(Cardiology Update) Expert Opinion : Endovascular Intervention in Carotid Artery Disease MD, DM. Interviewer : Ravi Singhvie, MD

Transcription

1 (Cardiology Update) Volume-1 Issue-5 November-December 2008 Editorial Board Editor of the Month Dr. Hemang Baxi (M) Cardiologist Dr. Urmil Shah, DM (M) Dr. Anish Chandarana, DM (M) Dr. Ajay Naik, DM (Mumbai) DNB, FACC (M) Dr. Satya Gupta, DM, FIC (FRANCE) (M) Dr. Gunvant Patel, DM (M) Dr. Joyal Shah (M) Dr. Mihir Tanna (M) Dr. Milan Chag, DM, DNB (M) Cardiac Physicians Dr. Ravi Singhvie (M) Dr. Jayesh Bhanushali (M) Editor : Dr. Keyur Parikh (USA) FCSI (India) FACC, FESC, FSCAI (M) (Now onwards Cardiology Update is ) Expert Opinion : Endovascular Intervention in Carotid Artery Disease Expert : Hemang Baxi, DM Interviewer : Ravi Singhvie, Dr. Ravi Singhvie: I'm with Dr. Hemang Baxi, a renowned cardiologist of Ahmedabad, Gujarat. Dr. Baxi, we will be discussing carotid artery disease and carotid interventions, first of all please tell me how common is the carotid disease? Who gets it, and why? Dr. Hemang Baxi: Although the precise prevalence of carotid artery stenosis is unknown, large studies have estimated that 0.5% of people in their sixties and 10% of people older than age 80 years have carotid artery stenosis. Atherosclerotic stenosis of the carotid artery has been estimated to be responsible for 20% to 30% of all strokes. More than 600,000 Americans suffer a stroke each year, more than one in four of them die. Currently, there are 4.6 million stroke survivors in the United States, where the disease is the third leading cause of death and the leading cause of major morbidity. Age, race, gender, genetics and family history are nonmodifiable factors that play a role in the development of carotid artery Message from Editor Dear Friends, Happy New Year to All of You! Carotid artery stenosis is responsible for 20-30% of ischemic strokes. The natural history of disease is directly related to the severity of the lesion and symptomatic status. Nearly 80% of the strokes due to artery to artery embolism in the carotid distribution may occur as the initial event without warning emphasizing the need for prevention and treatment of carotid artery stenosis. Medical therapy (E.g. Antiplatelets, lipid-lowering agents) has continuing role in reducing cardiovascular risk, but prospective randomized studies such as NASCET, ECST, ACAS have proved that carotid endarterectomy (CEA) is better than aspirin alone in stroke prevention in both symptomatic patients and in asymptomatic patients with severe carotid artery stenosis. Carotid angioplasty and stenting is now feasible and is increasing the performed and has shown great promise. Continued on Page-7

2 disease. Older age, African-American and Hispanic descent, male gender, and family history are all risk factors. Modifiable risk factors include smoking, hyperlipidemia, sedentary lifestyle, increased body mass index, oral contraceptive use, alcohol abuse, diabetes mellitus, hypertension, prior transient ischemic attack (TIA) or stroke, elevated homocysteine level, elevated anticardiolipin antibodies, presence of a carotid bruit, cardiac disease, increased fibrinogen, and low serum folate level. Dr. Ravi Singhvie: What are the symptoms of carotid disease? Dr. Hemang Baxi: The carotid arteries carry 80% of cerebral blood flow; irrigate the territories of the middle cerebral, anterior cerebral, and anterior choroidal arteries, and provide blood flow to the eyes through the ophthalmic arteries. The symptoms of carotid embolism vary according to the recipient artery. Ophthalmic artery occlusion results in monocular visual loss Anatomy of Carotid Vertebral arterial system often described as blurring, graying, or curtaining of vision. Middle cerebral artery syndrome often includes contralateral weakness affecting the face and arm more than the leg, contralateral sensory loss, and aphasia if the dominant hemisphere is affected, or hemi-inattention or neglect with nondominant lesions. In addition, there may be gaze deviation toward the affected hemisphere. Anterior cerebral artery strokes affect the contralateral leg and shoulder more than face and arm and can have