Stroke prevention in asymptomatic carotid stenosis. ΛΙΛΛΗΣ ΛΕΩΝΙΔΑΣ Καρδιολόγος Επιστημονικός Συνεργάτης Α Καρδιολογικής Κλινικής ΑΠΘ ΠΓΝΘ ΑΧΕΠΑ

Transcription

1 Stroke prevention in asymptomatic carotid stenosis ΛΙΛΛΗΣ ΛΕΩΝΙΔΑΣ Καρδιολόγος Επιστημονικός Συνεργάτης Α Καρδιολογικής Κλινικής ΑΠΘ ΠΓΝΘ ΑΧΕΠΑ Σεμινάρια Ομάδων Εργασίας Ελληνικής Καρδιολογικής Εταιρείας Θεσσαλονίκη, 17/02/2017

2 CONFLICTS OF INTEREST None

3 Asymptomatic carotid stenosis: Definition 50% carotid artery stenosis in patients without ipsilateral neurological symptoms in the previous 6 months

4 Asymptomatic carotid stenosis: Definition 50% carotid artery stenosis in patients without ipsilateral neurological symptoms in the previous 6 months

5 Asymptomatic carotid stenosis: Prevalence De Weerd et al, Stroke 2010

6 Asymptomatic carotid stenosis: Prevalence Taussky et al, Neurosurg Focus 2011

7 Asymptomatic carotid stenosis: Risk factors Age Male sex Smoking Hypertension Hyperlipidemia Diabetes mellitus Family history of early atherosclerosis

8 Asymptomatic carotid stenosis: Diagnosis Carotid bruit Carotid ultrasound

9 Asymptomatic carotid stenosis: Diagnosis CT angiography Conventional angiography

10 Asymptomatic carotid stenosis: Risks 20% of all ischemic strokes Grau et al, Stroke 2001

11 Asymptomatic carotid stenosis: Risks ~1% annual risk of stroke Marquardt et al, Stroke 2010

12 Giannopoulos et al, Eur J Vasc Endovasc Surg 2015

13 33% 10-year risk or cardiac mortality Giannopoulos et al, Eur J Vasc Endovasc Surg 2015

14 Asymptomatic carotid stenosis: Screening Conflicting recomendations

15 Asymptomatic carotid stenosis: Screening

16 Asymptomatic carotid stenosis: Screening

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20 Asymptomatic carotid stenosis: Screening Significant (>50%) stenosis up to 38% in FRS low-risk patients Eleid et al, Eur J Am Soc Echocardiogr 2010

21 Asymptomatic carotid stenosis: Screening

22 Asymptomatic carotid stenosis: Screening

23 Asymptomatic carotid stenosis: Screening Belcaro et al, Atherosclerosis 2001

24 TREATMENT

25 Asymptomatic carotid stenosis: Medical treatment Aggressive risk factor modifications (smoking cessation, physical activity, healthy diet) Antiplatelet therapy (aspirin or clopidogrel) Statins Antihypertensive treatment

26 Asymptomatic carotid stenosis: Medical treatment

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28 Revascularization?

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30 Vikatmaa et al, Eur J Vasc Endovasc Surg 2012

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35 Brott et al, N Engl J Med 2010

36 Brott et al, N Engl J Med 2016

37 Brott et al, N Engl J Med 2016

38 ACT I Trial design: Asymptomatic subjects with carotid artery stenosis were randomized to carotid artery stenting with embolic protection (n = 1,089) vs. carotid endarterectomy (n = 364). % (p for noninferiority = 0.01) Results Death, stroke, or MI within 30 days or ipsilateral stroke within 1 year: 3.8% of the carotid stent group vs. 3.4% of the carotid endarterectomy group (p for noninferiority = 0.01) Death or major stroke: 0.6% vs. 0.6% Carotid stenting Carotid endarterectomy Conclusions Among asymptomatic patients with carotid artery stenosis, carotid artery stenting with embolic protection was noninferior to carotid endarterectomy Long-term outcomes were similar between the groups Rosenfield K, et al. N Engl J Med 2016;374:

39 Asymptomatic carotid stenosis: Risk stratification Silent infarction on CT/MRI Stenosis progression Hypoechoic plaques Irregular plaques Ulceration Intraplaque haemorrhage Thin fibrous cap Lipid-rich core Spontaneous ebolization on TCD Prior ipsilateral or contralateral TIA/stroke Naylor et al, Eur J Vasc Endovasc Surg 2014

40 Asymptomatic carotid stenosis: The future

41 Take home messages Asymptomatic carotid stenosis is a marker of systemic atherosclerosis and OMT is essential Decision for revascularization needs careful selection of patients We treat PATIENTS not PLAQUES!

42 THANK YOU!