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Objective: Despite the publication of various national/international guidelines, several questions concerning the management of patients with asymptomatic (AsxCS) and symptomatic (SxCS) carotid stenosis remain unanswered. The aim of this international, multi-specialty, expert-based Delphi Consensus document was to address these issues to help clinicians make decisions when guidelines are unclear., Methods: Fourteen controversial topics were identified. A three-round Delphi Consensus process was performed including 61 experts. The aim of Round 1 was to investigate the differing views and opinions regarding these unresolved topics. In Round 2, clarifications were asked from each participant. In Round 3, the questionnaire was resent to all participants for their final vote. Consensus was reached when ≥75% of experts agreed on a specific response., Results: Most experts agreed that: (1) the current periprocedural/in-hospital stroke/death thresholds for performing a carotid intervention should be lowered from 6% to 4% in patients with SxCS and from 3% to 2% in patients with AsxCS; (2) the time threshold for a patient being considered "recently symptomatic" should be reduced from the current definition of "6 months" to 3 months or less; (3) 80% to 99% AsxCS carries a higher risk of stroke compared with 60% to 79% AsxCS; (4) factors beyond the grade of stenosis and symptoms should be added to the indications for revascularization in AsxCS patients (eg, plaque features of vulnerability and silent infarctions on brain computed tomography scans); and (5) shunting should be used selectively, rather than always or never. Consensus could not be reached on the remaining topics due to conflicting, inadequate, or controversial evidence., Conclusions: The present international, multi-specialty expert-based Delphi Consensus document attempted to provide responses to several unanswered/unresolved issues. However, consensus could not be achieved on some topics, highlighting areas requiring future research., Competing Interests: Disclosures D.P.M. has given talks, acted as a consultant or attended conferences sponsored by Amgen and Novo Nordisk. J.F.M. receives funding from the United States National Institute of Neurologic Disorders and Stroke for work related to running the CREST-2 clinical trial (U01NS080168) and the CREST-2 Long-term Observational Extension study (U01NS119169). E.A.S. has received research grants from the United States Food and Drug Administration, BD, Boston Scientific, Cook, CSI, Laminate Medical, Medtronic and Philips; has received consulting/speaking fees from Abbott, Bayer, BD, Boston Scientific, Cook, Cordis, CSI, Inari, Infraredx, Medtronic, Philips, Shockwave and VentureMed. H.-H.E. is a local Principal Investigator for the ROADSTER 2 trial and a scientific committee member of SPACE-1, SPACE-2 and ACST-2. T.R. is funded by grants from the National Institutes of Health (R01 MD012467, R01 NS029993, R01NS040807, 1U24NS107267), and the National Center for Advancing Translational Sciences (UL1 TR002736, KL2 TR002737). J.S.M. has received institutional research grants from Abbott, Cook, Endologix, Gore and Medtronic., (Copyright © 2023 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

Background: Carotid artery atherosclerosis is highly prevalent in the general population and is a well-established risk factor for acute ischemic stroke. Although the morphological characteristics of vulnerable plaques are well recognized, there is a lack of consensus in reporting and interpreting carotid plaque features., Objectives: The aim of this paper is to establish a consistent and comprehensive approach for imaging and reporting carotid plaque by introducing the Plaque-RADS (Reporting and Data System) score., Methods: A panel of experts recognized the necessity to develop a classification system for carotid plaque and its defining characteristics. Using a multimodality analysis approach, the Plaque-RADS categories were established through consensus, drawing on existing published reports., Results: The authors present a universal classification that is applicable to both researchers and clinicians. The Plaque-RADS score offers a morphological assessment in addition to the prevailing quantitative parameter of "stenosis." The Plaque-RADS score spans from grade 1 (indicating complete absence of plaque) to grade 4 (representing complicated plaque). Accompanying visual examples are included to facilitate a clear understanding of the Plaque-RADS categories., Conclusions: Plaque-RADS is a standardized and reliable system of reporting carotid plaque composition and morphology via different imaging modalities, such as ultrasound, computed tomography, and magnetic resonance imaging. This scoring system has the potential to help in the precise identification of patients who may benefit from exclusive medical intervention and those who require alternative treatments, thereby enhancing patient care. A standardized lexicon and structured reporting promise to enhance communication between radiologists, referring clinicians, and scientists., Competing Interests: Funding Support and Author Disclosures The views expressed in this paper are those of the authors and do not reflect the official policy of the Department of Army/Navy/Air Force, Department of Defense, or U.S. Government. The identification of specific products or scientific instrumentation does not constitute endorsement or implied endorsement on the part of the author, Department of Defense, or any component agency. The authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Copyright © 2024 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.)

Background: Current guidelines do not recommend screening for asymptomatic carotid artery stenosis (AsxCS). The rationale behind this recommendation is that detection of AsxCS may lead to an unnecessary carotid intervention. In contrast, screening for abdominal aortic aneurysms is strongly recommended., Methods: A critical analysis of the literature was performed to evaluate the implications of detecting AsxCS., Results: Patients with AsxCS are at high risk for future stroke, myocardial infarction and vascular death. Population-wide screening for AsxCS should not be recommended. Additionally, screening of high-risk individuals for AsxCS with the purpose of identifying candidates for a carotid intervention is inappropriate. Instead, selective screening for AsxCS should be considered and should be viewed as an opportunity to identify individuals at high risk for atherosclerotic cardiovascular disease and future cardiovascular events for the timely initiation of intensive medical therapy and risk factor modification., Conclusions: Although mass screening should not be recommended, there are several arguments suggesting that selective screening for AsxCS should be considered. The rationale supporting such selective screening is to optimize risk factor control and to initiate intensive medical therapy for prevention of future cardiovascular events, rather than to identify candidates for an intervention., Competing Interests: Declaration of Competing Interest All authors are members of the Faculty Advocating Collaborative and Thoughtful Carotid Artery Treatments (FACTCATS; available at www.FACTCATS.org) with the shared goal of optimizing stroke prevention. The views of particular FACTCATS do not necessarily reflect the views of other FACTCATS., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Despite the publication of several national/international guidelines, the optimal management of patients with asymptomatic carotid stenosis (AsxCS) remains controversial. This article compares 3 recently released guidelines (the 2020 German-Austrian, the 2021 European Stroke Organization [ESO], and the 2021 Society for Vascular Surgery [SVS] guidelines) vs the 2017 European Society for Vascular Surgery (ESVS) guidelines regarding the optimal management of AsxCS patients.The 2017 ESVS guidelines defined specific imaging/clinical parameters that may identify patient subgroups at high future stroke risk and recommended that carotid endarterectomy (CEA) should or carotid artery stenting (CAS) may be considered for these individuals. The 2020 German-Austrian guidelines provided similar recommendations with the 2017 ESVS Guidelines. The 2021 ESO Guidelines also recommended CEA for AsxCS patients at high risk for stroke on best medical treatment (BMT), but recommended against routine use of CAS in these patients. Finally, the SVS guidelines provided a strong recommendation for CEA+BMT vs BMT alone for low-surgical risk patients with >70% AsxCS. Thus, the ESVS, German-Austrian, and ESO guidelines concurred that all AsxCS patients should receive risk factor modification and BMT, but CEA should or CAS may also be considered for certain AsxCS patient subgroups at high risk for future ipsilateral ischemic stroke.

