Prevalence of atherothrombotic brain infarction and extracranial carotid arterial disease, and their association in elderly blacks, Hispanics and whites

Prevalence of Atherothrombotic Brain Infarction and Extracranial Carotid Arterial Disease, and Their Association in Elderly Blacks, Hispanics and Whites ’ Wilbert S. Aronow, MD, and Myron R. Schoenfeld, MD lack men are 2.5 times as likely to die of stroke as white men.’ Black women are 2.4 times as likely to B die of stroke as white women.’ In Los Angeles County,

was considered systolic hypertension. A diastolic blood pressure >90 mm Hg on 3 occasions was considered diastolic hypertension. Student’s t test and chi-square analysis were used to analyze data. Table I shows the prevalence of male and female sex and the mean ages in elderly blacks, Hispanics and whites. The mean age and percentage of men and women were not significantly d@erent in elderly blacks, Hispanics and whites. Table I also indicates the prevalence of prior ABI, prior coronary artery disease, prior peripheral arterial disease, ECAD, and systemic hypertension in elderly blacks, Hispanics and whites, and levels of statistical signi&ance.

stroke accounted for a greater percentageof the deaths from cardiovascular diseaseamong blacks and Hispanics than among non-Hispanic whites and Asians.2 Elderly blacks have a higher prevalence of atherothrombotic brain infarction (ABI) than elderly whites or Hispanic~.~Patientswith extracranial carotid arterial disease (ECAD) diagnosed by carotid duplex ultrasonography have at follow-up an increasedincidence of ABLM We are reporting data from a prospective study investigating the prevalence of ECAD with 40 to 100% arterial luminal diameter decreaseand of ABI, and their associaBilateral carotid duplex ultrasonography was pertion in 1,063 elderly blacks, Hispanics and whites. formed in 1,063 of 1,649 unselectedelderly blacks, HisIn a prospective study, technically adequate bilaterpanics and whites in our facility. Data from this study al carotid duplex ultrasonograms were obtained in in the 1,063 patients who had bilateral carotid duplex 1,063 unselected elderly blacks, Hispanics, and whites ultrasonography showed that Al31 occurred significantly in a long-term health care facility Of the 1,063 elder- more often in elderly blacks (50%) than in elderly Hispanics (31%) or whites (24%). If one combines the 586 ly patients, 204 (19%) were black, 42 (4%) were Hispatients who did not have bilateral carotid duplex panic, and 817 (77%) were white. Selection criteria for admission to the facility were similar for blacks, His- ultrasonography with the 1,063 patients who did, the prevalence of ABI was 47% in elderly blacks, 31% in panics and whites. Bilateral carotid duplex ultrasonography was per- elderly Hispanics, and 22% in elderly whites (p I .75 Blacks had a predominance of intracranial vascular lesions.11-14 Heyman et all5 also demonstratedin patients mls = 80 to 99% arterial luminal diameter reduction; Vmax 0.00 mls (no Doppler signal on 22 separate with ischemic stroke that blacks had a higher frequency tests) = 100% arterial luminal diameter reduction. of occlusive diseaseof the intracranial arteries, whereas whites were more likely to have occlusive diseaseof the Prior ABI was diagnosed if the patient had a cliniextracranial arteries. cal history of a documented sudden focal neurologic deficit lasting >24 hours in the absence of a known source of embolism, bloody cerebrospinal fluid, known hypercoagulable conditions, or other diseases causing focal brain deficits. lo ABI was diagnosed if the documented focal neurologic deficit lasted >24 hours and lef residual or no residual fdcal neurologic dejcit. A care@1 neurologic examination was perjormed in each patient for signs of a focal neurologic deficit by a neurologist. The focal neurologic deficit conformed to the typical vascular distribution of an ABI as confirmed by a neurologist. ABI was also confirmed by computerized axial tomography in 298 of 314 patients (95%). Prior coronary artery disease ana! peripheral arterial disease were diagnosed as previously described.3 A systolic blood pressure 2160 mm Hg on 3 occasions From the Hebrew Hospital Home, 2200 Givan Avenue, Bronx, New York 10475, and the Department of Geriatrics and Adult Development, Mount Sinai School of Medicine, New York, New York. Manuscript received August 18, 1992; revised manuscript received and accepted October 1, 1992.

