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
CONFLICTS OF INTEREST None
Asymptomatic carotid stenosis: Definition 50% carotid artery stenosis in patients without ipsilateral neurological symptoms in the previous 6 months
Asymptomatic carotid stenosis: Definition 50% carotid artery stenosis in patients without ipsilateral neurological symptoms in the previous 6 months
Asymptomatic carotid stenosis: Prevalence De Weerd et al, Stroke 2010
Asymptomatic carotid stenosis: Prevalence Taussky et al, Neurosurg Focus 2011
Asymptomatic carotid stenosis: Risk factors Age Male sex Smoking Hypertension Hyperlipidemia Diabetes mellitus Family history of early atherosclerosis
Asymptomatic carotid stenosis: Diagnosis Carotid bruit Carotid ultrasound
Asymptomatic carotid stenosis: Diagnosis CT angiography Conventional angiography
Asymptomatic carotid stenosis: Risks 20% of all ischemic strokes Grau et al, Stroke 2001
Asymptomatic carotid stenosis: Risks ~1% annual risk of stroke Marquardt et al, Stroke 2010
Giannopoulos et al, Eur J Vasc Endovasc Surg 2015
33% 10-year risk or cardiac mortality Giannopoulos et al, Eur J Vasc Endovasc Surg 2015
Asymptomatic carotid stenosis: Screening Conflicting recomendations
Asymptomatic carotid stenosis: Screening
Asymptomatic carotid stenosis: Screening
Asymptomatic carotid stenosis: Screening Significant (>50%) stenosis up to 38% in FRS low-risk patients Eleid et al, Eur J Am Soc Echocardiogr 2010
Asymptomatic carotid stenosis: Screening
Asymptomatic carotid stenosis: Screening
Asymptomatic carotid stenosis: Screening Belcaro et al, Atherosclerosis 2001
TREATMENT
Asymptomatic carotid stenosis: Medical treatment Aggressive risk factor modifications (smoking cessation, physical activity, healthy diet) Antiplatelet therapy (aspirin or clopidogrel) Statins Antihypertensive treatment
Asymptomatic carotid stenosis: Medical treatment
Revascularization?
Vikatmaa et al, Eur J Vasc Endovasc Surg 2012
Brott et al, N Engl J Med 2010
Brott et al, N Engl J Med 2016
Brott et al, N Engl J Med 2016
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) 3.8 3.4 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;374:1011-20
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
Asymptomatic carotid stenosis: The future
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!
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