Semin Neurol 2005; 25(4): 376-383
DOI: 10.1055/s-2005-923532
Copyright © 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.

Medical Management of Carotid Artery Disease

Kumar Rajamani1 , Seemant Chaturvedi1
  • 1Department of Neurology and Stroke Program, Wayne State University/Detroit Medical Center, Detroit, Michigan
Further Information

Publication History

Publication Date:
08 December 2005 (online)

ABSTRACT

It is estimated that more than 700,000 strokes occur in the United States annually, and stroke remains the third leading cause of death. As many as 20% of strokes are due to carotid artery disease. Approaches to therapy include surgery and stenting in appropriate settings, but medical therapy is a critical aspect of management of carotid artery disease. Best medical therapy for carotid stenosis has evolved in recent years and clinicians can now employ newer antiplatelet agents, aggressive use of statins, and targeted blood pressure reduction. Application of this multimodal cocktail holds promise for reducing vascular events in patients with carotid artery disease and may reduce the need for revascularization procedures.

REFERENCES

  • 1 Barnett H JM, Taylor D W, Eliasziw M et al.. The North American Symptomatic Carotid Endarterectomy Trial Collaborators. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis.  N Engl J Med. 1998;  339 1415-1425
  • 2 Executive Committee for the Asymptomatic Carotid Atherosclerosis Study . Endarterectomy for asymptomatic carotid stenosis.  JAMA. 1995;  273 1421-1428
  • 3 Albers G W, Amarenco P, Easton J D, Sacco R L, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke: the seventh ACCP conference on antithrombotic and thrombolytic therapy.  Chest. 2004;  126 483S-512S
  • 4 Antithrombotic Trialists Collaboration . Collaborative meta-analysis of randomised trials of antiplatelet therapy for prevention of death, myocardial infarction, and stroke in high-risk patients.  BMJ. 2002;  324 71-86
  • 5 The SALT Collaborative Group . Swedish low-dose trial (SALT) of 75 mg aspirin as secondary prophylaxis after cerebrovascular ischemic events.  Lancet. 1991;  338 1345-1349
  • 6 Algra A, van Gijn J. Aspirin at any dose above 30 mg offers only modest protection after cerebral ischemia.  J Neurol Neurosurg Psychiatry. 1996;  60 197-199
  • 7 Dutch TIA Trial Study Group . A comparison of two doses of aspirin (30 mg vs. 283 mg a day) in patients after a transient ischemic attack or minor ischemic stroke.  N Engl J Med. 1991;  325 1261-1266
  • 8 Taylor D W, Barnett H JM, Haynes R B et al.. Low-dose and high-dose acetylsalicylic acid for patients undergoing carotid endarterectomy: a randomised controlled trial.  Lancet. 1999;  353 2179-2184
  • 9 Diener H C, Cunha L, Forbes C et al.. European stroke prevention study 2: dipyridamole and acetylsalicylic acid in the secondary prevention of stroke.  J Neurol Sci. 1996;  143 1-13
  • 10 CAPRIE Steering Committee . A randomised, blinded, trial of clopidogrel versus aspirin in patients at risk of ischaemic events (CAPRIE).  Lancet. 1996;  348 1329-1339
  • 11 Hirsh J, Bhatt D L. Comparative benefits of clopidogrel and aspirin in high-risk patient populations: lessons from the CAPRIE and CURE studies.  Arch Intern Med. 2004;  164 2106-2110
  • 12 Chaturvedi S, Sohrab S, Tselis A. Carotid stent thrombosis: report of 2 fatal cases.  Stroke. 2001;  32 2700-2702
  • 13 Diener H C, Bogousslavsky J, Brass L M et al.. MATCH Investigators. Aspirin and clopidogrel compared with clopidogrel alone after recent stroke or transient ischemic attack in high-risk patients (MATCH): randomised, double-blind, placebo-controlled trial.  Lancet. 2004;  364 331-337
  • 14 Markus H S, Droste D W, Kaps M et al.. 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 (CARESS) trial.  Circulation. 2005;  111 2233-2240
  • 15 Chobanian A V, Bakris G L, Black H R et al.. The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure.  JAMA. 2003;  289 2560-2572
  • 16 Collins R, Petro R, Macmahon S et al.. Blood pressure, stroke and coronary artery disease, part 2: short term reductions in blood pressure-overview of randomized drug trials in their epidemiological context.  Lancet. 1990;  335 827-838
  • 17 The Heart Outcomes Prevention Evaluation Study Investigators . Effects of an angiotensin converting enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients.  N Engl J Med. 2000;  342 145-153
  • 18 Smith Jr S C, Blair S N, Bonow R O et al.. AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update. A statement for healthcare professionals from the American Heart Association and the American College of Cardiology.  Circulation. 2001;  104 1577-1579
