Predictors and clinical significance of progression or regression of asymptomatic carotid stenosis

Kakkos, Stavros K.; Nicolaides, Andrew; Charalambous, Ioanna; Thomas, Dafydd J.; Giannopoulos, Argirios; Naylor, A.R.; Geroulakos, George; Abbott, Anne L.

doi:10.1016/j.jvs.2013.10.073

Cited by 142 publications

(143 citation statements)

References 38 publications

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“…37) In the present study, no cardiovascular events were observed in the 8 patients who experienced stenosis progression during the follow-up period.…”

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confidence: 45%

Low Stroke Rate of Carotid Stenosis Under the Guideline-Oriented Medical Treatment Compared With Surgical Treatment

et al. 2016

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SummaryMedical treatment for asymptomatic carotid artery stenosis (ACAS) has advanced recently. The outcomes of medical treatment and surgical treatment were evaluated to clarify the optimal treatment for ACAS.Patients with ACAS of ≥ 50% luminal narrowing underwent serial follow-up carotid artery ultrasonography for one year or more at the Center for Cardiovascular Disease Prevention between November 2006 and October 2013. The incidence of cardiovascular events (stroke, myocardial infarction, cardiovascular death) was examined in 64 patients (medical treatment group), and in 47 patients (surgical group) who underwent surgical treatment (carotid endarterectomy or carotid artery stenting) during this same period at the Department of Neurosurgery.Annual cardiovascular event rate was 0.91% (2/219 person-year) in the group of guideline-oriented medical treatment with an annual check-up for disease management and 5.6% (6/107 person-year) in the surgical group (log-rank P = 0.027; HR in the medical treatment group, 0.19 [medical treatment/surgical]; 95% confidence interval [CI], 0.028 to 0.87). Annual stroke event rate was 0.46% (1/219 person-year) in the medical treatment group and 4.7% (5/107 personyear) in the surgical group (log-rank P = 0.016; HR in the medical treatment group, 0.11 [medical treatment/surgical]; 95% CI, 0.0057 to 0.70). Multivariate logistic analysis showed that the surgical group was an independent variable associated with cardiovascular events (P = 0.049).Annual cardiovascular and stroke event rates were low in patients receiving medical treatment for ACAS and better than surgical treatment. The present study shows that medical treatment is an important option for ACAS. (Int Heart J 2016; 57: 80-86)

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“…37) In the present study, no cardiovascular events were observed in the 8 patients who experienced stenosis progression during the follow-up period.…”

contrasting

confidence: 45%

Low Stroke Rate of Carotid Stenosis Under the Guideline-Oriented Medical Treatment Compared With Surgical Treatment

et al. 2016

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“…Considering other possible mechanisms or parameters characterizing carotid stenosis 'at risk' of developing cognitive deterioration, i.e. detecting microemboli, 39 defining the 'unstable' plaque, 40 monitoring the progression of the stenosis, 41 together with assessing the hemodynamic status, could help to identify subjects with ACS that could benefit the most from revascularization strategies. The lack of this kind of information represents a main limitation of the present study.…”

Section: Discussionmentioning

confidence: 99%

Thresholds of impaired cerebral hemodynamics that predict short-term cognitive decline in asymptomatic carotid stenosis

Buratti

Viticchi

Falsetti³

et al. 2016

J Cereb Blood Flow Metab

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Subjects with asymptomatic carotid stenosis (ACS) may be at risk of cognitive impairment due to cerebral hypoperfusion. In this study, we aimed to detect a threshold of cerebral hemodynamics which is able to identify subjects at risk of cognitive deterioration. In subjects with ACS, cerebral vasomotor reactivity (CVR) was assessed with the breath-holding index (BHI) transcranial Doppler-based method. Cognitive deterioration was defined as a decrease in the MMSE score by !2 points after one year. In order to define the threshold of impaired BHI, a ROC curve analysis was performed adopting the binary difference of MMSE score as the outcome and continuous BHI as the testing variable. A total of 548 subjects completed the follow-up. Cognitive deterioration was observed in 119 patients (21.7%). The BHI value ipsilateral to the stenosis was the strongest predictor of cognitive deterioration among the variables tested. The best cut-point to discriminate between normal and abnormal BHI resulted 0.89. The post-test probability of cognitive deterioration for an abnormal BHI was 44%, while a normal BHI showed a post-test probability of 9% for the same outcome. The present investigation provides a threshold of reduced CVR that can be useful to identify subjects with ACS at risk of cognitive deterioration.

