@article {749, title = {Distribution and correlates of sonographically detected carotid artery disease in the Cardiovascular Health Study. The CHS Collaborative Research Group.}, journal = {Stroke}, volume = {23}, year = {1992}, month = {1992 Dec}, pages = {1752-60}, abstract = {

BACKGROUND AND PURPOSE: This article describes the prevalence of extracranial carotid atherosclerosis assessed by ultrasonography, its association with risk factors, and its relation to symptomatic coronary disease and stroke in men and women aged > or = 65 years.

METHODS: Maximum percent stenosis, maximum common carotid artery wall thickness, and maximum internal carotid artery wall thickness were assessed using duplex ultrasound in 5,201 men and women aged > or = 65 years in the Cardiovascular Health Study, a study of the risk factors and natural history of cardiovascular disease in the elderly. Existing coronary disease and stroke were assessed by physical examination and participant history.

RESULTS: Detectable carotid stenosis was present in 75\% of men and 62\% of women, although the prevalence of > or = 50\% stenosis was low, 7\% in men and 5\% in women. Maximum stenosis and maximum wall thickness measurements increased with age and were uniformly greater at all ages in men than in women (p < 0.00001). Established risk factors for atherosclerosis (hypertension, smoking, diabetes) and indications of vascular disease (left ventricular hypertrophy, major electrocardiographic abnormality, bruits, and history of heart disease or stroke) related to all three carotid artery measures in the elderly. Of the three ultrasound measures, the best correlate for a history of coronary disease was maximum internal carotid artery wall thickness. For stroke the best correlate was common carotid artery wall thickness. Multiple logistic regression models of prevalent coronary heart disease and stroke that included the ultrasound findings indicated, after adjustment for age and sex, that maximum internal wall thickness and maximum common carotid wall thickness were significant correlates of both. Maximum stenosis did not add significantly to the correlation.

CONCLUSIONS: In the elderly the incidence of carotid atherosclerosis was high, although the frequency of severe disease was low. The prevalence and severity of carotid atherosclerosis continued to increase with age even in the late decades of life, and more disease was found in men than in women at all ages. Known risk factors for atherosclerosis continued to relate to carotid abnormalities in the later decades of life, both in symptomatic and asymptomatic subjects.

}, keywords = {Aged, Arteriosclerosis, Cardiomegaly, Carotid Artery Diseases, Cerebrovascular Disorders, Coronary Disease, Female, Humans, Male, Medical Records, Prevalence, Regression Analysis, Risk Factors, Ultrasonography}, issn = {0039-2499}, doi = {10.1161/01.str.23.12.1752}, author = {O{\textquoteright}Leary, D H and Polak, J F and Kronmal, R A and Kittner, S J and Bond, M G and Wolfson, S K and Bommer, W and Price, T R and Gardin, J M and Savage, P J} } @article {1431, title = {Assessment of cerebrovascular disease in the Cardiovascular Health Study.}, journal = {Ann Epidemiol}, volume = {3}, year = {1993}, month = {1993 Sep}, pages = {504-7}, abstract = {

The Cardiovascular Health Study (CHS) is a longitudinal population-based study of coronary heart disease and stroke in men and women 65 years and older. The initial CHS cohort consisted of 5201 men and women recruited from a random sample of the Health Care Financing Administration (HCFA) Medicare eligibility lists in four communities in the United States. Extensive historical, physical, and laboratory evaluations were performed at the baseline examination in 1989 to 1990 to identify risk factors and subclinical disease. Periodic contacts are carried out to ascertain and verify incident cardiac and stroke events and their sequelae. Since only a short time has passed since entry of all the patients into the study, data are not available on time trends in the mortality rate of stroke, but we expect to contribute in this area in the years ahead. This article then is a description of the CHS, of methods of assessing stroke in the CHS cohort, and of prevalence of stroke and transient ischemic attacks at the initial examination.