TABLE I Prevalence of Male and Female Sex, Atherothrombotic Brain Infarction (ABI), Extracranial Carotid Arterial Disease (ECAD), Coronary Artery Disease (CAD), Peripheral Arterial Disease (PAD) and Systemic Hypertension, and Mean Ages in Elderly Blacks, Hispanics and Whites Blacks (n = 204) Men Women ABI* ECAD CAD PADt HypertensionS Mean age (year)

55 (27%)

149 (73%) 102 (50%) 29 (14%) 93 (46%) 62 (30%) 103 (50%) 80 k 9 (62-101)

HIspanics (n = 42)

Whites (n = 817)

12 30 13 7 15

239 578 199 139 342

(29%) (71%) (31%) (17%) (36%)

(29%) (71%) (24%) (17%) (42%)

10 (24%)

188 (23%)

15 (36%) 80 k 8 (64-98)

284 (35%) 81 ?8 160-98)

*p
BRIEFREPORTS 999

Data from the uresent study showed that the orevalence of 40 to 100~ ECAD in-elderly patients wi;h and without ABI was similar in elderly blacks (14%), Hispanics (17%) and whites (17%). However, the prevalence of 40 to 100% ECAD in patients with prior ABI was significantly lower in elderly blacks (15%) than in elderly whites (33%), and insignificantly lower in elderly blacks (15%) than in elderly Hispanics (31%). Therefore, the higher prevalenceof ABI in our elderly blacks was due to a higher frequency of occlusive diseaseof the intracranial arteries as previously described.“-‘”

Shk

asvmvtoma~ic internal carotid Dccluion. 1YXh: 17:71X-722. 6.. B&ou\slavsky J. Despland PA, Regli F. Asymptomatic tight steno\i\ of the tntemnl carotid artery: long-term pmgnosi\. Ncwolqq~ 19X6%%-Xh3. 7. Ford CS. Frye JL. T&c JF. Letkowitr D. A\ymptomatic carotid bruit and steno\I\: a prwpectwe li~llow-up wdy. Aw/r Ncwol 1986343:219~222. 6. Amnow WS, Ahn C, Schoenfeld MR. Gut&n H. Extracranial carotid arterial disease: a prognostic factor Ix atherothrombotic brain infarction and cerebral tranuent iwhemic attack. N Y .Srrr/c .I MN/ lYY2:92:424-425. 9. Aronow WS. Schwnfeld MR. Paul P. Rihk factor\ fbr extrxranial internal or common carotid arterial diwax in pcrwn\ aged M) year\ and older. Anr .I Curd/d IYXY:h3:XX I-X82. 10. Aronow WS. Starlmg L. Etiennc F. D’Alba P. Edward\ M. Lee NH, Parungao RF. Sale\ FF. Ri\k fxton for atherothrombonc brain infarction in person\ over 62 year\ of ag!e I” a long-term health care facility. .I An, G‘wbrrr So<, 19X7:35: l-3. 11. Goreltck PB. Csplan LR. Hier DB. Parker SL. Pntel D. Ractnl difference\ in the distribution of anterior circulation occIu\~vc di\ea\e. Ncror&>,q~ IYX4:34:54-59. 12. Caplan L. Babiktan V, Helpawn C. Hier DB. Dewitt D. Pate1 D. Stem R. Occlusive dixae of the middle cerebral anery. Ncrrn~loq~ lYXS:34:97S~YX2. 13. Gorelick PB. Cnplan LR, Hier DB. Pate1 D. Langenlxrg P. Pes\in MS, Biller J. Komack D. Racial differences in the diwibution of pearior circulation occluhive dwxe. Sfr& IYXS: lh:7XS%7YO. 14. Caplan LR. Gorelick PB. Hier DB. Race. hex and IK.CIU\IVC cerebrovaudar disease: o review. So& IYX6: 17:64X+,55. 15. Hevman A, Fields WS. Keating RD. Joint \ludv of extracranial anertnl occluuon. VI. Racial difference\ in ho\iitalinxl patxnt\ wth iwhemic stroke. ./AMA 11)72:222:2X5-2x9.

