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Lindahl, B., Norberg, M., Johansson, H., Lindvall, K., Ng, N., Nordin, M., . . . Schulz, P. J. (2020). Health literacy is independently and inversely associated with carotid artery plaques and cardiovascular risk. European Journal of Preventive Cardiology, 27(2), 209-215
Open this publication in new window or tab >>Health literacy is independently and inversely associated with carotid artery plaques and cardiovascular risk
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2020 (English)In: European Journal of Preventive Cardiology, ISSN 2047-4873, E-ISSN 2047-4881, Vol. 27, no 2, p. 209-215Article in journal (Refereed) Published
Abstract [en]

Aims: Health literacy, the degree to which individuals understand and act upon health information, may have a pivotal role in the prevention of cardiovascular disease (CVD), with low health literacy potentially explaining poorer adherence to prevention guidelines. We investigated the associations between health literacy, ultrasound-detected carotid atherosclerosis and cardiovascular risk factors.

Methods: Baseline data (cross-sectional analysis) from a randomized controlled trial, integrated within the Västerbotten Intervention Program, Northern Sweden, was used. We included 3459 individuals, aged 40 or 50 years with ≥1 conventional risk factor or aged 60 years old. The participants underwent clinical examination, blood sampling, carotid ultrasound assessment of intima-media wall thickness (CIMT) and plaque formation, and answered a questionnaire on health literacy – the Brief Health Literacy Screen. The European Systematic Coronary Risk Evaluation and Framingham Risk Score were calculated.

Results: About 20% of the participants had low health literacy. Low health literacy was independently associated with the presence of ultrasound-detected carotid artery plaques after adjustment for age and education, odds ratio (95% confidence interval) 1.54 (1.28–1.85), demonstrating a similar level of risk as for smoking. Health literacy was associated with CIMT in men. Low health literacy was associated with higher CVD risk scores. Sensitivity analyses with low health literacy set to 9% or 30% of the study sample, respectively, yielded essentially the same results.

Conclusions: Low health literacy was independently associated with carotid artery plaques and a high level of CVD risk scores. Presenting health information in a fashion that is understood by all patients may improve preventive efforts.

Place, publisher, year, edition, pages
Sage Publications, 2020
Keywords
Health literacy, cardiovascular risk scores, carotid artery plaque, ultrasound
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-165791 (URN)10.1177/2047487319882821 (DOI)000491457000001 ()31615294 (PubMedID)2-s2.0-85074364646 (Scopus ID)
Available from: 2019-12-03 Created: 2019-12-03 Last updated: 2020-03-23Bibliographically approved
Nyman, E., Vanoli, D., Näslund, U. & Grönlund, C. (2020). Inter-sonographer reproducibility of carotid ultrasound plaque detection using Mannheim consensus in subclinical atherosclerosis. Clinical Physiology and Functional Imaging, 40(1), 46-51
Open this publication in new window or tab >>Inter-sonographer reproducibility of carotid ultrasound plaque detection using Mannheim consensus in subclinical atherosclerosis
2020 (English)In: Clinical Physiology and Functional Imaging, ISSN 1475-0961, E-ISSN 1475-097X, Vol. 40, no 1, p. 46-51Article in journal (Refereed) Published
Abstract [en]

Aims: To determine the inter-sonographer reproducibility of carotid ultrasound plaque detection using Mannheim consensus in a subclinical population and evaluate associations related to the reproducibility.

Methods and results: Bilateral ultrasound screening for carotid plaques defined by Mannheim consensus was performed on 106 subclinical participants. Two different sonographers scanned the same participant, and reproducibility of plaque detection was measured by Cohens kappa. Associations with reproducibility were evaluated by comparing wall, and plaque characteristics between subjects with plaques identified in one and both scans. In general, the inter-sonographer reproducibility of plaque detection was substantial with a kappa value of 0 center dot 70 (95% CI 0 center dot 60-0 center dot 80). Plaques detected in only one scan had significantly lower plaque area and plaque thickness (6 center dot 82 mm(2) and 1 center dot 45 mm) as compared to plaques detected in both scans (11 center dot 65 mm(2) and 1 center dot 96 mm, P<0 center dot 001).

Conclusion: Minor carotid plaques contribute to decreased reproducibility as compared to large plaques when screening for subclinical atherosclerosis using Mannheim consensus. Using an alternative plaque definition based on plaque thickness >1.5 mm and plaque area >10 mm(2) could increase the reproducibility of plaque detection in subclinical atherosclerosis.