}, keywords = {Aged, Aged, 80 and over, Cerebrovascular Disorders, Cohort Studies, Coronary Disease, Female, Humans, Ischemic Attack, Transient, Longitudinal Studies, Male, Prevalence}, issn = {1047-2797}, author = {Price, T R and Psaty, B and O{\textquoteright}Leary, D and Burke, G and Gardin, J} } @article {1440, title = {Sonographic evaluation of carotid artery atherosclerosis in the elderly: relationship of disease severity to stroke and transient ischemic attack.}, journal = {Radiology}, volume = {188}, year = {1993}, month = {1993 Aug}, pages = {363-70}, abstract = {

Doppler and real-time ultrasound (US) were performed to evaluate the extent of atherosclerotic changes in the carotid artery and to assess their relationship to prevalent cerebrovascular disease. Real-time US scans and Doppler measurements of the carotid arteries were analyzed in 5,201 subjects aged 65 years or older. Severity of atherosclerotic lesions was associated with increased frequencies of hyperechoic, irregular, and heterogeneous textured lesions (P < .0001). The severity of internal carotid artery stenosis was associated with thickening of the intima-media layer of the common carotid artery wall (r = .37, P < .0001). A history of stroke and transient ischemic attack (TIA) was more likely when hyperechoic, heterogeneous, and irregular lesions were seen in the carotid artery. Internal carotid artery stenosis correlated better with prevalent stroke and TIA than did sonographic descriptions of plaque texture. However, the prevalence of hyperechoic, heterogeneous, and irregular lesions increased as the degree of internal carotid stenosis increased. On real-time images alone, the average of the internal carotid artery maximal wall thickness is the sonographic measure of atherosclerosis that enables the best prediction of prevalent stroke and TIA.

}, keywords = {Aged, Arteriosclerosis, Carotid Artery Diseases, Carotid Artery, Internal, Carotid Stenosis, Cerebrovascular Disorders, Female, Humans, Ischemic Attack, Transient, Male, Ultrasonography}, issn = {0033-8419}, doi = {10.1148/radiology.188.2.8327679}, author = {Polak, J F and O{\textquoteright}Leary, D H and Kronmal, R A and Wolfson, S K and Bond, M G and Tracy, R P and Gardin, J M and Kittner, S J and Price, T R and Savage, P J} } @article {1449, title = {Methods of assessing prevalent cardiovascular disease in the Cardiovascular Health Study.}, journal = {Ann Epidemiol}, volume = {5}, year = {1995}, month = {1995 Jul}, pages = {270-7}, abstract = {

The objective of this article is to describe the methods of assessing cardiovascular conditions among older adults recruited to the Cardiovascular Health Study (CHS), a cohort study of risk factors for coronary disease and stroke. Medicare eligibility lists from four US communities were used to obtain a representative sample of 5201 community-dwelling elderly, who answered standardized questionnaires and underwent an extensive clinic examination at baseline. For each cardiovascular condition, self-reports were confirmed by components of the baseline examination or, if necessary, by a validation protocol that included either the review of medical records or surveys of treating physicians. Potential underreporting of a condition was detected either by the review of medical records at baseline for other self-reported conditions or, during prospective follow-up, by the investigation of potential incident events. For myocardial infarction, 75.5\% of the self-reports in men and 60.6\% in women were confirmed. Self-reported congestive heart failure was confirmed in 73.3\% of men and 76.6\% of women; stroke, in 59.6\% of men and 53.8\% of women; and transient ischemic attack, in 41.5\% of men and 37.0\% of women. Underreporting was also common. During prospective follow-up of an average of about 3 years per person, approximately 50\% of men and 38\% of women were hospitalized or investigated for at least one potential incident event; for each cardiovascular condition, about 1 to 4\% of those investigated during prospective follow-up were found to have had the cardiovascular condition prior to entry into the cohort.(ABSTRACT TRUNCATED AT 250 WORDS)

}, keywords = {Aged, Cerebrovascular Disorders, Cohort Studies, Coronary Disease, Electrocardiography, Epidemiologic Methods, False Negative Reactions, Female, Humans, Male, Population Surveillance, Prevalence, Prospective Studies, Reproducibility of Results, Risk Factors, Self Disclosure, United States}, issn = {1047-2797}, author = {Psaty, B M and Kuller, L H and Bild, D and Burke, G L and Kittner, S J and Mittelmark, M and Price, T R and Rautaharju, P M and Robbins, J} } @article {1463, title = {Short-term predictors of incident stroke in older adults. The Cardiovascular Health Study.}, journal = {Stroke}, volume = {27}, year = {1996}, month = {1996 Sep}, pages = {1479-86}, abstract = {

BACKGROUND AND PURPOSE: Risk factors for incident stroke have been examined in middle-aged persons, but less is known about stroke precursors in the elderly, who suffer the highest rates of stroke. Short-term risk factors for incident stroke were examined in a longitudinal, population-based study including extensive measures of subclinical disease.

