From the Laboratory of Clinical Investigation (Y.M., J.M.) and Laboratory
of Cardiovascular Science (E.G.L., J.L.F.), Gerontology Research Center,
National Institute on Aging, National Institutes of Health, Baltimore, Md;
Department of Neurology, Johns Hopkins Bayview Medical Center (C.J.E.,
M.K.K.); and Division of Cardiology, Johns Hopkins University School of
Medicine (L.C.B.), Baltimore, Md.
Correspondence to E. Jeffrey Metter, MD, Laboratory of Clinical Investigation, Gerontology Research Center-Box 06, 5600 Nathan Shock Dr, Baltimore, MD 21224. E-mail jeffrey{at}vax.grc.nia.nih.gov
Methods and Results—CCA IMT was measured by B-mode ultrasound in
community-dwelling volunteers from the Baltimore Longitudinal Study of
Aging, including 397 healthy subjects (age, 58.5±15.8 years) with
normal ECG responses to maximum treadmill exercise, 72
asymptomatic subjects (age, 66.1±13.4 years) with
exercise-induced horizontal or downsloping ST-segment depression
Conclusions—CCA IMT is increased in older subjects with
asymptomatic myocardial ischemia as evidenced by
exercise ECG alone or in combination with thallium scan. Carotid
ultrasound may help to identify asymptomatic individuals
with CAD.
B-mode ultrasonography allows for the noninvasive observation of
age-associated normative and pathological changes in the carotid
arterial structure, including wall
thickening5 6 and lumen
enlargement.7 8 An association has been
demonstrated between increased intimal-medial thickness (IMT) of the
common carotid artery (CCA) and conventional atherosclerotic risk
factors, including hypertension,9 10
diabetes,11 12
hyperlipidemia,13 14 and
cigarette smoking.15 16 Furthermore, several
studies have shown a significant association of CCA IMT not only with
cerebrovascular disease but also with clinical
CAD.6 17
Despite the association between increased CCA IMT and clinically
manifest CAD, it is unclear whether increased IMT also occurs in
subjects with subclinical CAD. We hypothesized that CCA IMT would be
increased in asymptomatic subjects with exercise-induced
myocardial ischemia. To examine this hypothesis, we performed
B-mode carotid ultrasonography and maximal treadmill exercise ECG
testing in a sample of apparently healthy community-dwelling
volunteers. To amplify the hypothesis, we performed exercise thallium
scintigraphy in those asymptomatic subjects
with positive (ie, ischemic) exercise ECGs and compared IMT in
the subsets defined by the thallium results.
The aim of this study was therefore to determine (1) whether CCA IMT is
increased in asymptomatic subjects with an exercise-induced
ischemic ST-segment depression and (2) whether among these
asymptomatic individuals with ischemic exercise
ECG, CCA IMT is larger in the subset with an abnormal exercise thallium
scan than in those with a negative scan.
Treadmill exercise testing has been used in the BLSA since 1969 to
screen for silent CAD. In 1977, exercise thallium
scintigraphy was incorporated into the BLSA and has been
offered to subjects >40 years at 8- to 10-year
intervals.1 Carotid and cerebral artery
ultrasound examinations were added to the BLSA evaluation in 1994.
