit of diet and place far too little emphasis on diet in the management of patients at high risk of cardiovascular events. In recent years there has been much controversy about the potential benefits of various approaches to diet, including low-carbohydrate diets, the keto and paleo diets, alternate-day fasting, and so on. However, it's not all that complicated: Based on the evidence from randomised clinical trials, the Cretan Mediterranean diet is the best for cardiovascular risk, although it's possible that a vegetarian diet might be as good or better. The reduction of actual cardiovascular risk with diet is much greater than the reduction of cardiovascular risk factors. The Cretan Mediterranean diet is a mainly vegetarian diet,2Keys A. Mediterranean diet and public health: personal reflections.Am J Clin Nutr. 1995; 611321S-3SGoogle Scholar high in whole grains, fruits, vegetables, legumes, and monounsaturated fat, and low in meat and dairy products. In the Seven Countries Study, the 10-year coronary risk among men in Crete was 1/15th that in Eastern Finland (200 vs 3000 events).3Willett W.C. Stampfer M.J. Rebuilding the food pyramid.Sci Am. 2003; 288: 64-71Crossref PubMed Google Scholar The percentage of calories from fat was 40% in Crete vs 38% in Finland, but in Crete it was olive oil and in Finland animal fat, which is always accompanied by cholesterol. Dietary cholesterol markedly increases the adverse effects of saturated fat.4Fielding C.J. Havel R.J. Todd K.M. et al.Effects of dietary cholesterol and fat saturation on plasma lipoproteins in an ethnically diverse population of healthy young men.J Clin Invest. 1995; 95: 611-618Crossref PubMed Google Scholar Notwithstanding controversy (probably largely industry generated), it is clear that dietary cholesterol intake is harmful.5Spence J.D. Srichaikul K.K. Jenkins D.J.A. Cardiovascular harm from egg yolk and meat: more than just cholesterol and saturated fat.J Am Heart Assoc. 2021; 10e017066Crossref Scopus (21) Google Scholar,6Spence J.D. Jenkins D.J. Davignon J. Dietary cholesterol and egg yolks: not for patients at risk of vascular disease.Can J Cardiol. 2010; 26: e336-e339Abstract Full Text PDF PubMed Google Scholar An excellent randomized controlled trial in Israel (> 90% adherence at 1 year and > 80% at 2 years) showed the same weight loss with a low-carbohydrate (Atkins-style) diet and the Mediterranean diet, and both were better than a low-fat diet. Importantly, the Mediterranean diet was the best for lowering fasting glucose, fasting insulin, and insulin resistance.7Shai I. Schwarzfuchs D. Henkin Y. et al.Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet.N Engl J Med. 2008; 359: 229-241Crossref PubMed Scopus (1546) Google Scholar The Spanish Primary Prevention of Cardiovascular Disease with a Mediterranean Diet (Prevención con Dieta Mediterránea [PREDIMED]) study randomised overweight nondiabetic persons with risk factors to a low-fat vs a Mediterranean diet, and there were 2 arms in the Mediterranean diet: supplementation with olive oil or mixed nuts. The primary end point was a major cardiovascular event (myocardial infarction, stroke, or death from cardiovascular causes). In the intention-to-treat analysis including all the participants and adjusting for baseline characteristics and propensity scores, the hazard ratios, compared with the control diet, were 0.69 (95% confidence interval [CI] 0.53-0.91) for a Mediterranean diet with extra-virgin olive oil and 0.72 (95% CI, 0.54-0.95) for a Mediterranean diet with nuts.8Estruch R. Ros E. Salas-Salvado J. et al.Primary prevention of cardiovascular disease with a Mediterranean diet supplemented with extra-virgin olive oil or nuts.N Engl J Med. 2018; 378: e34Crossref PubMed Scopus (1127) Google Scholar Regarding protein intake, supplements are not necessary, nor is animal flesh. Approximately 600 million people in India do just fine on a vegetarian diet. Legumes are missing some of the essential amino acids, whereas grains are missing different ones, so combining grains and legumes (eg, rice and beans or lentils) gives a complete protein. Furthermore, a vegetarian diet, in addition to being better for the environment, saves the consumer money.9Kahleova H. Sutton M. Maracine C. et al.Vegan diet and food costs among adults with overweight: a secondary analysis of a randomized clinical trial.JAMA Netw Open. 2023; 6e2332106Crossref Scopus (3) Google Scholar (Have you noticed the price of chicken and other kinds of animal flesh in our supermarkets lately?) Besides plant-based meat substitutes, there is great potential for reduction of cardiovascular risk with the use of egg substitutes. Cardiovascular harm from meat and egg yolks is not only due to the high content of cholesterol and saturated fat in meat, and the very high cholesterol content in egg yolks; it is also due to elevation of plasma levels of toxic metabolites of the intestinal microbiome, such as trimethylamine N-oxide (TMAO). Plasma levels of TMAO increase linearly with egg consumption.10Miller C.A. Corbin K.D. da Costa K.A. et al.Effect of egg ingestion on trimethylamine-N-oxide production in humans: a randomized, controlled, dose-response study.Am J Clin Nutr. 2014; 100: 778-786Abstract Full Text Full Text