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Prevalence of Atherosclerotic Stenosis of the Carotid and Cerebral Arteries in Patients with Stable Or Unstable Coronary Artery Disease

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Prevalence of Atherosclerotic Stenosis of the Carotid and Cerebral Arteries in Patients with Stable Or Unstable Coronary Artery Disease ORIGINAL ARTICLE Prevalence of atherosclerotic stenosis of the carotid and cerebral arteries in patients with stable or unstable coronary artery disease Przemysław Puz1,2, Anetta Lasek ‑Bal1,2, Aldona Warsz ‑Wianecka1,2, Maciej Kaźmierski3 1 Department of Neurology, Medical University of Silesia, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland 2 School of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland 3 3rd Department of Cardiology, Medical University of Silesia, Professor Leszek Giec Upper Silesian Medical Centre, Katowice, Poland KEY WORDS ABSTRACT atherosclerosis, INTRODUCTION Carotid artery atherosclerosis is a recognized predictor of cardiovascular events. carotid, cerebral, The coexistence of coronary atherosclerosis and cerebrovascular disease is associated with unfavorable coronary artery clinical outcomes. disease OBJECTIVES The aim of this study was to determine the prevalence of hemodynamically and clinically significant carotid and / or cerebral artery stenosis in patients with stable and unstable coronary artery disease (CAD). PATIENTS AND METHODS Cardiac and neurological examinations together with coronary angiography and carotid ultrasound were performed in 241 patients, and transcranial Doppler imaging of cerebral arteries in 114. The prevalence of hemodynamically significant internal carotid artery (ICA) stenosis, intracranial artery stenosis, and clinical signs of central nervous system ischemia were compared between patients with stable and unstable CAD. RESULTS There was no significant difference in the prevalence of ICA stenosis (15.3% vs 19%) and intracranial artery stenosis (18% vs 16%) between patients with stable and unstable CAD. Risk fac- tors for cerebral artery stenosis included ICA stenosis (odds ratio [OR], 13.21; 95% CI, 5.93–41.89) and advanced CAD (OR, 2.38; 95% CI, 1.13–4.09), and for ischemic events within the central nervous system, ICA stenosis (OR, 1.74; 95% CI, 1.01–3.16) and intracranial artery stenosis (OR, 3.01; 95% CI, 1.66–5.57). CONCLUSIONS No differences in the prevalence of atherosclerosis of the carotid and cerebral arteries were found between patients with stable and unstable CAD in this study. Advanced CAD is one of the risk factors for hemodynamically significant cerebral artery stenosis. INTRODUCTION Atherosclerosis is a systemic ar‑ studies, large international registries, and post‑ Correspondence to: 4-8 Przemysław Puz, MD, PhD, terial disease; however, the mechanisms under‑ mortem studies. Department of Neurology, lying the formation, development, and destabili‑ Polyvascular atherosclerosis in patients Medical University of Silesia, zation of concomitant lesions observed in arter‑ with single or multifocal clinical manifesta‑ Professor Leszek Giec Upper Silesian Medical Centre, ies of various calibers and varying reactivity pa‑ tions is associated with unfavorable clinical ul. Ziołowa 45, 40-635 Katowice, rameters remain unclear.1-3 outcomes.4-6,9 Poland, phone: +48 32 359 83 06, The involvement of arteries from different Atherosclerotic lesions in the carotid arter‑ email: [email protected] Received: March 19, 2020. vascular areas indicates a significant burden of ies and the thickness of the intima ‑media com‑ Revision accepted: April 16, 2020. the atherosclerotic process, even if patients have plex are recognized predictors of cardiovascular Published online: May 1, 2020. never experienced any clinical symptoms of ath‑ events in patients with symptomatic or asymp‑ Pol Arch Intern Med. 2020; erosclerosis. The coexistence of atherosclerosis in tomatic ischemic heart disease and of complica‑ 130 (5): 412-419 doi:10.20452/pamw.15330 the coronary arteries, carotid arteries, and oth‑ tions during coronary angiography and coronary Copyright by the Author(s), 2020 er vascular territories has been proven in clinical artery bypass graft (CABG) surgery.3,10-13 412 POLISH ARCHIVES OF INTERNAL MEDICINE 2020; 130 (5) WHAt’s nEW? selected randomly due to the availability of an ul‑ trasound device in the Department of Neurology In this study, the coexistence of carotid or intracranial atherosclerosis with during their hospitalization. Primarily, there were coronary artery disease (CAD) was confirmed in more than 16% of patients. 