 |
|
Effects of Intensive Medical Therapy on Microemboli and Cardiovascular Risk in Asymptomatic Carotid Stenosis
J. David Spence, MD;
Victoria Coates, BA, HBSc;
Hector Li, MD;
Arturo Tamayo, MD;
Claudio Muñoz, MD, PhD;
Daniel G. Hackam, MD, PhD;
Maria DiCicco, RVT;
Janine DesRoches, RVT;
Chrysi Bogiatzi, MD;
Jonathan Klein, MD;
Joaquim Madrenas, MD, PhD;
Robert A. Hegele, MD
Arch Neurol. 2010;67(2):180-186. Published online December 14, 2009 (doi:10.1001/archneurol.2009.289).
Objective To assess the effect of more intensive medical therapy on the rate of transcranial Doppler (TCD) microemboli and cardiovascular events in patients with asymptomatic carotid stenosis (ACS).
Design A prospective study.
Setting A teaching hospital.
Patients Four hundred sixty-eight patients with ACS greater than 60% by Doppler peak velocity.
Main Outcome Measures We compared (1) the proportion of ACS patients who had microemboli on TCD, (2) cardiovascular events, (3) rate of carotid plaque progression, and (4) baseline medical therapy, before and since 2003.
Results Among 468 ACS patients, 199 were enrolled between January 1, 2000, and December 31, 2002; and 269 were enrolled between January 1, 2003, and July 30, 2007. Microemboli were present in 12.6% before 2003 and 3.7% since 2003 (P < .001). The decline in microemboli coincided with better control of plasma lipids and slower progression of carotid total plaque area. Since 2003, there have been significantly fewer cardiovascular events among patients with ACS: 17.6% had stroke, death, myocardial infarction, or carotid endarterectomy for symptoms before 2003, vs 5.6% since 2003 (P < .001). The rate of carotid plaque progression in the first year of follow-up has declined from 69 mm2 (SD, 96 mm2) to 23 mm2 (SD, 86 mm2) (P < .001).
Conclusions Cardiovascular events and microemboli on TCD have markedly declined with more intensive medical therapy. Less than 5% of patients with ACS now stand to benefit from revascularization; patients with ACS should receive intensive medical therapy and should only be considered for revascularization if they have microemboli on TCD.
Author Affiliations: Stroke Prevention and Atherosclerosis Research Centre (Drs Spence, Tamayo, Muñoz, Hackam, Bogiatzi and Klein; and Mss Coates, DiCicco, and DesRoches), Immunology Laboratory (Dr Madrenas), and Blackburn Laboratory in Genetics of Atherosclerosis (Dr Hegele), Robarts Research Institute; and Schulich School of Medicine and Dentistry, University of Western Ontario (Drs Spence, Li, Hackam, Madrenas, Klein, and Hegele), London, Ontario, Canada; Brandon Regional Health Centre, Brandon, Manitoba, Canada (Dr Tamayo); and Medical School, Democritus University of Thrace, Alexandroupolis, Greece (Dr Bogiatzi).
 CiteULike  Connotea  Delicious  Digg  Facebook  Reddit  Technorati  Twitter
What's this?
RELATED ARTICLE
This Month in Archives of Neurology
Arch Neurol. 2010;67(2):143-144.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Relationships Between Recent Intraplaque Hemorrhage and Stroke Risk Factors in Patients With Carotid Stenosis: The HIRISC Study
Turc et al.
Arterioscler. Thromb. Vasc. Bio. 2012;32:492-499.
ABSTRACT
| FULL TEXT
A randomized trial of decision-making in asymptomatic carotid stenosis
Silver et al.
Neurology 2012;78:315-321.
ABSTRACT
| FULL TEXT
Translational Research: From Observational Studies to Health Policy: How a Cohort Study Can Help Improve Outcomes After Stroke
Saposnik and Estol
Stroke 2011;42:3336-3337.
FULL TEXT
Optimizing Protocols for Risk Prediction in Asymptomatic Carotid Stenosis Using Embolic Signal Detection: The Asymptomatic Carotid Emboli Study
King et al.
Stroke 2011;42:2819-2824.
ABSTRACT
| FULL TEXT
Ultrasonic plaque echolucency and emboli signals predict stroke in asymptomatic carotid stenosis
Topakian et al.
Neurology 2011;77:751-758.
ABSTRACT
| FULL TEXT
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery
Writing Committee Members et al.
Stroke 2011;42:e464-e540.
FULL TEXT
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery
Writing Committee Members et al.
Stroke 2011;42:e420-e463.
FULL TEXT
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery
Writing Committee Members et al.
Circulation 2011;124:e54-e130.
FULL TEXT
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery
Brott et al.
Circulation 2011;124:489-532.
FULL TEXT
What Is the Current Status of Invasive Treatment of Extracranial Carotid Artery Disease?
Naylor
Stroke 2011;42:2080-2085.
ABSTRACT
| FULL TEXT
Optimal contemporary management of symptomatic and asymptomatic carotid artery stenosis
Paraskevas et al.
Vascular 2011;19:117-120.
ABSTRACT
| FULL TEXT
Does Impaired Cerebrovascular Reactivity Predict Stroke Risk in Asymptomatic Carotid Stenosis?: A Prospective Substudy of the Asymptomatic Carotid Emboli Study
King et al.
Stroke 2011;42:1550-1555.
ABSTRACT
| FULL TEXT
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine and Society for Vascular Surgery Developed in collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography
Writing Committee Members: et al.
Journal of NeuroInterventional Surgery 2011;3:100-130.
FULL TEXT
Medical Versus Surgical Treatment of Asymptomatic Carotid Stenosis: The Ever-Changing Nature of Evidence-Based Medicine
Selim and Molina
Stroke 2011;42:1156-1157.
FULL TEXT
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery Developed in Collaboration With the American Academy of Neurology and Society of Cardiovascular Computed Tomography
Brott et al.
J Am Coll Cardiol 2011;57:e16-e94.
FULL TEXT
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary: A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery Developed in Collaboration With the American Academy of Neurology and Society of Cardiovascular Computed Tomography
Brott et al.
J Am Coll Cardiol 2011;57:1002-1044.
FULL TEXT
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/ SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Executive Summary
Brott et al.
Vasc Med 2011;16:35-77.
Of Horse Races, Trials, Meta-analyses, and Carotid Artery Stenosis
Caplan and Brott
Arch Neurol 2011;68:157-159.
FULL TEXT
Regarding Article "Treating Arteries Instead of Risk Factors: A Paradigm Change in Management of Atherosclerosis"
Hadjiev and Mineva
Stroke 2011;42:e21-e21.
FULL TEXT
The International Carotid Stenting Study and the North American Carotid Revascularization Endarterectomy Versus Stenting Trial: Fueling the Debate About Carotid Artery Stenting
Berkefeld and Chaturvedi
Stroke 2010;41:2714-2715.
FULL TEXT
Is there a role for revascularisation in asymptomatic carotid stenosis? No
Spence
BMJ 2010;341:c4900-c4900.
FULL TEXT
Treating Arteries Instead of Risk Factors: A Paradigm Change in Management of Atherosclerosis
Spence and Hackam
Stroke 2010;41:1193-1199.
ABSTRACT
| FULL TEXT
Carotid Artery Disease: Selecting the Appropriate Asymptomatic Patient for Intervention
Rockman and Riles
PERSPECT VASC SURG ENDOVASC THER 2010;22:30-37.
ABSTRACT
|