PDF PubMed Scopus (194) Google Scholar The toxic metabolites of the intestinal microbiome have been of increasing interest in recent years. In a study of extreme phenotypes of atherosclerosis, patients with unexplained atherosclerosis (severe atherosclerosis despite absence of traditional risk factors) were compared with a protected phenotype (normal arteries despite high levels of cardiovascular risk factors). "Plasma levels of TMAO, p-cresyl sulfate, p-cresyl glucuronide, and phenylacetylglutamine were significantly lower among patients with the protected phenotype, and higher in those with the unexplained phenotype, despite no significant differences in renal function or dietary intake of nutrient precursors of gut-derived uremic toxins. In linear multiple regression with a broad panel of risk factors, TMAO (P < 0.011) and p-cresyl sulfate (P < 0.011) were significant independent predictors of carotid plaque burden."11Bogiatzi C. Gloor G. Allen-Vercoe E. et al.Metabolic products of the intestinal microbiome and extremes of atherosclerosis.Atherosclerosis. 2018; 273: 91-97Abstract Full Text Full Text PDF PubMed Scopus (104) Google Scholar Carnitine in meat (particularly red meat) and phosphatidylcholine in egg yolk are converted by intestinal bacteria to trimethylamine, which is then oxidised in the liver to TMAO. The intestinal metabolites are renally eliminated; even moderate renal impairment (an estimated glomerular filtration rate < 66 mL/min/1.73 m2) significantly raises plasma levels of the toxic intestinal metabolites,12Pignanelli M. Bogiatzi C. Gloor G. et al.Moderate renal impairment and toxic metabolites produced by the intestinal microbiome: dietary implications.J Ren Nutr. 2019; 29: 55-64Abstract Full Text Full Text PDF PubMed Google Scholar and that level of renal function is normal in patients aged > 75 years.13Spence J.D. Urquhart B.L. Bang H. Effect of renal impairment on atherosclerosis: only partially mediated by homocysteine.Nephrol Dial Transplant. 2016; 31: 937-944Crossref PubMed Google Scholar This has important dietary implications: Patients with impaired renal function, including the elderly, should limit meat intake and avoid egg yolk. Thanks, no doubt, to inexplicably successful propaganda of the egg industry,14Greger M. Eggs and cholesterol: patently false and misleading claims.http://nutritionfacts.org/video/eggs-and-cholesterol-patently-false-and-misleading-claims/2013Date accessed: May 20, 2015Google Scholar, 15Barnard N.D. Long M.B. Ferguson J.M. Flores R. Kahleova H. Industry funding and cholesterol research: a systematic review.Am J Lifestyle Med. 2019; 15: 165-172Crossref Scopus (6) Google Scholar, 16Nestle M. Food industry funding of nutrition research: the relevance of history for current debates.JAMA Intern Med. 2016; 176: 1685-1686Crossref Scopus (48) Google Scholar most of the public, as well as most physicians, have no idea how harmful egg yolk is. Cardiovascular harm from meat and egg yolks was reviewed in 2021.5Spence J.D. Srichaikul K.K. Jenkins D.J.A. Cardiovascular harm from egg yolk and meat: more than just cholesterol and saturated fat.J Am Heart Assoc. 2021; 10e017066Crossref Scopus (21) Google Scholar Table 1 compares egg yolk with a dietary monstrosity, the Hardee's Monster Thickburger. Two large egg yolks contain much more cholesterol, and as much TMAO precursor, as the monster burger, which contains about 4 days' worth of meat on a healthy diet. Over a year, the harmful contents of 2 eggs a week would be equivalent to those of about 200 extra days' worth of meat!Table 1Egg yolk vs Hardee's Monster Thickburger: content of cholesterol and TMAO precursorsCholesterol contentTMAO precursor2 large egg yolks∗Jumbo (75 g) eggs.474 mg320 mg phosphatidylcholineHardee's Monster Thickburger†12 ounces of beef, 3 slices of cheese, 4 slices of bacon.265 mg320 mg carnitineTMAO, trimethylamine N-oxide.∗ Jumbo (75 g) eggs.† 12 ounces of beef, 3 slices of cheese, 4 slices of bacon. Open table in a new tab TMAO, trimethylamine N-oxide. An important clinical trial by Hazen's group showed that switching from red meat to white meat or meatless meals significantly reduced plasma TMAO within a month.17Wang Z. Bergeron N. Levison B.S. et al.Impact of chronic dietary red meat, white meat, or nonmeat protein on trimethylamine N-oxide metabolism and renal excretion in healthy men and women.Eur Heart J. 2019; 40: 583-594Crossref PubMed Scopus (0) Google Scholar Egg substitutes such as No Fat Egg Creations, Just Egg, Better'n Eggs, and others can be used to make tasty omelets, frittatas, egg salad sandwiches, and most other egg dishes. (Recipes are available from the author on request.) Like plant-based meat substitutes, they should be used much more frequently by persons at risk of cardiovascular disease. Persons at risk of cardiovascular disease should limit meat intake and avoid egg yolk, so plant-based meat substitutes and egg substitutes are helpful to patients wishing to reduce their cardiovascular risk. Their effect on reducing actual cardiovascular risk is undoubtedly much greater than their effect on cardiovascular risk factors. I thank Dr David Fitchett for pointing me to the comparison outlined in Table 1. The author has no funding sources to declare.