METHODS: Prospective study of 5201 women and men aged 65 years and older was undertaken in the multicenter Cardiovascular Health Study.

RESULTS: During an average 3.31-year follow-up, 188 incident strokes occurred. Stroke incidence increased significantly with age and was similar in women and men. Factors associated with increased stroke risk in multivariate analysis included age, aspirin use, diabetes, impaired glucose tolerance, higher systolic blood pressure, increased time needed to walk 15 ft. frequent falls, elevated creatinine level, abnormal left ventricular (LV) wall motion and increased LV mass on echocardiography, ultrasound-defined carotid stenosis, and atrial fibrillation. Increased LV mass and carotid stenosis were associated with twofold and threefold increases in incidences of stroke, respectively (P < .001). Aspirin users had a 52\% higher risk of stroke (relative risk, 1.52; 95\% confidence interval, 1.1 to 2.0; P < .007) after adjustment for other factors. This association was present only among aspirin users without prior coronary disease, atrial fibrillation, claudication, or transient ischemic attack, who had an 84\% higher risk (relative risk, 1.84; 95\% confidence interval, 1.2 to 2.8).

CONCLUSIONS: Short-term risk of stroke has a complex relationship with aspirin use and is strongly related to subclinical disease in this sample of older adults. These relationships should be considered in assessing stroke risk in the elderly, in whom recognized and subclinical cardiovascular disease is highly prevalent.

}, keywords = {Age Factors, Aged, Cardiovascular Physiological Phenomena, Cerebrovascular Disorders, Cohort Studies, Female, Health Status, Humans, Incidence, Longitudinal Studies, Male, Multivariate Analysis, Prognosis, Proportional Hazards Models, Prospective Studies, Risk Factors, Sex Factors, Time Factors}, issn = {0039-2499}, author = {Manolio, T A and Kronmal, R A and Burke, G L and O{\textquoteright}Leary, D H and Price, T R} } @article {1453, title = {Thickening of the carotid wall. A marker for atherosclerosis in the elderly? Cardiovascular Health Study Collaborative Research Group.}, journal = {Stroke}, volume = {27}, year = {1996}, month = {1996 Feb}, pages = {224-31}, abstract = {

BACKGROUND AND PURPOSE: We investigated the relationships between prevalent coronary heart disease (CHD), clinically manifest atherosclerotic disease (ASD), and major established risk factors for atherosclerosis and intima-media thickness (IMT) in the common carotid arteries (CCA) and internal carotid arteries (ICA) separately and in combination in older adults. We wished to determine whether a noninvasive measurement can serve as an indicator of clinically manifest atherosclerotic disease and to determine which of the two variables, CCA IMT or ICA IMT, is a better correlate.

METHODS: IMT of the CCA and ICA was measured with duplex ultrasound in 5117 of 5201 individuals enrolled in the Cardiovascular Health Study, a study of the risk factors and the natural history of cardiovascular disease in adults aged 65 years or more. Histories of CHD, peripheral arterial disease, and cerebrovascular disease were obtained during baseline examination. Risk factors included cholesterol levels, cigarette smoking, elevated blood pressure, diabetes, age, and sex. Relationships between risk factors and IMT were studied by multiple regression analysis and canonical variate analysis. Prediction of prevalent CHD and ASD by IMT measurements in CCAs and ICAs were made by logistic regression, adjusting for age and sex.

RESULTS: IMT measurements of the CCAs and ICAs were greater in persons with CHD and ASD than those without, even after controlling for sex (P < .001). IMT measurements in the ICA were greater than those in the CCA. Risk factors for ASD accounted for 17\% and 18\% of the variability in IMT in the CCA and ICA, respectively. These same risk factors accounted for 25\% of the variability of a composite measurement consisting of the sum of the ICA IMT and CCA IMT. The ability to predict CHD and ASD was greater for ICA IMT (odds ratio [confidence interval]: 1.36 [1.31 to 1.41] and 1.35 [1.25 to 1.44], respectively) than for CCA IMT (1.09 [1.05 to 1.13] and 1.17 [1.09 to 1.25]).