Place, publisher, year, edition, pages
John Wiley & Sons, 2020
Keywords
carotid, inter-sonographer, plaque, reproducibility, subclinical, ultrasound
National Category
Physiology
Identifiers
urn:nbn:se:umu:diva-165443 (URN)10.1111/cpf.12602 (DOI)000493037200001 ()31605665 (PubMedID)
Available from: 2019-11-27 Created: 2019-11-27 Last updated: 2020-01-10Bibliographically approved
Näslund, U., Lundgren, A., Vanoli, D. & Norberg, M. (2019). Is intima-media thickness a predictor for cardiovascular risk?: Authors' reply [Letter to the editor]. The Lancet, 394(10196), 381-381
Open this publication in new window or tab >>Is intima-media thickness a predictor for cardiovascular risk?: Authors' reply
2019 (English)In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 394, no 10196, p. 381-381Article in journal, Letter (Refereed) Published
Place, publisher, year, edition, pages
ELSEVIER SCIENCE INC, 2019
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-162305 (URN)10.1016/S0140-6736(19)30343-5 (DOI)000478698300018 ()31379329 (PubMedID)
Available from: 2019-08-27 Created: 2019-08-27 Last updated: 2019-08-27Bibliographically approved
Näslund, U., Ng, N., Lundgren, A., Fhärm, E., Grönlund, C., Johansson, H., . . . Norberg, M. (2019). Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA): a pragmatic, open-label, randomised controlled trial. The Lancet, 393(10167), 133-142
Open this publication in new window or tab >>Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA): a pragmatic, open-label, randomised controlled trial
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2019 (English)In: The Lancet, ISSN 0140-6736, E-ISSN 1474-547X, Vol. 393, no 10167, p. 133-142Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Primary prevention of cardiovascular disease often fails because of poor adherence among practitioners and individuals to prevention guidelines. We aimed to investigate whether ultrasound-based pictorial information about subclinical carotid atherosclerosis, targeting both primary care physicians and individuals, improves prevention.

METHODS: Visualization of asymptomatic atherosclerotic disease for optimum cardiovascular prevention (VIPVIZA) is a pragmatic, open-label, randomised controlled trial that was integrated within the Västerbotten Intervention Programme, an ongoing population-based cardiovascular disease prevention programme in northern Sweden. Individuals aged 40, 50, or 60 years with one or more conventional risk factors were eligible to participate. Participants underwent clinical examination, blood sampling, and ultrasound assessment of carotid intima media wall thickness and plaque formation. Participants were randomly assigned 1:1 with a computer-generated randomisation list to an intervention group (pictorial representation of carotid ultrasound plus a nurse phone call to confirm understanding) or a control group (not informed). The primary outcomes, Framingham risk score (FRS) and European systematic coronary risk evaluation (SCORE), were assessed after 1 year among participants who were followed up. This study is registered with ClinicalTrials.gov, number NCT01849575.

FINDINGS: 3532 individuals were enrolled between April 29, 2013, and June 7, 2016, of which 1783 were randomly assigned to the control group and 1749 were assigned to the intervention group. 3175 participants completed the 1-year follow-up. At the 1-year follow-up, FRS and SCORE differed significantly between groups (FRS 1·07 [95% CI 0·11 to 2·03, p=0·0017] and SCORE 0·16 [0·02 to 0·30, p=0·0010]). FRS decreased from baseline to the 1-year follow-up in the intervention group and increased in the control group (-0·58 [95% CI -0·86 to -0·30] vs 0·35 [0·08 to 0·63]). SCORE increased in both groups (0·13 [95% CI 0·09 to 0·18] vs 0·27 [0·23 to 0·30]).

INTERPRETATION: This study provides evidence of the contributory role of pictorial presentation of silent atherosclerosis for prevention of cardiovascular disease. It supports further development of methods to reduce the major problem of low adherence to medication and lifestyle modification.

