Asymptomatic Carotid Stenosis

Spence, J. David

doi:10.1161/circulationaha.112.153734

Cited by 20 publications

(9 citation statements)

References 22 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…A recent meta‐analysis of studies patients with severe carotid stenosis showed that the stroke rate decreased from 2·83% per year before 2000 to 1·13% per year after 2000 . As these results are in agreement with the concomitant increase in the use of statins and the improved control of blood pressure, the recommendations for nonmedical therapy (carotid endarterectomy [CEA], carotid angioplasty and stenting [CAS]) decreased .…”

Section: Clinical Consequences Of the Carotid Stenosismentioning

confidence: 88%

Carotid atherosclerotic plaque stenosis: the stabilizing role of statins

Artom

Montecucco

Dallegri

et al. 2014

Eur J Clin Investigation

View full text Add to dashboard Cite

show abstract

Section: Clinical Consequences Of the Carotid Stenosismentioning

confidence: 88%

Carotid atherosclerotic plaque stenosis: the stabilizing role of statins

Artom

Montecucco

Dallegri

et al. 2014

Eur J Clin Investigation

View full text Add to dashboard Cite

show abstract

“…Patients are typically presented with an estimated annual risk of ipsilateral carotid territory stroke of 2% with medical therapy alone, which can be cut in half by endarterectomy, according to the Asymptomatic Carotid Atherosclerosis Study (ACAS) trial (published in 1995) [7,8]. Recent data suggest that contemporary event rates with medical therapy may be much lower [9,10]. The American Heart Association/American Stroke Association guidelines on primary stroke prevention state that ‘the benefit of surgery may now be lower than anticipated based on randomized trial results' [5].…”

Section: Introductionmentioning

confidence: 99%

Asymptomatic Carotid Artery Stenosis Treated with Medical Therapy Alone: Temporal Trends and Implications for Risk Assessment and the Design of Future Studies

Hadar¹,

Raman²,

Moorthy³

et al. 2014

Cerebrovasc Dis

View full text Add to dashboard Cite

Background: The rate of adverse clinical outcomes among patients with asymptomatic carotid stenosis receiving medical therapy alone can be used to guide clinical decision-making and to inform future research. We aimed to investigate temporal changes in the incidence rate of clinical outcomes among patients with asymptomatic carotid stenosis receiving medical therapy alone and to explore the implications of these changes for the design of future comparative studies. Summary: We searched MEDLINE, the Cochrane Central Register of Controlled Trials, US Food and Drug Administration documents, and reference lists of included studies (last search: December 31, 2012). We selected prospective cohort studies of medical therapy for asymptomatic carotid artery stenosis and we extracted information on study characteristics, risk of bias, and outcomes. We performed meta-analyses to estimate summary incidence rates, meta-regressions to assess trends over time, and simulations to explore sample size requirements for the design of future studies comparing new treatments against medical therapy. The main outcomes of interest were ipsilateral stroke, any stroke, cardiovascular death, death, and myocardial infarction. We identified 41 studies of medical therapy for patients with asymptomatic carotid stenosis (last recruitment year: 1978-2009). The summary incidence rate of ipsilateral carotid territory stroke (25 studies) was 1.7 per 100 person-years. This incidence rate was significantly lower in recent studies (last recruitment year from 2000 onwards) as compared to studies that ended recruitment earlier (1.0 vs. 2.3 events per 100 person-years; p < 0.001). The incidence rates of any territory stroke (17 studies), cardiovascular death (6 studies), death (13 studies), and myocardial infarction (5 studies) were 2.7, 4.1, 4.6, and 1.8 per 100 person-years, respectively. Simulations showed that future studies would need to enroll large numbers of patients with a relatively high incidence rate under medical therapy, and evaluate interventions with large effect sizes, to have adequate power to reliably detect treatment effects. Key Messages: Improved prognosis under medical therapy alone has narrowed the potential range of risk reduction attainable with new treatments for asymptomatic carotid stenosis. Future comparative studies will need to enroll large numbers of patients to assess treatment effectiveness.

show abstract

“…In more recent years, however, improvements in medical therapy for stroke prevention have caused increasing controversy [6,7,8,9,10] about the role of surgical revascularization in the treatment of asymptomatic carotid stenosis. In the intervening 20 years since the first large treatment trials [2,3,4,5], intensive medical therapy has dramatically reduced the annual risk of stroke in asymptomatic carotid stenosis patients [11].…”

Section: Clinical Backgroundmentioning

confidence: 99%

“…Closer inspection of these data suggest that if only the most recent studies are included, the annual stroke risk may be less than 1% per year. For this reason, the modest stroke reduction benefit seen for asymptomatic carotid stenosis in these treatment trials is of questionable current relevance [9,12] for patients receiving modern intensive medical therapy.…”

Section: Clinical Backgroundmentioning

confidence: 99%

Moving Beyond Luminal Stenosis: Imaging Strategies for Stroke Prevention in Asymptomatic Carotid Stenosis

Gupta¹,

Marshall

2015

Cerebrovasc Dis

View full text Add to dashboard Cite

Background: With progressive improvements in medical therapy and resultant reductions in stroke risk, luminal stenosis criteria are no longer adequate to inform decisions to pursue surgical revascularization in patients with asymptomatic carotid artery stenosis. Summary: In this evidence-based review, we discuss the imaging-based risk stratification strategies that take into account factors beyond luminal stenosis measurements, including cerebral hemodynamics and plaque composition. The existing literature lends support to the use of certain imaging tests in patients with asymptomatic carotid stenosis including cerebrovascular reserve testing, MRI of plaque composition, ultrasound of plaque echolucency, and transcranial Doppler evaluation for microemboli. The highest quality evidence thus far in the literature includes only systematic reviews and meta-analyses of cohort studies with no randomized trials having yet been performed to show how these newer imaging biomarkers could be used to inform treatment decisions in asymptomatic carotid stenosis. Beyond the need for randomized trials, there are additional important steps needed to improve the relevance of evidence supporting risk assessment strategies. Imaging studies evaluating the risk of stroke in carotid disease should clearly define asymptomatic versus symptomatic disease, use uniform definitions of clearly defined outcome measures such as ipsilateral stroke, ensure that imaging interpretations are performed in a manner blinded to treatments and other risk factors, and include cohorts which are on modern intensive medical therapy. Such studies of risk stratification for asymptomatic carotid stenosis will be most valuable if they can integrate multiple high-risk features (including clinical risk factors) into a multi-factorial risk assessment strategy in a manner that is relatively simple to implement and generalizable across a wide range of practice settings. Key Messages: Together, modern imaging strategies allow for a more mechanistic assessment of stroke risk in carotid disease compared to luminal stenosis measurements alone, which, with further validation in randomized controlled trials, may improve current efforts at stroke prevention in asymptomatic carotid stenosis.

show abstract

Asymptomatic Carotid Stenosis

Cited by 20 publications

References 22 publications

Carotid atherosclerotic plaque stenosis: the stabilizing role of statins

Carotid atherosclerotic plaque stenosis: the stabilizing role of statins

Asymptomatic Carotid Artery Stenosis Treated with Medical Therapy Alone: Temporal Trends and Implications for Risk Assessment and the Design of Future Studies

Moving Beyond Luminal Stenosis: Imaging Strategies for Stroke Prevention in Asymptomatic Carotid Stenosis

Contact Info

Product

Resources

About