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5 - Medical treatment for carotid stenosis

from Background

Published online by Cambridge University Press:  03 December 2009

By
Matthew F. Giles  and
Peter M. Rothwell
Edited by
Jonathan Gillard ,
Martin Graves ,
Thomas Hatsukami  and
Chun Yuan
Matthew F. Giles
Affiliation:
University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, OX2 6HE, UK
Peter M. Rothwell
Affiliation:
University Department of Clinical Neurology, Radcliffe Infirmary, Oxford, OX2 6HE, UK
Jonathan Gillard
Affiliation:
University of Cambridge
Martin Graves
Affiliation:
University of Cambridge
Thomas Hatsukami
Affiliation:
University of Washington
Chun Yuan
Affiliation:
University of Washington
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Summary

Introduction

Reviews of the surgical or interventional management of patients with symptomatic or asymptomatic carotid stenosis are commonplace but consideration of what constitutes best medical treatment in these particular patients has generally been less detailed, and there have been few randomized trials of pharmacological interventions specifically in these patient groups. This paucity of research is due partly to the effectiveness of carotid endarterectomy and stenting in preventing stroke and the tendency for trials of medical treatments in prevention of stroke not to distinguish between patients with different underlying pathologies. Recommendations for particular medical treatments in patients with carotid disease are therefore often made on the basis of extrapolation from trials and observational studies in broader populations of patients with cerebrovascular disease.

However, although carotid endarterectomy and stenting can substantially reduce the risk of stroke in patients with symptomatic carotid stenosis, optimal medical treatment is still essential. First, a significant group of patients with symptomatic carotid stenosis (and a larger group with asymptomatic disease) decide against intervention or are not appropriate for various reasons. Second, given the particularly high risk of recurrent stroke in patients with symptomatic carotid stenosis following minor stroke or transient ischemic attack (TIA) (Lovett et al., 2004) and the frequent delays to carotid endarterectomy in such patients (Fairhead et al., 2005), medical treatment plays a very important role in this high-risk window between event and surgery.

Keywords

antiplatelet agentsblood-pressure-lowering drugscarotid stenosischolesterol-lowering drugsmedical treatmentintima-media thickness
Type
Chapter
Information
Carotid Disease
The Role of Imaging in Diagnosis and Management
 , pp. 59 - 71
Publisher: Cambridge University Press
Print publication year: 2006