CONCLUSIONS: Whereas CCA IMT is associated with major risk factors for atherosclerosis and existing CHD and ASD in older adults, this association is not as strong as that for ICA IMT. The combination of these measures relates more strongly to existing CHD and ASD and cerebrovascular disease risk factors than either taken alone.

}, keywords = {Adult, Aged, Arteriosclerosis, Blood Pressure, Carotid Artery, Common, Carotid Artery, Internal, Cholesterol, HDL, Cholesterol, LDL, Cohort Studies, Coronary Disease, Diabetes Mellitus, Diabetic Angiopathies, Electrocardiography, Female, Humans, Male, Medical History Taking, Physical Examination, Prospective Studies, Regression Analysis, Risk Factors, Sex Characteristics, Smoking, Tunica Intima, Tunica Media, Ultrasonography}, issn = {0039-2499}, author = {O{\textquoteright}Leary, D H and Polak, J F and Kronmal, R A and Savage, P J and Borhani, N O and Kittner, S J and Tracy, R and Gardin, J M and Price, T R and Furberg, C D} } @article {1483, title = {Silent brain infarction on magnetic resonance imaging and neurological abnormalities in community-dwelling older adults. The Cardiovascular Health Study. CHS Collaborative Research Group.}, journal = {Stroke}, volume = {28}, year = {1997}, month = {1997 Jun}, pages = {1158-64}, abstract = {

BACKGROUND AND PURPOSE: Infarctlike lesions are frequently detected in symptomatic and asymptomatic older persons undergoing cerebral MRI, but their significance in older adults has not been examined. We determined the prevalence of MRI infarcts in a population-based sample of men and women aged > or = 65 years and related these findings to demographic, cognitive, and neurological status.

METHODS: MRI scanning was performed in 3660 Cardiovascular Health Study (CHS) participants after brief neurological examinations and tests of cognitive function. MRIs were read centrally for the presence of an infarct > or = 3 mm in diameter or smaller infarctlike lesions.

RESULTS: MRI infarcts were detected in 1131 of 3647 participants with readable infarct information (31\%) and in 961 of the subgroup of 3397 participants (28\%) without known prior stroke ("silent" MRI infarcts). Smaller infarctlike lesions were found in 196 of 2516 participants who had no MRI infarcts > or = 3 mm. MRI infarcts were more common in participants who were older, had prior stroke, impaired cognition, visual field deficits, slowed repetitive finger tapping (all P < .0001), weakness on toe and heel walking, and history of memory loss, coma, or migraine headaches. Multivariate analysis in those without prior stroke showed strong associations of silent MRI infarcts with older age, history of migraines, lower digit symbol scores, and more abnormalities on neurological examination.

CONCLUSIONS: MRI evidence of brain infarction is common in older men and women without a clinical history of stroke. Their strong associations with impaired cognition and neurological deficits suggest that they are neither silent nor innocuous.

}, keywords = {Aged, Aged, 80 and over, Cerebral Infarction, Cognition, Female, Humans, Magnetic Resonance Imaging, Male, Neurologic Examination}, issn = {0039-2499}, author = {Price, T R and Manolio, T A and Kronmal, R A and Kittner, S J and Yue, N C and Robbins, J and Anton-Culver, H and O{\textquoteright}Leary, D H} } @article {1511, title = {Hypoechoic plaque at US of the carotid artery: an independent risk factor for incident stroke in adults aged 65 years or older. Cardiovascular Health Study.}, journal = {Radiology}, volume = {208}, year = {1998}, month = {1998 Sep}, pages = {649-54}, abstract = {

PURPOSE: To investigate the association between incident (first) stroke and the echogenicity of internal carotid arterial plaque at ultrasonography (US).