Inclusion criteria for the current study were (1) achievement of
Carotid Ultrasonography
Maximal Treadmill Exercise ECG
Exercise Thallium Scintigraphy
Assessment of CAD
Statistical Analysis
A progressive increase in CCA IMT was observed from no CAD
(0.52±0.14 mm) to possible CAD (0.64±0.13 mm) and to
definite CAD (0.75±0.16 mm) subjects (Figure 1
Association of CCA IMT With Coronary Risk Factors and
CAD Status
To further clarify the significant associates of CCA IMT, IMT was
regressed on age, sex, other coronary risk factors, and their
respective medications (Table 3
CCA IMT in Possible CAD Subjects Stratified by Thallium
Scintigraphic Findings
Among the 43 subjects undergoing thallium scanning, 30 had negative
scans and were classified as possible CAD-1 (positive exercise ECG
alone), and 13 had positive scans and were classified as possible CAD-2
(concordant positive exercise ECG and thallium results). Only 2 women
were possible CAD-2 subjects, making sex comparisons impossible. A
graded increase in IMT was observed from subjects with no CAD
(0.52±0.14 mm) to those classified as possible CAD-1
(0.61±0.12 mm) to possible CAD-2 (0.74±0.10 mm) (Figure 2
Prediction of CAD by CCA IMT
A positive association between carotid and coronary
atherosclerosis is well
recognized.23 24 The increase in IMT from no CAD
to possible CAD to definite CAD is consistent with the concept
that coronary atherosclerosis is a continuum
from normal through an asymptomatic stage to overt CAD.
Furthermore, the asymptomatic CAD was independently
associated with increased CCA IMT (Table 3
To further stratify the likelihood of asymptomatic CAD in
the possible CAD group, we subdivided this group on the basis of their
exercise thallium scintigraphic findings. A prior study from our
laboratory demonstrated that concordant positive exercise ECG and
thallium test results identify a subset of asymptomatic
subjects at twice the risk for CAD events as those with a positive ECG
alone,1 with
If CCA IMT increases in parallel with the likelihood of CAD, this
association may be useful in identifying asymptomatic
subjects with significant CAD. We have considered manifest CAD and
asymptomatic CAD (confirmed by the concordant positive
exercise ECG and thallium results) as essentially the same clinical
entity on the basis of our prior observations.1
On univariate analysis, the likelihood for CAD
increased by 2.39-fold for each 0.1-mm increase in IMT. Furthermore,
IMT was an independent predictor for CAD, increasing the risk by
1.91-fold for each 0.1 mm when controlling for the significant
effects of age, hypertensive, and hyperlipidemic
medications (Table 5
The increase in IMT with the likelihood of CAD appears to be similar
for both women and men. Men have thicker IMT than women at all levels
of CAD status, but the degree of thickening going from no CAD to
possible to definite CAD was similar by sex. In the multiple regression
analysis (Table 3
Although the overlap of CCA IMT between non-CAD and CAD subjects
(Figure 1
In addition, regression or slowed progression of IMT has been reported
in subjects on lipid-lowering therapy.27 If IMT
changes in parallel with the progression of CAD, serial measurement of
IMT may serve as a noninvasive marker for the efficacy of risk factor
modification with antihypertensive28 and
lipid-lowering therapy.27
Prior studies have shown independent effects of age and conventional
coronary risk factors on CCA IMT.9 10 11 12 13 14 15 16 In
the present study, IMT increased with age, systolic BP,
diastolic BP, and each lipid measure (Table 2
One limitation of the present study was a reliance on exercise ECG
and thallium scintigraphy to stratify the likelihood of
CAD. Although the ability of these exercise testing modalities to
identify asymptomatic individuals at higher risk for a
future coronary event has been shown in the
BLSA1 3 and in other
studies,2 29 such noninvasive stratification is
imperfect.
In summary, this study demonstrates a significant association between
asymptomatic exercise-induced myocardial ischemia
and increased CCA IMT, similar to that seen in patients with manifest
CAD. Although the primary purpose of carotid ultrasonography is not the
detection of CAD, determination of IMT may help to identify
asymptomatic individuals with a high likelihood for CAD and
provide a noninvasive window for monitoring the efficacy of risk factor
modification in these subjects.
Received January 28, 1998;
revision received June 10, 1998;
accepted June 13, 1998.
© 1998 American Heart Association, Inc.
Clinical Investigation and Reports
Increased Carotid Artery Intimal-Medial Thickness in Asymptomatic Older Subjects With Exercise-Induced Myocardial Ischemia
Abstract
Top
Abstract
Introduction
Methods
Results
Discussion
References
Background—Previous studies have
shown an association between symptomatic coronary
artery disease (CAD) and increased intimal-medial thickness of the
common carotid artery (CCA IMT), a purported index of
atherosclerosis. This study determines whether CCA IMT
is increased in asymptomatic older subjects with an
ischemic ST-segment response to treadmill exercise. 