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References

Aikawa, M., Rabkin, E., Sugiyama, S., et al. (2001). An HMG-b-hydroxy-b-methylglutaryl-CoA reductase inhibitor, cerivastatin, suppresses growth of macrophages expressing matrix metalloproteinases, and tissue factor in vivo, and in vitro. Circulation, 103, 276–83.CrossRefGoogle Scholar
Amarenco, P., Bogousslavsky, J., Callahan, A. S., et al. (2003). Design and baseline characteristics of the stroke prevention by aggressive reduction in cholesterol levels (Stroke prevention by aggressive reduction in cholesterol levels) study. Cerebrovascular Disease, 16, 389–95.Google ScholarPubMed
Amarenco, P., Labreuche, J., Lavallee, P. and Touboul, P. J. (2004). Statins in stroke prevention and carotid atherosclerosis: systematic review and up-to-date meta-analysis. Stroke, 35, 2902–9.CrossRefGoogle ScholarPubMed
Amin-Hanjani, S., Stagliano, N. E., Yamada, M., et al. (2001). Mevastatin, an HMG-b-hydroxy-b-methylglutaryl-CoA reductase inhibitor, reduces stroke damage and upregulated endothelial nitric oxide synthase in mice. Stroke, 32, 980–6.CrossRefGoogle ScholarPubMed
Antithrombotic Trialists Collaboration. (2002). Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high-risk patients. British Medical Journal, 324, 71–86.CrossRef
Bond, R., Rerkasem, K., Cuffe, R. and Rothwell, P. M. (2005). A systematic review of the associations between age and sex and the operative risks of carotid endarterectomy. Cerebrovascular Disease, 20, 69–77.CrossRefGoogle ScholarPubMed
Clopidogrel versus aspirin in patients at risk of ischemic events Steering Committee. (1996). A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (Clopidogrel versus aspirin in patients at risk of ischemic events). Lancet, 348, 1329–39.CrossRef
Chimowitz, M. I., Kokkinos, P., Strong, J., et al. (1995). For the Warfarin-Aspirin Symptomatic Intracranial Disease Study Group. The warfarin-aspirin symptomatic intracranial disease study. Neurology, 45, 1488–93.CrossRefGoogle Scholar
Chimowitz, M. I., Lynn, M. J., Howlett-Smith, H., et al. (2005). Comparison of warfarin and aspirin for symptomatic intracranial arterial stenosis. New England Journal of Medicine, 352, 1305–16.CrossRefGoogle ScholarPubMed
Crisby, M., Nordin-Fredricksson, G., Shah, P. K., et al. (2001). Pravastatin treatment increases collagen content and decreases lipid content, inflammation, metalloproteinases, and cell death in human carotid plaques. Implications for plaque stabilization. Circulation, 103, 926–33.CrossRefGoogle ScholarPubMed
Lorgeril, M., Salen, P., Martin, J. -L., et al. (1999). Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation, 99, 779–85.CrossRefGoogle ScholarPubMed
Diener, H. C., Bogousslavsky, J., Brass, I. M., et al. (2004). Aspirin and clopidogrel compared with clopidogrel alone after recent ischemic stroke or transient ischemic attack in high-risk patients (Management of atherothrombosis with clopidogrel in high-risk patients): randomised double-blind, placebo-controlled trial. Lancet, 364, 331–7.CrossRefGoogle Scholar
Diener, H. C., Cunha, L., Forbes, C., et al. (1996). European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke. Journal of the Neurological Sciences, 143, 1–13.CrossRefGoogle ScholarPubMed
Engelter, S. and Lyrer, P. (2003). Antiplatelet therapy for preventing stroke and other vascular events after carotid endarterectomy. Cochrane Database System Review, CD001458.CrossRefGoogle ScholarPubMed
European Carotid Surgery Trialists' Collaborative Group. (1991). Medical research council European Carotid Surgery Trial. Interim results for symptomatic patients with severe (70–99%) or with mild (0–29%) carotid stenosis. Lancet, 337, 1235–43.CrossRef
Fairhead, J. F., Mehta, Z. and Rothwell, P. M. (2005). Population-based study of delays in carotid imaging and surgery and the risk of recurrent stroke. Neurology, 65, 371–5.CrossRefGoogle ScholarPubMed
Goertler, M., Baeumer, M., Kross, R., et al. (1999). Rapid decline of cerebral microemboli of arterial origin after intravenous acetylsalicylic acid. Stroke, 30, 66–9.CrossRefGoogle ScholarPubMed
Gorelick, P. B. (1993). Distribution of atherosclerotic cerebrovascular lesions. Effects of age, race, and sex. Stroke, 24, 116–19.Google Scholar
Grubb, R. L. Jr, Derdeyn, C. P., Fritsch, S. M., et al. (1998). Importance of hemodynamic factors in the prognosis of symptomatic carotid occlusion. Journal of the American Medical Association, 280, 1055–60.CrossRefGoogle ScholarPubMed
