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Long-term Risk of Stroke and Other Vascular Events in Patients With Asymptomatic Carotid Artery Stenosis
Zurab G. Nadareishvili, MD, PhD;
Peter M. Rothwell, MD, PhD;
Vadim Beletsky, MD, PhD;
Angela Pagniello, BA;
John W. Norris, MD
Arch Neurol. 2002;59:1162-1166.
Context The annual risk of ischemic stroke in patients with asymptomatic carotid
artery stenosis is about 2% during the short-term (2-3 years), but the long-term
risks of stroke and other vascular events are unknown, although they may affect
surgical decision making.
Objective To evaluate the long-term risk of stroke and other vascular events in
patients with asymptomatic carotid artery stenosis.
Design Cohort study with a median follow-up of 10 years (range, 5-18 years).
Setting The teaching hospital of the University of Toronto, Toronto, Ontario.
Patients From the initial cohort of 500 patients, 106 patients with asymptomatic
carotid artery stenosis were selected because they had completed at least
5 years of follow-up.
Main Outcome Measures Ipsilateral stroke, myocardial infarction, and nonstroke vascular death.
Results The 10- and 15-year actuarial risks of ipsilateral stroke were 5.7%
(95% confidence interval [CI], 0%-12%) and 8.7% (95% CI, 1%-17%), respectively,
in patients with 0% to 49% internal carotid artery stenosis, and 9.3% (95%
CI, 1%-18%) and 16.6% (95% CI, 1%-32%) in patients with 50% to 99% internal
carotid artery stenosis. The 10- and 15-year risks of myocardial infarction
and nonstroke vascular death were 10.1% (95% CI, 4%-16%) and 24.0% (95% CI,
14%-34%). Age (P = .02), diabetes mellitus (P = .02), and internal carotid artery stenosis of 50% or
more (P = .04) were predictive of increased risks
of myocardial infarction and nonstroke vascular death. Internal carotid artery
stenosis of 50% or more did predict the risk of ipsilateral stroke (P = .003) when all 181 asymptomatic carotid arteries were
included.
Conclusions The annual stroke risk in patients with asymptomatic carotid artery
stenosis was low and remained stable during long-term follow-up. Any benefit
from carotid surgery is therefore unlikely to increase significantly with
long-term follow-up. The high long-term risks of myocardial infarction and
nonstroke vascular death suggest that prevention strategies should concentrate
on coronary risk more than stroke risk.
From the Stroke Research Unit, Sunnybrook and Women's College Health
Sciences Centre, University of Toronto, Toronto, Ontario (Drs Nadareishvili,
Beletsky, and Norris and Ms Pagniello); and the Stroke Prevention Research
Unit, Department of Clinical Neurology, Radcliffe Infirmary, Oxford, United
Kingdom (Dr Rothwell). Dr Nadareishvili is now with the National Institute
of Neurological Disorders and Stroke, National Institutes of Health, Bethesda,
Md.
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