Background: The optimal antithrombotic (antiplatelet or anticoagulant) treatment of patients undergoing extracranial carotid artery interventions is a subject of debate. The aim of this multidisciplinary document was to critically review the recommendations of current guidelines, taking into consideration the results of recently published studies., Methods: The various antithrombotic strategies reported were evaluated for asymptomatic and symptomatic patients undergoing extracranial carotid artery interventions (endarterectomy, transfemoral carotid artery stenting [CAS] or transcarotid artery revascularization [TCAR]). Based on a critical review, a series of recommendations were formulated by an international expert panel., Results: For asymptomatic patients, we recommend low-dose aspirin (75-100 mg/day) or clopidogrel (75 mg/day) with the primary goal to reduce the risk of myocardial infarction and cardiovascular event rates rather than to reduce the risk of stroke. For symptomatic patients, we recommend dual antiplatelet treatment (DAPT) initiated within 24 h of the index event to reduce the risk of recurrent events. We suggest that following transfemoral CAS or TCAR, patients continue DAPT for 1 month after which a single antiplatelet agent is used. High level of evidence to support anticoagulant treatment for patients with carotid artery disease is lacking., Conclusions: The antithrombotic treatment offered to carotid patients should be individualized, taking into account the presence of symptoms, the type of intervention and the goal of the treatment. The duration and type of DAPT (ticagrelor instead of clopidogrel) should be evaluated in future trials., Competing Interests: Declaration of Competing Interest Dr. Mikhailidis has given talks, acted as a consultant or attended conferences sponsored by Amgen and Novo Nordisk. Dr. Chaturvedi reports consulting for Astra Zeneca and BrainGate and serving as an Associate Editor for Stroke, and as an Editorial Board Member of Neurology and Journal of Stroke and Cerebrovascular Diseases. The other authors report no conflicts., (Copyright © 2022 Elsevier Inc. All rights reserved.)

International guidelines strongly recommend statins alone or in combination with other lipid-lowering agents to lower low-density lipoprotein cholesterol (LDL-C) levels for patients with asymptomatic/symptomatic carotid stenosis (AsxCS/SCS). Lowering LDL-C levels is associated with significant reductions in transient ischemic attack, stroke, cardiovascular (CV) event and death rates. The aim of this multi-disciplinary overview is to summarize the benefits and risks associated with lowering LDL-C with statins or non-statin medications for Asx/SCS patients. The cerebrovascular and CV beneficial effects associated with statins, proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors and other non-statin lipid-lowering agents (e.g. fibrates, ezetimibe) are reviewed. The use of statins and PCSK9 inhibitors is associated with several beneficial effects for Asx/SCS patients, including carotid plaque stabilization and reduction of stroke rates. Ezetimibe and fibrates are associated with smaller reductions in stroke rates. The side-effects resulting from statin and PCSK9 inhibitor use are also highlighted. The benefits associated with lowering LDL-C with statins or non-statin lipid lowering agents (e.g. PCSK9 inhibitors) outweigh the risks and potential side-effects. Irrespective of their LDL-C levels, all Asx/SCS patients should receive high-dose statin treatment±ezetimibe or PCSK9 inhibitors for reduction not only of LDL-C levels, but also of stroke, cardiovascular mortality and coronary event rates., (Copyright © 2022 Elsevier Inc. All rights reserved.)

The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement was to reconcile the conflicting views on the topic. A literature review was performed with a focus on data from recent studies. Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients <75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80-99% ACS indicate a higher stroke risk than 50-79% stenoses. Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients.

The optimal management of patients with asymptomatic carotid stenosis (ACS) is the subject of extensive debate. According to the 2017 European Society for Vascular Surgery Guidelines, carotid endarterectomy should (Class IIa; Level of Evidence: B) or carotid artery stenting may be considered (Class IIb; Level of Evidence: B) in the presence of one or more clinical/imaging characteristics that may be associated with an increased risk of late ipsilateral stroke (e.g. silent embolic infarcts on brain computed tomography/magnetic resonance imaging, progression in the severity of ACS, a history of contralateral transient ischemic attack/stroke, microemboli detection on transcranial Doppler, etc.), provided documented perioperative stroke/death rates are <3% and the patient's life expectancy is >5 years. Besides these clinical/imaging characteristics, there are additional individual, ethnic/racial or social factors that should probably be evaluated in the decision process regarding the optimal management of these patients, such as individual patient needs/patient choice, patient compliance with best medical treatment, patient sex, culture, race/ethnicity, age and comorbidities, as well as improvements in imaging/operative techniques/outcomes. The present multispecialty position paper will present the rationale why the management of patients with ACS may need to be individualized.

Diabetes mellitus (DM) is also a cause of cardiovascular (CV) disease (CVD). Addressing the atherosclerotic CVD (ASCVD) burden in DM should reduce premature death and improve quality of life. Diabetes mellitus-associated ASCVD can lead to complications in all vascular beds (carotids as well as coronary, lower extremity, and renal arteries). This narrative review considers the diagnosis and pharmacological treatment of noncardiac atherosclerotic vascular disease (mainly in patients with DM). Based on current knowledge and the fact that modern DM treatment guidelines are based on CV outcome trials, it should be noted that patients with noncardiac CVD may not have the same benefits from certain drugs compared with patients who predominantly have cardiac complications. This leads to the conclusion that in the future, consideration should be given to conducting well-designed trials that will answer which pharmacological treatment modalities will be of greatest benefit to patients with noncardiac ASCVD.

Background: Associations between dietary fats and mortality are unclear., Methods: We evaluated the relationship between quartiles of total fat, mono-unsaturated (MUFA), polyunsaturated (PUFA) and saturated fatty acid (SFA) consumption, and all-cause, coronary heart disease (CHD), stroke, and type 2 diabetes (T2D)-associated mortality in 24,144 participants from the National Health and Nutrition Examination Surveys (NHANES) 1999-2010. We added our results to a meta-analysis based on searches until November 2018., Results: In fully adjusted Cox-proportional hazard models in our prospective study, there was an inverse association between total fat (HR: 0.90, 95% confidence interval 0.82, 0.99, Q4 vs Q1) and PUFA (0.81, 0.78-0.84) consumption and all-cause mortality, whereas SFA were associated with the increased mortality (1.08, 1.04-1.11). In the meta-analysis of 29 prospective cohorts (n = 1,164,029) we found a significant inverse association between total fat (0.89, 0.82-0.97), MUFA (0.94, 0.89-0.99) and PUFA (0.89, 0.84-0.94) consumption and all-cause mortality. No association was observed between total fat and CVD (0.93, 0.80-1.08) or CHD mortality (1.03 0.99-1.09). A significant association between SFA intake and CHD mortality (1.10, 1.01-1.21) was observed. Neither MUFA nor PUFA were associated with CVD or CHD mortality. Inverse associations were observed between MUFA (0.80, 0.67-0.96) and PUFA (0.84, 0.80-0.90) intakes and stroke mortality., Conclusions: We showed differential associations of total fat, MUFA and PUFA with all-cause mortality, but not CVD or CHD mortalities. SFA was associated with higher all-cause mortality in NHANES and with CHD mortality in our meta-analysis. The type of fat intake appears to be associated with important health outcomes., (Copyright © 2020 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.)

