In coronary artery disease (CAD), a concomitant peripheral arterial disease (PAD) entails a more severe coronary atherosclerosis. We hypothesized that the severity of carotid artery disease is greater in CAD+PAD than in CAD alone. In 90 CAD and 79 CAD+PAD patients, carotid plaque echolucency was measured by gray-scale median (GSM), and the degree of carotid stenosis by routine Doppler criteria. Plaques were absent in 20 (22.2%) CAD and 8 (10.1%) CAD+PAD patients (p = 0.035), while the prevalence of carotid stenosis ≥ 50% was 16.7% and 25.3%, respectively (p = 0.166). The GSM score was 45.1 [21.7–67.7] in CAD+PAD vs 60.1 [44.9–83.1] in CAD alone (p < 0.001). Consistently, hypoechoic plaques (GSM < 25th percentile) were more common in CAD+PAD than in CAD patients (38.0% vs 11.4%, p < 0.001). On multivariate analysis, CAD+PAD was the only variable significantly associated with hypoechoic plaques (OR = 4.16, 95% CI 1.68–10.28). However, when the leukocyte count was added to the model, it showed the strongest association with hypoechoic plaques (OR = 6.70, 95% CI 2.13–21.10). In conclusion, compared with CAD alone patients, those with concomitant PAD showed a greater prevalence of plaques with characteristics of instability. Thus, our data suggest that in CAD+PAD, evaluation of carotid plaque echogenicity could contribute to improve clinical decision-making and differentiate treatments for individual patients.
1 Ness J Aronow WS . Prevalence of coexistence of coronary artery disease, ischemic stroke, and peripheral arterial disease in older persons, mean age 80 years, in an academic hospital-based geriatrics practice. J Am Geriatr Soc1999; 47: 1255–1256.
2.
2 Schmieder FA Comerota AJ . Intermittent claudication: magnitude of the problem, patient evaluation, and therapeutic strategies. Am J Cardiol2001; 87: 3–13.
3.
3 Brevetti G Piscione F Silvestro A . Increased inflammatory status and higher prevalence of three-vessel coronary artery disease in patients with concomitant coronary and peripheral atherosclerosis. Thromb Haemost2003; 89: 1058–1063.
4.
4 Erren M Reinecke H Junker R . Systemic inflammatory parameters in patients with atherosclerosis of the coronary and peripheral arteries. Arterioscler Thromb Vasc Biol1999; 19: 2355–2363.
5.
5 Murray CJ Lopez AD . Mortality by cause for eight regions of the world: Global Burden of Disease Study. Lancet1997; 349: 1269–1276.
6.
6 Barnett HJ Gunton RW Eliasziw M . Causes and severity of ischemic stroke in patients with internal carotid artery stenosis. JAMA2000; 283: 1429–1436.
7.
7 Vickrey BG Rector TS Wickstrom SL . Occurrence of secondary ischemic events among persons with atherosclerotic vascular disease. Stroke2002; 33: 901–906.
8.
8 Brevetti G Sirico G Lanero S De Maio JI Laurenzano E Giugliano G . The prevalence of hypoechoic carotid plaques is greater in peripheral than in coronary artery disease and is related to the neutrophil count. J Vasc Surg2008; 47: 523–529.
9.
9 Tegos TJ Sohail M Sabetai MM . Echomorphologic and histopathologic characteristics of unstable carotid plaques. Am J Neuroradiol2000; 21: 1937–1944.
10.
10 Mathiesen EB Bonaa KH Joakimsen O . Echolucent plaques are associated with high risk of ischemic cerebrovascular events in carotid stenosis: the Tromso study. Circulation2001; 103: 2171–2175.
11.
11 Grønholdt ML Nordestgaard BG Schroeder TV Vorstrup S Sillesen H . Ultrasonic echolucent carotid plaques predict future strokes. Circulation2001; 104: 68–73.
12.
12 Greenland P Abrams J Aurigemma GP . Prevention Conference V: beyond secondary prevention: identifying the high-risk patient for primary prevention: noninvasive tests of atherosclerotic burden: Writing Group III. Circulation2000; 101: 16–22.
13.
13 Yamagami H Kitagawa K Nagai Y . Higher levels of interleukin-6 are associated with lower echogenicity of carotid artery plaques. Stroke2004; 35: 677–681.
14.
14 Zanchetti A Bond MG Hennig M . European Lacidipine Study on Atherosclerosis investigators. Calcium antagonist lacidipine slows down progression of asymptomatic carotid atherosclerosis: principal results of the European Lacidipine Study on Atherosclerosis (ELSA), a randomized, double-blind, long-term trial. Circulation2002; 106: 2422–2427.
15.
15 Fosse E Johnsen SH Stensland-Bugge E . Repeated visual and computer-assisted carotid plaque characterization in a longitudinal population-based ultrasound study: the Tromso study. Ultrasound Med Biol2006; 32: 3–11.
16.