  • 19 PROGRESS Collaborative Group . Randomised trial of a perindopril-based blood-pressure-lowering regimen among 6105 individuals with previous stroke or transient ischaemic attack.  Lancet. 2001;  358 1033-1041
  • 20 Eliasziw M, Spence J D, Barnett H J. Carotid endarterectomy does not affect long-term blood pressure: observations from the NASCET (North American Symptomatic Carotid Endarterectomy Trial).  Cerebrovasc Dis. 1998;  8 20-24
  • 21 White H D, Simes R J, Anderson N E et al.. Pravastatin therapy and the risk of stroke.  N Engl J Med. 2000;  343 317-326
  • 22 Amarenco P, Labreuche J, Lavallee P, Touboul P J. Statins in stroke prevention and carotid atherosclerosis: systematic review and up-to-date meta-analysis.  Stroke. 2004;  35 2902-2909
  • 23 Kang S, Wu Y, Li X. Effects of statin therapy on the progression of carotid atherosclerosis: a systematic review and meta-analysis.  Atherosclerosis. 2004;  177 433-442
  • 24 The SPARCL Investigators . Design and baseline characteristics of the stroke prevention by aggressive reduction in cholesterol levels (SPARCL) study.  Cerebrovasc Dis. 2003;  16 389-395
  • 25 Nissen S E, Tuzcu E M, Schoenhagen P et al.. Effect of intensive compared with moderate lipid-lowering therapy on progression of coronary atherosclerosis: a randomized controlled trial.  JAMA. 2004;  291 1071-1080
  • 26 Expert Panel on Detection . Evaluation and treatment of high blood cholesterol in adults. Executive summary of the 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).  JAMA. 2001;  285 2486-2497
  • 27 Grundy S M, Cleeman J I, Merz C NB for the Coordinating Committee of the National Cholesterol Education Program, Endorsed by the National Heart Lung, and Blood Institute, American College of Cardiology Foundation, and American Heart Association et al. Implications of recent clinical trials for the national cholesterol education program adult treatment panel iii guidelines.  Circulation. 2004;  110 227-239
  • 28 Heart Protection Study Collaborative Group . MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial.  Lancet. 2002;  360 7-22
  • 29 Ross R. Atherosclerosis: an inflammatory disease.  N Engl J Med. 1999;  340 115-126
  • 30 Spagnoli L G, Mauriello A, Sangiorgi G et al.. Extracranial thrombotically active carotid plaque as a risk factor for ischemic stroke.  JAMA. 2004;  292 1845-1852
  • 31 Nakamura M, Lee D P, Yeung A C. Identification and treatment of vulnerable plaque.  Rev Cardiovasc Med. 2004;  5(suppl 2) S22-S33
  • 32 O'Leary D H, Polak J F, Kronmal R A, Manolio T A, Burke G L, Wolfson S K. The Cardiovascular Health Study Collaborative Research Group . Carotid-artery intima and media thickness as a risk factor for myocardial infarction and stroke in older adults.  N Engl J Med. 1999;  340 14-22
  • 33 Trivedi R A, U-King-Im J M, Graves M J et al.. MRI derived measurements of fibrous cap and lipid core thickness: potential for identifying vulnerable carotid plaques in vivo.  Neuroradiology. 2004;  46 738-743
  • 34 Davies J R, Rudd J H, Weissberg P L. Molecular and metabolic imaging of atherosclerosis.  J Nucl Med. 2004;  45 1898-1907
  • 35 Sacco R L, Benson R T, Kargman D E et al.. High-density lipoprotein cholesterol and ischemic stroke in the elderly: the Northern Manhattan Stroke Study.  JAMA. 2001;  285 2729-2735
  • 36 Brousseau M E, Schaefer E J, Wolfe M L et al.. Effects of an inhibitor of cholesteryl ester transfer protein on HDL cholesterol.  N Engl J Med. 2004;  350 1505-1515
  • 37 Halford J C. Clinical pharmacotherapy for obesity: current drugs and those in advanced development.  Curr Drug Targets. 2004;  5 637-646
  • 38 Sander D, Winbeck K, Klingelhofer J, Etgen T, Conrad B. Progression of early carotid atherosclerosis is only temporarily reduced after antibiotic treatment of Chlamydia pneumoniae seropositivity.  Circulation. 2004;  109 1010-1015
  • 39 Toole J F, Malinow M R, Chambless L E et al.. 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.  JAMA. 2004;  291 565-575
  • 40 Chaturvedi S. Should the multicenter carotid endarterectomy trials be repeated?.  Arch Neurol. 2003;  60 774-775
  • 41 Hass W K, Easton J D, Adams H P. A randomized trial comparing ticlopidine hydrochloride with aspirin for the prevention of stroke in high-risk patients.  N Engl J Med. 1989;  321 501-507
  • 42 Gent M, Blakely J A, Easton J D et al.. Canadian American ticlopidine study in thromboembolic stroke.  Lancet. 1989;  1 1215-1220

Seemant ChaturvediM.D. 

Department of Neurology and Stroke Program, Wayne State University

8C-UHC, 4201 St. Antoine, Detroit, MI 48201

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