1 mm, and 38 subjects (age, 77.4±7.8 years) with clinically
manifest CAD as diagnosed by medical history and resting ECG.
Forty-three subjects with abnormal exercise ECGs also underwent
exercise thallium scintigraphy. Exercise-induced ST-segment
depression was associated with increased IMT (P<0.0001)
independent of age and manifest CAD. After adjustment for age, IMT
values progressively increased from healthy subjects to
asymptomatic subjects with positive exercise ECG alone to
those with concordant positive ECG and thallium scintigraphic findings
who had virtually identical IMT to subjects with manifest CAD. Each
0.1-mm increase in IMT was associated with a 1.91-fold (95% CI, 1.46
to 2.50; P<0.0001) increased risk for concordant
positive exercise tests or manifest CAD, independent of other
significant predictors of CAD.
Key Words: coronary disease • carotid arteries • ultrasonics • exercise • risk factors
Introduction
Top
Abstract
Introduction
Methods
Results
Discussion
References
Asymptomatic coronary artery disease
(CAD) is prevalent in the general population,1 2
and individuals with CAD are at greater risk than those who are disease
free to progress to symptomatic CAD and cardiac
death.1 2 Early identification and preventive
treatment for asymptomatic CAD can potentially lower the
risk for subsequent symptomatic CAD. The exercise ECG
remains the most commonly used screening method to detect
asymptomatic myocardial ischemia. Numerous studies
have shown that an ischemic ST-segment response to exercise is
a risk factor for future coronary events in apparently healthy
adults.1 2 3 Moreover, the predictive value of
exercise ECG is improved by a combined use of thallium
scintigraphy.1 4
Methods
Top
Abstract
Introduction
Methods
Results
Discussion
References
Subjects
Subjects were recruited from the Baltimore Longitudinal Study of
Aging (BLSA).18 The BLSA is made up of
community-dwelling, predominantly white, college-educated volunteers
who are studied approximately every 2 years with 2.5 days of extensive
medical, physiological, and psychological
examinations. The BLSA was started in 1958 and has recruited
participants continuously since that time. 85%
of age-predicted maximal heart rate on treadmill exercise testing in
subjects without clinical CAD and (2) no stenosis 50% or
localized plaque in the CCA proximal to the bifurcation as detected by
duplex carotid ultrasonography. Both exercise testing and carotid
ultrasound protocols were approved by the Johns Hopkins Bayview
Institutional Review Board, and informed consent was obtained from all
subjects.
High-resolution B-mode carotid ultrasonography was performed by
use of a linear-array 5- to 10-MHz transducer (Ultramark 9 HDI,
Advanced Technology Laboratories, Inc). The subject lay in the supine
position in a dark, quiet room. Blood pressure (BP) was measured at
5-minute intervals during the measurements (Critikon 1846SX/P, version
085, Dinamap). The stabilized BP after 15 minutes from the onset of
testing was used for subsequent analyses. The right CCA was
examined with the head tilted slightly upward in the midline position.
The transducer was manipulated so that the near and far walls of the
CCA were parallel to the transducer footprint and the lumen diameter
was maximized in the longitudinal plane. A region 
1.5 cm proximal to
the carotid bifurcation was identified, and the IMT of the far wall was
evaluated as the distance between the luminal-intimal interface and the
medial-adventitial interface. IMT was measured on the frozen frame of a
suitable longitudinal image with the image magnified to achieve a
higher resolution of detail. The IMT measurement was obtained from 5
contiguous sites at 1-mm intervals, and the average of the 5
measurements was used for analyses. All the measurements were
performed by a single sonographer (M.K.K.) who was unaware of the
findings of the exercise ECG or thallium scintigraphy.
