Coronary heart disease mortality is four times higher in Lithuanian compared to Swedish middle-aged men. Using the same equipment (Acuson XP10 with 5 MHz linear transducer) and staff, we compared the amount of atherosclerosis in carotid and femoral arteries in 100 randomly sampled 50-year-old men in each of the cities Vilnius, Lithuania and Linköping, Sweden. Atherosclerotic plaques were more abundant in Vilnius men compared to Linköping men (53 versus 28% in the common carotid artery, 73 versus 37% in the common femoral artery, P < 0.001 for both). Plaques were thicker and more extended in arteries of Vilnius men, and an ultrasound atherosclerosis score was higher in both carotid and femoral arteries (P < 0.001 for all). More Vilnius men had a maximal intima-media thickness of the common femoral artery above 1 mm (P<0.005). Stiffness in the common carotid artery was higher in Vilnius men (P<0.001). In a linear regression model of the pooled material, after adjustment for city was made, smoking, systolic blood pressure, low density lipoprotein cholesterol and beta-carotene (inversely) significantly contributed to a high total ultrasound score (r2 = 0.32). These findings show that the higher coronary mortality noted in Lithuanian men goes together with a higher prevalence of early peripheral atherosclerosis.

In the prerandomization phase of a clinical trial it is essential to be able to exclude, in a non-invasive way, patients who cannot be randomized into the trial. The ability of routine non-invasive physiological examinations to detect arterial occlusion in the lower extremities was investigated in 182 patients with hypercholesterolaemia. Ankle blood pressure measurement, pulse oscillometry, digital pulse plethysmography and treadmill and cycle exercise tests were performed as part of the prerandomization phase of the Probucol Quantitative Regression Swedish Trial (PQRST). The PQRST was designed to compare the antiatherosclerotic effect of two different lipid-lowering regimens. Before randomization the patients also underwent aorto-femoral arteriography, which was used as 'gold standard'. The results were analysed with ROC methodology. Ankle blood pressure measurement (ABP) and inclination time (IT), measured with digital pulse plethysmography, without significant mutual difference, were the variables, best able to detect occlusions. For ABP, the AZ-values were 0.85, 0.82 and 0.94 in detection of right-sided, left-sided and bilateral occlusion, respectively. The corresponding figures for IT were AZ = 0.86, 0.91 and 0.93. If a bilateral occlusion was predicted in a patient with an ABP value of < = or 0.98, a specificity of 0.90 and a sensitivity of 0.87 were obtained, using arteriography as reference method. For IT, with a critical value of 320 ms, sensitivity and specificity were 0.83 and 0.90, respectively.

OBJECTIVES:The aim of this study was to make a prospective evaluation of the carotid arteries after thrombendarterectomy by combined clinical and duplex examination, to define an exact time of development of postoperative restenosis/occlusion and to relate early morphological changes to occurrences of new neurological events. MATERIAL AND METHODS:Sixty-four patients (66 operations), 48 men and 16 women, mean age of 63+/-8 (SD) years, with transient ischaemic attacks or minor stroke were examined clinically 1 day before and after the carotid surgery. All except 3 patients had stenosis > or =50%. Duplex scanning and periorbital Doppler were performed before aortic arch angiography, within 2 weeks after operation and thereafter at 3, 6 and 12 months. RESULTS:10 patients experienced minor stroke and one major stroke after operation, in 5 patients connected with occlusion on the operated side, which differed (P<0.01) from 56 patients with open vessels in whom 6 ipsilateral minor strokes occurred. Four of 6 patients with minor stroke, in whom the operated vessels were open, recovered, whereas the neurological deficits were permanent in all 5 patients with occlusion (P<0.05). Duplex scanning confirmed 10 new occlusions and 2 high grade stenoses >75% postoperatively. Persisting morbidity was 11% and no mortality at 3 months' control. At 12 months' control, 1 patient had stroke related to preoperatively diagnosed occlusion on the non-operated side and 14 flow reducing lesions >75% (11 occlusions and 3 stenoses >75%) were found in 57 (24.6%) of examined vessels. CONCLUSION:occlusion occurs in immediate postoperative period and seems to be a serious complication connected with significantly higher number of persistent neurological events than open vessels.