Place, publisher, year, edition, pages
Elsevier, 2019
National Category
Public Health, Global Health, Social Medicine and Epidemiology Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-154318 (URN)10.1016/S0140-6736(18)32818-6 (DOI)000455437100026 ()30522919 (PubMedID)
Funder
Västerbotten County Council, Dnr ALFVLL-298001Swedish Research Council, Dnr 521-2013-2708Swedish Research Council, 2016-01891Swedish Heart Lung Foundation, Dnr 20150369Swedish Heart Lung Foundation, 20170481
Available from: 2018-12-17 Created: 2018-12-17 Last updated: 2019-02-22Bibliographically approved
Vanoli, D. (2017). Vascular ultrasound for the assessment of carotid atherosclerosis. (Doctoral dissertation). Umeå: Umeå University
Open this publication in new window or tab >>Vascular ultrasound for the assessment of carotid atherosclerosis
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Atherosclerotic cardiovascular disease (CVD) is a common cause for mortality globally, and is expected to remain the single leading cause of death as the global population ages and as life expectancy increases.

Cardiovascular screening models have been developed, and continue to be developed, to identify individuals at high-risk of CVD.  This is necessary to establish prevention strategies to decrease the occurrence of an acute event or debilitating syndrome. These strategies largely take the form of lifestyle modification and pharmacological intervention. The Framingham risk score, NCEP/ATP II guidelines and SCORE risk assessment protocol are widely used screening models. Ultrasound based methods are non-invasive, affordable and have been suggested to improve assessment and definition of individual patients potential risk of CVD. Increased carotid artery intima-media thickness (cIMT) is a known and established sign of early atherosclerosis. The presence of plaque and the overall burden of atherosclerosis seems to have even greater value in predicting cerebrovascular and cardiovascular events. Ultrasound based texture characteristics of plaques such as entropy, grey scale median, discrete white area, coarseness and juxtaluminal hypoechoic black area have been proposed as useful possible predictors of plaque vulnerability. Moreover, ultrasound contrast agents have been developed to improve visualization and subsequent quantification of an atherosclerotic plaque. Considering the current available data and research, the importance of developing tools and techniques for detection and characterization of atherosclerotic changes, to indicate risk for CVD and the subsequent early intervention and prevention, appears clearly as an effort to improve public health. In this present collection of studies (4 papers) we aim to contribute to the development of clinically useful ultrasound methods and tools for the accurate assessment, understanding and management of atherosclerosis.

Methods: To validate ultrasound-based methods for assessment of early signs of atherosclerosis, measured as cIMT, a total of 144 subjects underwent bilateral carotid ultrasound. In study I, the performance of an ultrasonography software capable of fully automated on-screen cIMT measurements was tested and compared with the traditional manual measurement approach. The coefficient of variation and the intraclass correlation coefficient for both methods were compared to verify the reliability and reproducibility of results generated by the new ultrasound software. To test the accessibility and possible clinical applications of this new technology tested in study I, the new software was used by novice’s scanners in study II, and the intraobserver variability of the cIMT measurements were assessed and compared with that of an expert operator. In study III, ultrasound texture characteristics of 327 plaques including entropy, grey scale median, discrete white area, coarseness and juxtaluminal hypoechoic black area were assessed as possible predictors of future cerebrovascular events in a cohort of 133 patients with symptomatic carotid stenosis waiting for carotid surgery. The reproducibility of measuring plaque area (expressed as intraclass correlation coefficient) using conventional ultrasound and contrast enhanced ultrasound was tested in study IV in an attempt to find a simple and reproducible parameter for monitoring changes in atherosclerotic burden.

Results: The technology tested in study I was found to have good inter- and intra-system reproducibility compared with conventional methods. Moreover, it was found to produce reproducible results when used by expert and novice operators after a short period of training (study II), confirming the possibility for the employment of this technology in a large screening public health programs. Although such technology may have immediate practical application, other and more sophisticated ultrasound based plaque characteristics (such as grey scale median, entropy, coarseness, juxtaluminal hypoechoic black area) were not shown to be beneficial in predicting plaque vulnerability (study III). Contrast enhanced ultrasound technic tested in study IV did not improve quantification of atherosclerotic plaque burden. 

Conclusion: Medical ultrasound technology by using a automatically measure of carotid intima media thickness can be used with high reproducibility and also possible to be transferred to primary care by a well designed training program.  Plaque characteristic using carotid ultrasound was not found to be useful in risk stratifying symptomatic patients with severe carotid stenosis. Furthermore, contrast enhanced ultrasound technique was found to have high reproducibility in plaque area assessment but not better than conventional b-mode based method in quantifying the atherosclerotic burden. Therefore, more sophisticated ultrasound based methods for assessment plaque characteristics was not found to be beneficial in predicting plaque vulnerability.

