EGSYS score for the prediction of cardiac etiology in syncope: Is it useful in an outpatient setting? / Score EGSYS para predição de etiologia cardíaca na síncope: tem utilidade no contexto de consulta?

INTRODUCTION: The EGSYS score uses clinical variables to predict which patients may have cardiac (CS) or non-cardiac syncope (NCS) and has been validated in the emergency department setting. This study aims to determine whether the score has the same applicability in an outpatient setting. METHODS: In this retrospective study of all patients observed in the outpatient setting of a hospital with a syncope unit between January 2015 and December 2016, the EGSYS score was calculated for each patient, and its sensitivity and specificity were determined for the prediction of CS in patients with score ≥3. RESULTS: A total of 224 patients, mean age 64.3±21.7 years, 116 (51.8%) male, were analyzed. In the 163 (72.7%) patients with confirmed syncope, CS was diagnosed in 27 (16.6%) and NCS in 136 (83.4%). The EGSYS score was ≥3 in 40 (20.0%) patients with NCS and in 13 (48.1%) with CS. A positive score had a sensitivity of 48.2% (95% CI: 28.7-68.1), a specificity of 77.9% (95% CI: 70.0-84.6), and a positive and negative predictive value of 30.2% (95% CI: 20.8-41.8) and 88.3% (95% CI: 83.9-91.7), respectively. CONCLUSION: The EGSYS score has limited usefulness in an outpatient setting, where observed patients have already been been medically assessed. Given its high specificity and negative predictive value, it may be useful to reassure low-risk patients and family members.

Congenital left ventricular apical aneurysm presenting as ventricular tachycardia.

The authors present the case of a 34-year-old male patient seen in our department due to palpitations. On the electrocardiogram monomorphic ventricular tachycardia (VT) was documented, treated successfully with amiodarone. The subsequent study revealed a normal echocardiogram and an apical aneurysm of the left ventricle on magnetic resonance imaging, confirmed by computed tomography coronary angiography that also excluded coronary disease. He underwent an electrophysiological study to determine the origin of the VT and to perform catheter ablation using electroanatomical mapping. VT was induced and radiofrequency applications were performed in the left ventricular aneurysm area. VT was no longer inducible, with acute success. Despite this it was decided to implant a subcutaneous implantable cardioverter-defibrillator (ICD). Eight months after the ablation the patient was admitted again due to VT, treated by the ICD.

Evaluation of Motor Neuron Excitability by CMAP Scanning with Electric Modulated Current.

Introduction. Compound Muscle Action Potential (CMAP) scan is a noninvasive promissory technique for neurodegenerative pathologies diagnosis. In this work new CMAP scan protocols were implemented to study the influence of electrical pulse waveform on peripheral nerve excitability. Methods. A total of 13 healthy subjects were tested. Stimulation was performed with an increasing intensities range from 4 to 30 mA. The procedure was repeated 4 times per subject, using a different single pulse stimulation waveform: monophasic square and triangular and quadratic and biphasic square. Results. Different waveforms elicit different intensity-response amplitude curves. The square pulse needs less current to generate the same response amplitude regarding the other waves and this effect is gradually decreasing for the triangular, quadratic, and biphasic pulse, respectively. Conclusion. The stimulation waveform has a direct influence on the stimulus-response slope and consequently on the motoneurons excitability. This can be a new prognostic parameter for neurodegenerative disorders.

Failure to deliver a shock in a dual-chamber implantable cardioverter-defibrillator: a case report.

INTRODUCTION: Inappropriate implantable cardioverter-defibrillator (ICD) therapies due to supraventricular tachyarrhythmia (SVT) are a common problem. The authors report this case to warn of a possible detection problem and subsequent failure of deliver appropriate therapy in patients with atrial fibrillation (AF) and a dual-chamber ICD using the PARAD+ algorithm. To our knowledge this is the first reported case of failure to deliver a shock in a dual-chamber ICD due to the PARAD+ algorithm. CASE REPORT: The authors present a case of a 68-year-old Caucasian man with permanent AF and a dual-chamber Sorin Paradym ICD with the PARAD+ algorithm, who presented an episode of sustained ventricular tachycardia (VT). The ICD did not store the event and did not delivery a therapy, although the heart rate curve was consistent with an episode of VT. No evidence of system dysfunction was found. CONCLUSION: Due to simultaneous occurrence of VT and AF rhythms and alternation in rhythm classification by the PARAD+ algorithm the number of cycles needed to diagnose VT was not achieved and no therapy was delivered. In patients with permanent or long-term persistent AF with a dual-chamber ICD using the PARAD+ algorithm, discrimination should be based only on the ventricular channel. In patients with paroxysmal or persistent recurrent AF the risk of not delivering VT therapy must be weighed against the risk of inappropriate therapy.