Background and Aim: The prevalence and significance of lipoprotein abnormalities in intermittent claudication (IC) were investigated. From an epidemiological screening of 15,253 middle-aged men in Linkoping County, Sweden, 339 males were randomly selected within three strata: 115 subjects with IC, 115 healthy controls matched for sex, age and smoking habits, and 109 sex- and age-matched never-smokers. Methods and Results: All subjects underwent a treadmill exercise test to confirm or exclude hemodynamically significant peripheral atherosclerosis. The significance of the individual plasma lipoproteins was tested by multivariate logistic-regression analysis. Major risk factors for IC-smoke history, hypertension, diabetes-were included and adjustment made for factors that affect the lipoprotein concentrations. The most frequent lipoprotein abnormalities found in IC were abnormally high levels of low density lipoprotein (LDL) triglycerides (TG) and abnormally low concentrations of high density lipoprotein (HDL) cholesterol (Chol). Almost half of all claudicants had either one or both lipoprotein abnormalities. The lipid composition of LDL and HDL was changed with a significant increase of TG relative to Chol. The highest increase in risk of IC (by change of 1 standard deviation in lipoprotein concentration) was associated with elevation of LDL-Chol, 2.22 (1.44-3.43) [odds-ratio, 95% confidence interval] and lowering of HDL(2)-Chol 1.94 (1.19-3.19), while the lowest significant risk was associated with elevation of plasma TG 1.61 (1.01-3.09) and IDL-TG 1.55 (1.04-2.31). Multivariate logistic regression analysis in contrast to univariate disclosed that very low density lipoproteins (VLDL) were not significantly associated to IC. Neither were intermediate density lipoproteins (IDL) Chol or HDL's major protein (HDL-apoAI), multi-variately associated to IC. Apolipoprotein E phenotypes and epsilon-allele frequencies did not differ significantly between claudicants and healthy controls. Conclusions: The study shows that several lipoprotein abnormalities are present in claudicants. Multivariate analysis demonstrates that the risk of IC is mainly associated to the LDL and HDL particles, while VLDL, IDL-Chol, HDL-TG and HDL-apoAI lipoproteins are not associated to IC. The results of the study suggests that more attention should be paid to plasma lipoprotein concentrations in IC and that efforts should be made in lowering even slightly elevated LDL levels and increasing HDL-Chol. (C) 1996, Medikal Press.

The aim was to study a relationship between the flow pattern in the ophthalmic artery (OA), the siphon and vessels within the circle of Willis. 27 patients, 22 males and 5 females, mean age 63 +/- 15 years (SD) with unilateral occlusion of the internal carotid artery (ICA) were examined by 3-dimensional Transcranial Doppler scanner. Flow signals from the OA, the siphon and intracranial vessels were registered before and after i.v. injection of 1 g acetazolamide. Pathological flow pattern was found in 18 patients in the OA on the occluded side consisting of 12 retrograde and 6 isoelectric flow directions. After acetazolamide injection retrograde systolic velocities (SV) increased significantly (p < 0.01), but anterograde velocities remained unchanged as did 3 isoelectric flow patterns, 2 turned to retrograde and one to anterograde flow direction. In the siphon lower resting anterograde mean velocities (MV) were found on both sides (p < 0.05) compared to normal subjects. Six patients had the same retrograde flow as in the OA. After acetazolamide MV in the siphon increased (p < 0.01) only on the nonoccluded side. Baseline retrograde ophthalmic SV and MV in the siphon correlated (p < 0.01 and p < 0.05 respectively) with MV in the middle cerebral artery (MCA) according to linear regression analysis (r = 0.78 and 0.59 respectively). All patients, having impaired vasomotor reactivity (VMR) < or = 11% in the anterior cerebral artery (ACA) on the occluded side, had pathological flow pattern in the OA. Patients with greatest difference (delta) between MV in the ACA on the nonoccluded and occluded side had a tendency to anterograde flow (r = 0.56, p < 0.05). Pulsative index (PI) in the ACA on the occluded side was lowest in the category with retrograde flow in the OA (0.67 +/- 0.14) and differed (p < 0.05) from normals and from the category with isoelectric and anterograde flow. Correlation of retrograde flow direction in the OA and baseline MV in the MCA and low PI in the ACA on the occluded side indicates a supplying ophthalmic collateral to the anterior brain circulation. Impaired VMR in the ACA on the occluded side in connection with pathological flow pattern in the OA may reflect an exhaustion of the ACA as a supplying vessel.