Heart Protection Study Collaborative Group. (2002). Medical research council/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20 536 high-risk patients: a randomised placebo-controlled trial. Lancet, 360, 7–22.CrossRef
Heart Protection Study Collaborative Group. (2004). Effects of cholesterol lowering with simvastatin on stroke and other major vascular events in 20 536 people with cerebrovascular disease or other high risk conditions. Lancet, 363, 757–7.CrossRef
Hedblad, B., Wikstrand, J., Janzon, L., Wedel, H. and Berglund, G. (2001). Low-dose metoprolol CR/XL and fluvastatin slow progression of carotid intima-media thickness: main results from the Beta-Blocker Cholesterol-Lowering Asymptomatic Plaque Study (BCAPS). Circulation, 103, 1721–26.CrossRefGoogle Scholar
Hooper, L., Bartlett, C., Davey Smith, G. and Ebrahim, S. (2002). Systematic review of long term effects of advice to reduce dietary salt in adults. British Medical Journal, 325, 628–32.CrossRefGoogle ScholarPubMed
Hosomi, N., Mizushige, K., Ohyama, H., et al. (2001). Angiotensin-converting enzyme inhibition with enalapril slows progressive intima-media thickening of the common carotid artery in patients with non-insulin-dependent diabetes mellitus. Stroke, 32, 1539–45.CrossRefGoogle ScholarPubMed
Kaplan, E. D. (2003). Association between homocysteine levels and risk of vascular events. Drugs Today (Barc), 39, 175–92.CrossRefGoogle ScholarPubMed
Kennedy, J., Eliasziw, M., Hill, M. D. and Buchan, A. M. (2003). The Fast Assessment of Stroke and Transient Ischemic Attack to prevent Early Recurrence (Fast assessment of stroke and transient ischemic attack to prevent early recurrence) Trial. Seminars in Cerebrovascular Diseases and Stroke, 3, 25–30.CrossRefGoogle Scholar
Kodama, M., Yamasaki, Y., Sakamoto, K., et al. (2000). Antiplatelet drugs attenuate progression of carotid intima-media thickness in subjects with type 2 diabetes. Thrombosis Research, 97, 239–45.CrossRefGoogle ScholarPubMed
Langenfeld, M. R., Forst, T., Hohberg, C., et al. (2005). Pioglitazone decreases carotid intima-media thickness independently of glycemic control in patients with type 2 diabetes mellitus: results from a controlled randomized study. Circulation, 111, 2525–31.CrossRefGoogle ScholarPubMed
Laufs, U., Gertz, K., Dirnagl, U., et al. (2002). Rosuvastatin, a new HMG-b-hydroxy-b-methylglutaryl-CoA reductase inhibitor, upregulates endothelial nitric oxide synthase and protects from ischemic stroke in mice. Brain Research, 28, 23–30.CrossRefGoogle Scholar
Leonardi-Bee, J., Bath, P. M., Bousser, M. G., et al. (2005). Dipyridamole in Stroke Collaboration (DISC). Dipyridamole for preventing recurrent ischemic stroke and other vascular events: a meta-analysis of individual patient data from randomized controlled trials. Stroke, 36, 162–8.CrossRefGoogle ScholarPubMed
Lonn, E., Yusuf, S., Dzavik, V., et al. (2001). Effects of ramipril and vitamin E on atherosclerosis: the Study to Evaluate Carotid Ultrasound Changes in Patients Treated With Ramipril and Vitamin E (SECURE). Circulation, 103, 919–25.CrossRefGoogle Scholar
Lovett, J. K., Coull, A., Rothwell, P. M., on behalf of the Oxford Vascular Study. (2004). Early risk of recurrent stroke by aetiological subtype: implications for stroke prevention. Neurology, 62, 569–74.CrossRefGoogle Scholar
Mancini, G. B., Dahlof, B. and Diez, J. (2004). Surrogate markers for cardiovascular disease: structural markers. Circulation, 109 (Suppl. 1), 22–30.CrossRefGoogle ScholarPubMed
Markus, H. S., Droste, D. W., Kaps, M., et al. (2005). Dual antiplatelet therapy with clopidogrel and aspirin in symptomatic carotid stenosis evaluated using Doppler embolic signal detection: the Clopidogrel and Aspirin for Reduction of Emboli in Symptomatic Carotid Stenosis (Clopidogrel and aspirin for reduction of emboli in symptomatic carotid stenosis) trial. Circulation, 111, 2233–40.CrossRefGoogle ScholarPubMed
Mercuri, M., Bond, M. G., Sirtori, C. R., et al. (1996). Pravastatin reduces carotid intima-media thickness progression in an asymptomatic hypercholesterolemic Mediterranean population: The Carotid Atherosclerosis Italian Ultrasound Study. American Journal of Medicine, 101, 627–34.CrossRefGoogle Scholar
Molyneux, A. (2004). Nicotine replacement therapy. British Medical Journal, 328, 454–6.CrossRefGoogle ScholarPubMed