Stroke is a leading cause of death and disability worldwide. Approximately 15% of all first-ever strokes occur due to atheroembolism from a previously undetected/untreated asymptomatic carotid stenosis (ACS). Despite that, international guidelines do not recommend screening for ACS. The rationale for not recommending screening include: (a) the harm associated with screening, (b) the questionable clinical benefit associated with surgery, (c) the lack of proven reduction in the risk of stroke, (d) the large number of false positive/false negative tests, and (e) the cost-effectiveness of such screening programs. A critical analysis of each of these arguments is presented. Patients with ACS have a very high risk of all-cause and cardiac mortality. Detection of ACS should not be viewed as an indication for surgery, but rather as an opportunity to implement best medical treatment (BMT) and lifestyle changes to prevent not only strokes, but also cardiac events. The implementation of screening programs for abdominal aortic aneurysms (AAAs) has led to a considerable reduction in the number of ruptured AAAs and AAA-related deaths. Similarly, screening high-risk individuals for ACS would enable timely identification of patients with ACS and implementation of BMT and lifestyle measures to prevent future strokes and cardiac events.

The associations of egg consumption with total, coronary heart disease (CHD), and stroke mortality are poorly understood. We prospectively evaluated the link between total, CHD, and stroke mortality with egg consumption using a randomly selected sample of U.S. adults. Next we validated these results within a meta-analysis and systematic review of all available prospective results. We assessed the mean of cardiometabolic risk factors across the intake of eggs. We made the analysis based on data from the National Health and Nutrition Examination Surveys (NHANES; 1999-2010). In NHANES, vital status through December 31, 2011, was ascertained. Cox proportional hazard regression models were used to relate baseline egg consumption with all-cause and cause-specific mortality. PubMed, Scopus, Web of Science, and Google Scholar databases were also searched (up to December 2017). The DerSimonian-Laird method and generic inverse variance methods were used for quantitative data synthesis. Overall, 23,524 participants from NHANES were included (mean age of 47.7 years; 48.7% were men). Across increasing the intake of eggs, adjusted mean levels of cardiometabolic risk factors worsened. Adjusted logistic regression showed that participants in the highest category of egg intake had a greater risk of diabetes (T2DM; 30%) and hypertension (HTN; 48%). With regard to total and CHD mortality, multivariable Cox regression in a fully adjusted model showed no link in males and females. In males, egg intake had a reverse (66%) association with stroke mortality, while this link was not significant among females. The results of pooling data from published prospective studies also showed no link between CHD and total mortality with egg consumption, whereas we observed a reverse (28%) association between egg intake and stroke mortality. These findings were robust after sensitivity analysis. According to our findings, egg intake had no association with CHD and total mortality, whereas was associated with lower risk of mortality from stroke. Egg consumption was associated with T2DM, HTN, C-reactive protein, and markers of glucose/insulin homeostasis. If confirmed in clinical trials (causation), this information may have applications for population-wide health measures. Key teaching points No link between total and CHD mortality with eggs intake in males and females. In males, egg intake had a reverse association with stroke mortality, while this link was not significant among females. The results of pooling data from published prospective studies also showed no link between CHD and total mortality with egg consumption, whereas we observed a reverse association between egg intake and stroke mortality.

Aims: Relatively little is known about the health outcomes associated with very low plasma concentrations of high-density lipoprotein cholesterol (HDL-C) mainly because of the small numbers of individuals with such extreme values included in clinical trials. We, therefore, investigated the association between low and very low HDL-C concentration at baseline and incident all-cause-mortality, death from malignant disease (i.e. cancer), and with fatal or non-fatal incident coronary heart disease (CHD) in individuals from the Reasons for Geographical And Racial Differences in Stroke (REGARDS) study., Methods and Results: Analysis was based on 21 751 participants from the REGARDS study who were free of CHD, other cardiovascular disease, and cancer at baseline and were categorized by baseline HDL-C into <30 mg/dL (very low), 30-<40 mg/dL (low), and ≥40 mg/dL (reference). A series of incremental Cox proportional hazards models were employed to assess the association between the HDL-C categories and outcomes. Statistical analysis was performed using both complete case methods and multiple imputations with chained equations. After adjustment for age, race, and sex, the hazard ratios (HRs) comparing the lowest and highest HDL-C categories were 1.48 [95% confidence interval (CI) 1.28-1.73] for all-cause mortality, 1.35 (95% CI 1.03-1.77) for cancer-specific mortality and 1.39 (95% CI 0.99-1.96) for incident CHD. These associations became non-significant in models adjusting for demographics, cardiovascular risk factors, and treatment for dyslipidaemia. We found evidence for an HDL paradox, whereby low HDL (30-<40 mg/dL) was associated with reduced risk of incident CHD in black participants in a fully adjusted complete case model (HR 0.63; 95% CI 0.46-0.88) and after multiple imputation analyses (HR 0.76; 95% CI 0.58-0.98). HDL-C (<30 mg/dL) was significantly associated with poorer outcomes in women for all outcomes, especially with respect to cancer mortality (HR 2.31; 95% CI 1.28-4.16) in a fully adjusted complete case model, replicated using multiple imputation (HR 1.81; 95% CI 1.03-3.20)., Conclusion: Low HDL-C was associated with reduced risk of incident CHD in black participants suggesting a potential HDL paradox for incident CHD. Very low HDL-C in women was significantly associated with cancer mortality in a fully adjusted complete case model.

The identification/selection of appropriate patient subgroups with asymptomatic carotid artery stenosis and the performance of prophylactic carotid endarterectomy (CEA)/carotid artery stenting (CAS) exclusively on these asymptomatic patient subgroups is currently one of the "hottest" topics in vascular surgery. It is now clear that offering CEA/CAS to asymptomatic carotid patients based only on the degree of carotid stenosis is unjustified and scientifically flawed. On the other hand, offering only best medical therapy to every asymptomatic patient, irrespective of certain high-risk criteria (such as the detection of microemboli by transcranial Doppler, intraplaque hemorrhage, silent embolic infarcts on brain computed tomography/magnetic resonance imaging, elevated biomarkers, family history), is equally wrong. The validation of specific measures to identify those asymptomatic patients at high risk for developing symptoms is crucial to achieve optimal use of carotid interventions and avoid wasting stroke prevention resources.

Implementation of best medical treatment (BMT) is the cornerstone of the management of patients with either asymptomatic or symptomatic carotid artery stenosis. We review the literature to define the components of BMT. Smoking cessation, maintaining a healthy body weight, moderate exercise, and a Mediterranean diet are essential lifestyle measures. Moderate alcohol consumption may also be beneficial but recommending it to patients may be hazardous if they consume too much. The importance of lifestyle measures is largely underestimated by both physicians and patients. Blood pressure and diabetes control, antiplatelet agents, and lipid-lowering treatment with statins/ezetimibe comprise the pharmacological components of BMT. Initiation of an intensive regimen of BMT is a sine qua non for patients with carotid artery stenosis whether or not they are offered or undergo an invasive revascularization procedure., (© The Author(s) 2015.)

