Risk Factor Management in Extracranial Carotid and Vertebral Artery Disease: From the recent guideline

ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS
Circulation published online May 25, 2011

Surat Tanprawate, MD, MSc(Lond.), FRCPT Division of Neurology, Faculty of Medicine Chiang Mai University
Chiang Mai Stroke Unit 20/6/11
Monday, June 20, 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 was composed of experts in the areas of medicine, surgery, neurology, cardiology, radiology, vascular surgery, neurosurgery, neuroradiology, interventional radiology, noninvasive imaging, emergency medicine, vascular medicine, nursing, epidemiology, and biostatistics. The committee included representatives of the American Stroke Association (ASA), ACCF, AHA, American Academy of Neurology (AAN), American Association of Neuroscience Nurses (AANN), American Association of Neurological Surgeons (AANS), American College of Emergency Physicians (ACEP), American College of Radiology (ACR), American Society of Neuroradiology (ASNR), Congress of Neurological Surgeons (CNS), Society of Atherosclerosis Imaging and Prevention (SAIP), Society for Cardiovascular Angiography and Interventions (SCAI), Society of Cardiovascular Computed Tomography (SCCT), Society of Interventional Radiology (SIR), Society of NeuroInterventional Surgery (SNIS), Society for Vascular Medicine (SVM), and Society for Vascular Surgery (SVS)
Organization of the Writing Committee 2011
Monday, June 20, 2011

TOAST subtype of acute ischemic stroke

1) large-artery atherosclerosis 2) cardioembolism 3) small-vessel occlusion 4) stroke of other determined etiology 5) stroke of undetermined etiology
Stroke. 1993 Jan;24(1):35-41.

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Extracranial atherosclerotic disease accounts for up to 15% to 20% of all ischemic strokes Correlation between the degree of stenosis and the risk of stroke

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Risk Factor
Atherosclerotic risk

Small vessel disease

Large vessel carotid

atheroslerosis Cardioembolic

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What guideline said?

Identiable risk factor Association with all stroke Association with ECVD Management of risk factors

Intima-Media Thickness (IMT) Carotid artery disease

Embolic Hemodynamic

Stroke
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Hypertension Tobacco smoking Hyperlipidemia Diabetes

The risk factors

Atherosclerosis

Carotid stenosis Hyperhomocysteinemia Obesity Physical inactivity

60-80% risk factor for stroke

Cardioembolic
Monday, June 20, 2011

Atrial brillation Valvular heart disease

Hypertension Tobacco smoking Hyperlipidemia Diabetes

The risk factors

Atherosclerosis

Carotid stenosis Hyperhomocysteinemia Obesity Physical inactivity

60-80% risk factor for stroke

Cardioembolic
Monday, June 20, 2011

Atrial brillation Valvular heart disease

HT and Stroke
Increase BP increase risk of stroke BP reduction of 5-6 mm Hg reduction DBP
(10-12 mm Hg SBP) reduce the risk of stroke by 35-40%

5 mm Hg(DBP): ) 33% increase in stroke

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 diastolic blood pressure.

Hypertension: Pathophysiology, Diagnosis, and Management.1995:127144.

Monday, June 20, 2011

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 blood pressure

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?? Symptomatic patients with severe carotid artery stenosis ??

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No specic recommendation for the treatment of hypertension in patients with symptomatic patient with severe CAS

Monday, June 20, 2011

Monday, June 20, 2011

Tobacco smoking
Smoking and stroke risk increases the RR of ischemic stroke by
25%-50%

Smoking and CAS associated with extracranial carotid

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artery and progression of carotid IMT, the severity, and carotid artery stenosis
OLeary DH et al.Stroke. 1996;27: 224 31

Monday, June 20, 2011

Hyperlipidemia
Hyperlipidemia vs stroke risk Inconclusive Hyperlipidemia vs IMT association between cholesterol and
carotid 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% stroke risk decreasing 40 mg/dL decreasing LDL=> 22% stroke reduction

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Statin therapy reduces progression or induces regression of carotid atherosclerosis

Monday, June 20, 2011

Diabetes and stroke risk

Persons with DM have both an increased
susceptibility to atherosclerosis and an increased prevalence of proatherogenic risk factors, notably hypertension and abnormal blood lipids ischemic stroke with a relative risk 2-5 fold

DM is an independently increase risk of

Monday, June 20, 2011

Diabetes and stroke risk

DM and CAS DM is associated with carotid IMT and its
progression

Treatment of DM Pioglitazone caused less progression or

induced regression of carotid IMT compared with glimepiride
Haffner SM, et al. Am J Cardiol. 2000;85:1395400
Monday, June 20, 2011

Primary prevention of stroke

UKPDS: conventional vs intensive therapy

A reduction in MI, and all cause mortality was found, but stroke in incidence was not affected

ACCORD: intensive(HbA1c<6%) vs standard HbA1c<7.9%) therapy no difference of fatal or non-fatal stroke no effect of more intensive therapy on risk of non-fatal stroke
Stroke 2011;42;517-584

ADVANCE: intensive vs non-intensive therapy

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Secondary prevention of stroke

ACCORD: pt. with type 2 DM and vascular disease (intensive vs conventional)

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There was no signicant difference in the rate of nonfatal stroke

ADVANCE: pt. with type 2 DM and history of macrovascular disease(9% stroke) There was no signicant reduction in the occurrence of nonfatal stroke

PROactive: pt. with DM and macrovascular disease using pioglitazone Patient with history of stroke was associated with 47% risk reduction in recurrent stroke
Stroke 2011;42;517-584

Monday, June 20, 2011

Obesity and the Metabolic Syndrome

Metabolic syndrome (WHO denition)

Blood glucose, HT, dyslipidemia, body mass index, waist/hip ratio, and urinary albumin excretion

Its associated with carotid carotid atherosclerosis

Monday, June 20, 2011

Physical activity and stroke risk

Monday, June 20, 2011

Physical Inactivity
Stroke risk prevalence of 25%, RR of 2.7 Carotid atherosclerosis inconsistent between physical inactivity vs
carotid IMT

Exercise alone is benet in the absence of

Monday, June 20, 2011

effects on the other risk factors is not clear

Hyperhomocysteinemia

Hyperhomocysteinemia and stroke

25% difference in plasma homocysteine conc. associated with a 19% difference in stroke risk

However, the supplement with vitamin and folic acid dont decrease risk of CVD including stroke
Monday, June 20, 2011

Hyperhomocysteinemia and CAS

Selhub J,et al. NEJM 1995;332:286 91

Hypertension Tobacco smoking Hyperlipidemia Diabetes

The risk factors

Atherosclerosis

Carotid stenosis Hyperhomocysteinemia Obesity Physical inactivity

60-80% risk factor for stroke

Cardioembolic
Monday, June 20, 2011

Atrial brillation Valvular heart disease

Hypertension Tobacco smoking Hyperlipidemia Diabetes

The risk factors

Atherosclerosis

Carotid stenosis Hyperhomocysteinemia Obesity Physical inactivity

60-80% risk factor for stroke

Cardioembolic
Monday, June 20, 2011

Atrial brillation Valvular heart disease