Journal Article Vessel Wall Volume and Plaque Volume Should Replace Carotid Intima–Media Thickness Get access J David Spence J David Spence Neurology & Clinical Pharmacology, Western University, London, Ontario, CanadaStroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, London, Ontario, Canada Corresponding author: J. David Spence (dspence@robarts.ca). https://orcid.org/0000-0001-7478-1098 Search for other works by this author on: Oxford Academic PubMed Google Scholar American Journal of Hypertension, Volume 37, Issue 4, April 2024, Pages 270–272, https://doi.org/10.1093/ajh/hpae004 Published: 10 January 2024 Article history Received: 03 January 2024 Accepted: 06 January 2024 Published: 10 January 2024 Corrected and typeset: 23 January 2024

Background Pioglitazone significantly reduces the risk of stroke in people with diabetes, and in those with prediabetes, it markedly reduces the risk of stroke/myocardial infarction and new‐onset diabetes. Low‐dose pioglitazone provides most of the clinical benefits of high‐dose pioglitazone, with fewer adverse effects. We report an economic evaluation of the cost‐effectiveness of low‐dose pioglitazone versus placebo from a Canadian public payer perspective in 2023 Canadian dollars. Methods and Results A Markov model was developed at a lifetime horizon with an annual cycle length and 5 health states (event‐free, myocardial infarction, stroke, new‐onset diabetes, and death). Transition probabilities were extracted from the IRIS (Insulin Resistance Intervention in Stroke) trial. Health state costs and utilities were based on public sources. Annual discount rates of 1.5% were applied in the reference‐case analysis. Probabilistic analyses were conducted to deal with parameter uncertainty through 5000 simulations. The costs were estimated as $24 887 (interquartile range [IQR], $14 632–$41507) for low‐dose pioglitazone and $57 301 (IQR, $48 730–$67368) for placebo, resulting in a cost saving of −$30 287 (IQR, −$43 374 to −$14 587) in favor of low‐dose pioglitazone. Quality‐adjusted life years were estimated as 25.99 (IQR, 24.56–26.81) for the low‐dose pioglitazone and 19.44 (IQR, 18.68–20.13) for placebo, resulting in a difference of 6.37 (IQR, 5.07−7.36) in favor of low‐dose pioglitazone. Consistent findings were observed from scenario analyses and 1‐way probability sensitivity analyses. Conclusions Holding across a wide range of values in modeling parameters, low‐dose pioglitazone is found as the dominant strategy versus a placebo.

