Current Cardiology Reports

, Volume 13, Issue 1, pp 18–23 | Cite as

Intensive Medical Therapy for Asymptomatic Carotid Artery Stenosis

Article
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Abstract

The majority of carotid revascularization procedures are done in patients without recent symptoms of cerebral ischemia (asymptomatic carotid stenosis). In previous studies from the past two decades, the stroke risk associated with asymptomatic carotid stenosis has been estimated to be 2–2.5% per year. Given the relatively benign nature of asymptomatic carotid stenosis, it has been proposed that confining revascularization to a limited, higher-risk subgroup is a sensible strategy. Evidence is accumulating that improved medical therapy has led to a lower risk of stroke in medically treated patients and that ultrasound methods can identify higher-risk patients. These developments are highlighted in this article.

Keywords

Carotid stenosis Statins Asymptomatic stenosis Transcranial Doppler 

Clinical Trial Acronyms

ACST

Asymptomatic Carotid Surgery Trial

NASCET

North American Symptomatic Carotid Endarterectomy Trial

OXVASC

Oxford Vascular Study

SPACE-2

Stent-protected Angioplasty in Asymptomatic Carotid Artery Stenosis Versus Endarterectomy

SPARCL

Stroke Prevention by Aggressive Reduction in Cholesterol Levels

VACS

Veterans Affairs Cooperative Study

Notes

Disclosure

Conflicts of Interest

P. Bhattacharya: none; S. Chaturvedi works with Abbott Vascular and is an executive committee member for ACT, CAPTURE 2, and PROTECT.