The metabolic syndrome (MetS) is characterized by a cluster of risk factors including central obesity, hypertension, dyslipidemia and insulin resistance, The MetS is associated with an increased risk for cardiovascular disease (CVD) and type 2 diabetes mellitus (T2DM). Several international organizations have defined MetS using different diagnostic criteria that produced discrepancies in the results of previous studies, thus leading to the latest Joint Interim Societies (JIS) MetS definition. Other risk factors than the diagnostic criteria that have been associated with MetS include lipid abnormalities, uric acid, liver function, prothrombotic factors, cytokines, adipokines, vitamin D, arterial stiffness, polycystic ovary syndrome and obstructive sleep apnea. Apart from CVD and T2DM, MetS has been related to non-cardiac vascular diseases and in particular to stroke, carotid artery disease, peripheral artery disease, chronic kidney disease, atherosclerotic renal artery stenosis and abdominal aortic aneurysms. In this narrative review, the associations of these diseases with MetS and its components will be discussed. These associations may further increase CVD risk in MetS patients, highlighting the importance of treating such high-risk individuals early and "to target". In this context, multifactorial treatment including a statin has been proven beneficial, and thus should be considered, in MetS patients.

Introduction: An enlarged left atrium is associated with increased risk for stroke. However, there are controversies regarding how left atrial size should be measured., Material and Methods: Echocardiography and carotid artery ultrasound were performed in 120 patients with essential hypertension (HT group) and in 64 hypertensive patients admitted with a first-ever ischemic stroke (HT-stroke group). Left atrial size was measured as antero-posterior diameter (LAD) and as left atrial volume (LAV) and indexed to body surface area (LADi/LAVi). All patients were in sinus rhythm and without mitral valve disease., Results: In the HT-stroke group, LAVi and LADi were significantly larger as compared with the HT group (P ≤ 0.03 for all). In bivariate correlations, larger left atrial size was associated with higher SBPs and DBPs and significant carotid artery stenosis both in HT and HT-stroke groups (all P < 0.05). In multivariate logistic regression analysis, stroke was associated significantly with larger LAVi [odds ratio (OR) 1.73, 95% confidence interval (CI) 1.06-2.65]; left ventricular mass index (OR 1.11, 95% CI 1.03-1.21); significant carotid artery stenosis (OR 1.09, 95% CI 1.03-1.24); and any carotid artery stenosis (OR 1.07, 95% CI 1.03-1.14). Analysis of receiver operating characteristic curves revealed that LAVi was the best left atrial measurement for prediction of stroke (OR 0.77, 95% CI 0.70-0.84)., Conclusion: In hypertensive patients, a first-ever ischemic stroke was associated with larger left atrial size, left ventricular mass index and internal carotid artery stenosis. LAVi was the left atrial measurement most closely associated with ischemic stroke.

Background: Carotid artery stenting (CAS) is considered by many as an alternative to carotid endarterectomy (CEA) for the management of carotid artery stenosis. However, recent trials demonstrated inferior results for CAS in symptomatic patients compared with CEA. We reviewed the literature to evaluate the appropriateness of CAS for symptomatic carotid artery stenosis and to determine the pathogenetic mechanism(s) associated with stroke following the treatment of such lesions. Based on this, we propose steps to improve the results of CAS for the treatment of symptomatic carotid stenosis., Methods: PubMed/Medline was searched up to March 25, 2010 for studies investigating the efficacy of CAS for the management of symptomatic carotid stenosis. Search terms used were "carotid artery stenting," "symptomatic carotid artery stenosis," "carotid endarterectomy," "stroke," "recurrent carotid stenosis," and "long-term results" in various combinations., Results: Current data suggest that CAS is not equivalent to CEA for the treatment of symptomatic carotid stenosis. Differences in carotid plaque morphology and a higher incidence of microemboli and cerebrovascular events during and after CAS compared with CEA may account for these inferior results., Conclusions: Currently, most symptomatic patients are inappropriate candidates for CAS. Improved CAS technology referable to stent design and embolic protection strategies may alter this conclusion in the future., (Copyright © 2010 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.)

Purpose of Review: To assess the potential association between haemorrhagic stroke and achieving very low serum cholesterol levels with aggressive statin treatment., Recent Findings: The Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) study showed a reduction in both fatal and nonfatal stroke but an increase in the risk for haemorrhagic stroke during high-dose atorvastatin treatment. However, post-hoc analyses of this trial showed that this increased risk is primarily observed in elderly men with a history of haemorrhagic stroke. In addition, there was no relationship between baseline or on-treatment low-density lipoprotein cholesterol (LDL-C) levels and haemorrhagic stroke., Summary: Existing data suggest that low LDL-C levels during intensive statin treatment are not associated with an increased risk for haemorrhagic stroke, except in patients with a history of intracerebral haemorrhage. In patients with a history of ischaemic stroke, intensive statin treatment substantially reduces the risk for both recurrent ischaemic stroke and for coronary heart disease (CHD) events. Any possible excess of haemorrhagic stroke is greatly outweighed by the protective effect against ischaemic stroke and CHD events.

Objective: The effect of seasonal variation on the occurrence of stroke remains controversial. The objective of this study was to determine whether there is a seasonal variation in the occurrence of stroke in Northern Greece., Methods: We recorded the seasonal stroke rates over a 10 year period (from January 1997 to December 2006) in 8204 patients in Northern Greece. The findings were analysed separately for ischemic stroke (IS), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and transient ischemic attack (TIA)., Results: In patients with IS, there was a significant seasonal variation (p<0.001), with the peak incidence in spring (8.4% above average) and the lowest rate in summer (10.4% below average). There was no significant seasonal variation in the occurrence of the other stroke subtypes (ICH, SAH and TIA) when they were considered individually., Discussion: The seasonal effect on stroke incidence needs to be defined so as to improve the provision of preventive measures.

The General Anesthesia vs. Local Anesthesia for Carotid Surgery (GALA) trial did not show a difference in 30-day postoperative stroke, myocardial infarction and death rates between patients undergoing carotid endarterectomy (CEA) under local vs. general anesthesia. The present article discusses some limitations of the GALA trial. Firstly, the expected stroke and death rates following CEA is so low, that it was unlikely that the GALA trial would show any significant difference between local and general anesthesia. Secondly, preoperative statin use was not recorded. Thirdly, intraoperative shunt usa ge rates (a possible parameter for the development of stroke) varied considerably between the 2 groups (43% vs. 14%, for general vs. local anesthesia, respectively; P < .0001), as well as between UK and non-UK surgeons who always (73.6% vs. 20.8%, respectively; P < .0001), never (4.2% vs. 26%, respectively; P < .0002), or selectively (22.2% vs. 53.2%, respectively; P < .0001) used a shunt. Furthermore, no information was provided regarding the type of shunts used; for example, atraumatic shunts may be associated with lower perioperative stroke rates. These limitations could influence the interpretation of the results of the GALA trial. Due to lack of differences between the 2 groups and the presence of the above limitations, it seems likely that this trial will have little effect on clinical practice.