Polymorphic microsatellite markers in the brown seaweed Fucus vesiculosus.

BACKGROUND: Fucus vesiculosus is a brown seaweed dominant on temperate rocky shores of the northern hemisphere and, is typically distributed in the mid-upper intertidal zone. It is an external fertilizer that reproduces sexually, providing an excellent model to address conflicting theories related to mating systems and sexual selection. Microsatellite markers have been reported for several Fucus species, however the genomic libraries from where these markers have been isolated, have originated from two or more species pooled together (F. vesiculosus and F. serratus in one library; F. vesiculosus, F. serratus and Ascophyllum nodosum in a second library), or when the genomic DNA originated from only one species it was from Fucus spiralis. Although these markers cross-amplify F. vesiculosus individuals, the level of polymorphism has been low for relatedness studies. FINDINGS: The microsatellite markers described here were obtained from an enriched genomic library, followed by 454 pyrosequencing. A total of 9 microsatellite markers were tested across 44 individuals from the North of Portugal. The mean number of alleles across loci was 8.7 and the gene diversity 0.67. CONCLUSIONS: The high variability displayed by these microsatellite loci should be useful for paternity analysis, assessing variance of reproductive success and in estimations of genetic variation within and between populations.

Reflex vasovagal syncope--is there a benefit in pacemaker therapy?

Reflex vasovagal syncope often affects young populations and is associated with a benign prognosis in terms of mortality. However, a minority of patients have recurrent episodes, with a considerable impact on their quality of life. Pacemaker therapy has been an option in these patients since the 1990s if a conservative strategy fails. Initially, non-randomized and open-label randomized trials showed promising results, but these studies were associated with a significant placebo effect. Recently, an approach based on the use of implantable loop recorders has shown that some patients with reflex vasovagal syncope could benefit from implantation with dual-chamber pacemakers, particularly patients aged >40 years, with recurrent syncopal episodes resulting in frequent injuries, in whom a long asystole (≥3 s asystole with syncope or ≥6 s asystole without syncope) has been documented with an implantable loop recorder. The authors present a literature review on the role of cardiac pacing in reflex vasovagal syncope and propose a diagnostic and therapeutic decision flowchart for patients with syncope of probable reflex etiology.

Financial impact of adopting implantable loop recorder diagnostic for unexplained syncope compared with conventional diagnostic pathway in Portugal.

BACKGROUND: To estimate the short- and long-term financial impact of early referral for implantable loop recorder diagnostic (ILR) versus conventional diagnostic pathway (CDP) in the management of unexplained syncope (US) in the Portuguese National Health Service (PNHS). METHODS: A Markov model was developed to estimate the expected number of hospital admissions due to US and its respective financial impact in patients implanted with ILR versus CDP. The average cost of a syncope episode admission was estimated based on Portuguese cost data and landmark papers. The financial impact of ILR adoption was estimated for a total of 197 patients with US, based on the number of syncope admissions per year in the PNHS. Sensitivity analysis was performed to take into account the effect of uncertainty in the input parameters (hazard ratio of death; number of syncope events per year; probabilities and unit costs of each diagnostic test; probability of trauma and yield of diagnosis) over three-year and lifetime horizons. RESULTS: The average cost of a syncope event was estimated to be between 1,760€ and 2,800€. Over a lifetime horizon, the total discounted costs of hospital admissions and syncope diagnosis for the entire cohort were 23% lower amongst patients in the ILR group compared with the CDP group (1,204,621€ for ILR, versus 1,571,332€ for CDP). CONCLUSION: The utilization of ILR leads to an earlier diagnosis and lower number of syncope hospital admissions and investigations, thus allowing significant cost offsets in the Portuguese setting. The result is robust to changes in the input parameter values, and cost savings become more pronounced over time.

The value of electrocardiography for differential diagnosis in wide QRS complex tachycardia.