References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. 1.
    Abbott AL, Bladin CF, Levi CR, Chambers BR: What should we do with asymptomatic carotid stenosis? Int J Stroke 2007, 2:27–39.CrossRefPubMedGoogle Scholar
  2. 2.
    Chambers BR, Norris JW: Outcome in patients with asymptomatic neck bruits. N Engl J Med 1986, 315:860–865.CrossRefPubMedGoogle Scholar
  3. 3.
    Inzitari D, Eliasziw M, Gates P, et al.: The causes and risk of stroke in patients with asymptomatic internal-carotid-artery stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 2000, 342:1693–1700.CrossRefPubMedGoogle Scholar
  4. 4.
    Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study [no authors listed]. JAMA 1995, 273:1421–1428.Google Scholar
  5. 5.
    Halliday A, Mansfield A, Marro J, et al.: Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004, 363:1491–1502.CrossRefPubMedGoogle Scholar
  6. 6.
    Redgrave JN, Rothwell PM: Asymptomatic carotid stenosis: what to do. Curr Opin Neurol 2007, 20:58–64.PubMedGoogle Scholar
  7. 7.
    Barnett HJ: Carotid endarterectomy. Lancet 2004, 363:1486–1487.CrossRefPubMedGoogle Scholar
  8. 8.
    Barnett HJ, Meldrum HE, Eliasziw M: The appropriate use of carotid endarterectomy. CMAJ 2002, 166:1169–1179.PubMedGoogle Scholar
  9. 9.
    Bond R, Rerkasem K, Rothwell PM: Systematic review of the risks of carotid endarterectomy in relation to the clinical indication for and timing of surgery. Stroke 2003, 34:2290–2301.CrossRefPubMedGoogle Scholar
  10. 10.
    Naylor AR, Gaines PA, Rothwell PM: Who benefits most from intervention for asymptomatic carotid stenosis: patients or professionals? Eur J Vasc Endovasc Surg 2009, 37:625–632.CrossRefPubMedGoogle Scholar
  11. 11.
    Rothwell PM, Goldstein LB: Carotid endarterectomy for asymptomatic carotid stenosis: asymptomatic carotid surgery trial. Stroke 2004, 35:2425–2427.CrossRefPubMedGoogle Scholar
  12. 12.
    Rerkasem K, Rothwell PM: Temporal trends in the risks of stroke and death due to endarterectomy for symptomatic carotid stenosis: an updated systematic review. Eur J Vasc Endovasc Surg 2009, 37:504–511.CrossRefPubMedGoogle Scholar
  13. 13.
    Chaturvedi S, Madhavan R, Santhakumar S, et al.: Higher risk factor burden and worse outcomes in urban carotid endarterectomy patients. Stroke 2008, 39:2966–2968.CrossRefPubMedGoogle Scholar
  14. 14.
    Yadav JS, Wholey MH, Kuntz RE, et al.: Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med 2004, 351:1493–1501.CrossRefPubMedGoogle Scholar
  15. 15.
    Mas JL, Trinquart L, Leys D, et al.: Endarterectomy Versus Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial: results up to 4 years from a randomised, multicentre trial. Lancet Neurol 2008, 7:885–892.CrossRefPubMedGoogle Scholar
  16. 16.
    McPhee JT, Schanzer A, Messina LM, Eslami MH: Carotid artery stenting has increased rates of postprocedure stroke, death, and resource utilization than does carotid endarterectomy in the United States, 2005. J Vasc Surg 2008, 48:1442–1450, 1450e1.CrossRefPubMedGoogle Scholar
  17. 17.
    Ringleb PA, Chatellier G, Hacke W, et al.: Safety of endovascular treatment of carotid artery stenosis compared with surgical treatment: a meta-analysis. J Vasc Surg 2008, 47:350–355.CrossRefPubMedGoogle Scholar
  18. 18.
    • Abbott AL: Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis. Stroke 2009, 40:e573–e583. This is a comprehensive analysis of studies with an adequate cohort of medically treated patients from a variety of settings over recent decades, suggesting improved results with medical therapy. CrossRefPubMedGoogle Scholar
  19. 19.
    Collins R, Armitage J, Parish S, et al.: Effects of cholesterol-lowering with simvastatin on stroke and other major vascular events in 20536 people with cerebrovascular disease or other high-risk conditions. Lancet 2004, 363:757–767.CrossRefPubMedGoogle Scholar
  20. 20.
    Amarenco P, Bogousslavsky J, Callahan A 3rd, et al.: High-dose atorvastatin after stroke or transient ischemic attack. N Engl J Med 2006, 355:549–559.CrossRefPubMedGoogle Scholar
  21. 21.
    • Marquardt L, Geraghty OC, Mehta Z, Rothwell PM: Low risk of ipsilateral stroke in patients with asymptomatic carotid stenosis on best medical treatment: a prospective, population-based study. Stroke 2010, 41:e11–e17. Although the sample size is limited and the number of patients with severe stenosis is relatively low, there is important preliminary information about the annual stroke risk being lower than 1% using contemporary medical therapy. CrossRefPubMedGoogle Scholar
  22. 22.
    Spence JD, Tamayo A, Lownie SP, et al.: Absence of microemboli on transcranial Doppler identifies low-risk patients with asymptomatic carotid stenosis. Stroke 2005, 36:2373–2378.CrossRefPubMedGoogle Scholar
  23. 23.
    Spence JD, Eliasziw M, DiCicco M, et al.: Carotid plaque area: a tool for targeting and evaluating vascular preventive therapy. Stroke 2002, 33:2916–2922.CrossRefPubMedGoogle Scholar
  24. 24.
    • Spence JD, Coates V, Li H, et al.: Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis. Arch Neurol 2010, 67:180–186. This is an important study identifying that patients with active microemboli are a relatively small subgroup and that the stroke risk without microemboli is quite low. CrossRefPubMedGoogle Scholar
  25. 25.
    Jones PH, Davidson MH, Stein EA, et al.: Comparison of the efficacy and safety of rosuvastatin versus atorvastatin, simvastatin, and pravastatin across doses (STELLAR* Trial). Am J Cardiol 2003, 92:152–160.CrossRefPubMedGoogle Scholar
  26. 26.
    Nissen SE, Tuzcu EM, Schoenhagen P, et al.: Effect of intensive compared with moderate lipid-lowering therapy on progression of coronary atherosclerosis: a randomized controlled trial. JAMA 2004, 291:1071–1080.CrossRefPubMedGoogle Scholar
  27. 27.
    Schrier RW, Estacio RO, Esler A, Mehler P: Effects of aggressive blood pressure control in normotensive type 2 diabetic patients on albuminuria, retinopathy and strokes. Kidney Int 2002, 61:1086–1097.CrossRefPubMedGoogle Scholar
  28. 28.
    Taylor AJ, Villines TC, Stanek EJ, et al.: Extended-release niacin or ezetimibe and carotid intima-media thickness. N Engl J Med 2009, 361:2113–2122.CrossRefPubMedGoogle Scholar
  29. 29.
    Reiff T, Stingele R, Eckstein HH, et al.: Stent-protected angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy: SPACE2—a three-arm randomised-controlled clinical trial. Int J Stroke 2009, 4:294–299.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  1. 1.Department of Neurology & Stroke ProgramWayne State UniversityDetroitUSA

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