Purpose of Review: To provide an update of the literature describing the link between lipoprotein a and vascular disease., Recent Findings: There is evidence that elevated plasma lipoprotein a levels are associated with coronary heart disease, stroke and other manifestations of atherosclerosis. Several mechanisms may be implicated, including proinflammatory actions and impaired fibrinolysis., Summary: Lipoprotein a potentially represents a useful tool for risk stratification in the primary and secondary prevention setting. However, there are still unresolved methodological issues regarding the measurement of lipoprotein a levels. Targeting lipoprotein a in order to reduce vascular risk is hampered by the lack of well tolerated and effective pharmacological interventions. Moreover, it has not yet been established whether such a reduction will result in fewer vascular events. The risk attributed to lipoprotein a may be reduced by aggressively tackling other vascular risk factors, such as low-density lipoprotein cholesterol.

Ischemic stroke is a major cause of morbidity and mortality. Whereas dyslipidemia is a major risk factor for coronary heart disease (CHD), its role in the pathogenesis of ischemic stroke is less clear. Epidemiological studies have provided conflicting findings regarding the association of dyslipidemia with ischemic stroke. Overall, elevated LDL-C levels appear to increase the risk of ischemic stroke. Low HDL-C levels also appear to be associated with a greater risk whereas the importance of high triglyceride levels is less clear. The discordant results of observational studies might result from the heterogeneity of stroke, since dyslipidemia is less likely to play a major role in the pathogenesis of some ischemic stroke subtypes (e.g. lacunar and cardioembolic strokes) and elevated LDL-C levels might increase the risk of hemorrhagic stroke. In clinical trials, statins consistently reduced the risk of ischemic stroke in patients with or without CHD whereas the data on the effects of other lipid modifying drugs on stroke risk are limited. In patients with a previous stroke, statins reduce the risk of both ischemic stroke and other vascular events but also increase the risk of hemorrhagic stroke. Accordingly, current guidelines recommend the same lipid targets for the primary and secondary prevention of both stroke and CHD. In addition, stroke and transient ischemic attacks of carotid origin are considered CHD risk equivalents. Nevertheless, more trials are required to identify which patients with stroke but without CHD will benefit more from statin treatment.

The purpose of this study was to investigate the relationship between alcohol consumption and the prevalence of the metabolic syndrome (MetS), type 2 diabetes mellitus (DM), coronary heart disease (CHD), stroke, peripheral arterial disease (PAD), and overall cardiovascular disease (CVD) in a Mediterranean cohort. It consisted of a cross-sectional analysis of a representative sample of Greek adults (n = 4,153) classified as never, occasional, mild, moderate, or heavy drinkers. Cases with overt CHD, stroke, or PAD were recorded. In our population, 17% were never, 23% occasional, 27% mild, 24% moderate, and 9% heavy drinkers. Moderate alcohol consumption was associated with a lower trend for the prevalence of the MetS (P = .0001), DM (P < .0001), CHD (P = .0002), PAD (P = .005), and overall CVD (P = .001) but not stroke compared with no alcohol use. Heavy drinking was associated with an increase in the prevalence of all of these disease states. Wine consumption was associated with a slightly better effect than beer or spirits consumption on the prevalence of total CVD, and beer consumption was associated with a better effect than spirits consumption. Alcohol intake was positively related with body weight, high-density lipoprotein cholesterol levels, and hypertension. Moderate alcohol consumption is associated with a lower prevalence of the MetS, DM, PAD, CHD, and overall CVD but not stroke compared with no alcohol use in a Mediterranean population. Heavy drinking was associated with an increase in the prevalence of all of these disease states. Advice on alcohol consumption should probably mainly aim at reducing heavy drinking.

Objective: We aimed to define the role of treatment using statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) in the management of patients with carotid artery disease., Literature Search Methods: We searched PubMed for studies evaluating the effect of statins on carotid IMT and the occurrence of cerebrovascular events., Literature Search Results: Current evidence indicates that routine statin therapy reduces carotid intima-media thickness progression and stroke risk. Additionally, statin treatment significantly reduces perioperative as well as long-term morbidity and mortality in patients undergoing carotid surgery or endovascular interventions. It would also be expected that statins would reduce coronary events in this high-risk population., Conclusions: Statins should be considered as an essential component of the therapeutic approach of patients with carotid artery stenosis.

Background: The prognostic significance of uric acid (UA) levels in acute stroke is unclear, so the objective of this study was to determine the association between levels of serum UA (SUA) and mortality in acute stroke., Methods and Results: Consecutive patients (n=435) presenting with ischemic stroke and intracerebral hemorrhage were included in the study. The length of stay in hospital and the occurrence of death were recorded. On univariate analysis, the occurrence of death was associated with older age, smoking, presence of congestive heart failure or atrial fibrillation, absence of hyperlipidemia, and intracerebral hemorrhage as the index event. Furthermore, glucose, urea, creatinine and SUA at admission were significantly higher in patients who died, whereas total and high-density-lipoprotein cholesterol were significantly lower. On multiple logistic regression analysis, the independent relationship between higher SUA levels and death was confirmed (odds ratio (OR), 1.37; 95%confidence interval (CI), 1.13-1.67; p=0.001). The only other variables independently associated with the occurrence of death were urea concentration and presence of atrial fibrillation. If urate was >7.8 mg/dl (0.47 mmol/L), then there would be a high probability of early death (87%)., Conclusions: Elevated levels of SUA are independently associated with an increased risk of early death in acute stroke.

Background and Purpose: Metabolic syndrome (MetSyn) represents a constellation of lipid and nonlipid risk factors for cardiovascular disease and is a recognized target for increased behavioral therapy., Objective: The association between acute ischemic/nonembolic stroke and the MetSyn in elderly individuals was assessed in a population-based case-control study in the prefecture of Ioannina, Greece., Study Population: A total of 163 patients aged older than 70 years admitted with first-ever-in-a-lifetime acute ischemic/nonembolic stroke and 166 controls were included., Results: The prevalence of MetSyn (defined according to NCEP/ATP III criteria) was high in stroke patients (46.0% versus 15.7%, P<0.001). Compared with controls as a group (with and without MetSyn), stroke patients with the MetSyn showed higher concentrations of triglycerides, lipoprotein(a), uric acid, and fibrinogen, and lower high-density lipoprotein (HDL) cholesterol and apolipoprotein A-I levels. In logistic regression analysis, crude and adjusted odd ratios (ORs) for MetSyn were 5.33 (95% confidence interval [CI], 2.91 to 9.79; P<0.0001) and 2.59 (95% CI, 1.24 to 5.42; P=0.012), respectively. The analysis of interaction between MetSyn and its individual components revealed significant associations with abdominal obesity (adjusted OR, 2.74; 95% CI, 1.15 to 6.50; P=0.02), hypertension (OR, 2.03; 95% CI, 0.91 to 4.49; P=0.08), high fasting glucose levels (OR, 2.95; 95% CI, 1.19 to 7.35; P=0.02), high triglyceride (OR, 5.55; 95% CI, 2.71 to 11.37; P<0.0001]), and low HDL cholesterol (OR, 5.42; 95% CI, 2.85 to 10.30; P<0.0001). Notably, in stroke patients with the MetSyn the inverse relationship between HDL cholesterol levels and ischemic stroke was negated (OR, 1.04; 95% CI, 1.02 to 1.05; P<0.0001)., Conclusions: MetSyn is associated with an increased risk for acute ischemic/nonembolic stroke in elderly subjects with significant contributions from its individual components. In the presence of MetSyn, HDL cholesterol loses its protective role against ischemic stroke.

