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Carotid artery stenosis medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Charmaine Patel, M.D. [2]; Aarti Narayan, M.B.B.S [3]; Raviteja Guddeti, M.B.B.S. [4]

Overview

Medical therapy for carotid artery stenosis includes; antihypertensives to control blood pressure, antiplatelet agents, management of lipids, and management of diabetes through tight control of blood glucose levels. Management also includes assessment of the global cardiovascular risk, as well as a yearly surveillance ultrasound, and educating the patient about the symptoms of TIA and stroke.

Medical Therapy

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS: Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease (DO NOT EDIT)[1]

Treatment of Hypertension (DO NOT EDIT)[1]

Class I
“1. Antihypertensive treatment is recommended for patients with hypertension and asymptomatic atherosclerotic ECVD to maintain blood pressure (BP) less than 140/90 mm Hg.[2][3][4][5][6] (Level of Evidence: A) ”
Class IIa
“1. Except during the hyperacute period, antihypertensive treatment is probably indicated in patients with hypertension and symptomatic atherosclerotic ECVD, but the benefit of treatment to a specific BP has not been established in relation to the risk of exacerbating cerebral ischemia. (Level of Evidence: C) ”

Control of Hyperlipidemia (DO NOT EDIT)[1]

Class I
“1. Treatment with a statin is recommended for all patients with atherosclerotic ECVD (Extracranial Carotid and Vertebral artery disease) to lower low density lipoprotein cholesterol to less than 100 mg/dL.[3][7][8] (Level of Evidence: B) ”
Class IIa
“1. Treatment with a statin is reasonable for all patients with atherosclerotic ECVD who sustain ischemic stroke to reduce low-density lipoprotein cholesterol to a level less than or equal to 70 mg/dL.[7] (Level of Evidence: B) ”
“2. If treatment with a statin (including trials of higher-dose statins and higher-potency statins) does not achieve the goal selected for a patient, intensifying LDL-lowering drug therapy with an additional drug from among those with evidence of improving outcomes (ie, bile acid sequestrants or niacin) can be effective.[9][10][11][12] (Level of Evidence: B) ”
“3. For patients who do not tolerate statins, therapy with bile acid sequestrants and/or niacin is reasonable.[9][11][13] (Level of Evidence: B) ”

Management of Diabetes Mellitus in Patients With Atherosclerosis of the Extracranial Carotid or Vertebral Arteries (DO NOT EDIT)[1]

Class IIa
“1. Diet, exercise, and glucose-lowering drugs can be useful for patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis. The stroke prevention benefit, however, of intensive glucose lowering therapy to a glycosylated hemoglobin A1c level less than 7.0% has not been established.[14][15] (Level of Evidence: A)”
“2. Administration of statin-type lipid-lowering medication at a dosage sufficient to reduce LDL cholesterol to a level near or below 70 mg/dL is reasonable in patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis for prevention of ischemic stroke and other ischemic cardiovascular events.[16] (Level of Evidence: B)”

Antithrombotic Therapy in Patients With Extracranial Carotid Atherosclerotic Disease Not Undergoing Revascularization (DO NOT EDIT)[1]