associated abulia and incontinence. The anterior choroidal stroke affects the basal ganglia and internal capsule, with contralateral hemiplegia, hemisensory loss, and hourglass-shaped homonymous visual field defects. Anterior choroidal infarcts may be difficult to differentiate from lacunar strokes because of occlusion of small penetrators. Dr. Ravi Singhvie: What is the risk of stroke in patients with carotid stenosis? Dr. Hemang Baxi: Well, it depends on history of prior symptoms and degree of carotid stenosis. Patients with history of symptoms e.g. stroke, TIA, amaurosis fugax are at a much higher risk of recurrent stroke. The North American Symptomatic Carotid Endarterectomy Trial (NASCET) defined a 26% risk of ipsilateral stroke at 2 years in the presence of stenosis of 70% or more for those treated medically, with increasing risk at greater degree of stenosis. The risk of stroke after purely ocular symptoms (amaurosis fugax) is less than in those with cerebral symptoms. For stenosis of 50-69% in symptomatic patients, the risk of stroke was less impressive: at 5 years, the risk of ipsilateral stroke in those undergoing antiplatelet therapy was 22.2%. Stenosis under 50% is unlikely to result in stroke. The risk of stroke with asymptomatic carotid stenosis is clearly less than after a TIA or stroke. The Asymptomatic Carotid Atherosclerosis Study (ACAS) studied carotid stenosis of 60% or more; in the medically treated group, the risk of ipsilateral stroke was estimated at 11% at 5 years, suggesting an annual risk of 2.2%. Dr. Ravi Singhvie: What is the best initial test to detect carotid disease? Dr. Hemang Baxi: Dr. Ravi, extracranial duplex ultrasonography is a reliable, noninvasive and relatively inexpensive method to study the extracranial carotid system. It combines B-mode ultrasound and color-coded Doppler; whereas B- mode provides, in grayscale, an image of the common, internal, and external carotid arteries. Doppler techniques allow a physiologic evaluation of the blood flow characteristics. Many ultrasonographic criteria have been established to estimate the degree of stenosis, and each ultrasound laboratory should validate its own criteria against angiographic standards. In general, a peak systolic flow velocity of 140 cm/sec correlates with about 50% stenosis, and 2

3 velocities of 200 cm/sec or more suggest more than 70% stenosis. Carotid ultrasound has a sensitivity of 90-95% and specificity of 85% compared with catheter angiography. Ultrasound may be unable to detect high-grade stenosis and mistakenly diagnoses a carotid occlusion in 5% of cases. Although power Doppler and echocontrast agents may improve the odds of a correct diagnosis. Both MRA and CTA adequately image the carotid system, with the advantage of visualizing the intracranial circulation. These techniques are more expensive and have accuracy that is similar to ultrasound for detecting extracranial carotid stenosis. Dr. Ravi Singhvie: Is carotid angiography needed to confirm carotid stenosis diagnosed by ultrasound? Dr. Hemang Baxi: Although ultrasound is usually the first diagnostic study, patients with significant stenosis in whom revascularization is being considered should have a confirmatory test. Establishing the degree of stenosis by ultrasound may be misleading in the presence of contralateral significant stenosis or occlusion, high carotid bifurcation, or severely calcified plaques, and in those with thick and short necks. Catheter angiography is the gold standard diagnostic test, but it carries a risk of clinical stroke of about 1%, although experienced centers have a lower rate of complications. With a reported sensitivity and specificity as high as 90%, MRA is playing an increasingly important role in the selection of surgical candidates and may replace catheter angiography in the future. Dr. Ravi Singhvie: When is carotid revascularization indicated? Dr. Hemang Baxi: Dr. Ravi, as we have already discussed, the risk of stroke after ischemic symptoms is significant, and carotid endarterectomy trials have unequivocally shown that those with symptomatic carotid stenosis should be revascularized. These data are strongest for stenosis of 