Intrarater correlation between repeated IMT measurements from 10
subjects was 0.96 (P<0.001), with similar averages for the
2 sets of readings (0.47±0.13 versus 0.45±0.12 mm,
P=NS).
Maximal treadmill exercise testing was conducted according to a
modified Balke protocol19 in which the treadmill
speed was held constant (usually 3.5 mph for men and 3.0 mph for women)
and the elevation was raised 3% every 2 minutes, starting from
horizontal, until exhaustion. A 12-lead ECG was recorded during the
final 30 seconds of each 2-minute stage and every 2 minutes for at
least 6 minutes of recovery. The exercise ECG was interpreted according
to Minnesota Code criteria.20 A positive ECG
response for ischemia was defined as horizontal or downsloping
ST-segment depression 1 mm. Lesser degrees of ST-segment
depression were interpreted as negative.
The test was performed in the Johns Hopkins Hospital Nuclear
Cardiology Laboratory with the identical maximal
treadmill exercise protocol.21
201Tl (3 mCi IV) was injected 1 minute before
anticipated exercise cessation. After 5 to 10 minutes of postexercise
ECG monitoring, myocardial scanning was begun. Tomographic imaging was
performed with a Technicare Omega 500 rotating, large-field-of-view
camera interfaced to a Technicare 560 computer. Delayed imaging was
performed 3 hours later without reinjection of thallium. Image
interpretation was performed visually by an experienced nuclear
cardiologist (L.C.B.) who was unaware of the clinical history, carotid
ultrasound results, and exercise ECG findings. Results were coded as
positive or negative for reversible ischemia. A positive
thallium tomogram was defined by a segmental perfusion defect on the
immediate postexercise images in at least 2 contiguous tomographic
slices and 2 image orientations, with definite improvement or
normalization on the delayed images.
On the basis of medical history, resting ECG, maximal treadmill
exercise ECG, and clinical symptomatology, subjects were classified
into 3 CAD categories: no CAD, possible CAD, and definite CAD. The no
CAD group comprised subjects with no history of angina pectoris or
myocardial infarction and without pathological Q waves or
exercise-induced horizontal or downsloping ST-segment depression
1 mm. Possible CAD was defined by asymptomatic
ischemic ST-segment depression 1 mm but without clinical
symptoms or resting ECG evidence of myocardial infarction. The results
of thallium scintigraphy were used to further stratify
possible CAD subjects into 2 subsets: group 1, possible CAD-1, with a
positive exercise ECG but negative thallium scan, and group 2, possible
CAD-2, with concordant positive exercise ECG and thallium scan. We
analyzed only those subjects who had undergone thallium
scintigraphy within 5 years of the carotid examination
(mean, 2.0±1.9 years). Definite CAD was diagnosed by a history of
acute myocardial infarction, silent infarction documented by
significant Q waves on ECG (Minnesota Code 1:1 or 1:2), or unequivocal
angina pectoris as defined by the Rose
questionnaire.22 These individuals did not
undergo exercise testing.
Intergroup differences in age, coronary risk factors,
and CCA IMT were examined by 1-way ANOVA followed by Bonferroni's
multiple-comparisons test. The risk factors considered in this study
were male sex, body mass index (BMI), systolic BP,
diastolic BP, fasting plasma glucose (FPG), serum total
cholesterol (TChol), TChol/HDL cholesterol
ratio (TChol/HDL), LDL cholesterol (LDL-C), and smoking.
Smoking status was categorically defined on the basis of self-reports,
with a smoker defined by current or past smoking 10 cigarettes per
day. The association of IMT with coronary risk factors and CAD
status was evaluated by multiple regression analyses. The
association of IMT with thallium scintigraphic findings was assessed by
the differences in age-adjusted mean IMT. The ability of IMT to predict
CAD was examined by logistic regression analysis. Data are
presented as mean±SD unless otherwise specified, and a
2-tailed P<0.05 was considered statistically significant.
All analyses were performed by use of SPSS for Windows 6.1.
