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2016 ; 1
(2
): 64-71
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Appropriate management of asymptomatic carotid stenosis
#MMPMID28959466
Spence JD
; Song H
; Cheng G
Stroke Vasc Neurol
2016[Jun]; 1
(2
): 64-71
PMID28959466
show ga
With modern intensive medical therapy, the annual risk of ipsilateral stroke in
patients with asymptomatic carotid stenosis (ACS) is now down to ?0.5%. Despite
this, there is a widespread practice of routine intervention in ACS with carotid
endarterectomy (CEA) and stenting (CAS). This is being justified on the basis of
much higher risks with medical therapy in trials conducted decades ago, compared
with lower risks of intervention in recent trials with no medical arm. Such
extrapolations are invalid. Although recent trials have shown that after
subtracting periprocedural risks the outcomes with CEA and CAS are now comparable
to medical therapy, the periprocedural risks still far outweigh the risks with
medical therapy. In the asymptomatic carotid trial (ACT) 1 trial, the 30-day risk
of stroke or death was 2.9% with CAS and 1.7% with CEA. In the CREST trial, the
30-day risk of stroke or death among asymptomatic patients was 2.5% for stenting
and 1.4% for endarterectomy. Thus, intensive medical therapy is much safer than
either CAS or CEA. The only patients with ACS who should receive intervention are
those who can be identified as being at high risk. The best validated method is
transcranial Doppler embolus detection. Other approaches in development for
identifying vulnerable plaques include intraplaque haemorrhage on MRI, ulceration
and plaque lucency on ultrasound, and plaque inflammation on positron emission
tomography/CT. Intensive medical therapy for ACS includes smoking cessation, a
Mediterranean diet, effective blood pressure control, antiplatelet therapy,
intensive lipid-lowering therapy and treatment with B vitamins (with
methylcobalamin instead of cyanocobalamin), particularly in patients with
metabolic B(12) deficiency. A new strategy called 'treating arteries instead of
risk factors', based on measurement of carotid plaque volume, is promising but
requires validation in randomised trials.
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