70-99% and less robust for stenosis of 50-69%. For patients with asymptomatic carotid stenosis, the decision to revasularize is more difficult; because the natural history of asymptomatic carotid stenosis is relatively benign (annual risk of stroke of about 2%), the decision to intervene should be weighed against the inherent risk of the procedure. To maintain the benefits of revascularization in asymptomatic individuals, the surgical morbidity and mortality should be kept under 3%. This concept should apply to both endarterectomy and endovascular procedures. Besides other traditional vascular risk factors, certain qualifiers increase the risk of stroke in patients with asymptomatic carotid stenosis and provide grounds to proceed with revascularization. These qualifiers include high-grade stenosis in otherwise healthy and relatively young patients; those with documented progression of carotid stenosis; individuals with poor collateral flow or vasomotor reactivity; and the presence of asymptomatic embolism detected by transcranial Doppler monitoring or by its sequelae, silent strokes on cerebral imaging. Dr. Ravi Singhvie: Is angioplasty and stenting equivalent to carotid endarterectomy? Dr. Hemang Baxi: Carotid angioplasty and stenting is now feasible and is increasingly performed. To date, the endovascular approach has not been proven to be as safe or more efficacious than endarterectomy. However, it is an evolving technique, and the development of new materials and distal protection devices, as well as stents coated with different vasoactive substances, may make it the procedure of choice in the future. Current indications for carotid artery stent placement are for symptomatic (diameter more than 50%) and asymptomatic (80%) stenoses in patients at 3

4 increased Increased risk Risk for of Complications carotid surgery for who Carotid are anatomically Stent Placement good candidates for CAS (Table1). Currently, Tortuous patients aortic who arch do not meet high surgical risk criteria Platelet (Table or 2) clotting should disorder be offered surgery or participation Difficult in vascular a clinical access trial. Trials are continuing to enroll Lesion low surgical or vessel risk calcification patients, prophylactic medical Visible thrombus therapy is improving and, as always, the best patient Table 1 Factors Associated with Increased Risk for Carotid Artery Surgery Anatomical criteria High cervical or intrathoracic lesion Prior neck surgery or radiation therapy Contralateral carotid artery occlusion Prior ipsilateral carotid endarterectomy Contralateral laryngeal nerve palsy Medical comorbidities Age>80 yrs Class III/IV CHF/Angina LMCA/Severe DVD or TVD Ejection fraction < 30%, Recent MI Severe chronic obstructive lung disease Table 2 care will continue to require knowledge skills, and the judicious application by the physician. Dr. Ravi Singhvie: What are the long-term results of stenting? Dr. Hemang Baxi: In the largest review of more than 5000 carotid artery stenting procedures, 2.1% of patients were found to have restenosis of greater than 50% at 6 months. The restenosis rate after 12 months was found to be 3.5%. The major stroke and death rate at 1 year was 2.4%. Dr. Ravi Singhvie: What is the appropriate timing to revascularize carotid stenosis when coronary artery bypass graft (CABG) surgery is planned? Dr. Hemang Baxi: CABG is associated with a significant risk of stroke. Most perioperative strokes are embolic, either from an aortic arch plaque damaged by clamping or cannulation of the aorta or from fatty material recirculated in the cardiopulmonary pump machine. However, hemodynamic strokes distal to a significant carotid stenosis may occur and are caused by the significant hypotension achieved during surgery. Controversy exists regarding the timing of carotid revascularization: should it be done before or during CABG? In our experience, a staged procedure of carotid revascularization followed by coronary surgery is most appropriate, but management decisions need to be individualized. Dr. Ravi Singhvie: What is the future of Carotid Artery Stenting? Dr. Hemang Baxi: The Carotid Revascularization Endarterectomy Versus Stent Trial (CREST) is currently enrolling patients for a multicenter clinical trial to compare the efficacy of CEA and carotid angioplasty stenting in symptomatic patients with stenosis greater than or equal to 50%. SAPPHIRE (Stenting and Angioplasty with Protection in Patients at High-Risk for Endarterectomy) is the first randomized study to compare carotid stenting using a distal protection device with carotid endarterectomy (CEA) in high-risk patients. A total of 307 patients were entered in the randomized trial, with 156 patients enrolled in the stented arm and 151 entered in the CEA group. The composite endpoint of death, stroke, or MI was 5.8% for the stented patients and 12.6% for the surgical patients (P=.047). The future use of carotid artery stenting will most likely grow safer, with less complications as biomedical technology advances with new materials and devices that accommodate current limitations. These include dedicated carotid stenting equipment with low profile stent delivery systems and a variety of stent designs and better access sheaths, specialty balloons, and guidewires. A variety of neuroprotective devices are likely to be optimized to decrease the incidence of embolic debris events. Drug-coated stents will also play a role in carotid stent development. Next Issue Topic : Trans Radial Intervention Editor : Dr. Satya Gupta 4

5 3-C Con 2009 Annual Conference on Cardiovascular Medicine Dates : January 9-11, 2009 Venue : Tagore Hall, Ahmedabad The Grand Bhagwati, Ahmedabad Organizing Committee Conference Chairman Chair, Scientific Committee Dr Keyur Parikh Dr Milan Chag (M) (M) Conference Directors Dr Urmil Shah (M) Dr Hemang Baxi (M) Dr Anish Chandarana (M) Dr Ajay Naik (M) Dr Satya Gupta (M) Dr Gunvant Patel (M) Dr Joyal Shah (M) Dr Mihir Tanna (M) Conference Co-Ordinators Dr Ravi Singhvie (M) Dr Jayesh Bhanushali (M) Dr Jay Kantharia (M) Dr Sarfaraz Shaikh (M) Dr Goral Panchal (M) Echocardiography Fellowship Course Course Director : Dr. Satya Gupta, DM Cardiology (CMC Vellore) Registration Fees : INR 10,000 Practising Physicians INR 5000 Residents / Interns / Nurses / Allied Health Professionals Time : 9.00 am to 5.00 pm (Monday to Saturday) Place : The Heart Care Clinic, Ahmedabad Dates of Echocardiography Course (A) to (B) to (C) to (D) to (E) to (F) to For Registration kindly contact Mrs. Komal Shah (M ) ASAP Please visit to Download Program Brochure & Registration Form LAST CHANCE Registration Form for 3-C Con 2009 Cheque or DD's to be made A/C payee and in the name of ''Care Cardiovascular Consultants Pvt. Ltd." Kindly mail the registration form along with the cheque/dd to our office. All Cash Payment at 'The Heart Care Clinic, Ahmedabad' only. Registration Fees (Please make a choice as per modules below) Moduler Registration Fees (A) Main Conference Module (9-11 Jan, 09) 6000 (B) Certification Courses (11 Jan, 09) * ECG 2000 * Clinical Cardiology 2000 * Financial Planning & Office, Clinic & Hospital Management 2000 * Lipid, Cardiovascular Metabolic 2000 Disorders and Diabetes Management (C) Total (A + B) (D) ** Deposit for Hotel Accommodation 3000 (Separate cheque) (E) For students doing (Medicine)with proof 3000 (F) AAPI Members $ 400 (G) Foreign Delegates $ 500 (H) % Deduction (in case of cancellation) No Refund * Choose any one module, ** Hotel Accommodation is optional. If you need accommodation please send a separate deposit cheque for Rs to cover the cost of your stay for two nights. Students also need to pay for Hotel Accommodation at the same rate. Hotel will be available from Rs Rs on twin sharing basis after June, 2008 for all India delegates. Tick options vertically. Due to limited sitting in various venues, Please register early to avoid disappointments Mail to : The Heart Care Clinic Prof. Dr Mr. Mrs. Ms. First Name : Middle Name : Last Name : Qualification : Resi. Address : City : State : Pin Code : Telephone (STD Code) (O) (R) Mobile : Fax : Payment Details : Rs. Rupees in word : Draft/Cheque No. Bank Dated If you want hotel accommodation? Yes No (If yes, Rs. 3,000/-) Final program ready with over 150 lectures and over 50 faculty LAST CHANCE Signature Last Chance to Register 3-C Con delegates already registered 5