Results
Top
Abstract
Introduction
Methods
Results
Discussion
References
Baseline Characteristics Stratified by CAD Status
CCA IMT and CAD status were evaluated in 507 subjects, including
261 men (age, 64.0±15.7 years; range, 25 to 95 years) and 246 women
(age, 57.8±15.6 years; range, 27 to 93 years). Baseline
characteristics for the no CAD, possible CAD, and definite CAD groups
are shown in Table 1
. A stepwise
increase in age was seen across the 3 groups. The percentage of men and
systolic BP were higher in the 2 CAD groups than in the no CAD
group, whereas FPG was higher in the definite CAD than in the no CAD
group. The percentage of subjects on antihypertensive medication was
higher in the definite CAD group (63%) than in the no CAD (16%) or
possible CAD (26%) group, whereas subjects on lipid-lowering drugs
increased from the no CAD (4%) to the possible CAD (13%) to the
definite CAD (29%) group. A higher percentage of definite CAD subjects
was taking diabetic medication (11%) than no CAD (2%) or possible CAD
(6%) subjects.
View this table:
[in a new window]
Table 1. Baseline Characteristics by CAD
Status ). The relative increase in IMT was
similar for women (0.49, 0.61, and 0.67 mm) and men (0.55, 0.65,
and 0.78 mm) in the no CAD, possible CAD, and definite CAD groups,
although IMT was larger in men than in women (0.60±0.17 versus
0.52±0.13 mm, P<0.001) across CAD categories.
View larger version (51K):
[in a new window]
Figure 1. CCA IMT by CAD status defined by exercise ECG and
clinical manifestations. Group definitions are as follows: no CAD,
subset with negative clinical history and normal exercise ECG; possible
CAD, subset with negative clinical history but ischemic
exercise ECG; and definite CAD, subset with angina pectoris, a history
of myocardial infarction, and/or pathological Q waves in resting ECG.
Error bars indicate SD.
By univariate regression analysis, CCA IMT
increased with age, systolic BP, diastolic BP, FPG,
and each lipid measure but not with BMI (Table 2). A quadratic term was also examined
for each variable, but the explicable variance was similar to that
obtained by linear regression. IMT also was larger in smokers than in
nonsmokers (0.59±0.15 versus 0.55±0.16 mm,
P<0.01).
View this table:
[in a new window]
Table 2. Univariate Regressions of Coronary Risk Factors on
CCA
IMT ). By
backward elimination, medications, smoking, TChol, FPG, LDL-C,
diastolic BP, and BMI did not significantly contribute to
the models and are not shown in the table. Larger CCA IMT was
associated with older age (ß=0.59, P<0.0001), male sex
(ß=0.08, P<0.05), higher systolic BP (ß=0.15,
P<0.0001), and higher TChol/HDL (ß=0.08,
P<0.05) (Table 3, model 1). When CAD status was added to
the original model, age had the strongest association with IMT
(ß=0.53, P<0.0001), followed by definite CAD (ß=0.20,
P<0.0001), possible CAD (ß=0.14, P<0.0001),
systolic BP (ß=0.14, P<0.0001), and TChol/HDL
(ß=0.09, P<0.01) (Table 3, model 2), with overall
r2 improving from 0.50 to 0.55. Sex and CAD
status had no interaction with age or other continuous variables.
Furthermore, no sex differences were found in predicting IMT with CAD
status included (Table 3, model 2).
View this table:
[in a new window]
Table 3. Multiple Regression of CCA IMT on Age, Coronary Risk
Factors, and CAD Status
To further clarify the relationship between CCA IMT and CAD
status, we further stratified possible CAD subjects by exercise
thallium scintigraphic findings. Sixty percent of possible CAD subjects
(43 of 72) underwent thallium scans. Coronary risk factors and
CCA IMT were similar between subjects with thallium scan results and
those without them (data not shown). ). These group differences in IMT
remained significant after adjustment for age (Table 4). Of note, the IMT in possible CAD-2
subjects was virtually identical to that in the definite CAD group.
