ABSTRACT: This study assessed the accuracy of the screening vascular physical examination for predicting asymptomatic peripheral arterial disease (PAD) or subclinical atherosclerosis in asymptomatic and apparently healthy subjects.
A standardized physical examination and a carotid and femoral ultrasonography were administered to 2736 men and women aged 20 to 90 years old, with no personal history of cardiovascular disease (CVD) and no complaint of neurologic, coronary, or lower limb symptom. We assessed the accuracy of auscultation for bruits and pulse palpation for identifying the presence of significant carotid stenosis, carotid plaque, femoral plaque, and ankle-brachial index (ABI) <0.9 at ultrasonography.
The presence of a femoral bruit provided information on the presence of both an ABI <0.9 (positive likelihood ratio [+LR], 2.90; 95% confidence interval [CI], 1.63 to 5.16) and a femoral plaque (+LR, 3.23; 95% CI, 2.22 to 4.71), and this information was independent from the cardiovascular risk factors. The absence of both pedal pulses also provided additional information, beyond risk factors, on the presence of an ABI <0.9 (+LR, 3.57; 95% CI, 1.93 to 6.60). The presence of a carotid bruit did not affect the likelihood of carotid stenosis, plaque, or intima-media thickness above the median.
Unlike carotid auscultation, pulse palpation and auscultation for femoral bruits provided valuable information on the presence of asymptomatic PAD and underlying atherosclerosis in apparently healthy subjects.
Journal of Vascular Surgery 01/2008; 46(6):1215-21. · 3.21 Impact Factor
ABSTRACT: Despite major improvement in surgical techniques and intensive care management, stroke remains one of the most devastating complications of coronary artery bypass grafting (CABG). We aimed to determine factors predicting the occurrence of stroke during CABG. A special interest was focused on preoperative therapies.
We prospectively enrolled 810 consecutive candidates for CABG alone in a specific database, including all pre- and perioperative data (history, clinical, therapeutic, cardiac catheterization, surgical and intensive care data). Univariate tests and then multiple logistic regression analysis were used to determine independent predictive factors.
During the first postoperative month, stroke occurred in 11 cases and transient ischemic attack (TIA) in 4 additive cases (cumulative rate: 1.85%). After the multivariate analysis, the following factors remained significant (p<0.05) in the predictive model, with corresponding odds ratios between brackets: redo cardiac surgery (7.45), unstable cardiac status (4.74), past history of cerebrovascular disease (4.14), past history of peripheral arterial disease (3.55), whereas the presence of preoperative statins was protective (0.24, 95% IC: 0.07-0.78). The addition of perioperative data (aortic calcification, postoperative arrhythmia, on/off-pump surgery) did not change the final predictive model.
To our knowledge, this is the first real-world observational report highlighting the interest of statins for the prevention of stroke in the very special situation of CABG. Even though according to randomized trials coronary patients have a benefit from these drugs, a special level of interest should be directed towards those presenting the above-mentioned risk factors.
European Journal of Cardio-Thoracic Surgery 09/2006; 30(2):300-4. · 2.55 Impact Factor
ABSTRACT: This study was designed to determine the prevalence of peripheral arterial disease (PAD) in candidates for coronary artery bypass grafting (CABG) and to assess the predictive value of different types of subclinical PAD (peripheral occlusive disease and medial arterial calcification [incompressible ankle arteries]).
Observational studies report poor prognosis after CABG in the presence of clinical PAD, but data on subclinical PAD are scarce.
We prospectively enrolled CABG candidates and measured ankle-brachial index (ABI) preoperatively. Patients were divided into four groups: clinical PAD, subclinical PAD (ABI <0.85), incompressible arteries (ABI >1.5), and no PAD. The primary end point was a composite combining death, acute coronary syndrome, stroke or transient ischemic attack (TIA), and coronary or peripheral revascularization. Secondary end points were overall and cardiovascular death, acute coronary syndrome, and stroke or TIA. Statistical analyses were performed using the Cox regression model.