1. Gillum RF. Stroke in black\.

Stwkc 1YXX:IY: I-Y. 2. Haywood LJ. Hypertension in minority populations. Accen to care. Am .I MaI IYYo:XX(suppl 3B): l7S-20s. 3. Aronow WS. Prevalence of atherothmmbatic brain infarction. coronary anely disease. and peripheral atterial diseae in elderly black\, Hispanic\. and white\. /\nr .I Co,r/id lYY2:70: I2 12-l 2 13. 4. Chamben BR. Norris JW. Outcome in patient\ with aymptomalic neck bruit\. N En,y/ .I Md 19X6:3 1.5:Xh(xxx% 5. Hennerici M. Hulsbomer HB. Rautenberg W. Hefter H. Spontaneow history of

Three-Dimensional Transesophageal Descending Thoracic Aorta John J. Ross, Jr.,

RCPT,

Arthur J. D’Adamo, Dean G. Karalis, MD, and Krishnaswamy Chandrasekaran, MD

ransesophageal2-dimensional echocardiographyprovides high-quality imagesof the thoracic aorta.‘,2AlT though this display technique is generally quite adequate for diagnosis, it does not optimally communicate the 3dimensional nature of the anatomyand the full extent of pathology. Therefore, the purpose of this study was (1) to evaluate the feasibility of generating 3-dimensional images of the descendingthoracic aorta from sequential 2-dimensional transesophagealechocardiographicimages in vivo, and (2) to assessthe optimal display technique to communicate the morphologic information. Transesophageal ec.hoc,a~dioRI-aphi~, images of the aorta were obtained from 3 patients Mith aortic dissection, 3 patients Mith atherosclerotic descending thoracic aor-tic aneurysm, and I patient Mlith a normal aorta using cvmmerr*ially a\wilahle ultrasound equipment. To obtain the cross-sectional images of the aorta, the probe is adlnnced to apprwimately 40 to 45 cm jbom the tip of the incisors. By rotating the scope c,ounter.-c,lot,kMlise the descending thoracic aorta is \isuali:ed. Then. by gentle advancement or withdrawal, the origin of the superior- mesenteric ar.tegl M’as iden@ed. This Maas used as a beginning marker. for data collection. After optimizing the image c,harzrc,ter.istils, L,tnss-set.tional images oj the descending thor-acic aorta w’ere obtained by gradual tiithdraw~al jiom the incisors, in increments c)f 0.5 cm for a length elf IO to 15 cm. Dilated aorta wt seeil in its entire circumference M’as omitted. Sequential c~r.oss-sec~ti(~r7LII images oj thtj aorta jiy)nl %-inch \?deotape M’ere digitized onto a 512 X 482. Xbit matri.v hating 256 gray le\vels. Volume gencrwtiorl From the Likoff Cdrdiovascuhu’ Institute. Hahnemann University Hospital. Cardiac Ultrasound Lab. Broad and Vine. Mail Stop 313. Philadelphia. Pennsylvania 19102. Manuscript received August 24. 1992; revised manuscript received and accepted September 30. lYY2.

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Echo Imaging of the

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,j%m digitized images M’as per,formed on a Sun tiwkstation using ANALYZE sofilare:‘J Sequential cr-ass sections were then concentrated into a single image volume. Individual image slices M’ere slice-edited to retain the aorta. The volume images of the aorta were transferred from Sun wwkstation to a Macintosh Ilci computer for further analysis and display. The wlume image of the aorta can he displayed on the Macintosh Ilci using commerr~ially a\~ailahle Spy-

FlGURE 1. Volume cubs showing the 3 data slices, 1 pixel in thickness, representing each of the 3 dimensions - 0, 1, and 2 - in a patient with a type III aortic dissection. Arrow indicate6 precise coordinates determined from the number of entries (data points) in each dimension. The total number of numbers in the data set would bs equal to the product of the 3 dimensions. APRlL15,1993