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


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


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


CONCLUSIONS
Peripheral endothelial function may improve discrimination in identifying at-risk patients for future cardiovascular events when added to FCVRS-MPS-based risk stratification.
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
Yasushi
Y
Matsuzawa
Department of Clinical Physiology, Department of Molecular and Clinical Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
Sara
S
Svedlund
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
Tatsuo
T
Aoki
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
Raviteja R
RR
Guddeti
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
Taek-Geun
TG
Kwon
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
Rebecca
R
Cilluffo
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
R Jay
RJ
Widmer
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA.
Rebecca E
RE
Nelson
Division of biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, USA.
Ryan J
RJ
Lennon
Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN, USA.
Lilach O
LO
Lerman
Department of Clinical Physiology, Department of Molecular and Clinical Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden.
Sinsia
S
Gao
Division of Cardiology, San Francisco General Hospital, San Francisco, CA, USA; Department of Medicine, University of California, San Francisco, CA, USA.
Peter
P
Ganz
Department of Clinical Physiology, Department of Molecular and Clinical Medicine, Institute of Medicine at Sahlgrenska Academy, University of Gothenburg and Sahlgrenska University Hospital, Gothenburg, Sweden; AstraZeneca R&D, Mölndal, Sweden. Electronic address: li-ming.gan@gu.se.
Li-Ming
LM
Gan
Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA. Electronic address: lerman.amir@mayo.edu.
Amir
A
Lerman
D000368:Aged; D060050:Angina, Stable / Q000175:diagnosis* / Q000503:physiopathology*; D059168:Carotid Intima-Media Thickness / Q000706:statistics & numerical data*; D004730:Endothelium, Vascular / Q000502:physiology*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D016037:Single-Blind Method
Cardiovascular disease; Carotid intima–media thickness; Endothelial function; Framingham Cardiovascular Risk Score; Myocardial perfusion; Noninvasive