Class I
“1. Antiplatelet therapy with aspirin, 75 to 325 mg daily, is recommended for patients with obstructive or nonobstructive atherosclerosis that involves the extracranial carotid and/or vertebral arteries for prevention of myocardial infarction (MI) and other ischemic cardiovascular events, although the benefit has not been established for prevention of stroke in asymptomatic patients.[8][17][18][19] (Level of Evidence: A) ”
“2. In patients with obstructive or nonobstructive extracranial carotid or vertebral atherosclerosis who have sustained ischemic stroke or TIA, antiplatelet therapy with aspirin alone (75 to 325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin plus extended-release dipyridamole (25 and 200 mg twice daily, respectively) is recommended (Level of Evidence: B) and preferred over the combination of aspirin with clopidogrel.[8][19][20][21][22][23] (Level of Evidence: B) Selection of an antiplatelet regimen should be individualized on the basis of patient risk factor profiles, cost, tolerance, and other clinical characteristics, as well as guidance from regulatory agencies.
“3. Antiplatelet agents are recommended rather than oral anticoagulation for patients with atherosclerosis of the extracranial carotid or vertebral arteries with[24][25] (Level of Evidence: B) or without (Level of Evidence: C) ischemic symptoms. (For patients with allergy or other contraindications to aspirin, see Class IIa recommendation #2, this section)
Class III (Harm)
“1. Full-intensity parenteral anticoagulation with unfractionated heparin or low-molecular-weight heparinoids is not recommended for patients with extracranial cerebrovascular atherosclerosis who develop transient cerebral ischemia or acute ischemic stroke.[26][27][28] (Level of Evidence: B) ”
“2. Administration of clopidogrel in combination with aspirin is not recommended within 3 months after stroke or TIA. (Level of Evidence: B) ”
Class IIa
“1. In patients with extracranial cerebrovascular atherosclerosis who have an indication for anticoagulation, such as atrial fibrillation or a mechanical prosthetic heart valve, it can be beneficial to administer a vitamin K antagonist (such as warfarin, dose adjusted to achieve a target international normalized ratio (INR) of 2.5 [range 2.0 to 3.0]) for prevention of thromboembolic ischemic events.[29] (Level of Evidence: C) ”
“2. For patients with atherosclerosis of the extracranial carotid or vertebral arteries in whom aspirin is contraindicated by factors other than active bleeding, including allergy, either clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) is a reasonable alternative. (Level of Evidence: C) ”

Management of Patients With Fibromuscular Dysplasia of the Extracranial Carotid Arteries (DO NOT EDIT)[1]

Class III (No Benefit)
“1. Revascularization is not recommended for patients with asymptomatic FMD (Fibromuscular dysplasia) of a carotid artery, regardless of the severity of stenosis. (Level of Evidence: C) ”
Class IIa
“1. Annual noninvasive imaging of the carotid arteries is reasonable initially for patients with fibromuscular dysplasia (FMD) to detect changes in the extent or severity of disease, although the effect on outcomes is unclear. Studies may be repeated less frequently once stability has been confirmed. (Level of Evidence: C) ”
“2. Administration of platelet-inhibitor medication can be beneficial in patients with FMD of the carotid arteries to prevent thromboembolism, but the optimum drug and dosing regimen have not been established. (Level of Evidence: C) ”
“3. Carotid angioplasty with or without stenting is reasonable for patients with retinal or hemispheric cerebral ischemic symptoms related to FMD of the ipsilateral carotid artery, but comparative data addressing these methods of revascularization are not available. (Level of Evidence: C) ”

