best practice in asymptomatic carotid stenosis
TRANSCRIPT
Best practice in asymptomatic carotid stenosis
Dr. Pascual Lozano VilardellAngiología y Cirugía Vascular
ACAS. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421-1428
Halliday A et al. Prevention of disabling and fatal strokes by successful CEA in patients without recent neurologic symptoms: a randomised controlled trial. Lancet 2004;363:1491-1502
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISClinical trials
30 days risk CEA
ACAS 2,3%
ACST 2,8%
ACAS. Endarterectomy for asymptomatic carotid artery stenosis. JAMA 1995;273:1421-1428
Halliday A et al. Prevention of disabling and fatal strokes by successful CEA in patients without recent neurologic symptoms: a randomised controlled trial. Lancet 2004;363:1491-1502
Halliday A, et al. 10-year stroke prevention after successful CEA for asymptomatic carotid stenosis (ACST-1): a multicenter randomised trial. Lancet 2010;376:1074-1084
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISClinical trials
ACAS 5,1% 11,0% 54% 84
ACST 6,4% 11,8% 46% 70
10 year risk
ACST 13,4% 17,9% 26%
5 year risk CEA BMT RRR NNT
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS
ESVS, SVS, AHA…
Carotid endarterectomy is indicated in all patients with asymptomatic carotid stenosis > 60%, if periprocedural rate of death-stroke is < 3%
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISCREST results in asymptomatic
CREST ASYMPTOMATIC periprocedural 4 years
CEA 1,4% 2,7%
CAS 2,5% 4,5%
Death-stroke. MI excluded
Brott et al. Stenting versus endarterectomy for treatment of carotid artery stenosis. N Eng J Med 2010;363:11-13
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISCREST results in asymptomatic
SVS REGISTRY
CEA 2,0 %CAS 4,6 %
Combined death-stroke-MI
Giles KA et al. Stroke and death after CEA and CAS with and without high risk criteria. J Vasc Surg 2010;52:1497-1504
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSIS2008 survey
Klein A et al. Management of carotid stenosis- polling results. N Eng J Med 2008,358:e23
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISConcerns about revascularization
Marginal surgical benefit (annual ARR 1%)Patient selectionNature of interventionsResults “in the real world”Reporting methodsEmerging rol of CASIncreased evidence risk of stroke is declining with the improvement of BMT
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISConcerns about revascularization
Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. A systematic review. Stroke 2009;573-83
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISRecurrent stroke rate 1960-2010
Hong K et al. Declining Stroke and Vascular Events Recurrence Rates in Secondary Prevention Trials. Circulation 2011;123:2111-2119
8,71%
4,04%
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISRecurrent stroke rate 1960-2010
Declining of event rates per decade
Recurrent stroke 1,0 %Fatal stroke 0,3 %
Major vascular events 1,3%
Hong K et al. Declining Stroke and Vascular Events Recurrence Rates in Secondary Prevention Trials. Circulation 2011;123:2111-2119
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISStroke rates in asymptomatic 1985-2007
Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. Stroke 2009;40:573-583
Stroke type time Decrease
Ipsilateral stroke 1985-2007 1,7%Ipsilateral stroke/TIA 1985-2005 7%
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISStroke rates in asymptomatic 1985-2007
Abbott AL. Medical intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis. Stroke 2009;40:573-583
ipsilateral stroke any stroke
Naylor AR. What is the current status of invasive treatment of extracraneal carotid artery disease? Stroke 2011;42:2080-85
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISStroke rates in medical arm ACAS and ACST 1985-2010
3,5%
2,4%1,4%
2,2%
1,1%0,7%
OXFORD VASCULAR STUDY (2002-2009)
101 patients with ACS BMT
Annual ipsilateral stroke rate 0,34%
Marquardt L et al. Low risk of ipsilateral stroke in patients with ACS on best medical treatment. Stroke 2010;41:11-17
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISRate of stroke in asymptomatics
Spence JD et al. Absence of MES on TCD identifies low-risk patients with Asymptomatic Carotid Stenosis. Stroke 2005;36:2373-2378
Presence of MES are related to risk of stroke
90% no MES AAR <1%
10% with MES AAR 15%
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISEmbolic signals and stroke
ACES (Asymptomatic Carotid Emboli Study)
Prospective multicenter studyObjective: to detect MES by TCDEndpoints: TIA or ipsilateral strokeHypothesis: MES predicts ipsilateral TIA or stroke
Markus HS et al. Asymptomatic embolisation for prediction of stroke in the ACES: a prospective observational study. Lancet Neurol 2010;9:663-671
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISEmbolic signals and stroke
Markus HS et al. Asymptomatic embolisation for prediction of stroke in the ACES: a prospective observational study. Lancet Neurol 2010;9:663-671
Patients with MES Mean number MES
Baseline 1 10% 2,63 (1-20)
Baseline 2 11% 2,23 (1-11)
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISEmbolic signals and stroke
32 primary endpoints: 26 TIA, 6 strokes
Markus HS et al. Asymptomatic embolisation for prediction of stroke in the ACES: a prospective observational study. Lancet Neurol 2010;9:663-671
AAR ipsilateral stroke
MES 3,62%No MES 0,70%
HR 2,54 (95%CI 1,20-5,36)
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISEmbolic signals and stroke
Spence JD et al. Effects of Intensive Medical Therapy on Microemboli and Cardiovascular Risk in ACS. Arch Neurol 2010;67:180-86
468 patients
199 (2000-2002)
269 (2003-2007) Intensive medical therapy
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISEmbolic signals and stroke
Spence JD et al. Effects of Intensive Medical Therapy on Microemboli and Cardiovascular Risk in ACS. Arch Neurol 2010;67:180-86
Patients with MES Carotid plaque
Cardiovascular events
2000-2002 12,6% 69 mm2 17,6%
2003-2007 3,7% 23 mm2 5,6%
BEST PRACTICE FOR ASYMPTOMATIC CAROTID STENOSISEmbolic signals and stroke
CONCLUSIONS
In patients with asymptomatic carotid stenosis
Risk of stroke is declining over time
Medical treatment has improved
Annual risk of stroke on BMT < 1%
CONCLUSIONS
In patients with asymptomatic carotid stenosis
There is a subgroup at high risk of stroke
We must identify this subgroup
Embolic signals on TCDCerebrovascular reservePlaque morphologyStenosis progresion rateSerum biomarkers
PREDICTION OF STROKE IN ACS
CONCLUSIONS
In patients with asymptomatic carotid stenosis
However, we don’t have level IA evidence of this afirmations
We need clinical trials