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
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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
Hyperhomocysteinemia
Obesity
Physical inactivity
60-80% riskfactor for
stroke
Atherosclerosis
Cardioembolic Atrial fibrillation
Valvular heart disease
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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Hyperhomocysteinemia
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
Hyperhomocysteinemia
Obesity
Physical inactivity
60-80% riskfactor for
stroke
Atherosclerosis
Cardioembolic Atrial fibrillation
Valvular heart disease
Carotid stenosis
Monday, June 20, 2011
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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