North American Symptomatic Carotid Endarterectomy Trial Collaborators (1991). Beneficial effect of carotid endarterectomy in symptomatic patients with high-grade carotid stenosis. New England Journal of Medicine, 325, 445–53.CrossRef
Pignoli, P., Tremoli, E., Poli, A., Oreste, P. and Paoletti, R. (1986). Intimal plus medial thickness of the arterial wall: a direct measurement with ultrasound imaging. Circulation, 74, 1399–406.CrossRefGoogle ScholarPubMed
Progress Collaborative Group. (2001). Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack. Lancet, 358, 1033–41.CrossRef
Prospective Studies Collaboration (1995). Cholesterol, diastolic blood pressure, and stroke: 13,000 strokes in 450,000 people in 45 prospective cohorts. Lancet, 346, 1647–53.CrossRef
Rosenson, R. S. (2004). Statins in atherosclerosis: lipid-lowering agents with antioxidant capabilities. Atherosclerosis, 173, 1–12.CrossRefGoogle ScholarPubMed
Rothwell, P. M., Eliasziw, M., Gutnikov, S. A., Warlow, C. P. and Barnett, H. J. (2004). Carotid Endarterectomy Trialists Collaboration Endarterectomy for symptomatic carotid stenosis in relation to clinical subgroups and timing of surgery. Lancet, 363, 915–24.CrossRefGoogle ScholarPubMed
Rothwell, P M., Howard, S. C. and Spence, D. (2003). Relationship between blood pressure and stroke risk in patients with symptomatic carotid occlusive disease. Stroke, 34, 2583–90.CrossRefGoogle ScholarPubMed
Rothwell, P. M., Mehta, Z., Howard, S. C., Gutnikov, S. A. and Warlow, C. P. (2005). From subgroups to individuals: general principles and the example of carotid endartectomy. Lancet, 365, 256–65.CrossRefGoogle Scholar
Rothwell, P. M., Warlow, C. P. on behalf of the European carotid surgery Collaborators. (1999). Prediction of benefit from carotid endarterectomy in individual patients: A risk-modelling study. Lancet, 353, 2105–10.CrossRefGoogle ScholarPubMed
Stiller, C. A. (1994). Centralised treatment, entry to trials and survival. British Journal of Cancer, 70, 352–62.CrossRefGoogle Scholar
Stroke Prevention in Reversible Ischemia Trial (Stroke prevention in reversible ischemia trial) Study Group. (1997). A randomized trial of anticoagulants versus aspirin after cerebral ischemia of presumed arterial origin. Annals of Neurology, 42, 857–65.CrossRef
Takemoto, M.and Liao, J. K. (2001). Pleiotropic effects of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors. Arteriosclerosis, Thrombosis and Vascular Biology, 21, 1712–19.CrossRefGoogle ScholarPubMed
Thiele, B. L., Young, J. V., Chikos, P. M., Hirsch, J. H. and Strandness, D. E. (1980). Correlation of arteriographic findings and symptoms in cerebrovascular disease. Neurology, 30, 1041–6.CrossRefGoogle ScholarPubMed
Toole, J. F., Malinow, M. R., Chambless, L. E., et al. (2004). Lowering homocysteine in patients with ischemic stroke to prevent recurrent stroke, myocardial infarction, and death: the Vitamin Intervention for Stroke Prevention (VISP) randomized controlled trial. Journal of the American Medical Association, 291, 565–75.CrossRefGoogle ScholarPubMed
Grond, J., Balm, R., Kappelle, J., Eikelboom, B. C. and Mali, W. P. (1995). Cerebral metabolism of patients with stenosis or occlusion of the internal carotid artery. Stroke, 26, 822–8.CrossRefGoogle ScholarPubMed
Vaughan, C. J., Murphy, M. B. and Buckley, B. M. (1996). Statins do more than just lower cholesterol. Lancet, 348, 1079–82.CrossRefGoogle ScholarPubMed
VITATOPS Trial Study Group. (2002). The VITATOPS (Vitamins to Prevent Stroke) Trial: rationale and design of an international, large, simple, randomised trial of homocysteine-lowering multivitamin therapy in patients with recent transient ischaemic attack or stroke. Cerebrovascular Disease, 13, 120–6.CrossRef
Warfarin Aspirin Recurrent Stroke Study Group. (2001). A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke. New England Journal of Medicine, 345, 1444–51.CrossRef
Waters, D. D., Schwartz, G. G., Olsson, A. G., et al. (2002). Effects of atorvastatin on stroke in patients with unstable angina or non-Q-wave myocardial infarction. A Myocardial Ischemia Reduction with Aggressive Cholesterol Lowering (MIRACL) substudy. Circulation, 106, 1690–5.CrossRefGoogle ScholarPubMed
Wennberg, D. E., Lucas, F. L., Birkmeyer, J. D., Bredenberg, C. E. and Fisher, E. S. (1998). Variation in carotid endarterectomy mortality in the Medicare population: trial hospitals, volume, and patient characteristics. Journal of the American Medical Association, 279, 1278–81.CrossRefGoogle ScholarPubMed

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