6 Question and Answer of Previous Issue Vol-1 Issue-4 (September-October 2008) Diet in Cardiovascular Health And Disease 1 All the following are included in the revised cardiac risk index to predict patients at high risk of sustaining peri-operative cardiovascular complications except a. Chronic kidney disease with a pre- operative creatinine > 2.0 mg/dl b. Current tobacco use c. History of congestive heart failure d. History of ischemic heart disease e. Insulin therapy for diabetes mellitus 2 Which condition does not require Infective Endocarditis prophylaxis? a. VSD b. PDA c. ASD d. TOF 3 All the following ECG findings are suggestive of LVH except a. (S in V1 + R in V5 or V6) >35 mm b. R in avl > 11 mm c. R in avf > 20 mm d. (R in I + S in III) > 25 mm e. R in avr > 8 mm 4 All are associated with a high risk of stroke in patients with atrial fibrillation except a. Diabetes mellitus b. Hypercholesterolemia c. Congestive heart failure d. Hypertension 5 A 58-year-old female undergoes successful stenting of LAD & LCX arteries after a NSTEMI. She should be discharged on all the medications except a. Aspirin b. Metoprolol c. Clopidogrel d. Lisinopril e. Warfarin 6 A 25-year-old asymptomatic male without any significant family history is seen in the clinic for a routine physical examination. A III/VI systolic murmur is heard at the apex. On Valsalva maneuver the murmur decreases in intensity, and the murmur is accentuated with sustained handgrip. His murmur probably is due to: a. Aortic regurgitation c. Aortic stenosis b. Mitral regurgitation d. Hypertrophic cardiomyopathy e. Pulmonic stenosis 7 Which of the following congenital cardiac disorders will lead to a leftto-right shunt, generally with cyanosis? a. Anomalous origin of the left coronary artery from the pulmonary trunk b. Patent ductus arteriosus without pulmonary hypertension c. Total anomalous pulmonary venous connection d. Ventricular septal defect e. Sinus venosus atrial septal defect 8 Acute hyperkalemia is associated with which ECG changes? a. QRS widening b. Prolongation of the ST segment c. A decrease in the PR interval d. Prominent U waves e. T-wave flattening 9 Which drug has been demonstrated to reduce perioperative mortality in patients undergoing non-cardiac surgery? a. Nitrates c. Calcium channel blocker b. Beta blocker d. Alpha 2 Agonist e. Diuretic therapy 10 Which of the following parameters adds predictive information regarding cardiovascular risk stratification and the measurement of serum cholesterol? a. Anti Chlamydia pneumoniae antibodies b. C-reactive protein c. Homocysteine d. Lipoprotein A e. Plasminogen activator inhibitor 1 6 Feed Back Form Please send your feedback and answers to the Quiz for this issue and drop it in the post box: Name: Degree Name of clinic/hospital: Address: City: State: Pin : Contact No. (O) (Mobile) ID: Did you like this issue? Yes No Did you like the Topic of the issue? Yes No Do you think this issue updated your Yes No academic knowledge? Put a cross inside the correct answer Only one best answer for each question Three top answerers will get prizes with their name, address and photo published in next issue Everybody who answers all the 10 questions and mails the answers will still get a Certificate of CME of One Hour ( 1 Hour) from 3 C CON Please send your answers by post to our office address before 15 January, 2009 Answer Sheet of the Quiz of Volume 1 Issue-5 (November-December 2008) Question No. A B C D E Question-1 Question-2 Question-3 Question-4 Question-5 Question-6 Question-7 Question-8 Question-9 Question-10 The Heart Care Clinic 201, Balleshwar Avenue, Opp Rajpath Club, S.G. Highway, Bodakdev, Ahmedabd Phones : , , , Fax : , Mobiles : , info@heartcareclinic.org

