How good is current best medical therapy (BMT) for stroke prevention in patients with asymptomatic carotid stenosis?
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1 How good is current best medical therapy (BMT) for stroke prevention in patients with asymptomatic carotid stenosis? Dorothee Saur Department of Neurology University of Leipzig
2 Disclosure for Dorothee Saur I have the following potential conflicts of interest to report: Consulting Employment in industry Stockholder of a healthcare company Owner of a healthcare company Other(s) x I do not have any potential conflicts of interest
3 Patient presentation RP, femal, 75Y TIA with aphasia and weakness of the right arm over 30 min Risk factors: smoking, hypertension DW-MRI Duplex ultrasoundsonography 300/100 cm/s L right (!) ICA -> asymptomatic ~ 70% (NASCET) ICA stenosis -> Therapy: aspirin, simvastatin 40mg, antihypertensive medication, quit smoking However, optimal therapy of aysmptomatic ICA stenosis is unclear.
4 Efficacy of conventional medical therapy (MT) Evidence from randomized trials Years rate of events ([TIA],stroke, death) 20% MT ASS + risk factor modification 10 10% 11% 11,8% CEA 5 5,1% 6,4% 0 VACS (1993) n = 444 ACAS (1995) n = 1662 ACST (2004) n = 3120 Σ CEA is superior to medical therapy alone VACS=Veterans Affairs Cooparative Study; ACAS=Asymptomatic Carotid Atherosclerosis Study; ACST =Asymptomatic Carotid Surgery Trial
5 Management of contemporary BMT Treatment of hypertension - RR < 140 / 90 mm Hg (Class I- LoE: A) - type of therapy less important than response (Class I- LoE: A) Control of Hyperlipidemia - statin therapy - LDL cholesterol < 100 mg/dl (Class I, LoE: B) - diabetes: LDL cholesterol < 70 mg/dl (Class IIa, LoE: B) - non-statin therapies* are not yet established in preventing stroke (Class IIb, LoE: C) Management of Diabetes mellitus - usefulness of diet, exercise and glucose-lowering drugs (Class IIa, LoE: A) with HbA1c values < 7.0% *ezetimibe, bile acid sequestrants, fibrates, niacin ASA ect. Guideline, Brott, JACC, 2011
6 Management of contemporary BMT Antithrombotic Therapy - aspirin mg /d is recommended (Class I, LoE: A) for prevention of MI / cardiovascular events; benefit for primary stroke prevention not established - if aspirin is contraindicated: clopidogrel 75 mg / d, ticlopidine 2 x 250 mg /d Lifestyle changes - smoking cessation (Class I, LoE: B) - physical activity at least 40 min/d at 3-4 d/week (Class I, LoE: B) - weight reduction for lowering blood pressure - mediterranean diet rich in fruits and vegetables Duplex ultrasonography yearly in patients with NASCET > 50% ASA ect. Guideline, Brott, JACC, 2011
7 Efficacy of current BMT for stroke prevention Evidence from prospective (cohort) studies Johnson, 1985 Toronto, 1986 VACS, 1993 ACAS, 1995 ECST, 1995 ACBS, 1997 CHS, 1998 ACSRS, 2005 ASED, 2005 SMART, 2007 n = 3292 Annual (ipsilateral)stroke rate CHS ACBS ACSRS ASED SMART 1,5% for CEA in ACAS/ACST [Publication Year] Σ annual stroke rate associated with BMT has fallen ( 25-year fall ) Abbott, Stroke, 2009
8 Efficacy of current BMT for stroke prevention The OXVASC study (prospective, population-based) Annual stroke/(tia) rates TIA avarage annual event rates: ipsilateral stroke = 0,34% ipsilateral TIA = 1,78% Stroke Σ low risk mainly due to use of statins and RR-lowering medication Marquardt, Stroke, 2010
9 How good is current BMT for stroke prevention? Evidence from prospective cohort studies Annual risk rate for ipsilateral stroke Recruitment period [year] Σ decrease of annual risk of stroke from ~2,5-3% to ~1% Marquardt, Stroke, 2010
10 Summary Current BMT of asymptomatic carotid stenosis consists of - antiplatelet therapy, intensive risk factor treatment including statins and life style modification Current BMT has reduced rates of ipsilateral stroke to ~ 1% per year Results from large randomized trials comparing CAS, CEA AND BMT are recquired to determin optimal treatment for asymptomatic carotid stenosis [closed] CREST-2 Trial [start in 12/2014]
11 Abbott, Stroke, 2009
12 How good is current best medical therapy (BMT) for stroke prevention in patients with asymptomatic carotid stenosis? Dorothee Saur Department of Neurology University of Leipzig
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