Correct diagnosis in wide QRS complex tachycardia remains a challenge. Differential diagnosis between ventricular and supraventricular tachycardia has important therapeutic and prognostic implications, and although data from clinical history and physical examination may suggest a particular origin, it is the 12-lead surface electrocardiogram that usually enables this differentiation. Since 1978, various electrocardiographic criteria have been proposed for the differential diagnosis of wide complex tachycardias, particularly the presence of atrioventricular dissociation, and the axis, duration and morphology of QRS complexes. Despite the wide variety of criteria, diagnosis is still often difficult, and errors can have serious consequences. To reduce such errors, several differential diagnosis algorithms have been proposed since 1991. However, in a small percentage of wide QRS tachycardias the diagnosis remains uncertain and in these the wisest decision is to treat them as ventricular tachycardias. The authors' objective was to review the main electrocardiographic criteria and differential diagnosis algorithms of wide QRS tachycardia.

Characterization of polymorphic microsatellite loci in the Antarctic krill Euphausia superba.

BACKGROUND: The Antarctic krill, Euphausia superba is a pelagic crustacean, abundant in high-density swarms (10,000 - 30,000 ind/m2) with a circumpolar distribution and a key role in the food web of the Southern Ocean. Only three EST derived microsatellite markers have been used in previous genetic studies, hence we developed additional highly polymorphic microsatellite markers to allow robust studies of the genetic variability and population differentiation within this species. FINDINGS: The microsatellite markers described here were obtained through an enriched genomic library, followed by 454 pyrosequencing. A total of 10 microsatellite markers were tested in 32 individuals from the Antarctic Peninsula. One of the tested loci was fixed for one allele while the other was variable. Of the remaining nine markers, seven showed no departure from Hardy-Weinberg equilibrium. The mean number of alleles was 14.9. CONCLUSIONS: These markers open perspectives for population genetic studies of this species to unravel genetic structure, dispersal and population biology, vital information for future conservation.

[Syncope unit: experience of a center using diagnostic flowcharts for syncope of uncertain etiology after initial assessment]. / Unidade de Síncope - Experiência de um centro com base em organigramas de decisão para síncope de etiologia incerta após a avaliação inicial.

INTRODUCTION AND OBJECTIVES: Syncope is a common symptom that leads to 1% of admissions to hospital emergency departments, and is associated with high costs to the health system. The cardiology department of Faro Hospital has had a syncope unit since July 2007. The aim of this study is to analyze its results in terms of etiological diagnosis and treatment of syncope, using diagnostic flowcharts based on European Society of Cardiology (ESC) guidelines. METHODS: We conducted a retrospective study of all patients referred to the syncope unit of Faro Hospital between July 2007 and August 2011. We analyzed demographic data, characteristics of syncopal episodes, diagnostic methods, etiology of syncope and treatment. The percentages of syncope of cardiac and uncertain etiology were compared with data from other international syncope units. Statistical analysis was performed using SPSS version 13.0. RESULTS: Of the 304 patients referred to the syncope unit for loss of consciousness, 245 (80.7%) had syncope. Most had reflex syncope (52.2%), 20% had cardiac syncope, 15.6% had orthostatic hypotension, and in 12% of cases etiology remained undetermined. The percentages of cardiac and uncertain etiology were similar to data published by other syncope units. CONCLUSIONS: The Faro Hospital syncope unit obtained similar results to those published by other international syncope units through application of diagnostic flowcharts for etiological diagnosis of syncope. The flowcharts presented can be of value for the proper application of ESC guidelines on syncope.

Implementation of a pre-hospital network favoring primary angioplasty in STEMI to reduce mortality: the Algarve Project.

OBJECTIVE: To analyze the impact of reperfusion by either primary percutaneous coronary intervention (PPCI) or fibrinolysis, and mortality rates of a pre-hospital fast-track network for treating patients with ST-elevation myocardial infarction (STEMI). METHODS AND RESULTS: A pre-hospital network for STEMI patients, designated the Green Lane for Acute Myocardial Infarction (GL-AMI), has been implemented in the southern region of Portugal --the Algarve Project. We performed an observational study based on a prospective registry of 1338 patients admitted to Faro Hospital between 2004 and 2009, classified in two groups according to the method of admission: emergency department group (EDG) and GL-AMI group (GLG). More patients from GLG were reperfused (p < 0.0001). PPCI was the preferred method of reperfusion, 73.1% in GLG and 45.3% in EDG. Time delays were significantly shorter in GLG, except for pre-hospital delay: pre-hospital delay (p = 0.11); door-to-needle (p < 0.0001); door-to-balloon (p < 0.0001); and delay between symptoms and reperfusion (p < 0.0001). In-hospital mortality (4.3% vs 9.2%, p = 0.0007) and 6-month mortality (6.3% vs 13.8%, p < 0.0001) were significantly lower in GLG. CONCLUSIONS: The Algarve Project significantly reduced the time delay between onset of symptoms and reperfusion, significantly increased the rate of reperfusion, and significantly reduced in-hospital and six-month mortality.