Place, publisher, year, edition, pages
Umeå: Umeå University, 2017. p. 50
Series
Umeå University medical dissertations, ISSN 0346-6612 ; 1912
Keywords
Ultrasound, Plaque, IMT, Atherosclerosis, CEUS, Carotid vessels
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Medicine, cardiovascular disease
Identifiers
urn:nbn:se:umu:diva-139538 (URN)978-91-7601-748-7 (ISBN)
Public defence
2017-10-13, Sal D, 9 tr, Norrlands Universitetssjukhus, Umeå, 13:00 (English)
Opponent
Supervisors
Available from: 2017-09-22 Created: 2017-09-16 Last updated: 2018-06-09Bibliographically approved
Nyman, E., Vanoli, D., Grönlund, C., Näslund, U. & Lindqvist, P. (2016). Area measurement of carotid plaque comparing B-MODE, Doppler color and contrast-enhanced ultrasound imaging. Paper presented at Congress of the European-Atherosclerosis-Society (EAS), MAY 29-JUN 01, 2016, Innsbruck, AUSTRIA. Atherosclerosis, 252, E191-E191
Open this publication in new window or tab >>Area measurement of carotid plaque comparing B-MODE, Doppler color and contrast-enhanced ultrasound imaging
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2016 (English)In: Atherosclerosis, ISSN 0021-9150, E-ISSN 1879-1484, Vol. 252, p. E191-E191Article in journal, Meeting abstract (Other academic) Published
Abstract [en]

Objectives: Carotid plaque characteristic analysis are suggested to improve risk stratification. Plaque area and echolucent plaques have shown to correlate with increased risk for cardiovascular diseases. A limitation with B-mode imaging is the uncertainty that the whole plaque area is identified, primarily on echolucent plaques. Contrast-enhanced ultrasound (CEUS) is used to improve carotid imaging including better plaque area measurement. Aim: Evaluate if CEUS could improve accurate plaque area measurement compared with B-mode and Doppler color flow imaging. Methods: The study included 28 participants (50% females, mean age 58 years) with identified asymptomatic carotid plaques. We performed B-mode, Doppler color and CEUS ultrasound imaging whereas the plaque area was manually outdrawn by a single operator. Plaques were also subjectively classified as 1 echogenic, 2 echolucent, or 3 mixed plaques. Results: We did not find a significant difference in plaque area measurements between different ultrasound image modalities having all plaque types included. In the group of echolucent plaques (n= 11) we found a significant different between B-mode and CEUS (p=0.049) and also between B-mode and Doppler color imaging (p=0.039) (Illustrated in Fig 1). Conclusions: Echolucent plaque can be underestimated with B-mode imaging. Use of contrast-enhanced ultrasound should be considered in carotid plaque imaging on echolucent plaques when plaque outline is difficult to identify.

Place, publisher, year, edition, pages
Elsevier, 2016
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-130113 (URN)10.1016/j.atherosclerosis.2016.07.881 (DOI)000388978400649 ()
Conference
Congress of the European-Atherosclerosis-Society (EAS), MAY 29-JUN 01, 2016, Innsbruck, AUSTRIA
Note

Meeting Abstract: EAS16-0052, Vascular Biology: Myocardial Infarction, Stroke, Peripheral Vascular Disease

Available from: 2017-01-13 Created: 2017-01-11 Last updated: 2018-06-09Bibliographically approved
Vanoli, D. & Lindqvist, P. (2016). Plaque characterisation and analysis in the risk stratifying patients with symptomatic carotis stenosis. Paper presented at Congress of the European-Atherosclerosis-Society (EAS), MAY 29-JUN 01, 2016, Innsbruck, AUSTRIA. Atherosclerosis, 252, E191-E191
Open this publication in new window or tab >>Plaque characterisation and analysis in the risk stratifying patients with symptomatic carotis stenosis
2016 (English)In: Atherosclerosis, ISSN 0021-9150, E-ISSN 1879-1484, Vol. 252, p. E191-E191Article in journal, Meeting abstract (Other academic) Published
Place, publisher, year, edition, pages
Elsevier, 2016
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-130112 (URN)10.1016/j.atherosclerosis.2016.07.880 (DOI)000388978400648 ()
Conference
Congress of the European-Atherosclerosis-Society (EAS), MAY 29-JUN 01, 2016, Innsbruck, AUSTRIA
Note

Meeting Abstract: EAS16-0024, Vascular Biology: Myocardial Infarction, Stroke, Peripheral Vascular Disease

