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Appropriate Management of Asymptomatic Carotid Stenosis

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Appropriate Management of Asymptomatic Carotid Stenosis Open Access Review Stroke Vasc Neurol: first published as 10.1136/svn-2016-000016 on 27 April 2016. Downloaded from Appropriate management of asymptomatic carotid stenosis J David Spence,1 Hongsong Song,2 Guanliang Cheng3 To cite: Spence JD, Song H, ABSTRACT markedly reduce risk.1 Indeed, the risk of Cheng G. Appropriate With modern intensive medical therapy, the annual risk myocardial infarction in ACS is higher than management of of ipsilateral stroke in patients with asymptomatic the risk of stroke. It is thus immaterial that asymptomatic carotid carotid stenosis (ACS) is now down to ∼0.5%. Despite stenosis. Stroke and Vascular randomised controlled trials have not been this, there is a widespread practice of routine Neurology 2016;1:e000016. carried out to test the efficacy of interventions intervention in ACS with carotid endarterectomy (CEA) doi:10.1136/svn-2016- such as antiplatelet therapy. In the Veteran’s 000016 and stenting (CAS). This is being justified on the basis 2 of much higher risks with medical therapy in trials Administration trial of ACS, patients with no conducted decades ago, compared with lower risks of prior history of coronary disease had a 33% 4-year risk of myocardial infarction. Among Received 17 March 2016 intervention in recent trials with no medical arm. Such Revised 9 April 2016 extrapolations are invalid. Although recent trials have patients with diabetes, intracranial stenosis Accepted 12 April 2016 shown that after subtracting periprocedural risks the and peripheral vascular disease, the 4-year outcomes with CEA and CAS are now comparable to risk of a coronary event was 69%. It is axio- medical therapy, the periprocedural risks still far matic, therefore, that all patients with ACS outweigh the risks with medical therapy. In the should receive intensive medical therapy. asymptomatic carotid trial (ACT) 1 trial, the 30-day risk However, despite widespread belief that of stroke or death was 2.9% with CAS and 1.7% with carotid endarterectomy (CEA) and stenting CEA. In the CREST trial, the 30-day risk of stroke or (CAS) are justified in ACS, most patients death among asymptomatic patients was 2.5% for ∼ stenting and 1.4% for endarterectomy. Thus, intensive ( 90%) with ACS would be better treated medical therapy is much safer than either CAS or CEA. with intensive medical therapy than with The only patients with ACS who should receive either stenting or endarterectomy. In this nar- intervention are those who can be identified as being at rative review, we will summarise the evidence high risk. The best validated method is transcranial for that statement, and describe optimal Doppler embolus detection. Other approaches in medical management for patients with ACS. development for identifying vulnerable plaques include http://svn.bmj.com/ intraplaque haemorrhage on MRI, ulceration and plaque lucency on ultrasound, and plaque inflammation INTENSIVE MEDICAL THERAPY on positron emission tomography/CT. Intensive Lifestyle medical therapy for ACS includes smoking cessation, a Mediterranean diet, effective blood pressure control, Intensive medical therapy (best medical antiplatelet therapy, intensive lipid-lowering therapy and therapy) for ACS has recently been 3 treatment with B vitamins (with methylcobalamin reviewed. The effect of a healthy lifestyle is on September 27, 2021 by guest. Protected copyright. instead of cyanocobalamin), particularly in patients much greater than most physicians suppose. with metabolic B12 deficiency. A new strategy called Among women in the US Health ‘treating arteries instead of risk factors’, based on Professionals Study and Nurses’ Health measurement of carotid plaque volume, is promising Study, adopting all five healthy lifestyle but requires validation in randomised trials. choices (not smoking, moderate alcohol 1Robarts Research Institute, intake, a body mass index <25, 30 min of Western University, London, daily exercise and a healthy diet score in the Ontario, Canada Patients with asymptomatic carotid stenosis top 40%) reduced the risk of stroke by 80%.3 2 Peking University Third (ACS) have severe atherosclerosis and, Unhealthy lifestyle choices accounted for Hospital, Beijing, The People’s Republic of China besides a moderate risk of stroke, are at high half of stroke. The US lifestyle is so 4 3Huai’an First People’s risk of myocardial infarction. Although unhealthy that this might not be very sur- Hospital, Nanjing Medical screening for asymptomatic stenosis is not jus- prising. However, in Sweden, where the University, Huai’an, The tified for the purpose of identifying patients population may be healthier, healthy life- ’ People s Republic of China for inappropriate intervention, ultrasound styles reduced the risk of stroke by 60% 5 Correspondence to assessments of atherosclerosis severity may be among women, and the risk of myocardial Dr J David Spence; useful in identifying patients at high risk, in infarction by 80% among men with hyper- [email protected] whom intensive