Contemporary medical therapies of atherosclerotic carotid artery disease

Abstract

Contemporary medical therapy consists of identification and treatment of all patient-modifiable vascular risk factors. Specific atherosclerotic disease therapies are designed to reduce the risk of thrombosis, and the disease progression in order to reduce the risk of future cardiovascular events. Contemporary medical management emphasizes the need to support the patient in achieving lifestyle modifications and to adjust medication to achieve individualized target values for specific quantifiable risk factors. Antiplatelet therapy in the form of aspirin or clopidogrel is routinely used for the prevention of ischemic stroke in patients who have had a transient ischemic attack or stroke. There is evidence from a recent trial that the use of combination antiplatelet therapy with aspirin and clopidogrel started within 24 hours of minor stroke or transient ischemic attack reduces the risk of recurrent stroke compared to the use of aspirin alone, and therefore we use aspirin plus clopidogrel in recently symptomatic patients with carotid stenosis pending carotid revascularization. Anticoagulation with heparins or vitamin K antagonist is not recommended except in patients at risk for cardio-embolic events. Lowering blood pressure to target levels has been shown to slow down the progression of carotid artery stenosis and reduces the intima-media thickness of the carotid plaque, while lowering lipid levels with statins has become an essential element in the medical therapy of carotid artery stenosis. Diabetes management should be optimized. Lifestyle choices, including tobacco smoking, physical inactivity, unhealthy diet, obesity, and excessive alcohol intake, are all important modifiable vascular risk factors. The combination of dietary modification, physical exercise, and use of aspirin, a statin, and an antihypertensive agent can be expected to give a cumulative relative stroke risk reduction of 80%. The evidence suggests that intensive medical therapy is so effective that carotid revascularization may no longer be necessary in many of the patients in whom carotid surgery or stenting is currently performed. Two large ongoing trials are therefore comparing the risks and benefits of carotid revascularization versus intensive medical therapy alone.

Prevalence of extracranial carotid atherosclerosis in the patients with coronary artery disease in a tertiary hospital in Malaysia

“…[11] In Turkey, the mean CIMT was found to be significantly higher in the patients with triple-vessel disease in comparison to the control subjects and the patients with single-vessel disease. [15]…”

Extracranial Carotid Atherosclerosis in the Patients with Transient Ischemic Attack

“…The pharmacological management involves antiplatelet therapy and statin use [5,42]. The antiplatelet therapy which routinely administered is aspirin or clopidogrel [43]. Adequate blood pressure control is necessary with a target blood pressure of less than 140/90 [42].…”

“…Adequate blood pressure control is necessary with a target blood pressure of less than 140/90 [42]. A reduction in blood pressure to the ideal level slows down the progression of carotid artery stenosis and also reduces the carotid intima media thickness (CIMT) [43]. Identification and treatment of vascular risk factors are important [43].…”

“…In addition, lifestyle choices such as unhealthy diet and excessive alcohol intake are modifiable risk factors [43]. The combination of dietary modification, physical exercise, and use of aspirin, statin, and an antihypertensive agent can give a cumulative relative stroke risk reduction of 80% [43]. The antiplatelet therapy and statin use reduce the risk of recurrent stroke in patients with symptomatic extracranial carotid stenosis [5].…”

“…The revascularization procedures reduce the 90-day risk of subsequent ischemic stroke in the patients with severe extracranial carotid artery stenosis [5]. While awaiting the revascularization procedures, a combination of aspirin and clopidogrel in recently symptomatic patients with carotid stenosis can be given [43].…”