Available from: 2017-01-13 Created: 2017-01-11 Last updated: 2018-06-09Bibliographically approved
Nyman, E., Grönlund, C., Vanoli, D., Lindqvist, P. & Näslund, U. (2015). Carotid artery plaque assessment within the Västerbotten intervention programme: VIPVIZA. Paper presented at 83rd Congress of the European-Atherosclerosis-Society (EAS), MAR 22-25, 2015, Glasgow, SCOTLAND. Atherosclerosis, 241(1), E159-E159
Open this publication in new window or tab >>Carotid artery plaque assessment within the Västerbotten intervention programme: VIPVIZA
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2015 (English)In: Atherosclerosis, ISSN 0021-9150, E-ISSN 1879-1484, Vol. 241, no 1, p. E159-E159Article in journal, Meeting abstract (Other academic) Published
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-109463 (URN)000360100600527 ()
Conference
83rd Congress of the European-Atherosclerosis-Society (EAS), MAR 22-25, 2015, Glasgow, SCOTLAND
Available from: 2015-10-07 Created: 2015-09-28 Last updated: 2018-06-07Bibliographically approved
Vanoli, D., Backman, C. & Holmgren, A. (2015). Inferior infarction complicated by ruptured interventricular septum [Letter to the editor]. International Cardiovascular Forum Journal, 2(1), 44-45
Open this publication in new window or tab >>Inferior infarction complicated by ruptured interventricular septum
2015 (English)In: International Cardiovascular Forum Journal, ISSN 2410-2636, Vol. 2, no 1, p. 44-45Article in journal, Letter (Refereed) Published
Place, publisher, year, edition, pages
Barcaray International Publishing, 2015
National Category
Cardiac and Cardiovascular Systems
Identifiers
urn:nbn:se:umu:diva-107644 (URN)10.17987/icfj.v2i1.80 (DOI)
Available from: 2015-08-25 Created: 2015-08-25 Last updated: 2018-06-07Bibliographically approved
Vanoli, D., Wiklund, U., Lindqvist, P., Henein, M. & Näslund, U. (2014). Successful novice's training in obtaining accurate assessment of carotid IMT using an automated ultrasound system. European Heart Journal Cardiovascular Imaging, 15(6), 637-642
Open this publication in new window or tab >>Successful novice's training in obtaining accurate assessment of carotid IMT using an automated ultrasound system
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2014 (English)In: European Heart Journal Cardiovascular Imaging, ISSN 2047-2404, E-ISSN 2047-2412, Vol. 15, no 6, p. 637-642Article in journal (Refereed) Published
Abstract [en]

Aims The aim of this study was to assess the feasibility and learning curve of training novice operators in using automated ultrasound to achieve satisfactory carotid intima-media thickness (CIMT) measurements.

Methods and results Four novices underwent 4 weeks carotid ultrasound training using a newly developed automated ultrasonograph. A longitudinal B-mode image of the distal right common carotid artery (CCA) was acquired in 96 patients. The interoperator CIMT reproducibility was analysed by the coefficient of variation (CV) and intraclass correlation coefficient (ICC) for every week and compared with that from an expert operator. The weekly mean CV of the measurements on the 24 patients made by all novices was consistently reduced: 0.06, 0.05, 0.03, and 0.02, respectively. For the expert, the mean CV was 0.02, 0.02, 0.03, and 0.02, respectively. The novices' standard deviation (SD) of CVs also reduced weekly from 0.04 in the first week to 0.01 in the last week (P < 0.05). The corresponding weekly variation in the SD for the expert was 0.02 for the first week to 0.01 in the last week (P = 0.27). The agreement between measurements made by the novices was expressed by the ICC being 0.97 (P < 0.001) in the first week and increased to 0.99 (P < 0.001) in the fourth week.

Conclusion CIMT assessment by novices using an automated ultrasound could be reliably achievable after a short training period. These results may have encouraging implications when designing screening programmes for primary prevention in community health service.

Place, publisher, year, edition, pages
Oxford: Oxford University Press, 2014
Keywords
Carotid artery, Intima-media thickness, Health screening, Vascular ultrasound
National Category
Cardiac and Cardiovascular Systems Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:umu:diva-91057 (URN)10.1093/ehjci/jet254 (DOI)000336994300009 ()
Available from: 2014-07-11 Created: 2014-07-10 Last updated: 2018-06-07Bibliographically approved
Organisations
Identifiers
ORCID iD: ORCID iD iconorcid.org/0000-0003-2078-3658

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