Female gender: an independent factor in ST-elevation myocardial infarction.

INTRODUCTION: Cardiovascular disease is the leading cause of death in women. In ST-elevation myocardial infarction (STEMI) in particular, the question has been raised whether specific characteristics of women confer a worse prognosis. OBJECTIVE: To evaluate the differences in STEMI patients between the genders in cardiovascular risk profile, clinical presentation, therapeutic approach and in-hospital and 6-month mortality rates. METHODS: We analyzed 1578 patients admitted consecutively with STEMI during a 7-year period (from January 13, 2002 to December 31, 2008). The patients were divided into two groups according to gender, and compared in terms of baseline clinical and demographic characteristics, pre-hospital and in-hospital delay, clinical presentation on admission, reperfusion therapy, severity of coronary disease and in-hospital and 6-month mortality. RESULTS: Of the 1578 patients, 26% were female. Women were older (by 8 years), and had a higher cardiovascular risk profile. On admission, their clinical presentation was more severe, with a higher frequency of anterior myocardial infarction and acute heart failure symptoms. Women had longer ischemic times and lower rates of reperfusion therapy. Mortality in women was significantly higher than in men, both in-hospital (17.5 vs. 5.3%) and at 6 months (23.5% vs. 8.2%). After adjustment in multivariate analysis, mortality in women remained higher. CONCLUSIONS: The adverse demographic and clinical profile could partially explain the worse prognosis of STEMI in women. This, together with longer pre-hospital delays, led to underuse of reperfusion therapy. Even so, female gender by itself had a negative and independent influence on mortality in STEMI patients.

[Endomyocardial fibrosis with massive calcification of the left ventricle]. / Fibrose endomiocárdica com calcificação maciça do ventrículo esquerdo.

Endomyocardial fibrosis is a rare disease, endemic in tropical countries. It is characterized by fibrosis of the endocardium that can extend to myocardium. Important calcification of the endocardium is rare with only a few cases reported in the literature. We report a case of endomyocardial fibrosis in a european caucasian patient, associated with massive calcification of left ventricle.

Atrial fibrillation ablation using simultaneous multielectrode application of radiofrequeney energy.

Despite technological advances in equipment for ablation of atrial fibrillation (AF), conventional pulmonary vein (PV) isolation with point-by-point radiofrequency application encircling the PV ostia remains a complex procedure requiring a high degree of operator skill and experience. Novel multielectrode catheters have been developed that deliver duty-cycled bipolar and unipolar radiofrequency energy, designed for PV electrical isolation and for ablation of complex fractionated electrograms in the left atrium. Initial studies suggest good results, reducing procedure time and with safety and efficacy equivalent to the conventional method. We describe the first four cases of AF ablation in our center using this method, with acute success in two patients: one with paroxysmal AF and the other with chronic AF.

Atrial fibrillation ablation: importance of cavotricuspid isthmus block.

