Risk factor management in Extracranial carotid artery stenosis: From Recent 2011 Guideline

8/6/2019 Risk factor management in Extracranial carotid artery stenosis: From Recent 2011 Guideline

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Risk Factor Management in ExtracranialCarotid and Vertebral Artery Disease:

From the recent guideline

Surat Tanprawate, MD, MSc(Lond.), FRCPTDivision of Neurology, Faculty of Medicine

Chiang Mai University

ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS

Circulation published online May 25, 2011

Chiang Mai Stroke Unit 20/6/11

Monday, June 20, 2011


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ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/

SIR/SNIS/SVM/SVS

Guideline on the Management of Patients With Extracranial Carotid and VertebralArtery Disease was composed of experts in the areas of medicine, surgery,neurology, cardiology, radiology, vascular surgery, neurosurgery, neuroradiology,

interventional radiology, noninvasive imaging, emergency medicine, vascularmedicine, nursing, epidemiology, and biostatistics. The committee includedrepresentatives of the American Stroke Association (ASA), ACCF, AHA,American Academy of Neurology (AAN), American Association of NeuroscienceNurses (AANN), American Association of Neurological Surgeons (AANS),American College of Emergency Physicians (ACEP), American College of

Radiology (ACR), American Society of Neuroradiology (ASNR), Congress ofNeurological Surgeons (CNS), Society of Atherosclerosis Imaging and Prevention(SAIP), Society for Cardiovascular Angiography and Interventions (SCAI), Societyof Cardiovascular Computed Tomography (SCCT), Society of InterventionalRadiology (SIR), Society of NeuroInterventional Surgery (SNIS), Society forVascular Medicine (SVM), and Society for Vascular Surgery (SVS)

Organization of the Writing Committee 2011



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TOAST subtype of acuteischemic stroke

1) large-arteryatherosclerosis

2) cardioembolism

3) small-vesselocclusion

4) stroke of otherdetermined etiology

5) stroke ofundetermined etiology

Stroke. 1993 Jan;24(1):35-41.



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Extracranial atherosclerotic

disease accounts for up to

15% to 20% of all ischemicstrokes

Correlation between the

degree of stenosis and therisk of stroke



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Risk

Factor

Atherosclerotic risk

Large vessel carotidatheroslerosis

Cardioembolic

Small vessel disease



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What guideline said?

Identifiable risk factor

Association with all stroke

Association with ECVD

Management of risk factors

Intima-Media

Thickness (IMT)

Carotid artery

disease

Stroke

Embolic

Hemodynamic



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The risk factors

Hypertension

Tobacco smoking

Hyperlipidemia

Diabetes

Hyperhomocysteinemia

Obesity

Physical inactivity

60-80% riskfactor for

stroke

Atherosclerosis

Cardioembolic Atrial fibrillation

Valvular heart disease

Carotid stenosis



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The risk factors

Hypertension

Tobacco smoking

Hyperlipidemia

Diabetes


Obesity

Physical inactivity


stroke

Atherosclerosis



Carotid stenosis



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HT and Stroke

Increase BP increase risk of stroke

5 mm Hg(DBP): ) 33% increase in stroke

BP reduction of5-6 mm Hg reduction DBP

(10-12 mm Hg SBP) reduce the risk ofstroke by 35-40%

The RISC Group. Lancet.1990;335: 827-830

Neal B. MacMahon S.J Hypertens.1995; 13:1869-1873



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Stroke death rate by categories of systolic blood pressure and diastolicblood pressure.

Hypertension: Pathophysiology, Diagnosis, and Management.1995:127144.Monday, June 20, 2011


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Hypertension

HT and the risk of developing carotid

atherosclerosis

In the Framingham Heart Study

2-fold greater risk of CAS 25% for each

20-mm Hg increase in systolic bloodpressure



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?? Symptomatic patients with

severe carotid artery stenosis ??Monday, June 20, 2011


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No specific

recommendation

for the treatmentof hypertension

in patients with

symptomatic

patient withsevere CAS



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Tobacco smoking

Smoking and stroke risk

increases the RR of ischemic stroke by25%-50%

Smoking and CAS

associated with extracranial carotid

artery and progression of carotid IMT,

the severity, and carotid artery stenosis

OLeary DH et al.Stroke. 1996;27: 224 31



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Hyperlipidemia

Hyperlipidemia vs stroke risk

Inconclusive

Hyperlipidemia vs IMT

association between cholesterol andcarotid artery atherosclerosis (IMT)

Sharrett AR et al. Arterioscler Thromb. 1994;14:1098 104



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Statin and stroke

Statin lower the risk of stroke

10% reduction Cholesterol => 15.6% strokerisk decreasing

40 mg/dL decreasing LDL=> 22% strokereduction

Statin therapy reduces progression or inducesregression of carotid atherosclerosis



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Diabetes and stroke risk

Persons with DM have both an increased

susceptibility to atherosclerosis and an

increased prevalence ofproatherogenic risk

factors, notably hypertension and abnormalblood lipids

DM is an independently increase risk ofischemic stroke with a relative risk 2-5 fold



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Diabetes and stroke risk

DM and CAS

DM is associated with carotid IMT and its

progression

Treatment of DM

Pioglitazone caused less progression orinduced regression of carotid IMT

compared with glimepiride

Haffner SM, et al. Am J Cardiol. 2000;85:1395400



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Primary prevention of stroke

UKPDS: conventional vs intensive therapy

A reduction in MI, and all cause mortality wasfound, but stroke in incidence was not affected

ACCORD: intensive(HbA1c


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Secondary prevention of stroke

ACCORD: pt. with type 2 DM and vascular disease (intensive vsconventional)

There was no significant difference in the rate of nonfatalstroke

ADVANCE: pt. with type 2 DM and history of macrovasculardisease(9% stroke)

There was no significant reduction in the occurrence ofnonfatal stroke

PROactive: pt. with DM and macrovascular disease usingpioglitazone

Patient with history of stroke was associated with 47% riskreduction in recurrent stroke

Stroke2011;42;517-584Monday, June 20, 2011


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Obesity and the MetabolicSyndrome

Metabolic syndrome (WHO definition)

Blood glucose, HT, dyslipidemia, body mass index,

waist/hip ratio, and urinary albumin excretion

Its associated with carotid carotid atherosclerosisMonday, June 20, 2011


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Physical activity and stroke risk



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Physical Inactivity

Stroke risk

prevalence of 25%, RR of 2.7

Carotid atherosclerosis

inconsistent between physical inactivity vs

carotid IMT

Exercise alone is benefit in the absence of

effects on the other risk factors is not clear



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Hyperhomocysteinemiaand stroke

25% difference in

plasma homocysteineconc. associated witha 19% difference instroke risk

Selhub J,et al. NEJM 1995;332:286 91

Hyperhomocysteinemia and CAS

However, the supplementwith vitamin and folic acid

dont decrease risk of

CVD including strokeMonday, June 20, 2011


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The risk factors

Hypertension

Tobacco smoking

Hyperlipidemia

Diabetes


Obesity

Physical inactivity


stroke

Atherosclerosis



Carotid stenosis



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The risk factors

Hypertension

Tobacco smoking

Hyperlipidemia

Diabetes


Obesity

Physical inactivity


stroke

Atherosclerosis



Carotid stenosis

Documents

Risk factor management in Extracranial carotid artery stenosis: From Recent 2011 Guideline