Patients with symptoms of acute pulmonary thromboembolism (APE) of short duration were investigated with digital subtraction angiography (DSA) and ventilation/perfusion lung scintigraphy (V/Q scan), and a standardised clinical evaluation was performed. Forty-six angiograms (96%) were diagnostic at the segmental level and were used as reference. In all V/Q scans classified as normal or of high probability for APE, a complete agreement with DSA was found. In scan categories with low or intermediate probability, where the incidence of APE was 32%, there was considerable inter-observer disagreement. Clinical assessment alone was of limited value, but in patients with low clinical suspicion no APE was found. The results indicate that normal and high probability V/Q scans are very reliable for excluding and identifying APE, respectively, but also that fairly large APE cannot be diagnosed with lung scanning. Subdivision of V/Q scans into more than three categories (normal, high probability and inconclusive) seems to be of no practical value. Using a pulsed sequence technique, high frame rate and central injection, DSA is a valuable clinical tool for diagnosing APE down to the segmental level.

Seventeen patients, 14 males and 3 females, mean age 64 years (range 45-77 years) with longstanding unilateral occlusion of the internal carotid artery and minimal neurological deficit, were evaluated in order to find criteria for potential benefit of extracranial-intracranial by-pass surgery. 3-D transcranial Doppler was used for estimation of mean velocities and pulsatility index in the middle cerebral artery, anterior cerebral artery and posterior cerebral artery before and after iv injection of 1 g acetazolamide. The anterior cerebral artery was the supplying vessel to the occluded side in 16 patients and mean velocities were significantly (p < 0.001) faster on the occluded (59.3 +/- 14.5 cm sec-1) and nonoccluded (91.6 +/- 29.6 cm sec-1, p < 0.05)) side than those found in the middle cerebral artery (39.2 +/- 13.7 and 50.9 +/- 8.5 cm sec-1). In two patients a decrease of mean velocity after acetazolamide was noted in middle cerebral artery indicating 'steal' effect. In another 4 patients, poor vasomotor response was seen with less than 11% of mean velocity increase in the middle cerebral artery. Differences between posterior cerebral artery on the occluded and nonoccluded side were insignificant as well as those between middle and posterior on the occluded side. Resting values of pulsatility index differed significantly (p < 0.01) only between anterior and posterior cerebral artery on the nonoccluded side.(ABSTRACT TRUNCATED AT 250 WORDS)

