Winter William K, Zorach Benjamin B, Arpin Patrick A, Nelson Jason, Mackey William C
Department of Surgery, Tufts University School of Medicine, Boston, Mass.
Department of Surgery, Tufts University School of Medicine, Boston, Mass.
J Vasc Surg. 2016 Jun;63(6):1505-10. doi: 10.1016/j.jvs.2015.12.051. Epub 2016 Mar 26.
Our goals were to investigate the degree to which patient demographics, risk factors, laboratory data, and medications influence moderate carotid disease progression among patients with asymptomatic moderate carotid disease and whether such associations are solely based on how progression is defined. In addition, we aimed to establish optimal threshold criteria to categorize patients at high risk of progression.
In this retrospective study, 621 arteries were evaluated for internal carotid artery (ICA) stenosis between January 1997 and January 2014 and were determined to have moderate (50%-79%) stenosis via color duplex ultrasonography. "Moderate stenosis" was defined as an ICA peak systolic velocity (PSV) ≥120 cm/s and a diastolic ICA velocity <140 cm/s. Kaplan-Meier analysis of the time to progression was conducted using three independent end points: PSV ≥230 cm/s (liberal criterion); ICA/common carotid artery (CCA) ratio ≥4.0 (moderate criterion), and diastolic ICA velocity ≥140 cm/s (strict criterion). Kaplan-Meier survival curves were generated, and multivariate analysis was performed using Cox regression models. Risk stratification criteria were based on optimal sensitivity and specificity generated from receiver operating characteristic (ROC) curve analysis.
The overall rate of progression was 28.5%, 21.1%, or 5.1% of study-eligible arteries over 5 years using liberal, moderate, or strict criterion, respectively. Using liberal criterion, multivariate analysis suggested that initial PSV ≥200 cm/s, ICA/CCA ratio ≥3, and male gender were significantly associated with progression. Using the moderate criterion, multivariate analysis revealed that initial PSV ≥200 cm/s, ICA/CCA ratio ≥3, age, and male gender were significantly associated with progression. Using the strict criterion, multivariate analysis revealed that initial PSV ≥200 cm/s was the only statistically significant predictor of progression. No additional patient demographics, comorbidities, initial laboratory values, or medications consistently influenced disease progression across any criteria in our study. ROC analysis suggests PSV ≥165 cm/s is an ideal threshold value for the categorization of high risk patients, as this resulted in an optimal screening sensitivity of nearly 91% and a specificity of 59% over 2 years.
The timing and incidence of carotid disease progression depends on the definition of disease progression. Among all three criteria, only severity of disease at initial presentation reliably predicted progression. Based on the results of our ROC curve analysis, we propose that an initial ICA PSV ≥165 cm/s (sensitivity: 90.7%, specificity: 58.7%) represents a reasonable value for defining high progression risk over a 2-year interval.
我们的目标是研究患者人口统计学、风险因素、实验室数据和药物治疗对无症状中度颈动脉疾病患者中度颈动脉疾病进展的影响程度，以及这些关联是否仅基于进展的定义方式。此外，我们旨在建立最佳阈值标准，以对进展高危患者进行分类。
在这项回顾性研究中，对1997年1月至2014年1月期间的621条动脉进行了颈内动脉（ICA）狭窄评估，并通过彩色双功超声确定为中度（50%-79%）狭窄。“中度狭窄”定义为ICA收缩期峰值流速（PSV）≥120 cm/s且舒张期ICA流速<140 cm/s。使用三个独立终点对进展时间进行Kaplan-Meier分析：PSV≥230 cm/s（宽松标准）；ICA/颈总动脉（CCA）比值≥4.0（中度标准），以及舒张期ICA流速≥140 cm/s（严格标准）。生成Kaplan-Meier生存曲线，并使用Cox回归模型进行多变量分析。风险分层标准基于受试者操作特征（ROC）曲线分析产生的最佳敏感性和特异性。
使用宽松、中度或严格标准，符合研究条件的动脉在5年内的总体进展率分别为28.5%、21.1%或5.1%。使用宽松标准，多变量分析表明初始PSV≥200 cm/s、ICA/CCA比值≥3和男性性别与进展显著相关。使用中度标准，多变量分析显示初始PSV≥200 cm/s、ICA/CCA比值≥3、年龄和男性性别与进展显著相关。使用严格标准，多变量分析显示初始PSV≥200 cm/s是唯一具有统计学意义的进展预测因素。在我们的研究中，没有其他患者人口统计学、合并症、初始实验室值或药物治疗在任何标准下持续影响疾病进展。ROC分析表明，PSV≥165 cm/s是对高危患者进行分类的理想阈值，因为在2年内这导致了近91%的最佳筛查敏感性和59%的特异性。
颈动脉疾病进展的时间和发生率取决于疾病进展的定义。在所有三个标准中，只有初始表现时的疾病严重程度可靠地预测了进展。基于我们的ROC曲线分析结果，我们建议初始ICA PSV≥165 cm/s（敏感性：90.7%，特异性：58.7%）代表在2年间隔内定义高进展风险的合理值。
