Stroke prevention in asymptomatic carotid stenosis. ΛΙΛΛΗΣ ΛΕΩΝΙΔΑΣ Καρδιολόγος Επιστημονικός Συνεργάτης Α Καρδιολογικής Κλινικής ΑΠΘ ΠΓΝΘ ΑΧΕΠΑ
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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
27
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!
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