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Intensive Therapy for Asymptomatic Carotid Stenosis Reduces Cardiovascular Events CHICAGO -- December 14, 2009 -- Intensive medical therapy, including aggressive control of blood pressure and cholesterol levels, for patients with asymptomatic carotid stenosis appears to be associated with reduced rates of cardiovascular events and reduced risk of microemboli in the brain arteries, according to a study published early online and appearing in the February 2010 print issue of the Archives of Neurology. J. David Spence, MD, Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, London, Ontario, and colleagues studied 468 patients (mean age, 69.7 years) with asymptomatic carotid stenosis. Each patient’s plaque areas were assessed when they enrolled in the study and then approximately annually throughout the study. They also underwent transcranial Doppler to detect microemboli in the brain arteries. Of the participants, 199 were enrolled between 2000 and 2002. The other 269 were enrolled between 2003 and 2007. By 2003, the clinic at which the study was conducted implemented an intensive medical treatment program for asymptomatic carotid stenosis. The approach involved showing plaque measurements and images to the patients to motivate them to make diet, exercise, and other lifestyle changes; more aggressive pharmacotherapy for cholesterol levels and insulin resistance; and optimising blood pressure control. All were followed up for at least 1 year, through July 2008. Patients who began the study following the implementation of this intensive medical therapy were less likely to have microemboli (3.7% after 2003 vs 12.6% before 2003). This decline in microemboli coincided with better control of blood cholesterol levels and slower progression of the total plaque area in the carotid artery (23 square mm vs 69 square mm in the first year of follow-up). “Since 2003, there have been significantly fewer cardiovascular events among patients with asymptomatic carotid stenosis: 17.6% had stroke, death, myocardial infarction or carotid endarterectomy for symptoms before 2003, versus 5.6% since 2003,” the authors wrote. Study participants with microemboli had significantly more cardiovascular events in both time periods -- 32.4% of patients with microemboli had a stroke or myocardial infarction, died or underwent carotid endarterectomy for symptoms, compared with 8.6% of those without microemboli. “The arguments against routine revascularisation of patients with asymptomatic carotid stenosis have previously been reviewed,” the authors wrote. “Given our finding that intensive medical therapy has reduced the prevalence of microemboli to only 3.7% and markedly reduced cardiovascular events, particularly stroke, we suggest that such intensive medical therapy be regarded as the first line of therapy for patients with asymptomatic carotid stenosis. Given that with intensive medical therapy, the risk of stroke in patients without microemboli is less than the risk of endarterectomy or stenting, we think that revascularisation should be considered only for the rare patients with microemboli.” SOURCE: Archives of Neurology E-mail this page to a friend or colleague! To print, use this version