126 patients selected; however, in the end, 114 pa‑ We did not find any significant difference in the prevalence of internal carotid tients were included into our study due to lack of artery and intracranial arterial stenoses between patients with stable CAD an appropriate acoustic window for the TCD ex‑ and those with the unstable disease. Advanced CAD was a risk factor for amination in 12 patients. the hemodynamically significant stenosis of cerebral arteries. Our findings Existing diseases and conditions commonly support a multivessel approach in patients with a single clinical manifestation considered actual and possible risk factors for stroke were determined based on recent medical of atherosclerosis. Knowledge of the site and severity of atherosclerotic lesions records and results of in ‑hospital tests. is of importance to clinicians who qualify patients for interventional treatment Heart failure, CAD, and myocardial infarction of various vascular areas, as patients with multivessel disease gain fewer were defined based on the previously described benefits. Our findings confirmed that extensive diagnostic procedures per- and established recommendations,21,22 whereas formed in patients with advanced CAD, including the examination of intracranial stroke and transient ischemic attack (TIA) were arteries, can help identify those at risk of central nervous system ischemia. defined according to the current American Stroke Association guidelines.23 All patients were eval‑ uated for risk factors for atherosclerosis, which included arterial hypertension, diabetes, obesi‑ Significant coronary artery disease (CAD) co‑ ty, lipid disorders, and nicotinism. existing with carotid stenosis in patients under‑ Unstable CAD was defined as a coronary vas‑ going interventional treatment of carotid artery cular disease causing acute coronary syndrome. stenosis (stenting or endarterectomy) is associ‑ The status of cardiac ischemia which did not lead ated with the risk of periprocedural cardiac com‑ to acute coronary syndrome was classified as sta‑ plications (myocardial infarct).14,15 ble CAD. An increase and / or decrease in cardi‑ Available data emphasizing the clinical rele‑ ac troponin levels, with at least 1 value above vance of coronary atherosclerosis, particularly the 99th percentile of the upper reference lim‑ of the asymptomatic disease, in the evaluation it, was a parameter used to confirm acute coro‑ of the prevalence of cerebral artery atherosclero‑ nary syndrome. sis and the risk for cerebral events are still scarce, The abovementioned conditions were confirmed which prompted us to investigate this area.16-18 by a neurologist, a cardiologist, or an internist. Vascular ultrasound examination with Doppler The exclusion criteria were as follows: nonath‑ color flow imaging is a modality routinely used to erosclerotic stenosis, potential causes of cere‑ assess morphological changes in the carotid ar‑ bral embolism other than atherosclerotic lesions teries and blood flow disturbances caused by ath‑ in the carotid artery (atrial fibrillation, mitral erosclerosis. Ultrasound examination of the in‑ and / or aortic valve stenosis, mechanical heart tracranial arteries can also be used as an addi‑ valve, persistent foramen ovale or another de‑ tional method to evaluate the risk of cardiovas‑ fect, interatrial septal aneurysm, cardiac myxo‑ cular events in patients with atherosclerosis.19,20 ma, or a thrombus in the left ventricle or atrium), The aim of this study was to determine carotid artery dissection or intraluminal throm‑ the prevalence of hemodynamically significant bosis visible on ultrasound and brain damage oth‑ stenosis of the carotid and / or cerebral arteries er than of vascular origin (detected on comput‑ in patients with stable and unstable CAD. ed tomography or magnetic resonance imaging An additional aim was to determine the preva‑ of the head), central nervous system (CNS) isch‑ lence of symptomatic carotid and cerebral artery emic symptoms in the area of the posterior cere‑ stenosis coexisting with CAD. bral circulation. All patients underwent coronary angiography PATIENTS AND METHODS The study involved according to the standard protocol.24 Based on 241 patients with CAD who were hospitalized in coronary angiography results, patients with ad‑ the 3rd Department of Cardiology at Medical Uni‑ vanced coronary lesions were identified. These versity of Silesia, Katowice, Poland. were patients who had atherosclerotic lesions In all patients, a medical history was taken and causing stenosis greater than 50% in more than a physical examination was performed, including 2 sites and those with mild atherosclerotic le‑ cardiac and neurological examinations, electro‑ sions causing stenosis greater than 50%, found cardiography, echocardiography, coronary angi‑ in 1 site or 2 sites. ography, carotid artery ultrasound, and laborato‑ Duplex Doppler ultrasound of the carotid and ry tests routinely carried out in patients admit‑ vertebral arteries was performed with the 7.5‑ ted to the Department of Cardiology in order to ‑MHz linear array probe (Elegra, Siemens, Erlan‑ diagnose CAD. In 114 patients, an additional ul‑ gen, Germany) and the degree of stenosis and ath‑ trasound examination of the intracranial arter‑ erosclerotic
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