INTRODUCTION AND OBJECTIVE: Maintenance of atrial fibrillation (AF) depends on the presence of multiple reentrant circuits in the atria. In AF ablation, after pulmonary vein (PV) isolation, substrate modification can be increased by performing linear lesions in the left atrium that reduce the fibrillatory surface. A cavotricuspid isthmus (CTI) block may be an easier and safer alternative to left atrial lines for this purpose. Non-inducibility after AF ablation is associated with a higher success rate. The aim of this study is to assess whether CTI ablation after PV isolation reduces inducibility of atrial arrhythmias, particularly AF. METHODS AND RESULTS: In 29 consecutive patients (23 male, mean age 54.6+/-11.4 years, 11 (38%) with hypertension and four (14%) with structural heart disease, mean left atrial dimension 43+/-6 mm) undergoing PV isolation for paroxysmal or persistent AF, atrial arrhythmia inducibility was tested before and after CTI ablation. The procedure was performed using a CARTO-Merge mapping system, one or two Lasso catheters, an irrigated ablation catheter and radiofrequency energy. Atrial arrhythmia inducibility was tested with burst pacing down to 150 ms or atrial refractoriness from the proximal coronary sinus. Atrial arrhythmias were considered inducible if they persisted for more than 60 seconds. Of the 29 patients, 26 (90%) had an inducible arrhythmia before CTI ablation--AF in 16, typical atrial flutter (AFL) in seven and atypical AFL in three. Three (10%) were non-inducible. After CTI ablation, only 11 patients (38%) maintained arrhythmia inducibility (p<0.001)--AF in nine and atypical AFL in two. There was a significant reduction of AF inducibility (16 vs. 9/29, p=0.016) and of combined AF and atypical AFL inducibility (19 vs. 11/29, p=0.021). After one year of follow-up, 23 patients (79%) had no recurrence of arrhythmia. Success rates were 83% in patients without and 73% in patients with inducible arrhythmias at the end of the procedure (p=NS). CONCLUSION: CTI ablation, in addition to PV isolation, significantly reduced the number of patients with inducible atrial arrhythmias and inducible AF.

Diaphragmatic myopotential oversensing in pacemaker-dependent patients with CRT-D devices.

AIMS: To evaluate the incidence and clinical significance of diaphragmatic myopotential (dMP) oversensing in pacemaker (PM)-dependent patients with CRT-Ds. METHODS AND RESULTS: We retrospectively evaluated patients with CRT-Ds implanted at our institution between January 2000 and August 2006. PM-dependent patients were identified, and the incidence of inappropriate detections due to dMP oversensing and their possible clinical implications (inappropriate therapies, syncope, and death of any cause) were evaluated. CRT-Ds were implanted in 122 patients, 37 were or became PM dependent. During a mean follow-up of 22 +/- 17 months, 7(18.9%) PM-dependent patients revealed inappropriate detections due to dMP oversensing. All oversensing episodes occurred in CRT-Ds with automatic gain control (AGC) sensing and integrated bipolar (IBP) leads in the RV apex. These detections led to inappropriate shocks in 2(5.4%) patients and syncope in 1(2.7%). Five (13.5%) patients died. CONCLUSION: dMP oversensing in PM-dependent patients with CRT-Ds is an important problem, particularly in CRT-Ds with AGC sensing and IBP leads, with over 20% of patients with these devices revealing inappropriate detections. The clinical impact of dMP oversensing is less marked but relevant, with both inappropriate therapies and syncope occurring in this small group of 37 patients and the possibility of related deaths.

Benefit of cardiac resynchronization therapy in atrial fibrillation patients vs. patients in sinus rhythm: the role of atrioventricular junction ablation.

AIMS: To assess the clinical benefit of cardiac resynchronization therapy (CRT) in patients with atrial fibrillation (AF) compared with patients in sinus rhythm (SR), and to evaluate the impact of atrioventricular junction (AVJ) ablation on the outcome of AF patients undergoing CRT. METHODS AND RESULTS: We conducted a retrospective analysis of 131 consecutive heart failure (HF) patients who underwent CRT implantation. Three groups were considered: SR (n = 78), AF with AVJ ablation (n = 26), and AF without AVJ ablation (n = 27). Patients were evaluated for the occurrence of cardiac death, hospitalization for HF, and responsiveness to CRT (survival with improvement of >or=1 New York Heart Association class at 6 months). The three groups showed a significant improvement in functional class. However, the proportion of responders was significantly lower in AF patients without AVJ ablation (52 vs. 79% in SR and 85% in AF with AVJ ablation, P < 0.008). Atrial fibrillation without AVJ ablation was also independently associated with mortality (HR 5.22, 95% CI: 1.60-17.01, P = 0.006) and hospitalization for HF during the first 12 months (HR 6.23, 95% CI: 2.09-18.54, P = 0.001). The outcomes of AF with AVJ ablation patients were similar to the outcomes of patients in SR. CONCLUSION: Sinus rhythm and AF patients display similar survival and clinical improvement after CRT implantation, provided that AVJ ablation is performed in the latter.

Evaluation of glucose metabolism profile in coronary disease. Prospective study in hospitalized patients.