medical therapy would tension and hyperlipidaemia.6 Spence JD, et al. Stroke and Vascular Neurology 2016;1:e000016. doi:10.1136/svn-2016-000016 1 Copyright 2016 by BMJ Publishing Group Ltd. Open Access Stroke Vasc Neurol: first published as 10.1136/svn-2016-000016 on 27 April 2016. Downloaded from Smoking cessation Approximately half of the patients will admit that they Smoking increases the risk of stroke approximately are not taking their medication; follow-up with the sixfold, and even secondhand smoke nearly doubles car- patient’s pharmacy can determine if the patient has diovascular risk.7 It is likely that smoking cessation is the refilled prescriptions in a timely manner. Substances that single most important measure for stroke prevention. patients consume that may impair blood pressure Physicians should therefore not simply accept that control include salt, licorice, alcohol, decongestant, patients will not quit smoking; it is vital to persuade birth control medications and non-steroidal anti- patients to quit. Governments should also be implement- inflammatory agents (NSAIDS). The only NSAID that ing measures to reduce smoking. An important measure does not raise blood pressure is sulindac.14 Salt restric- in smoking cessation is the use of adequate nicotine tion to 2–3 g/day of salt (∼780–1200 mg of sodium) and replacement. Smoking is very hard to quit, because it is a Mediterranean diet similar to the Dietary Approaches not due to just a powerful addiction to nicotine; it is also to Stop Hypertension (DASH–Salt) diet15 and moder- a habit, a social activity, a crutch and for some patients ation of alcohol intake may be important measures in even an identity. It is important to advise the patient to resistant hypertension. Sodium restriction may be par- use enough nicotine replacement to deal with the addic- ticularly important in China.16 17 A high intake of tion, while becoming accustomed to becoming a non- sodium and high prevalence of hypertension go hand in smoker. In severe addicts (who may get up at night to hand, and are particularly prevalent in the central smoke), this may require two nicotine patches, plus a provinces.18 nicotine inhaler when cravings strike. Medications such An important problem in blood pressure control is as bupropion and varenicline may also be helpful. the common assumption that all patients are the same. A good review of strategies for smoking cessation is a They are not. When a patient has uncontrolled hyper- chapter by Pipe.8 tension despite two or more classes of drugs, it is import- Smoking is a particular problem among Chinese men. ant to identify the underlying cause of the hypertension. In a 2010 survey, 68% of men over age 15 smoked, com- Once rare causes of hypertension have been excluded pared with 3% of women; smoking was more prevalent (such as pheochromocytoma, aortic coarctation, licorice in rural than urban sites.9 and renal tumours), an efficient approach is to measure plasma renin and aldosterone. Diet Table 1 shows an algorithm for identifying the appro- The diet for which the best evidence exists for vascular priate treatment for patients with resistant hyperten- prevention is the Cretan Mediterranean diet. This is a sion.19 If plasma renin is low and plasma aldosterone is mainly vegetarian diet10 that is high in olive oil, canola high, the problem is primary aldosteronism, and the oil, fruits, vegetables, lentils, beans, chickpeas, nuts and best treatment is an aldosterone antagonist (spironolac- whole grains. It is possible that a vegan diet may be even tone for women, or eplerenone for men). If plasma better for cardiovascular prevention, but this has not renin is high and aldosterone is high (secondary hyper- http://svn.bmj.com/ been tested. Furthermore, for many patients, a vegan aldosteronism), the primary treatment would be an diet may not be achievable. In an important Israeli inhibitor of angiotensin II (ARB). If the renin and aldos- study, the Cretan Mediterranean diet was compared with terone levels are both low (a Liddle syndrome pheno- a low-fat diet and a low-carbohydrate diet. Among dia- type), the primary treatment would be amiloride. betic participants, the Mediterranean diet was clearly Primary aldosteronism accounts for ∼20% of resistant the most efficacious at reducing fasting blood sugar, hypertension; variants of Liddle’s syndrome account for on September 27, 2021 by guest. Protected copyright. fasting insulin levels and insulin resistance.11 In second- ∼6% of resistant hypertension, and are important ary prevention, this diet reduced stroke and recurrent because there is a specific therapy—amiloride. myocardial infarction by more than 60%.12 In primary prevention, this diet reduced stroke by nearly 50%.13 Antiplatelet therapy Although in the past the diet in China was largely pro- There is unwarranted controversy regarding absence of tective against atherosclerosis, with increasing prosperity evidence that antiplatelet agents reduce stroke in ACS. there has been increased intake of fat and cholesterol, Since patients with ACS are at high risk of myocardial and a corresponding major increase in atherosclerosis.
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