Chronic kidney disease (CKD) increases cardiovascular risk, however, traditional cardiovascular risk factors cannot entirely explain it. A real-world investigation examined the concept that renal function decline is linked to carotid total plaque area progression, which strongly confirms cardiovascular risk. We analyzed CKD patients in stages 1–3 to find risk factor relationships before the onset of severe CKD. We monitored 328 patients for 16 ± 5 months. Participants were classified at baseline by estimated glomerular filtration rate (eGFR) stage: G1 (≥ 90), G2 (60–89), and G3 (30–59 ml/min/1.73m2). Ultrasound-guided total plaque area tracked atherosclerosis. Age, sex, blood pressure, lipids, and HbA1c were covariates. Total plaque area and variables were measured on day 1 and at the conclusion of observation. We used a multilevel mixed effects model to assess biological and behavioral factors on total plaque area progression in the general population. For validation, this research was conducted on 73 CKD patients with optimal traditional cardiovascular risk factor management during 15 ± 5 months. Multiple analyses showed an inverse relationship between eGFR decline and total plaque area progression [β-exponent = 0.99 (95

The carotid artery is unique; it is the only vessel to bifurcate into a bulb larger than itself. The history of its anatomic description, understanding of its pathophysiology and evolution of its imaging are relevant to current controversies regarding measurement of stenosis, surgical/endovascular therapies and medical management of carotid stenosis in stroke prevention. Treatment decisions on millions of symptomatic and asymptomatic patients are routinely based on information from clinical trials from over 30 years ago. This article briefly summarizes the highlights of past research in key areas and discuss how they led to current challenges of diagnosis and treatment.

In a recent paper in this journal, Oliveira et al. 1 Constancio Oliveira V. Oliveira P. Silva E. et al. Best medical treatment in patients with asymptomatic carotid stenosis: Myth or Reality?. Ann Vasc Surg. 2023; 96: 125-131 Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar present the poor results of medical therapy in their patients with asymptomatic carotid stenosis (ACS). Among their most recent 120 patients with ACS, "Blood pressure control, normal weight, statin with/without ezetimibe association, and antiaggregant therapy were only achieved in 33 patients and only 5 had additionally low-density lipoprotein levels <70 mg/dL, hemoglobin A1c < 7%, and were nonsmokers." They plead that "in the real world" better results are not likely to be achievable.

Background: Little is known about the benefits of lipid-lowering medications in those age >= 75 years. We assessed the effect of lipid-lowering medications on progression to severe atherosclerosis in patients age > 75. Methods: Data was retrospectively obtained from the Stroke Prevention & Atherosclerosis Research Centre, Canada. Atherosclerosis burden was measured as carotid total plaque area (TPA), a powerful predictor of cardiovascular risk. Survival time free of severe atherosclerosis (SFSA) was defined as the period when TPA remained <1.19 cm(2). Kaplan-Meier, multiple Cox proportional hazard and hierarchical mixed-effect models were used to determine the effects of lipid-lowering medications on progression to severe atherosclerosis. Results: In total 1404 cases (mean age 81 +/- 4 years; women 52%) were included. Those taking lipid-lowering medications were more likely to have a history of diabetes and a higher burden of atherosclerosis at baseline. In Kaplan-Meier analysis, the SFSA was significantly longer in those receiving lipid-lowering therapy. In multivariable-adjusted analyses, those not receiving lipid lowering therapy (irrespective of their vascular disease at baseline) were more likely to have TPA > 1.19 cm(2) (hazard ratio (HR) = 1.37, 95% confidence interval (CI): 1.09,0.71). Similar findings were observed in mixed effects models when plaque progression was defined as any change >0.05 cm(2) per year (odds ratio (OR):2.17, 95% CI:1.38,3.57). Conclusion: Lipid-lowering therapy is effective in controlling the burden of atherosclerosis among older adults with and without vascular disease. The measurement of plaque burden can guide selection and follow-up of those who may benefit from treatment.

Vitamin B12 (cobalamin) is needed for DNA synthesis, so its deficiency causes megaloblastic anemia and other hematological problems, as well as neuropathy, myelopathy, and dementia. It also raises plasma total homocysteine (tHcy), a powerful risk factor for cardiovascular disease. Although “biochemical” B12 deficiency is easily recognized by a serum B12 level below the reference range, “metabolic B12 deficiency” (with inadequate metabolically active B12) is often missed, because measurement of holotranscobalamin, tHcy, or methylmalonic acid is required to detect it. Lowering of homocysteine with B vitamins reduces the risk of stroke, but harm from cyanocobalamin among study participants with renal failure obscures the benefit in early studies. Methylcobalamin or hydroxycobalamin should be used instead of cyanocobalamin, particularly in patients with impaired renal function, including the elderly. Because B12 deficiency is common, has serious consequences, and is easily treated, it should receive more attention.