16 Elatrozy T Nicolaides A Tegos T Zarka AZ Griffin M Sabetai M . The effect of B-mode ultrasonic image standardisation on the echodensity of symptomatic and asymptomatic carotid bifurcation plaques. Int Angiol1998; 17: 179–186.
17.
17 Nicolaides AN Shifrin EG Bradbury A . Angiographic and duplex grading of internal carotid stenosis: can we overcome the confusion. J Endovasc Surg1996; 3: 158–165.
18.
18 Creager MA Jones DW Easton JD . American Heart Association.Atherosclerotic Vascular Disease Conference: Writing. Group V: medical decision making and therapy. Circulation2004; 109: 2634–2642.
19.
19 Lal BK Hobson RW Pappas PJ . Pixel distribution analysis of B-mode ultrasound scan images predicts histologic features of atherosclerotic carotid plaques. J Vasc Surg2002; 35: 1210–1217.
20.
20 Spagnoli LG Bonanno E Mauriello A . Multicentric inflammation in epicardial coronary arteries of patients dying of acute myocardial infarction. J Am Coll Cardiol2002; 40: 1579–1588.
21.
21 Notø AT Bøgeberg Mathiesen E Amiral J Vissac AM Hansen JB . Endothelial dysfunction and systemic inflammation in persons with echolucent carotid plaques. Thromb Haemost2006; 96: 53–59.
22.
22 Rossi A Franceschini L Fusaro M . Carotid atherosclerotic plaque instability in patients with acute myocardial infarction. Int J Cardiol2006; 111: 263–266.
23.
23 Lombardo A Biasucci LM Lanza GA . Inflammation as a possible link between coronary and carotid plaque instability. Circulation2004; 109: 3158–3163.
24.
24 Nieto FJ Szklo M Folsom AR Rock R Mercuri M . Leukocyte count correlates in middle-aged adults: the Atherosclerosis Risk in Communities (ARIC) Study. Am J Epidemiol1992; 136: 525–537.
25.
25 Hansen LK Grimm RH Neaton JD . The relationship of white blood cell count to other cardiovascular risk factors. Int J Epidemiol1990; 19: 881–888.
26.
26 Ludwig PW Hunninghake DB Hoidal JR . Increased leucocyte oxidative metabolism in hyperlipoproteinaemia. Lancet1982; 2: 348–350.
27.
27 Mehta J Dinerman J Mehta P . Neutrophil function in ischemic heart disease. Circulation1989; 79: 549–556.
28.
28 Sacks T Moldow CF Craddock PR Bowers TK Jacob HS . Oxygen radicals mediate endothelial cell damage by complement-stimulated granulocytes. An in vitro model of immune vascular damage. J Clin Invest1978; 61: 1161–1167.
30 Vink A Schoneveld AH Richard W . Plaque burden, arterial remodeling and plaque vulnerability: determined by systemic factors. J Am Coll Cardiol2001; 38: 718–723.
31.
31 Gibbons RJ Abrams J Chatterjee K . American College of Cardiology. American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina; American College of Cardiology; American Heart Association Task Force on Practice Guidelines. Committee on the Management of Patients With Chronic Stable Angina. ACC/AHA 2002 guideline update for the management of patients with chronic stable angina–summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on the Management of Patients With Chronic Stable Angina). Circulation2003; 107: 149–158.
32.
32 Kurvers HA van der Graaf Y Blankensteijn JD Visseren FL Eikelboom BC . ; SMART Study Group.Screening for asymptomatic internal carotid artery stenosis and aneurysm of the abdominal aorta: comparing the yield between patients with manifest atherosclerosis and patients with risk factors for atherosclerosis only. J Vasc Surg2003; 37: 1226–1233.
33.
33 Crisby M Nordin-Fredriksson G Shah PK Yano J Zhu J Nilsson J . Pravastatin treatment increases collagen content and decreases lipid content, inflammation, metalloproteinases, and cell death in human carotid plaques: implications for plaque stabilization. Circulation2001; 103: 926–933.
34.
34 Watanabe K Sugiyama S Kugiyama K . Stabilization of carotid atheroma assessed by quantitative ultrasound analysis in nonhypercholesterolemic patients with coronary artery disease. J Am Coll Cardiol2005; 46: 2022–2030.
35.
35 Amarenco P Labreuche J Lavallée P Touboul PJ . Statins in stroke prevention and carotid atherosclerosis: systematic review and up-to-date meta-analysis. Stroke2004; 35: 2902–2909.
36.
36 El-Barghouty N Geroulakos G Nicolaides A Androulakis A Bahal V . Computer-assisted carotid plaque characterisation. Eur J Vasc Endovasc Surg1995; 9: 389–393.
37.
37 Matsagas MI Vasdekis SN Gugulakis AG Lazaris A Foteinou M Sechas MN . Computer-assisted ultrasonographic analysis of carotid plaques in relation to cerebrovascular symptoms, cerebral infarction, and histology. Ann Vasc Surg2000; 14: 130–137.
38.
38 Paraskevas KI Hamilton G Mikhailidis DP . Statins: an essential component in the management of carotid artery disease. J Vasc Surg2007; 46: 373–386.