The authors investigated whether apolipoprotein (apo) E polymorphism has an allelic and/or genotypic impact on the risk of an ischemic vascular event (IVE) in Greek patients with cardiovascular diseases (CVD). They compared apo E polymorphisms in 1) a group of 165 patients with IVE [IVE(+)], of whom 107 had survived a myocardial infarction and 58 an ischemic stroke; 2) a group of 165 patients, matched with the first group for age and gender, with angiographically confirmed coronary artery disease but without IVE [IVE(-)]; 3) a group of 240 healthy younger individuals with no family history of CVD. The apo epsilon2 allele was 5.2-fold less frequent in the IVE(+) group compared to the IVE(-) group (1.2% vs 6.2%, p = 0.001). The frequency of the epsilon2 allele in healthy subjects was 8.1%, which is 6.7-fold higher than in the IVE(+) group (p < 0.001), and more than twice as high compared to all CVD patients (p = 0.001). No significant differences in epsilon4 allele frequencies were observed between IVE(+) and IVE(-) patients (9.8% vs 8.4%) or between patients with CVD and healthy subjects (9.1% vs 10.2%). The epsilon4 allele was not associated with an increased risk for CVD or IVE. In contrast, an inverse and beneficial association of the epsilon2 allele with IVE was observed among Greek patients with CVD. These results suggest that the epsilon4 and epsilon2 alleles have a variable significance in terms of predicting the risk of vascular events in different populations. Therefore, it is important to carry out "local" studies.

The optimal management of patients with asymptomatic carotid stenosis (AsxCS) is enduringly controversial. We updated our 2021 Expert Review and Position Statement, focusing on recent advances in the diagnosis and management of patients with AsxCS. A systematic review of the literature was performed up to August 1, 2023, using PubMed/PubMed Central, EMBASE and Scopus. The following keywords were used in various combinations: "asymptomatic carotid stenosis," "carotid endarterectomy" (CEA), "carotid artery stenting" (CAS), and "transcarotid artery revascularization" (TCAR). Areas covered included (i) improvements in best medical treatment (BMT) for patients with AsxCS and declining stroke risk, (ii) technological advances in surgical/endovascular skills/techniques and outcomes, (iii) risk factors, clinical/imaging characteristics and risk prediction models for the identification of high-risk AsxCS patient subgroups, and (iv) the association between cognitive dysfunction and AsxCS. BMT is essential for all patients with AsxCS, regardless of whether they will eventually be offered CEA, CAS, or TCAR. Specific patient subgroups at high risk for stroke despite BMT should be considered for a carotid revascularization procedure. These patients include those with severe (≥80%) AsxCS, transcranial Doppler-detected microemboli, plaque echolucency on Duplex ultrasound examination, silent infarcts on brain computed tomography or magnetic resonance angiography scans, decreased cerebrovascular reserve, increased size of juxtaluminal hypoechoic area, AsxCS progression, carotid plaque ulceration, and intraplaque hemorrhage. Treatment of patients with AsxCS should be individualized, taking into consideration individual patient preferences and needs, clinical and imaging characteristics, and cultural, ethnic, and social factors. Solid evidence supporting or refuting an association between AsxCS and cognitive dysfunction is lacking. The optimal management of patients with AsxCS should include BMT for all individuals and a prophylactic carotid revascularization procedure (CEA, CAS, or TCAR) for some asymptomatic patient subgroups, additionally taking into consideration individual patient needs and preference, clinical and imaging characteristics, social and cultural factors, and the available stroke risk prediction models. Future studies should investigate the association between AsxCS with cognitive function and the role of carotid revascularization procedures in the progression or reversal of cognitive dysfunction. [ABSTRACT FROM AUTHOR]

Introduction: The impact of low-density lipoprotein cholesterol (LDL-C) on the risk of different types of strokes is unclear. Therefore, we systematically evaluated the impact of LDL-C levels (cohort studies) and lipid-lowering agents (LLAs) (randomized controlled trials) on the different types of stroke.Material and methods: PubMed, SCOPUS, Web of Science and Google Scholar were searched up to 1st September 2019. The DerSimonian-Laird method and generic inverse variance methods were used for quantitative data synthesis. The leave-one-out method was performed as sensitivity analysis. Trial sequential analysis (TSA) was used to evaluate the optimal sample size to detect a 35% reduction in outcomes after administration of LLAs.Results: Participants in the highest category of LDL-C had a lower risk of hemorrhagic stroke (RR = 0.91, 95% CI: 0.85-0.98, I2 = 0%) compared with the lowest category of LDL-C. Subjects with the highest category of LDL-C had a higher risk of ischemic stroke (RR = 1.11, 95% CI: 1.07-1.14, I2 = 0%) compared to the lowest LDL-C category. LLAs decreased the risk of all types of strokes for those who achieved LDL-C < 1.8 mmol/l (< 70 mg/dl; RR = 0.88, 95% CI: 0.80-0.96, absolute risk reduction (ARR): 0.7%, number needed to treat (NNT): 143, I2 = 53%, n = 13). Statin therapy decreased the risk of all strokes (RR = 0.88, 95% CI: 0.80-0.97, ARR = 0.6%, NNT = 167, I2 = 56%). With regard to ischemic stroke only, LLAs decreased the risk of ischemic stroke for those who achieved LDL-C < 1.8 mmol/l (< 70 mg/dl; RR = 0.75, 95% CI: 0.67-0.83, ARR = 1.3%, NNT = 77, I2 = 0%); the same was observed for statins (RR = 0.76, 95% CI: 0.69-0.84, ARR = 1.3%, NNT = 77, I2 = 32%). TSA indicated that both benefit boundaries and optimal sample size were reached. There was no significant effect of LLAs regardless of the achieved level of LDL-C on the risk of hemorrhagic stroke; however, TSA indicated that further studies are needed to settle the question and most of the effects were subject to high levels of heterogeneity.Conclusions: Our study sheds light on the debatable association between low LDL-C and different type of strokes. This information can help determine the optimal LDL-C range for stroke prevention, and help plan future LLA studies. [ABSTRACT FROM AUTHOR]

Cilostazol, a phosphodiesterase III inhibitor, has vasodilating and antiplatelet properties with a low rate of bleeding complications. It has been used over the past 25 years for improving intermittent claudication in patients with peripheral artery disease (PAD). Cilostazol also has demonstrated efficacy in patients undergoing percutaneous revascularization procedures for both PAD and coronary artery disease. In addition to its antithrombotic and vasodilating actions, cilostazol also inhibits vascular smooth muscle cell proliferation via phosphodiesterase III inhibition, thus mitigating restenosis. Accumulated evidence has shown that cilostazol, due to its "pleiotropic" effects, is a useful, albeit underutilized, agent for both coronary artery disease and PAD. It is also potentially useful after ischemic stroke and is an alternative in those who are allergic or intolerant to classical antithrombotic agents (eg, aspirin or clopidogrel). These issues are herein reviewed together with the pharmacology and pharmacodynamics of cilostazol. Large studies and meta-analyses are presented and evaluated. Current guidelines are also discussed, and the spectrum of cilostazol's actions and therapeutic applications are illustrated. [ABSTRACT FROM AUTHOR]