The Probucol Quantitative Regression Swedish Trial tested whether treatment of hypercholesterolemic persons with probucol for 3 years affected femoral atherosclerosis. The primary end point was the change in atheroma volume estimated as change in lumen volume of the femoral artery assessed by quantitative arteriography. Three hundred three patients with visible atherosclerosis were randomized to probucol 0.5 g, twice daily, or to placebo. All patients were given diet and cholestyramine, 8 to 16 g/day. Twenty-nine patients were excluded because of inadequate primary end point measurements. The mean age of the remaining 274 subjects (158 were men) was 55 years. Seventeen percent had intermittent claudication and 24% had angina pectoris. After 3 years, the probucol-treated patients had 17% lower serum cholesterol, 12% lower low-density lipoprotein cholesterol, 24% lower total high-density lipoprotein cholesterol, and 34% lower high-density lipoprotein2 cholesterol levels than control subjects. All lipoprotein differences between the treatment groups remained highly significant during the trial. There was no statistically significant change in lumen volume between the probucol and the control group. Furthermore, there was no difference between the treatment groups with regard to change in arterial edge roughness or amount of aorto-femoral atherosclerosis; neither were there any differences between the treatment groups with regard to change in ST-segment depressions on exercise tests or ankle/arm blood pressure (secondary end points). In the control group, lumen volume increased (p < 0.001) and roughness of the femoral artery decreased (p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Objectives. The extent of atherosclerosis in the superficial femoral artery and the severity of arterial disease in the aorto-iliac and femoro-popliteal arterial districts were related to clinical diagnosis of coronary and peripheral atherosclerosis in hypercholesterolaemic patients.Design. The study constitutes baseline cross-sectional data of a randomized double-blind clinical trial on Probucol, using both computer based and visual estimations of angiographies as endpoints.Subjects. Two hundred and ninety men and women (mean age 54 years) with hypercholesterolaemia.Main outcome measures. Atherosclerosis was estimated with arteriographies. Lumen volume and edge roughness (vessel inner wall irregularity) of a 20 cm segment of the femoral artery were estimated by computer. A visual atherosclerosis score of the abdominal aorta to the popliteal arteries was made on both sides.Results. Patients with peripheral arterial disease had significantly more advanced disease according to all three angiographic variables than those without symptoms of peripheral vascular disease. Both men and women with coronary artery disease had significantly lower femoral lumen volume and higher roughness values than patients without. Men with previous myocardial infarction had significantly higher mean visual scores of atherosclerosis than those without, while lumen volume and roughness did not differ in either sex.Conclusions. Femoral atherosclerosis is an expression of a generalized disease, associated with clinical symptoms of coronary artery disease. Femoral atherosclerosis is often accompanied by atherosclerosis also in the coronary arteries. Keywords: coronary artery disease, femoral atherosclerosis, hypercholesterolaemia, intermittent claudication, myocardial ischaemia, peripheral arterial disease.

The role of lipoprotein(a) (Lp[a]) and apolipoprotein(a) (apo[a]) isoforms in symptomatic peripheral atherosclerosis was studied in 100 randomly selected middle-aged (45-69 years) men with intermittent claudication (IC) and 100 randomly selected healthy control (C) subjects. IC and C subjects were matched pairwise for sex, age, and smoking habits. Plasma Lp(a) concentrations were significantly higher in IC subjects, with a median value of 20.12 mg/dl, compared with 11.11 mg/dl in C subjects (p less than 0.0009). The elevated Lp(a) concentration was to a great extent due to a significant difference in the frequency distribution of apo(a) isoforms between IC and C subjects (p less than 0.029). Low-molecular-weight apo(a) isoforms were more prevalent in IC than C subjects. Also, IC subjects with apo(a) S2 and S3 phenotypes had higher Lp(a) concentrations than control subjects with the same phenotypes: S2:60.70 mg/dl (IC) and 48.69 mg/dl (C), p less than 0.038; and S3: 30.18 mg/dl (IC) and 12.01 mg/dl (C), p less than 0.042, so other still-unknown factors, genetic or nongenetic, may be important. Stepwise logistic regression analysis demonstrated that Lp(a) concentration contributed significantly (p less than 0.0002) to IC, independent of age, smoking, hypertension, diabetes mellitus, plasma total cholesterol, low density lipoprotein cholesterol, high density lipoprotein cholesterol, apo B, and plasma total triglycerides. Apo(a) isoforms grouped according to molecular weight were also independent of the above risk factors associated (p = 0.016) with the occurrence of IC because of their low-molecular-weight but were not independent of Lp(a) concentrations.(ABSTRACT TRUNCATED AT 250 WORDS)

Abstract. The aim of this study was to test the question of hyperhomocyst(e)inaemia as a risk factor for intermittent claudication (IC) independent of other important risk factors for peripheral atherosclerotic disease, such as smoking, hypertension, diabetes mellitus, hypercholesterolaemia, hypertriglyceridaemia, low levels of high‐density‐lipoprotein (HDL) cholesterol and age. The study population was recruited from an epidemiological study in LinkÖping County, Sweden, where all middle‐aged men (n = 15253, 45–69 years of age) were screened for IC. Seventy‐eight subjects with verified IC and 98 healthy sex‐ and age‐matched controls were randomly selected. Plasma levels of homocyst(e)ine (including the sum of free and bound forms of homocysteine and their disulphide oxidation products, homocystine, and homocysteine‐cysteine mixed disulphide) were significantly higher (16.74 ± 5.45 μmol l−1, mean value ± SD, P = 0.0002) in IC subjects than in controls (13.80 ± 3.21 μmol l−1), with 23% of the claudicants above the 95th percentile for controls. Stepwise logistic regression analysis revealed that the difference in plasma homocyst(e)ine was independent of the other above‐mentioned risk factors. Moreover, the elevation of plasma homocyst(e)ine in claudicants was mainly confined to subjects with serum folate levels of < 11.0 nmol l−1. The results suggest that folic acid supplementation should be tried in IC subjects with hyperhomocyst(e)inaemia.

