Adult; Aged; Aged, 80 and over; Asymptomatic Diseases; Carotid Stenosis/diagnosis; Carotid Stenosis/diagnostic imaging; Carotid Stenosis/epidemiology; Disease Progression; Europe/epidemiology; Female; Humans; Incidence; Kaplan-Meier Estimate; Male; Middle Aged; Plaque, Atherosclerotic; Predictive Value of Tests; Prognosis; Remission Induction; Retinal Diseases/epidemiology; Risk Factors; Stroke/epidemiology; Time Factors; Ultrasonography, Doppler, Duplex; Victoria/epidemiology; Carotid Artery, Internal/diagnostic imaging; Surgery; Cardiology and Cardiovascular Medicine
Abstract :
[en] [en] OBJECTIVE: To determine baseline clinical and ultrasonographic plaque factors predictive of progression or regression of asymptomatic carotid stenosis and the predictive value of changes in stenosis severity on risk of first ipsilateral cerebral or retinal ischemic events (including stroke).
METHODS: A total of 1121 patients with asymptomatic carotid stenosis of 50% to 99% in relation to the bulb diameter (European Carotid Surgery Trial [ECST] method) underwent six monthly clinical assessments and carotid duplexes for up to 8 years (mean follow-up, 4 years). Progression or regression was considered present if there was a change of at least one grade higher or lower, respectively, persisting for at least two consecutive examinations.
RESULTS: Regression occurred in 43 (3.8%), no change in 856 (76.4%), and progression in 222 (19.8%) patients. Younger age, high grades of stenosis, absence of discrete white areas in the plaque, and taking lipid lowering therapy were independent baseline predictors of increased incidence of regression. High serum creatinine, male gender, not taking lipid lowering therapy, low grades of stenosis, and increased plaque area were independent baseline predictors of progression. One hundred and thirty first ipsilateral cerebral or retinal ischemic events, including 59 strokes, occurred. Forty (67.8%) of the strokes occurred in patients whose stenosis was unchanged, 19 (32.2%) in those with progression, and zero in those with regression. For the entire cohort, the 8-year cumulative ipsilateral cerebral ischemic stroke rate was zero in patients with regression, 9% if the stenosis was unchanged, and 16% if there was progression (average annual stroke rates of 0%, 1.1%, and 2.0%, respectively; log-rank, P = .05; relative risk in patients with progression, 1.92; 95% confidence interval, 1.14-3.25). For patients with baseline stenosis 70% to 99% in relation to the distal internal carotid (North American Symptomatic Carotid Endarterectomy Trial [NASCET] method), in the absence of progression (n = 349), the 8-year cumulative ipsilateral cerebral ischemic stroke rate was 12%. In the presence of progression (n = 77), it was 21% (average annual stroke rates of 1.5% and 2.6%, respectively; log-rank, P = .34). Only nine (30%) of the 30 strokes occurred in the progression group.
CONCLUSIONS: Progressive asymptomatic carotid stenosis identified a subgroup with about twice the risk of ipsilateral stroke compared with those without progression. However, the clinical value of screening for progression simply for selecting patients for carotid procedures is limited because of the low frequency of progression and its relatively low associated stroke rate. The cost effectiveness of screening for change in stenosis severity to better direct current optimal medical treatment needs testing.
Disciplines :
Cardiovascular & respiratory systems
Author, co-author :
Kakkos, Stavros K; Department of Vascular Surgery, Imperial College, London, United Kingdom
Nicolaides, Andrew N; Department of Vascular Surgery, Imperial College, London, United Kingdom. Electronic address: anicolaides1@gmail.com
Charalambous, Ioanna; Vascular Screening and Diagnostic Center, Nicosia, Cyprus
Thomas, Dafydd; Department of Neurology, St. Mary's Hospital, London, United Kingdom
Giannopoulos, Argyrios; Department of Vascular Surgery, Imperial College, London, United Kingdom
Naylor, A Ross; Department of Vascular Surgery, Leicester Royal Infirmary, Leicester, United Kingdom
Geroulakos, George; Department of Vascular Surgery, Imperial College, London, United Kingdom, Department of Vascular Surgery, Ealing Hospital, London, United Kingdom
Abbott, Anne L; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia, Preventive Health Division of Baker IDI Heart and Diabetes Institute, Melbourne, Australia, Stroke Division of the Florey Institute of Neuroscience and Mental Health, Melbourne, Australia
Asymptomatic Carotid Stenosis and Risk of Stroke (ACSRS) Study Group
Sprynger, Muriel ; Université de Liège - ULiège > Département des sciences cliniques
Language :
English
Title :
Predictors and clinical significance of progression or regression of asymptomatic carotid stenosis.
Supported by a grant from the European Commission (Biomed II) Program ( PL 650629 ) for the first 3 years and subsequently by a grant from the CDER Trust (United Kingdom).
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