View larger version (22K):
[in a new window]
Figure 2. CCA IMT by CAD status defined by exercise ECG,
thallium scintigraphy, and clinical manifestations. Group
definitions are as follows: possible CAD-1, subset with positive
exercise ECG but negative thallium scan; possible CAD-2, subset with
concordant positive exercise ECG and thallium scan; and no CAD and
definite CAD as defined in Figure 1 
. Each point represents the
mean IMT of subjects in a given age decade for a specific CAD category
(*50s and 60s combined for possible CAD-2; 
70s and 80s combined for
possible CAD-1; and 
80s and 90s combined for no CAD and definite
CAD). Error bars indicate SE; numbers in parentheses indicate number of
subjects represented by each data point. After adjustment
for age, IMT significantly increased from no CAD to possible CAD-1 to
possible CAD-2 but did not differ between possible CAD-2 and definite
CAD (see Table 4 for statistics).
View this table:
[in a new window]
Table 4. CCA IMT by CAD Status Defined by Exercise ECG,
Thallium Scintigraphy, and Clinical
Manifestations
To examine the contribution of CCA IMT in predicting CAD, we
performed a logistic regression analysis with both possible
CAD-2 and definite CAD as end points. In this analysis, the
univariate risk for CAD increased by 2.39-fold
(
2=84.0; P<0.0001; 95% CI, 1.92
to 2.96) for each 0.1-mm increase in IMT compared with no CAD subjects.
Furthermore, IMT was an independent predictor for CAD when controlling
for age, coronary risk factors, and their respective
medications. With backward elimination, each 0.1-mm-greater IMT
independently increased the risk for CAD by 1.91 (1.46 to 2.50) in the
most parsimonious model (Table 5). No interaction was observed
among these variables.
View this table:
[in a new window]
Table 5. Multiple Logistic Regression for Predicting Coronary
Artery Disease, Defined by Either Possible CAD-2 or Definite
CAD
Discussion
Top
Abstract
Introduction
Methods
Results
Discussion
References
The present study demonstrates a significant independent
association between increased IMT and asymptomatic CAD as
evidenced by ischemic ST-segment depression on the exercise
ECG. Furthermore, there was a graded increase in IMT from CAD-free
subjects to those with only a positive exercise ECG to those with
concordant positive exercise ECG and thallium scans. These last
individuals had an IMT that was essentially equal to that in patients
with clinically manifest CAD. By logistic regression analysis,
CCA IMT proved to be an independent predictor for manifest CAD and
concordant positive exercise test results. ), suggesting that not only
subjects with clinically manifest CAD but also those with evidence for
asymptomatic CAD have increased IMT. 50% of these "double
positives" developing clinical end points over a mean follow-up of
4.6 years.2 In the present study, after
adjustment for age, a graded increase in IMT was observed from CAD-free
subjects to those with only a positive exercise ECG to those with
concordant positive ECG and thallium tests (Table 4). Thus, CCA IMT
appears to increase in parallel with the increase in risk for
myocardial ischemia as assessed by these noninvasive tests. It
is noteworthy that this latter subset with asymptomatic
ischemia on both exercise ECG and thallium scan demonstrated a
mean IMT virtually identical to that in the group with manifest CAD
(Figure 2). ). , model 2), sex did not add to the prediction
of IMT when stage of CAD was included. Also, sex did not affect the
prediction of CAD by IMT (Table 3). However, with only 8 women
with definite CAD and 2 women with possible CAD- 2, our power to detect
sex differences was limited in Table 3. ) precludes the use of IMT alone as a diagnostic
marker for CAD, our observation suggests the utility of further
screening for CAD in subjects with increased IMT, even if
asymptomatic. As suggested in Table 5, such
screening would likely be most useful in older subjects with
hypertension or hyperlipidemia. The threshold for
exercise screening will depend on factors such as the pretest
likelihood of CAD, the age and lifestyle of the individual, and the
cost of exercise testing. Although aggressive medical or surgical
treatment of silent myocardial ischemia has proven beneficial
in patients with symptomatic
CAD,25 26 the utility of such therapy in totally
asymptomatic subjects remains unclear. ) and was
larger in men and in smokers. However, independent associations were
confirmed only with age, systolic BP, male sex, and TChol/HDL
(Table 3, model 1). Age, systolic BP, and TChol/HDL remained
significant predictors of IMT even after CAD status was included in the
model (Table 3, model 2), suggesting their strong atherogenic effects.