We consecutively enrolled 1,022 patients (mean age 66.9 +/- 9.2 years). In addition to the 14% with clinical PAD, we detected subclinical PAD in 13% and medial artery calcification in 12%. During an actuarial follow-up of 4.4 years, 81.2% of patients remained event-free. Adverse factors were (p < 0.05) supraventricular arrhythmia (odds ratio [OR] 2.5), ejection fraction <0.40 (OR 2.3), combined valvular surgery (OR 2.5), clinical PAD (OR 3.6), subclinical PAD (OR 3.3), and medial artery calcification (OR 1.9). The latter three factors were also independently predictive for overall and cardiovascular death.
Beyond clinical PAD, the measurement of ABI before coronary surgery provides substantial information on long-term postoperative prognosis. To our knowledge, this is the first study highlighting the prognostic role of incompressible ankle arteries in secondary prevention.
Journal of the American College of Cardiology 10/2005; 46(5):815-20. · 14.16 Impact Factor
ABSTRACT: We aimed to assess the utility of common carotid intima-media thickness (CCA-IMT) to predict secondary cardiovascular events after coronary artery bypass grafting (CABG). In primary prevention, carotid-IMT is known as a valuable cardiovascular risk marker, but its interest in secondary prevention has been less studied. We hypothesized that CCA-IMT could be used for peri-operative and long-term risk stratification in candidates for CABG.
A total of 609 patients (66.8+/-9.2 years) were prospectively enrolled for preoperative CCA-IMT measurement and follow-up. The primary end-point combined cardiovascular death, non-fatal acute coronary syndromes, stroke, secondary coronary revascularization and peripheral arterial surgery during follow-up. The secondary end-point was the 1-month post-operative death. Univariate and multivariate analysis were performed by usual methods.
A subgroup of 150 patients (24.6%) was individualized with a CCA-IMT above 90th percentile (>0.90 mm) or presenting plaques in their CCA. At 1 month, there was no significant difference in the prevalence of elevated CCA-IMT between deceased patients and survivors (16.7 vs. 24.9%, P=ns). During a mean follow-up of 41.8+/-16 months, 121 patients (19.8%) met the primary end-point. High CCA-IMT was predictive (OR=1.67, 95% CI 1.14-2.46, P=0.009) in the univariate analysis. In the multivariate analysis, age (OR=1.03, 95% CI 1.00-1.05, P=0.029) concomitant valvular surgery (OR=2.17, P=0.003) arrhythmia (OR=2.20, P=0.021), and peripheral arterial disease (OR=2.41, P<0.001) were significant independent prognostic factors whereas CCA-IMT failed to remain independently significant.
Pre-operative CCA-IMT can provide prognostic information for candidates to CABG. However, clinical data present stronger prognostic values.
European Journal of Cardio-Thoracic Surgery 10/2005; 28(3):415-9. · 2.55 Impact Factor
ABSTRACT: The occurrence of stroke during coronary artery bypass grafting (CABG) is multifactorial but the coexistence of carotid disease is considered as one of the avoidable sources. Beyond the perioperative management, the detection of carotid disease in a coronary patient could be of prognostic significance. A systematic screening for all candidates for CABG could, however, be a non-efficient strategy. We aimed to optimize the Duplex screening of candidates for CABG by studying risk factors of significant concomitant carotid lesions.
We prospectively studied 1043 consecutive candidates for CABG by Duplex scanning. A first subgroup of 825 patients permitted to establish the predictive model of >50% stenosis. A multivariate analysis provided independent predictive factors. The ability of the model to predict >50% and >70% stenosis of neck arteries has been prospectively assessed on the 218 consecutive patients.
In the first group, 108 (13.1%) and 58 (7%) had respectively at least a >50% and >70% stenosis. The independent risk factors were: past history of stroke or transient ischemic attack, neck bruit, clinically apparent peripheral arterial disease (PAD) or subclinical PAD (ABI <0.85 or >1.5), and age >70 years (P<0.05). Among the subsequent 218 patients, the presence of at least one of these factors was able to detect 24 out of 26 patients (92.3%) with a >50% stenosis, and 100% of those with >70% stenosis, and could rule out 41% from a systematic Duplex screening.
The excellent sensitivity of this risk assessment approach, makes an efficient screening of cerebrovascular disease possible in CABG patients.
Interactive cardiovascular and thoracic surgery 04/2005; 4(2):90-5.