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December 29, 2020 — Journal of the American Society of Echocardiography (JASE)



Stress echocardiography (SE) is used for diagnosis and risk stratification of patients with known or suspected coronary artery disease (CAD). Contrast-enhanced ultrasound (CEUS) detects carotid intraplaque neovascularization (IPN).


We hypothesized that combining SE with carotid CEUS in patients with known or suspected CAD may provide incremental prognostic value beyond clinical risk factors and either test alone for the occurrence of cardiovascular events.


185 patients (69 + 8 years; 79% men) with known or suspected CAD referred for SE and found to have carotid plaque on screening were recruited for carotid CEUS imaging. IPN was graded by presence and location within plaque. Patients were followed for cardiovascular events (CVE) including cardiac death, myocardial infarction, unstable angina, transient ischemic attack /stroke. A subset of patients (n=27) underwent carotid magnetic resonance imaging (MRI) within one month of CEUS; carotid plaque was assessed for lipid-rich necrotic core (LRNC %), loose matrix, and presence of intraplaque hemorrhage(IPH).


Sixty-nine patients had abnormal SE. IPN was identified in 112 patients; 52 patients had IPN localized to plaque shoulder (IPNS). Plaques with IPNS had larger LRNC% and were more likely to have IPH. During follow-up (median 31 months), 26 CVE occurred. Multivariate Cox proportional hazard analysis showed IPN and IPNS to be predictors of CVE [hazard ratio (95% CI): 3.34 (1.25-8.93), P=0.02 and 4.88 (1.77-13.49), p=0.002,respectively]. The presence of IPNS increased the likelihood of CVE beyond SE andhistory of CAD (χ2=9.0, p=0.02).


Carotid intraplaque neovascularization detected by CEUS and localized to plaque shoulder, was an independent predictor of CVE in patients referred for stress echocardiography.

Authors: Runqing Huang, Ph.D.1, J. Kevin DeMarco, M.D.2, Hideki Ota, M.D.3, Thanila A. Macedo, M.D.4, Sahar S. Abdelmoneim, MBBCh. MSc MS, John Huston III, M.D.4, Patricia A. Pellikka, M.D.1, Sharon L. Mulvagh, M.D.6

1 Department of Cardiovascular Medicine, Mayo Clinic College of Medicine; 2 Department of Radiology, Walter Reed National Military Medical Center; 3 Department of Diagnostic Radiology, Tohoku University Hospital, Sendai, Japan; 4 Department of Radiology, Mayo Clinic College of Medicine; 5 Department of Cardiology, New York-Presbyterian Hospital; 6 Queen Elizabeth II Health Sciences Center, Halifax, Canada

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