The relatively low mean levels of FPG, TChol, and LDL-C in the BLSA
subjects, as well as the low prevalence of smokers, probably account
for their weak associations with IMT.
Acknowledgments
This research was done as a part of the intramural research
program of the National Institute on Aging. We are grateful to the
participants of the BLSA who were willing to undergo exercise testing
and carotid ultrasonography.
References
Top
Abstract
Introduction
Methods
Results
Discussion
References
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A. Scuteri, S. S. Najjar, D. C. Muller, R. Andres, H. Hougaku, E. J. Metter, and E. G. Lakatta Metabolic syndrome amplifies the age-associated increases in vascular thickness and stiffness J. Am. Coll. Cardiol., April 21, 2004; 43(8): 1388 - 1395. [Abstract] [Full Text] [PDF]
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A. Scuteri, T. A. Manolio, E. K. Marino, A. M. Arnold, and E. G. Lakatta Prevalence of specific variant carotid geometric patterns and incidence of cardiovascular events in older persons: The cardiovascular health study (CHS E-131) J. Am. Coll. Cardiol., January 21, 2004; 43(2): 187 - 193. [Abstract] [Full Text] [PDF]
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S. Alan, M. S. Ulgen, O. Ozturk, B. Alan, L. Ozdemir, and N. Toprak Relation Between Coronary Artery Disease, Risk Factors and Intima-Media Thickness of Carotid Artery, Arterial Distensibility, and Stiffness Index Angiology, May 1, 2003; 54(3): 261 - 267. [Abstract] [PDF]
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 Z. A. Fayad and V. Fuster Clinical Imaging of the High-Risk or Vulnerable Atherosclerotic Plaque Circ. Res., August 17, 2001; 89(4): 305 - 316. [Abstract] [Full Text] [PDF]
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C. R. Sirtori, L. Calabresi, G. Franceschini, D. Baldassarre, M. Amato, J. Johansson, M. Salvetti, C. Monteduro, R. Zulli, M. L. Muiesan, et al. Cardiovascular Status of Carriers of the Apolipoprotein A-IMilano Mutant : The Limone sul Garda Study Circulation, April 17, 2001; 103(15): 1949 - 1954. [Abstract] [Full Text] [PDF]
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W. F. Terpstra, J. F. May, A. J. Smit, P. A. de Graeff, F. H. Schuurman, B. M.-d. Jong, and H. J. G. M. Crijns Silent ST Depression and Cardiovascular End-Organ Damage in Newly Found, Older Hypertensives Hypertension, April 1, 2001; 37(4): 1083 - 1088. [Abstract] [Full Text] [PDF]
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P. M. Okin, M. J. Roman, and R. B. Devereux Exercise-Induced Ischemia and Carotid Atherosclerosis Circulation, December 14, 1999; 100 (24): e119 - e119. [Full Text] [PDF]
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Y. Nagai, E J. Metter, and J. L Fleg Increased carotid artery intimal-medial thickness: risk factor for exercise-induced myocardial ischemia in asymptomatic older individuals Vascular Medicine, August 1, 1999; 4(3): 181 - 186. [Abstract] [PDF]
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 A. Festa, R. D'Agostino Jr, P. Rautaharju, D. H. O'Leary, M. Rewers, L. Mykkanen, and S. M. Haffner Is QT Interval a Marker of Subclinical Atherosclerosis in Nondiabetic Subjects? : The Insulin Resistance Atherosclerosis Study (IRAS) Stroke, August 1, 1999; 30(8): 1566 - 1571. [Abstract] [Full Text] [PDF]
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