Objectives. Mechanisms influencing the course of physical and mental functioning after an atherosclerotic event are unclear. We examined effects of white matter lesion (WML) activity on changes in functioning in patients with symptomatic atherosclerotic disease. Methods. In 486 patients ( years) of the Second Manifestations of ARTerial disease-Magnetic Resonance (SMART-MR) study, volumetric WML measurements on 1.5T MRI were performed at baseline and years followup. Functioning was assessed with the modified Short-Form 12 (SF-12) questionnaire. Associations of WML progression with changes in functioning were adjusted for age, sex, and vascular risk factors. Results. Physical functioning (baseline: 44, 10th–90th percentile 29–55) improved, whereas mental functioning (baseline: 51, 10th–90th percentile 32–60) declined during followup. WML progression (highest quartile versus rest) contributed to a stronger decline in mental functioning ( , 95% CI ？3.11 to ？0.42), but did not influence changes in physical functioning. Conclusions. Progression of WML volume contributes to a decline in mental functioning in patients with symptomatic atherosclerotic disease. 1. Introduction Ischemic heart disease and stroke are leading causes of disability and mortality worldwide [1]. As a result of improved survival and the lifelong aspect of these diseases, health-related quality of life (HRQoL), including physical and mental functioning, has become an increasingly important clinical and research outcome when evaluating burden of disease and treatment benefits. In addition, reduced physical and mental functioning not only interferes with daily living, but also increases the risk of incident ischemic vascular events and mortality [2–4]. Compared to the general population, HRQoL is substantially lower in patients with ischemic heart disease and stroke, especially in the domain of physical functioning [5–7]. A recent study indicated that HRQoL not only is lower in the acute phase of recovery from stroke, but also can decline up to five years after stroke in survivors free of recurrence or myocardial infarction [8]. Also, marked impairments in HRQoL have been observed in patients with other manifestations of atherosclerotic disease, including peripheral arterial disease [9, 10] and abdominal aortic aneurysm [11, 12]. Patients with symptomatic vascular disease frequently have atherosclerotic changes in the small vasculature in the brain, which are characterized by white matter lesions (WMLs) on magnetic resonance imaging (MRI) [13]. Although WMLs are often asymptomatic, they have
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