Twenty-one patients with common carotid artery occlusion confirmed by both angiography and duplex scanning were followed prospectively for 50 months (mean) by repeated clinical and duplex examination. Intracranial vessels were investigated in 16 patients using transcranial Doppler sonography and compared with an age-matched group of controls with normal angiographic findings. A patent bifurcation was found in 12 common carotid artery occlusions, in 10 of these flow was maintained from the external to the internal carotid artery, and in 2 the flow direction was opposite. In 10 instances both internal and common carotid arteries were occluded. Maximal and mean velocities in the middle cerebral artery were 64 +/- 22 and 43 +/- 16 cm/s on the occluded side, 85 +/- 44 and 52 +/- 23 cm/s on the non-occluded side, and 84 +/- 12 and 56 +/- 9 cm/s in controls (p < 0.05). Pulse curves in the middle cerebral artery had different shapes with significantly delayed pulse rise time (p < 0.01) and acceleration (p < 0.001, compared to the normal controls). Cross-over collaterals via the anterior cerebral artery were found only in association with stenosis < 75% on the contralateral side, whereas posterior collaterals were commoner if contralateral stenosis > 75% was present. Most patients with common carotid artery occlusion and patent bifurcation experienced attacks of amaurosis fugax and vertigo, but none with patent bifurcation and well-functioning intracranial collaterals had a major stroke. In contrast, 5 of 10 patients with combined internal and common carotid artery occlusion had a major stroke.

In Sweden the editing of unconfirmed, automatically classified reports in a computer-based ECG management system is often done by physicians with relatively little typewriter experience. It is suggested that input devices other than the terminal keyboard might speed up and make more enjoyable the editing procedure for these physicians. A voice recognition system was tested and showed approximately a 10% failure in recognizing a short list of various ECG statements. The main reasons for this were a nonoptimal microphone technique and many phonetically similar phrases. After minimizing these sources of error, a clinical trial of the voice recognizing system connected to a commercial ECG management system was performed. Preliminary results show that ECG editing using a voice recognition system is feasible, but that technical difficulties must be overcome to achieve a clinically useful system

Nine patients with type III hyperlipoproteinaemia and homozygosity for the apolipoprotein E2 isoform were treated with 15 g daily of MaxEPA, a fish oil preparation rich in eicosapentaenoic acid (2.7 g daily) and docosahexaenoic acid (1.8 g daily) for 16 weeks. Plasma lipoprotein and apolipoprotein concentrations were compared with those obtained during treatment with an olive oil preparation. MaxEPA treatment decreased plasma median total cholesterol, triglyceride and apolipoprotein B concentrations by 16, 53 and 19%, respectively. Plasma median very low density lipoprotein (VLDL)-cholesterol, triglyceride and apolipoprotein B concentrations were reduced by 45, 62 and 75% respectively, while the abnormal VLDL-cholesterol/triglyceride ratio remained unchanged. Individual reductions of VLDL concentrations varied considerably, for VLDL-cholesterol between 10 and 75%. In the majority of cases the abnormal late pre beta-bands on agarose electrophoresis, typical for type III hyperlipoproteinaemia normalized to pre beta-mobility on MaxEPA treatment. LDL-cholesterol and apolipoprotein B tended to increase after 8 weeks on MaxEPA but decreased again after 16 weeks. Median plasma high density lipoprotein cholesterol and apolipoprotein A-I did not change during MaxEPA treatment. It is concluded that MaxEPA have decreasing effects on plasma VLDL lipid and apolipoprotein concentrations in apolipoprotein E2 homozygous type III hyperlipoproteinaemia but that this effect is variable and unpredictable.