BACKGROUND: In 1995, it was estimated that 4% of the adult population had a diagnosis of diabetes mellitus. The trend is for growing prevalence, with a prediction of 300 million individuals with diabetes diagnosed in 2025. There seems to be a large number of asymptomatic individuals with undiagnosed disorders of glucose metabolism. These disorders, whether diabetes mellitus or conditions considered as prediabetic, including impaired glucose tolerance or impaired fasting glucose, represent an important risk factor for coronary disease and worsen the prognosis of established disease. The aim of this study was to evaluate the prevalence of glucose metabolism disorders in individuals admitted to hospital with coronary disease and to determine whether a significant number of these patients had previously undiagnosed diabetes or prediabetic conditions. METHODS: We conducted a prospective study of 44 consecutive patients admitted to the Cardiology Department with a diagnosis of coronary disease, whether previously established or established at the time of admission. We measured morning plasma glucose in all patients, after at least eight hours fasting, and all except those with a previous diagnosis of diabetes underwent an oral glucose tolerance test with 75 g of glucose before hospital discharge. For classification of glucometabolic state, we used the values defined by the World Health Organization (1999). RESULTS: The mean age of our cohort was 64.2+/-13.6 years. The most prevalent disorder was diabetes, with 19 patients (43.2%). Of these, 12 patients (27.3%) had a previous diagnosis of diabetes and 7 patients (15.9%) were unaware that they had the disease. We identified isolated impaired glucose tolerance in 11 patients (25%), isolated impaired fasting glucose in one patient (2.3%) and combined impaired glucose tolerance and impaired fasting glucose in another (2.3%). The remaining 12 patients (27.3%) revealed normal glycemia values. CONCLUSIONS: Glucose metabolism disorders including diabetes and impaired glucose tolerance have a high prevalence in coronary patients. This population includes a significant number of asymptomatic patients with undiagnosed diabetes or undetected prediabetic conditions. A systematic evaluation of the glucometabolic state of individuals with coronary disease during hospitalization, using an oral glucose tolerance test, may enable earlier identification of these disorders and implementation of measures to reduce their future impact.

Are degenerative changes in the aortic valve an additional important marker of atherosclerosis?

BACKGROUND AND AIM: Degenerative changes of the mitral annulus are associated with atherosclerotic disease. It has recently been suggested that degenerative changes in the aortic valve may also be associated with atherosclerosis. The intima-media thickness of the carotid arteries has been used as one of the best and earliest markers of atherosclerosis. The aim of this study was to evaluate whether the additional presence of degenerative changes in the aortic valve in coronary patients with mitral annular degenerative disease reflects different degrees of intima-media thickness as assessed by carotid ultrasonography. METHODS: The study group included 55 patients admitted for myocardial infarction who presented with degenerative changes of the mitral annulus assessed by echocardiography. Exclusion criteria were moderate or severe valvular heart disease and chronic renal failure. All patients underwent echocardiography, cardiac Doppler and carotid ultrasonography. Based on the echocardiographic findings, two sub-groups were formed: 1--with degenerative changes of the aortic valve; and 2--without degenerative changes of the aortic valve. Carotid ultrasonography was performed with a 7.5-10 MHz linear transducer and the following parameters were evaluated: 1--bilateral measurement of intima-media thickness in the common carotid artery; 2-- incidence of atheromatous plaques in the carotid arteries, and 3--incidence of >50% lesion in the internal carotid arteries assessed by pulsed Doppler (Vmax >125 cm/s). RESULTS: Thirty-three patients (aged 71.6 +/- 7.1 years), 21 men and 12 women, did not present degenerative changes in the aortic valve. The other group consisted of 22 individuals (aged 72.9 +/- 6.8 years), 14 men and 8 women, who did have such changes. Differences in age and gender distribution between the two groups were not significant. Patients with degenerative aortic valve disease had greater intima-media thickness than the control group (1.6 +/- 0.3 mm versus 1.3 +/- 0.4 mm, p < 0.001). Fifteen (68%) patients with aortic degenerative disease had plaques in the carotid arteries compared to 11 (33%) patients in the control group (p < 0.05). No significant differences were found between the two groups regarding the incidence of >50% atherosclerotic lesion in the internal carotid artery (22% versus 12%; NS). CONCLUSIONS: Patients with degenerative changes in the aortic valve presented significantly greater intima-media thickness and a higher incidence of atherosclerotic plaques than the control group, suggesting that their presence may constitute an additional important marker of severity of atherosclerotic disease.