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“…This serious deficiency was not portrayed in any contemporary guideline we identified, possibly with the exception of 1 case. 52 Also missing are inclusions of discoveries that transcranial embolus detection, 8 degree of stenosis, 9 plaque echolucency, 10 and asymptomatic progression 11 are not powerful enough individually to identify asymptomatic patients likely to benefit from carotid procedures (even in the context of relatively less effective historical medical treatment). Combinations of risk markers offer the best hope of clinically meaningful risk stratification.…”

Section: Representation Of the Evidence Basementioning

confidence: 99%

Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis

Abbott

Paraskevas

Kakkos

et al. 2015

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Background and Purpose-We systematically compared and appraised contemporary guidelines on management of asymptomatic and symptomatic carotid artery stenosis. Methods-We systematically searched for guideline recommendations on carotid endarterectomy (CEA) or carotid angioplasty/stenting (CAS) published in any language between January 1, 2008, and January 28, 2015. Only the latest guideline per writing group was selected. Each guideline was analyzed independently by 2 to 6 authors to determine clinical scenarios covered, recommendations given, and scientific evidence used. Results-Thirty-four eligible guidelines were identified from 23 different regions/countries in 6 languages. Of 28 guidelines with asymptomatic carotid artery stenosis procedural recommendations, 24 (86%) endorsed CEA (recommended it should or may be provided) for ≈50% to 99% average-surgical-risk asymptomatic carotid artery stenosis, 17 (61%) endorsed CAS, 8 (29%) opposed CAS, and 1 (4%) endorsed medical treatment alone. For asymptomatic carotid artery stenosis patients considered high-CEA-risk because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 13 guidelines (46%). Thirty-one of 33 guidelines (94%) with symptomatic carotid artery stenosis procedural recommendations endorsed CEA for patients with ≈50% to 99% average-CEA-risk symptomatic carotid artery stenosis, 19 (58%) endorsed CAS and 9 (27%) opposed CAS. For high-CEA-risk symptomatic carotid artery stenosis because of comorbidities, vascular anatomy, or undefined reasons, CAS was endorsed in 27 guidelines (82%). Guideline procedural recommendations were based only on results of trials in which patients were randomized 12 to 34 years ago, rarely reflected medical treatment improvements and often understated potential CAS hazards. Qualifying terminology summarizing recommendations or evidence lacked standardization, impeding guideline interpretation, and comparison. This systematic review of contemporary international guidelines was performed to compare and appraise recommendations for the management of patients with ACS and SCS (including accessibility, organization, clarity, and consistency) and the evidence used in making these recommendations. Conclusions-This Methods Guideline SearchesGuidelines with recommendations on the use of CEA or CAS or both patients with ACS or SCS or both were sought systematically using popular search engines, bibliographies, and author professional networks. PubMed and ISI Web of Knowledge were searched independently and synchronously by 2 authors on September 9, 2013 (A.L.A., K.I.P.). PubMed was searched using carotid guideline and then stroke guideline in the title, yielding 91 references after duplicate removal. ISI Web of Knowledge was searched using carotid and guideline and then stroke and guideline in the title, yielding 422 references after removal of duplicates, abstracts, reference materials, letters, corrections, meetings, news, and case reports. Wider searches using the words carotid or stroke and guideline in any ...

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Predictors and clinical significance of progression or regression of asymptomatic carotid stenosis

Cited by 142 publications

References 38 publications

Low Stroke Rate of Carotid Stenosis Under the Guideline-Oriented Medical Treatment Compared With Surgical Treatment

Low Stroke Rate of Carotid Stenosis Under the Guideline-Oriented Medical Treatment Compared With Surgical Treatment

Thresholds of impaired cerebral hemodynamics that predict short-term cognitive decline in asymptomatic carotid stenosis

Systematic Review of Guidelines for the Management of Asymptomatic and Symptomatic Carotid Stenosis

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