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL; et al. (2011). “2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery”. Circulation. 124 (4): 489–532. doi:10.1161/CIR.0b013e31820d8d78. PMID 21282505.
  2. ↑ Rashid P, Leonardi-Bee J, Bath P (2003). “Blood pressure reduction and secondary prevention of stroke and other vascular events: a systematic review”. Stroke. 34 (11): 2741–8. doi:10.1161/01.STR.0000092488.40085.15. PMID 14576382. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 Sacco RL, Adams R, Albers G; et al. (2006). “Guidelines for prevention of stroke in patients with ischemic stroke or transient ischemic attack: a statement for healthcare professionals from the American Heart Association/American Stroke Association Council on Stroke: co-sponsored by the Council on Cardiovascular Radiology and Intervention: the American Academy of Neurology affirms the value of this guideline”. Stroke. 37 (2): 577–617. doi:10.1161/01.STR.0000199147.30016.74. PMID 16432246. Unknown parameter |month= ignored (help)
  4. ↑ “Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6,105 individuals with previous stroke or transient ischaemic attack”. Lancet. 358 (9287): 1033–41. 2001. doi:10.1016/S0140-6736(01)06178-5. PMID 11589932. Unknown parameter |month= ignored (help)
  5. ↑ Lawes CM, Bennett DA, Feigin VL, Rodgers A (2004). “Blood pressure and stroke: an overview of published reviews”. Stroke. 35 (3): 776–85. doi:10.1161/01.STR.0000116869.64771.5A. PMID 14976329. Unknown parameter |month= ignored (help)
  6. ↑ Neal B, MacMahon S, Chapman N (2000). “Effects of ACE inhibitors, calcium antagonists, and other blood-pressure-lowering drugs: results of prospectively designed overviews of randomised trials. Blood Pressure Lowering Treatment Trialists’ Collaboration”. Lancet. 356 (9246): 1955–64. PMID 11130523. Unknown parameter |month= ignored (help)
  7. ↑ 7.0 7.1 Amarenco P, Bogousslavsky J, Callahan A; et al. (2006). “High-dose atorvastatin after stroke or transient ischemic attack”. N. Engl. J. Med. 355 (6): 549–59. doi:10.1056/NEJMoa061894. PMID 16899775. Unknown parameter |month= ignored (help)
  8. ↑ 8.0 8.1 8.2 Adams RJ, Albers G, Alberts MJ; et al. (2008). “Update to the AHA/ASA recommendations for the prevention of stroke in patients with stroke and transient ischemic attack”. Stroke. 39 (5): 1647–52. doi:10.1161/STROKEAHA.107.189063. PMID 18322260. Unknown parameter |month= ignored (help)
  9. ↑ 9.0 9.1 “Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) final report”. Circulation. 106 (25): 3143–421. 2002. PMID 12485966. Unknown parameter |month= ignored (help)
  10. ↑ Frick MH, Elo O, Haapa K; et al. (1987). “Helsinki Heart Study: primary-prevention trial with gemfibrozil in middle-aged men with dyslipidemia. Safety of treatment, changes in risk factors, and incidence of coronary heart disease”. N. Engl. J. Med. 317 (20): 1237–45. doi:10.1056/NEJM198711123172001. PMID 3313041. Unknown parameter |month= ignored (help)
  11. ↑ 11.0 11.1 Kris-Etherton PM, Harris WS, Appel LJ (2002). “Fish consumption, fish oil, omega-3 fatty acids, and cardiovascular disease”. Circulation. 106 (21): 2747–57. PMID 12438303. Unknown parameter |month= ignored (help)
  12. ↑ Rubins HB, Robins SJ, Collins D; et al. (1999). “Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group”. N. Engl. J. Med. 341 (6): 410–8. doi:10.1056/NEJM199908053410604. PMID 10438259. Unknown parameter |month= ignored (help)
  13. ↑ Brown BG, Zhao XQ, Chait A; et al. (2001). “Simvastatin and niacin, antioxidant vitamins, or the combination for the prevention of coronary disease”. N. Engl. J. Med. 345 (22): 1583–92. doi:10.1056/NEJMoa011090. PMID 11757504. Unknown parameter |month= ignored (help)
  14. ↑ Gerstein HC, Miller ME, Byington RP; et al. (2008). “Effects of intensive glucose lowering in type 2 diabetes”. N. Engl. J. Med. 358 (24): 2545–59. doi:10.1056/NEJMoa0802743. PMID 18539917. Unknown parameter |month= ignored (help)
  15. ↑ Patel A, MacMahon S, Chalmers J; et al. (2008). “Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes”. N. Engl. J. Med. 358 (24): 2560–72. doi:10.1056/NEJMoa0802987. PMID 18539916. Unknown parameter |month= ignored (help)