MATERIALS AND METHODS: A cohort of 4, 886 individuals who, at baseline, were 65 years of age or older and without symptoms of cerebrovascular disease was followed up for an average of 3.3 years. Baseline clinical findings were from color Doppler and duplex US studies of the carotid arteries and a record of traditional risk factors: age, sex, presence of diabetes mellitus, pack-years of cigarette smoking, presence of hypertension, elevated systolic and diastolic blood pressure, elevated low-density lipoprotein cholesterol level.

RESULTS: Incident strokes, excluding hemorrhagic strokes and strokes of cardiac origin, were seen in 104 individuals (2.1\%) at risk. Age- and sex-adjusted odds ratios for incident stroke were significant for hypoechoic plaque (odds ratio, 2.53; 95\% CI, 1,42,4.53). After controlling for risk factors in a Cox proportional hazards model, the relative risk (RR) of incident stroke was 1.72 (p = .015) for hypoechoic plaque and 2.32 (P = .004) for internal carotid arterial narrowing of at least 50\%. In addition, hypoechoic plaque (RR, 2.78; CI, 1.36,5.69) and 50\%-100\% stenosis (RR, 3.08; CI, 1.28, 7.41) were associated with ipsilateral, nonfatal stroke.

CONCLUSION: In asymptomatic adults aged 65 years or older, that risk of incident stroke was associated with two US features: hypoechoic internal carotid arterial plaque and an estimated internal carotid arterial stenosis of 50\%-100\%.

}, keywords = {Aged, Aged, 80 and over, Carotid Artery, Internal, Carotid Stenosis, Cerebrovascular Disorders, Cohort Studies, Female, Humans, Intracranial Arteriosclerosis, Male, Proportional Hazards Models, Risk, Ultrasonography, Doppler, Duplex, Ultrasonography, Doppler, Transcranial}, issn = {0033-8419}, doi = {10.1148/radiology.208.3.9722841}, author = {Polak, J F and Shemanski, L and O{\textquoteright}Leary, D H and Lefkowitz, D and Price, T R and Savage, P J and Brant, W E and Reid, C} } @article {1514, title = {Lacunar infarcts defined by magnetic resonance imaging of 3660 elderly people: the Cardiovascular Health Study.}, journal = {Arch Neurol}, volume = {55}, year = {1998}, month = {1998 Sep}, pages = {1217-25}, abstract = {

OBJECTIVE: To identify risk factors for and functional consequences of lacunar infarct in elderly people.

METHODS: The Cardiovascular Health Study (CHS) is a longitudinal study of people 65 years or older, in which 3660 participants underwent cranial magnetic resonance imaging (MRI). Neuroradiologists read scans in a standard fashion without any clinical information. Lacunes were defined as subcortical areas consistent with infarcts measuring 3 to 20 mm. In cross-sectional analyses, clinical correlates were contrasted among groups defined by MRI findings.

RESULTS: Of the 3660 subjects who underwent MRI, 2529 (69\%) were free of infarcts of any kind and 841 (23\%) had 1 or more lacunes without other types present, totaling 1270 lacunes. For most of these 841 subjects, their lacunes were single (66\%) and silent (89\%), namely without a history of transient ischemic attack or stroke. In multivariate analyses, factors independently associated with lacunes were increased age, diastolic blood pressure, creatinine, and pack-years of smoking (listed in descending order of strength of association; for all, P < .005), as well as maximum internal carotid artery stenosis of more than 50\% (odds ratio [OR], 1.81; P < .005), male sex (OR, 0.74; P < .005), and history of diabetes at entrance into the study (OR, 1.33; P < .05). Models for subgroups of single, multiple, silent, and symptomatic lacunes differed only minimally. Those with silent lacunes had more cognitive, upper extremity, and lower extremity dysfunction not recognized as stroke than those whose MRIs were free of infarcts.

CONCLUSIONS: In this group of older adults, lacunes defined by MRI are common and associated with factors that likely promote or reflect small-vessel disease. Silent lacunes are also associated with neurologic dysfunction.

}, keywords = {Aged, Cerebral Infarction, Female, Humans, Longitudinal Studies, Magnetic Resonance Imaging, Male, Multivariate Analysis, Risk Factors}, issn = {0003-9942}, author = {Longstreth, W T and Bernick, C and Manolio, T A and Bryan, N and Jungreis, C A and Price, T R} }