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Observational Study
. 2015:190:90-8.
doi: 10.1016/j.ijcard.2015.04.124. Epub 2015 Apr 16.

Utility of both carotid intima-media thickness and endothelial function for cardiovascular risk stratification in patients with angina-like symptoms

Yasushi Matsuzawa  1 , Sara Svedlund  2 , Tatsuo Aoki  1 , Raviteja R Guddeti  1 , Taek-Geun Kwon  1 , Rebecca Cilluffo  1 , R Jay Widmer  1 , Rebecca E Nelson  1 , Ryan J Lennon  3 , Lilach O Lerman  4 , Sinsia Gao  2 , Peter Ganz  5 , Li-Ming Gan  6 , Amir Lerman  7
Affiliations
Observational Study

Utility of both carotid intima-media thickness and endothelial function for cardiovascular risk stratification in patients with angina-like symptoms

Yasushi Matsuzawa et al. Int J Cardiol. 2015.

Abstract

Background: Myocardial perfusion scintigraphy (MPS) is used widely to assess cardiovascular risk in patients with chest pain. The utility of carotid intima-media thickness (CIMT) and endothelial function as assessed by reactive hyperemia-peripheral arterial tonometry index (RHI) in risk stratifying patients with angina-like symptoms needs to be defined. We investigated whether the addition of CIMT and RHI to Framingham Cardiovascular Risk Score (FCVRS) and MPS improves comprehensive cardiovascular risk prediction in patients presenting with angina-like symptoms.

Methods: We enrolled 343 consecutive patients with angina-like symptoms suspected of having stable angina. MPS, CIMT, and RHI were performed and patients were followed for cardiovascular events for a median of 5.3 years (range 4.4-6.2). Patients were stratified by FCVRS and MPS.

Results: During the follow-up, 57 patients (16.6%) had cardiovascular events. Among patients without perfusion defect, low RHI was significantly associated with cardiovascular events in the intermediate and high FCVRS groups (hazard ratio (HR) [95% confidence interval (CI)] of RHI ≤ 2.11 was 6.99 [1.34-128] in the intermediate FCVRS group and 6.08 [1.08-114] in the high FCVRS group). Furthermore, although MPS did not predict, only RHI predicted hard cardiovascular events (cardiovascular death, myocardial infarction, and stroke) independent from FCVRS, and adding RHI to FCVRS improved net reclassification index (20.9%, 95% CI 0.8-41.1, p = 0.04). Especially, RHI was significantly associated with hard cardiovascular events in the high FCVRS group (HR [95% CI] of RHI ≤ 1.93 was 5.66 [1.54-36.4], p = 0.007).

Conclusions: Peripheral endothelial function may improve discrimination in identifying at-risk patients for future cardiovascular events when added to FCVRS-MPS-based risk stratification.

Keywords: Cardiovascular disease; Carotid intima–media thickness; Endothelial function; Framingham Cardiovascular Risk Score; Myocardial perfusion; Noninvasive.

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Figures

Figure 1
Figure 1. Study design
CIMT: carotid intima media thickness, and RHI: reactive hyperemia-peripheral arterial tonometry index.
Figure 2
Figure 2. Kaplan-Meier analysis for the probability of cardiovascular events according to RHI in each group by Framingham risk category and myocardial perfusion defect
(A) Kaplan-Meier curves according to RHI in intermediate FCVRS with PD (−) group. (B) Kaplan-Meier curves according to RHI in high FCVRS with PD (−) group. FCVRS: Framingham Cardiovascular Risk Score, PD: perfusion defect, and RHI: reactive hyperemia-peripheral arterial tonometry index.
Figure 3
Figure 3. Kaplan-Meier analysis for the probability of hard cardiovascular events according to established risk prediction models and RHI
FCVRS: Framingham Cardiovascular Risk Score, PC_ASCVDRS; atherosclerotic cardiovascular disease risk score by the Pooled Cohort Equation, and RHI: reactive hyperemia-peripheral arterial tonometry index.
Figure 4
Figure 4. Proposed sequence of tests for cardiovascular risk assessment in patients with angina-like symptom
FCVRS: Framingham Cardiovascular Risk Score, MPS: myocardial perfusion scintigraphy, and RHI: reactive hyperemia-peripheral arterial tonometry index.
See this image and copyright information in PMC

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