  16. ↑ Colhoun HM, Betteridge DJ, Durrington PN; et al. (2004). “Primary prevention of cardiovascular disease with atorvastatin in type 2 diabetes in the Collaborative Atorvastatin Diabetes Study (CARDS): multicentre randomised placebo-controlled trial”. Lancet. 364 (9435): 685–96. doi:10.1016/S0140-6736(04)16895-5. PMID 15325833.
  17. ↑ Goldstein LB, Adams R, Alberts MJ; et al. (2006). “Primary prevention of ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council: cosponsored by the Atherosclerotic Peripheral Vascular Disease Interdisciplinary Working Group; Cardiovascular Nursing Council; Clinical Cardiology Council; Nutrition, Physical Activity, and Metabolism Council; and the Quality of Care and Outcomes Research Interdisciplinary Working Group: the American Academy of Neurology affirms the value of this guideline”. Stroke. 37 (6): 1583–633. doi:10.1161/01.STR.0000223048.70103.F1. PMID 16675728. Unknown parameter |month= ignored (help)
  18. ↑ “A randomized trial of aspirin and sulfinpyrazone in threatened stroke. The Canadian Cooperative Study Group”. N. Engl. J. Med. 299 (2): 53–9. 1978. doi:10.1056/NEJM197807132990201. PMID 351394. Unknown parameter |month= ignored (help)
  19. ↑ 19.0 19.1 “Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high risk patients”. BMJ. 324 (7329): 71–86. 2002. PMC 64503. PMID 11786451. Unknown parameter |month= ignored (help)
  20. ↑ “A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE). CAPRIE Steering Committee”. Lancet. 348 (9038): 1329–39. 1996. PMID 8918275. Unknown parameter |month= ignored (help)
  21. ↑ Diener HC, Bogousslavsky J, Brass LM; et al. (2004). “Aspirin and clopidogrel compared with clopidogrel alone after recent ischaemic stroke or transient ischaemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial”. Lancet. 364 (9431): 331–7. doi:10.1016/S0140-6736(04)16721-4. PMID 15276392.
  22. ↑ Diener HC, Cunha L, Forbes C, Sivenius J, Smets P, Lowenthal A (1996). “European Stroke Prevention Study. 2. Dipyridamole and acetylsalicylic acid in the secondary prevention of stroke”. J. Neurol. Sci. 143 (1–2): 1–13. PMID 8981292. Unknown parameter |month= ignored (help)
  23. ↑ Sacco RL, Diener HC, Yusuf S; et al. (2008). “Aspirin and extended-release dipyridamole versus clopidogrel for recurrent stroke”. N. Engl. J. Med. 359 (12): 1238–51. doi:10.1056/NEJMoa0805002. PMC 2714259. PMID 18753638. Unknown parameter |month= ignored (help)
  24. ↑ Mohr JP, Thompson JL, Lazar RM; et al. (2001). “A comparison of warfarin and aspirin for the prevention of recurrent ischemic stroke”. N. Engl. J. Med. 345 (20): 1444–51. doi:10.1056/NEJMoa011258. PMID 11794192. Unknown parameter |month= ignored (help)
  25. ↑ Halkes PH, van Gijn J, Kappelle LJ, Koudstaal PJ, Algra A (2007). “Medium intensity oral anticoagulants versus aspirin after cerebral ischaemia of arterial origin (ESPRIT): a randomised controlled trial”. Lancet Neurol. 6 (2): 115–24. doi:10.1016/S1474-4422(06)70685-8. PMID 17239798. Unknown parameter |month= ignored (help)
  26. ↑ Adams HP, del Zoppo G, Alberts MJ; et al. (2007). “Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists”. Stroke. 38 (5): 1655–711. doi:10.1161/STROKEAHA.107.181486. PMID 17431204. Unknown parameter |month= ignored (help)
  27. ↑ Woessner R, Grauer M, Bianchi O; et al. (2004). “Treatment with anticoagulants in cerebral events (TRACE)”. Thromb. Haemost. 91 (4): 690–3. doi:10.1267/THRO04040690. PMID 15045129. Unknown parameter |month= ignored (help)
  28. ↑ “Low molecular weight heparinoid, ORG 10172 (danaparoid), and outcome after acute ischemic stroke: a randomized controlled trial. The Publications Committee for the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) Investigators”. JAMA. 279 (16): 1265–72. 1998. PMID 9565006.
  29. ↑ “Risk factors for stroke and efficacy of antithrombotic therapy in atrial fibrillation. Analysis of pooled data from five randomized controlled trials”. Arch. Intern. Med. 154 (13): 1449–57. 1994. PMID 8018000. Unknown parameter |month= ignored (help)

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