Best Medical Treatment for Patients with Carotid Stenosis: Evidence-Based Medicine or Wishful Thinking?

Paraskevas, Kosmas I.; Cambria, Richard P.

doi:10.1177/0003319717709860

Cited by 9 publications

(10 citation statements)

References 33 publications

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“…The ECST data on which the model was based, were gathered during 1981–1991 with follow-up extending until 1998. Since then and more specifically from the early 2000s onwards, drug treatment has changed rigorously, with a >60% increase in statin use within a time period of 12 years and an increase in anti-platelet use ( 30 ). The use of statins causes a relative risk reduction of 21% for stroke, while anti-platelet is associated with a 12% risk reduction of serious vascular events ( 31 ).…”

Section: Overview Of Prediction Modelsmentioning

confidence: 99%

Emerging Role of Carotid MRI for Personalized Ischemic Stroke Risk Prediction in Patients With Carotid Artery Stenosis

et al. 2021

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Rupture of a vulnerable carotid plaque is an important cause of ischemic stroke. Prediction models can support medical decision-making by estimating individual probabilities of future events, while magnetic resonance imaging (MRI) can provide detailed information on plaque vulnerability. In this review, prediction models for medium to long-term (>90 days) prediction of recurrent ischemic stroke among patients on best medical treatment for carotid stenosis are evaluated, and the emerging role of MRI of the carotid plaque for personalized ischemic stroke prediction is discussed. A systematic search identified two models; the European Carotid Surgery Trial (ECST) medical model, and the Symptomatic Carotid Atheroma Inflammation Lumen stenosis (SCAIL) score. We critically appraised these models by means of criteria derived from the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modeling Studies) and PROBAST (Prediction model Risk Of Bias ASsessment Tool). We found both models to be at high risk of bias. The ECST model, the most widely used model, was derived from data of large but relatively old trials (1980s and 1990s), not reflecting lower risks of ischemic stroke resulting from improvements in drug treatment (e.g., statins and anti-platelet therapy). The SCAIL model, based on the degree of stenosis and positron emission tomography/computed tomography (PET/CT)-based plaque inflammation, was derived and externally validated in limited samples. Clinical implementation of the SCAIL model can be challenging due to high costs and low accessibility of PET/CT. MRI is a more readily available, lower-cost modality that has been extensively validated to visualize all the hallmarks of plaque vulnerability. The MRI methods to identify the different plaque features are described. Intraplaque hemorrhage (IPH), a lipid-rich necrotic core (LRNC), and a thin or ruptured fibrous cap (TRFC) on MRI have shown to strongly predict stroke in meta-analyses. To improve personalized risk prediction, carotid plaque features should be included in prediction models. Prediction of stroke in patients with carotid stenosis needs modernization, and carotid MRI has potential in providing strong predictors for that goal.

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Section: Overview Of Prediction Modelsmentioning

confidence: 99%

Emerging Role of Carotid MRI for Personalized Ischemic Stroke Risk Prediction in Patients With Carotid Artery Stenosis

et al. 2021

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“…More than 85% of strokes are ischemic due to cerebral embolism. An estimate of 20-30% of all strokes are associated with carotid artery stenosis and it is believed that about 15% of all strokes and TIAs are caused by unstable carotid plaque (58). The research of factors that are involved in the process of atherosclerotic plaque activation causing it to evolve into an unstable plaque is being carried out extensively.…”

Section: Discussionmentioning

confidence: 99%

“…This proves that the therapeutic approach to atheroma stabilization should be broad and multifactorial. The fact that statins have pleiotropic effects, including anti-inflammatory and antioxidant properties, is well-documented (58,59). According to the recent recommendation of ESVS statin therapy is recommended for long-term prevention of stroke, myocardial infarction and other cardiovascular events in all patients with ACS.…”

Section: Treatment Optionsmentioning

confidence: 99%

New insight into biology, molecular diagnostics and treatment options of unstable carotid atherosclerotic plaque: a narrative review

Migdalski¹,

Jawień²

2021

Ann Transl Med

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Indications for intervention in hemodynamically relevant carotid artery stenosis (carotid endarterectomy or stenting) are primarily based on a degree of stenosis and symptomatology. To date the plaque vulnerability is rarely taken into account in clinical decision making although development of molecular imaging allows a better understanding of plaque biology and provides new techniques detecting potentially vulnerable plaque at risk. A significant number of reports describing the mechanisms of unstable plaque formation suggest that it is a multifactorial process. Inflammation, lipid accumulation, apoptosis, proteolysis, the thrombotic process and angiogenesis are among the main factors of carotid plaque destabilization. Although inflammation is a key process in development of plaque vulnerability, the hemostasis and neoangiogenesis should be regarded as equally important. Only a small group of asymptomatic patients may benefit from the invasive treatment and it remains a challenge to determine whether initially asymptomatic carotid plaque become unstable or vulnerable. Currently, the main task of research on atherosclerotic lesion imaging is focused on functional state of the plaque. The presence of one or more features such as stenosis progression, large plaque area, large juxta-luminal black area, plaque echolucency, intra-plaque hemorrhage, impaired cerebral vascular reserve and spontaneous embolization may indicate patients at higher risk for stroke suitable for revascularization. Treatment of carotid stenosis as one of the manifestations of generalized atherosclerosis requires a broad approach. Nowadays pharmacological treatment options for the atherosclerotic process are largely aimed at stimulating the plaque stabilization, but in symptomatic patients and selected asymptomatic patients, carotid plaque should be removed as a potential source of embolism.

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“…7 The optimal management of patients with asymptomatic and symptomatic carotid stenosis is still debated, although the contention that modern BMT has made intervention for ACS obsolete is refuted by recent publications. 12,13 Transfemoral CAS is gradually becoming obsolete with the availability of TCAR. [14][15][16][17] Increasing physician expertise/procedural volume will hopefully lead to even lower perioperative stroke/ death rates after CEA/CAS in the future.…”

Section: Clinical Implications Of Low Perioperative Stroke/death Ratesmentioning

confidence: 99%

“…11 This view is based on improvements in stroke/ death rates in contemporary studies compared with the outcomes achieved in the landmark randomized controlled trials nearly 30 years ago. 12 It also includes several misconceptions, such as the inappropriate definition of "advanced carotid stenosis" as "50-75% stenosis of the carotid bulb." 13 The low perioperative stroke/death rates reported in recent registries from different countries 1,9,10 suggest that the currently applied thresholds for intervention (<3% for ACS patients; <6% for symptomatic patients) 7 may now be too high.…”

Section: Clinical Implications Of Low Perioperative Stroke/death Ratesmentioning

confidence: 99%

Carotid Revascularization Procedural Volume and Perioperative Outcomes

Paraskevas,

Cambria

2021

Angiology

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Best Medical Treatment for Patients with Carotid Stenosis: Evidence-Based Medicine or Wishful Thinking?

Cited by 9 publications

References 33 publications

Emerging Role of Carotid MRI for Personalized Ischemic Stroke Risk Prediction in Patients With Carotid Artery Stenosis

Emerging Role of Carotid MRI for Personalized Ischemic Stroke Risk Prediction in Patients With Carotid Artery Stenosis

New insight into biology, molecular diagnostics and treatment options of unstable carotid atherosclerotic plaque: a narrative review

Carotid Revascularization Procedural Volume and Perioperative Outcomes

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