7 Case of the Month History: A 64 years old male patient presented with history of left sided weakness with slurring of speech and confusion, with spontaneous recovery within 6 hours. Carotid Doppler showed 90% left internal carotid artery stenosis. CT scan was suggestive of right thalamic infarct. Carotid Angiography was done which was s/o critical bilateral ICA stenosis. Successful PTA with stenting of right ICA was done using Distal protection Angioguard filter device. 80 % lesion in right ICA Angioguard Filter in C2 Carotid Stent (Self expanding) Message from Editor Final Result 80 % lesion in Left ICA Continued on Page-1 It is an evolving technique and the development of new materials and distal protection devices as well as stents coated with different vaso-active substances may make it the procedure of choice in near future. I hope this issue will be useful for your clinical judgement viz-a-viz management of patients with carotid artery disease. Dr. Hemang Baxi Quiz of the Month 1) True about ACE Inhibitors is all except: A. Increase renin B. Increase angiotensin-1 C. Decrease renal blood flow D. Increase bradykinin 2) Digoxin level is increased in all except: A. Phenytoin B. Amiodarone C. Erythromycin D. Verapamil 3) The most densely vascularized area of the heart is: A. Apex B. Diaphragmatic surface C. Interventricular septum D. Anterolateral wall 4) RV impulse is prominent in: A. MS with severe PAH B. Ebstein's anomaly C. Tricuspid atresia D. TOF with pulmonary atresia 5) Down's syndrome: most commonly associated with: A. Endocardial Cushion Defect B. TOF C. Pulmonary stenosis D. VSD 6) Eplerenone is: A. Aldosterone antagonist B. Endothelin antagonist C. Cholesterol absorption inhibitor D. Phosphodiesterase 3 inhibitor 7) Regression of atherosclerosis is by all except: A. Statins B. Nitrates C. Calcium channel blockers D. ACE-inhibitors 8) Severity of MR is assessed by all except: A. Cardiomegaly B. Loudness of murmur C. Wide splitting of S2 D. M 9) Non synchronized DC shock is used for: A. VF B. A flutter C. AF D. VT 10) Kussmaul sign is not found in: A. Chronic Constrictive Pericarditis B. Cardiac tamponade C. RVMI D. Pulmonary embolism Errata : Corrected Question & Answer of Q-1 of Quiz of Volume-1, Issue-3, (Dr. Urmil Shah s Issue) Which of the following drugs are not class I indications for treatment of patient with Post MI LV dysfunction? A. Ramipril B. Carvedilol C. Eplerenone D. Diltiazem 7

8 Top Answerers of September-October Issue Dr. J. D. Shah Dr. Anil Baroopal Dr. Monika Maheshwari Dr. Kirit Akhani Dr. B. R. Vyas Paras Hospital, Bayad Resident J.L.N. Medical College & Hospital, Ajmer, DNB (Gen. Med.) J.L.N. Medical College & Hospital, Ajmer Trupti Heart & Medical Hospital, Ahmedabad (Med.) LL.B. Dr. Vyas Day Care Clinic, Banswara Peripheral Vascular Disease (PVD Clinic) (Every Day / Every Week / Every Month for the Year 2008 & 2009) Patients with H/O: Claudication Stroke/TIA Uncontrolled Hypertension/Impaired RFT Flash pulmonary oedema Multiple vascular risk factors (DM, HT, Smoking) Experience : Pioneer of Peripheral Angioplasty since 1985 First Aortic Stent placed in India by us at Nizam Institute, Hyderabad in 1992! Over 5000 Peripheral Cases with over hundreds of Angioplasty done Over 50 Carotid Intervention & Stents in last few months with 0 % immediate Mortality & Morbidity and over 99 % long term success Send these patients for PVD Evaluation Registered patients will get FREE consultation FREE ABI (Ankle - Branchial Index) 50 % discount on color doppler (Renal/Carotid) For registration contact Reception. PVD Targets We have the Solutions Carotid If you have spells of dizziness, you may have Carotid Artery Blockage If you have been diagnosed as a case of PVD, you may come for treatment If you have incurable high BP you may have Renal Artery Blockage If you get pain in legs after walking you may have Iliac or Femoral Artery Blockage In association with The Heart Care Clinic. 201, Balleshwar Avenue, Opp Rajpath Club, S.G. Highway, Bodakdev, Ahmedabd Phones : , , , Mobiles : , NO OPTIONS CLINIC If you have a patient with recent MI (< 1 week) OR If you have a patient of unstable angina (or NSTEMI) with Positive Trop-I OR patients with angina & abnormal TMT, who are unwilling for invasive procedures they will be offered (A) Free consultation (B) Echocardiography 50 % OFF (C) Various innovative, non-invasive modalities of treatment Please contact any of us for consultation All the patients will be appropriately sent back to you for further management. Newer modalities of treatment and supportive care will be offered to the patient & family.! 8