We evaluated the association of egg consumption with liver tests (LTs) and non-alcoholic fatty liver disease (NAFLD). This relationship is poorly documented. The National Health and Nutrition Examination Survey (NHANES, 2005–2010) database was used. Analysis of covariance, adjusted linear and logistic regression models were used. Of the 14,369 participants, 46.8% were men and 45.2% had NAFLD. After correction for several variables including: age, gender, race, education, poverty to income ratio, alcohol intake, energy intake, smoking, and physical activity - fatty liver index (FLI), serum aspartate aminotransferase (AST) alanine aminotransferase (ALT) were 36.9, 25.8 (U/L) and 23.9 (U/L), respectively, in the first tertile (T1) reaching 68.7, 34.9 and 36.5, respectively, in the third tertile (T3) (p < 0.001 for all comparisons). In the model with same covariates, there was significant positive linear relationship between FLI (standard β coefficient (β): 0.196), AST (β: 0.099) and ALT (β: 0.112) with egg consumption and participants in the highest tertile (T3) of egg consumption had 11% higher chance of NAFLD compared with T1 (odds ratio: 1.11 and 95% confidence interval: 1.07–1.17). Of note, after more correction for triglycerides, hypertension and diabetes, the significant link between egg consumption and LTs and/or NAFLD attenuated and disappeared. Our findings highlight the adverse role of egg consumption on LTs and likelihood of NAFLD. These associations seem to be attributable to cardio-metabolic risk factors. These findings require confirmation to improve our understanding of the role of egg consumption in the pathogenesis of NAFLD. • The association of egg consumption with non-alcoholic fatty liver disease (NAFLD) was evaluated. • After adjustment, participants in the third tertile (T3) of egg consumption had 11% higher chance of NAFLD compared with T1. • After further correction, the significant link between egg consumption and NAFLD attenuated and disappeared. [ABSTRACT FROM AUTHOR]

Objective: Familial hypercholesterolaemia (FH) is a common autosomal dominant inherited disease, affecting 1 in 200-500 individuals worldwide. FH is characterized by elevated circulating low-density lipoprotein cholesterol (LDL-C) concentrations. Its association with increased risk of coronary heart disease (CHD) (>10-fold, compared with patients without FH) is well documented. However, the association between FH and non-CHD atherosclerotic cardiovascular disease (ASCVD) risk has been poorly documented.Methods: PubMed was searched for English language publications regarding the association between FH and carotid artery stenosis, stroke, peripheral artery disease (PAD; lower limbs and other arterial beds), aortic valve calcification (AoVC), aortic and renal artery disease, chronic kidney disease, atrial fibrillation and heart failure, from conception until 22 December 2019.Results: Despite the small number of available studies, as well as their characteristics (sample size, diagnostic criteria used, retrospective or cross-sectional design), there is evidence for a positive association between FH and stroke, PAD or AoVC. More data are needed for definitive conclusions regarding aortic and renal artery disease, chronic kidney disease, atrial fibrillation and heart failure. There is paucity of data with respect to homozygous FH. Increased lipoprotein (a) concentrations, often seen in FH patients, may also contribute to this non-CHD atherosclerotic process. A key question is whether statins or other LDL-C-lowering therapies, provide an additional reduction in the risk of these less-recognized vascular and non-vascular complications in FH patients.Conclusions: Heterozygous FH is associated with increased risk for stroke, PAD and AoVC. Clinicians should take these non-CHD ASCVD aspects into consideration for optimal management of FH patients. [ABSTRACT FROM AUTHOR]

Introduction: The long-term effect of potato consumption on mortality and cardiovascular (CV) and cardiometabolic risk factors is still largely unknown. Using the National Health and Nutrition Examination Surveys (NHANES) 1999-2010, we evaluted the long-term impact of potato intake on total and cause-specific (cardiovascular disease (CVD), cerebrovascular disease and cancer) mortality, and the results were next validated in a systematic review and meta-analysis of cohort studies investigating pooled associations of potato consumption with all-cause and cause-specific death.Material and Methods: Vital status up to December 31, 2011 was ascertained in NHANES. Cox proportional hazards were applied to determine the hazard ratios (HRs) and 95% confidence intervals (95% CI) of mortality for each quartile of the potato intake, with the lowest quartile (Q1 - with the lowest intake) used as a reference. In the meta-analysis we used adjusted Cox regression to determine the risk ratio (RR) and 95% CI, as well as random effects models and generic inverse variance methods to synthesize quantitative and pooled data, followed by a leave-one-out method for sensitivity analysis.Results: Among 24,856 participants included, 3433 deaths occurred during the mean follow-up of 6.4 years. In multivariate adjusted models, total (42%), CVD (65%), cerebrovascular (26%) and cancer (52%) mortality risk was greater in individuals with higher potato consumption than those with the lowest intake (p < 0.001 for all comparisons). However, this link disappeared after adjustment for confounding factors. Results from pooling current prospective studies revealed a non-significant association between total (RR = 1.25, 0.98-1.60, p = 0.066), CVD (RR = 0.99, 0.90-1.08, p = 0.845) and stroke mortality (RR = 0.94, 0.85-1.03, p = 0.214) with potato consumption. Individuals with a higher potato intake had a less favorable profile of cardiometabolic factors, including greater waist circumference (97.2 vs. 99.5 cm, p < 0.001) and a less favorable profile of systolic and diastolic blood pressure, levels of triglycerides (TG), high-density lipoprotein-cholesterol (HDL-C) and TG/HDL-C ratio (p < 0.001 for all comparisons).Conclusions: Our results revealed no significant effects of potato intake on long-term mortality rates, whereas higher potato consumption was adversely related to cardiometabolic risk factors. These findings should be taken into consideration for public health strategies, establishing the position for potatoes in the food pyramid. [ABSTRACT FROM AUTHOR]

Abstract Background The health outcomes associated with extremely low or high plasma concentrations of high-density lipoprotein cholesterol (HDL-C) are not well documented mainly because of the small numbers of participants with such values included in the clinical trials. Objective We prospectively investigated the association between extremely low and high HDL-C with: 1) the risk of overall, coronary heart disease (CHD), cerebrovascular and cancer mortality, and, 2) their link with inflammatory factors. Methods Analysis was based on subjects ≥18 years old from the National Health and Nutrition Examination Surveys (NHANES). We categorized HDL-C levels as follows: [low HDL-C group ≤30 (extremely low), 30–40 (low), and ≥40 (reference)] [high HDL-C group = 40–80 (reference), 80–100 (high) and ≥100 mg/dl (extremely high). Cox proportional hazard regression models and analysis of covariance accounted for survey design, masked variance and sample weights. Results After adjustment for age, race and sex, we found that the very low HDL-C category (<30 mg/dl) had a greater risk of total mortality (risk ratio [RR]: 3.00, 95%CI: 2.20–4.09). RR for CHD and stroke mortality was 2.00 and 2.53, respectively; there was no link between cancer and level of HDL-C (p = 0.235). The association between total mortality, CHD and stroke with the level of HDL-C attenuated but remained significant even after adjustment for demographics, dietary, cardiovascular risk factors and treatment for dyslipidemia (all p < 0.001). After adjustments, subjects with extremely high HDL-C levels had a higher risk of mortalities (all p < 0.001). Mexican-American ethnicity, subjects in the low level of HDL-C (30–40 mg/dl) category had higher risk of mortalities than those with a very low level (all p < 0.001). Concentration of C-reactive protein, fibrinogen and white blood count significantly decreased as the level of the HDL-C increased; these findings were robust after adjustment for demographics, dietary, cardiovascular risk factors and treatment for dyslipidemia (all p < 0.001); further subjects with extremely high HDL-C levels have a greater levels of inflammatory factors (all p < 0.001). Conclusions Both extremely low and high HDL-C levels were associated with greater risk of mortalities (total, CHD and stroke) and higher level of inflammatory factors, while there was no link between level of HDL-C and risk of cancer. Moreover, we found evidence of an HDL-C paradox in Mexican-American ethnicity participants. Highlights • After adjustment we found that the very low HDL-C category (<30 30 mg/dl) had three times greater risk of total mortality. • RR for CHD and stroke mortality was 2.00 and 2.53, respectively; there was no link between cancer and level of HDL-C. • After adjustments, subjects with extremely high HDL-C levels had a higher risk of mortalities (all p < 0.001). • Concentration of CRP, fibrinogen and white blood count significantly decreased as the level of the HDL-C increased. [ABSTRACT FROM AUTHOR]

The General Anesthesia vs. Local Anesthesia for Carotid Surgery (GALA) trial did not show a difference in 30-day postoperative stroke, myocardial infarction and death rates between patients undergoing carotid endarterectomy (CEA) under local vs. general anesthesia. The present article discusses some limitations of the GALA trial. Firstly, the expected stroke and death rates following CEA is so low, that it was unlikely that the GALA trial would show any significant difference between local and general anesthesia. Secondly, preoperative statin use was not recorded. Thirdly, intraoperative shunt usage rates (a possible parameter for the development of stroke) varied considerably between the 2 groups (43% vs. 14%, for general vs. local anesthesia, respectively; P < .0001), as well as between UK and non-UK surgeons who always (73.6% vs. 20.8%, respectively; P < .0001), never (4.2% vs. 26%, respectively; P < .0002), or selectively (22.2% vs. 53.2%, respectively; P < .0001) used a shunt. Furthermore, no information was provided regarding the type of shunts used; for example, a traumatic shunts may be associated with lower perioperative stroke rates. These limitations could influence the interpretation of the results of the GALA trial. Due to lack of differences between the 2 groups and the presence of the above limitations, it seems likely that this trial will have little effect on clinical practice. [ABSTRACT FROM AUTHOR]

The recommendations of international guidelines for the management of asymptomatic carotid stenosis (ACS) often vary considerably and extend from a conservative approach with risk factor modification and best medical treatment (BMT) alone, to a more aggressive approach with a carotid intervention plus BMT. The aim of the current multispecialty position statement is to reconcile the conflicting views on the topic. A literature review was performed with a focus on data from recent studies. Several clinical and imaging high-risk features have been identified that are associated with an increased long-term ipsilateral ischemic stroke risk in patients with ACS. Such high-risk clinical/imaging features include intraplaque hemorrhage, impaired cerebrovascular reserve, carotid plaque echolucency/ulceration/ neovascularization, a lipid-rich necrotic core, a thin or ruptured fibrous cap, silent brain infarction, a contralateral transient ischemic attack/stroke episode, male patients < 75 years and microembolic signals on transcranial Doppler. There is growing evidence that 80–99% ACS indicate a higher stroke risk than 50–79% stenoses. Although aggressive risk factor control and BMT should be implemented in all ACS patients, several high-risk features that may increase the risk of a future cerebrovascular event are now documented. Consequently, some guidelines recommend a prophylactic carotid intervention in high-risk patients to prevent future cerebrovascular events. Until the results of the much-anticipated randomized controlled trials emerge, the jury is still out regarding the optimal management of ACS patients. [ABSTRACT FROM AUTHOR]

Established vascular risk factors (ie, smoking, hypertension, diabetes mellitus, and dyslipidemia) play an important role in the development of vascular disease. Emerging evidence suggests that some of these risk factors may have a more intense effect on specific arterial beds, a finding that holds implications for a prognostic role for certain types of vascular disease. [ABSTRACT FROM AUTHOR]

Objective: To elucidate the clinical relevance of carotid bruits. Methods: A search using PubMed was performed using the terms: 'carotid bruit', 'stroke', 'cerebrovascular symptoms', 'carotid artery stenosis' and 'carotid artery disease' in various combinations. The reference lists of the gathered reports were also considered. Results: Current evidence shows that a carotid bruit is a useful clinical sign with a high specificity (>90%) for the detection of carotid artery stenosis. The negative predictive value (>90%), as well as the accuracy (>90%), of this inexpensive method, are additional advantages. The low sensitivity (<30%) and low positive predictive values (<30%) of carotid auscultation are its main disadvantages. A carotid bruit is also a useful indicator of systemic atherosclerosis. Carotid bruits are also associated with a higher prevalence of vascular risk factors. Discussion: Carotid auscultation is a useful and inexpensive diagnostic tool that should be included as part of a general physical examination. Its clinical relevance in terms of carotid disease, however, needs to be verified by further investigation (e.g. ultrasonography). Since carotid bruits are predictors of systemic atherosclerosis, their detection provides an opportunity to initiate further investigations and preventive measures. [ABSTRACT FROM AUTHOR]

A large number of patients require antiplatelet therapy (mainly aspirin and/or clopidogrel). Recent studies suggest that the combination of these agents is useful in patients with acute coronary syndrome and after percutaneous coronary intervention with stent placement. On the other hand, bleeding complications, most of which arise from the upper gastrointestinal (UGI) tract, can limit the use of antiplatelet drugs. Clopidogrel appears to be associated with fewer UGI side effects and bleeding compared with aspirin. However, a history of previous UGI bleeding is a major risk factor for clopidogrel-associated bleeding. The use of proton-pump inhibitors (PPIs) decreases the rate of UGI bleeding in patients receiving aspirin or clopidogrel. Furthermore, a recent study suggested that the administration of low-dose aspirin plus high-dose esomeprazole (a potent PPI) was associated with fewer episodes of UGI bleeding than clopidogrel alone in patients with a history of recent UGI haemorrhage. However, this study had several limitations and its results should be cautiously extrapolated into clinical practice. The combination of aspirin plus clopidogrel increases the risk of UGI bleeding. Unfortunately, there are no data on the effect of PPI prophylaxis in this setting. Available evidence suggests that where aspirin and/or clopidogrel are to be started or continued in patients with a recent history of UGI ulceration or bleeding (after ulcer healing and eradication of H. pylori infection), treatment with a PPI is a useful precaution. The patients should also be carefully monitored for recurrence of UGI bleeding. [ABSTRACT FROM AUTHOR]