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Thiraworawong T, Pathonsmith C. Cilostazol-based dual antiplatelet treatment in ischemic stroke or transient ischemic attack patients with asymptomatic carotid artery disease: a propensity score matching analysis. Front Neurol 2024; 15:1362124. [PMID: 38426175 PMCID: PMC10902642 DOI: 10.3389/fneur.2024.1362124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 02/05/2024] [Indexed: 03/02/2024] Open
Abstract
Background The optimal treatment for asymptomatic atherosclerotic carotid artery disease remains controversial. Data on the efficacy of antiplatelet agents and stroke outcomes are limited. This study aimed to examine the efficacy and safety of cilostazol-based dual antiplatelet therapy in patients with ischemic stroke or transient ischemic attack and asymptomatic carotid artery disease. Methods This retrospective cohort study was conducted in a tertiary-care setting and included baseline characteristics and clinical outcomes of participants. The study included patients who had experienced first-ever ischemic stroke or transient ischemic attack and asymptomatic atherosclerotic carotid artery stenosis, with a minimum follow-up period of 1 year. Asymptomatic carotid artery stenosis refers to stenosis in patients without neurological symptoms referable to the carotid arteries. Propensity scores were estimated using a logistic regression model based on participants' baseline characteristics. The efficacy outcome was the composite outcome of recurrent ischemic events and vascular-related death in patients with ischemic stroke or transient ischemic attack and asymptomatic carotid artery stenosis. The safety outcome was the occurrence of hemorrhagic complications such as intracranial hemorrhages or extracranial hemorrhages. The effectiveness of dual therapy compared to monotherapy was evaluated at various time points following the initiation of antiplatelet treatment. Results This study included 516 patients with a 1-year follow-up period. At 1 year, composite events occurred in 10 (6.3%) patients in the dual antiplatelet group compared with 12 (7.6%) in the single antiplatelet group (HR, 0.74; 95% CI, 0.61-0.90; p = 0.024). Extracranial hemorrhage occurred in 12 (7.6%) patients in the dual antiplatelet group compared with nine (5.7%) in the single antiplatelet group (HR, 1.35; 95% CI, 1.13-1.48; p = 0.017). No intracranial hemorrhages were observed in this cohort. Conclusion Patients with asymptomatic carotid artery stenosis who received cilostazol-based dual antiplatelet therapy had a lower risk of composite events but a higher risk of minor extracranial hemorrhage than those who received a single antiplatelet agent.
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Affiliation(s)
- Thon Thiraworawong
- Division of Vascular Neurology, Department of Neurology, Neurological Institute of Thailand, Bangkok, Thailand
| | - Chadawan Pathonsmith
- Division of Geriatric Medicine, Faculty of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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2
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Li C, Rockman C, Chang H, Patel VI, Siracuse JJ, Cayne N, Veith FJ, Torres JL, Maldonado TS, Nigalaye AA, Jacobowitz G, Garg K. Neuroprotective association of preoperative renin-angiotensin system blocking agents use in patients undergoing carotid interventions. Vascular 2023; 31:1143-1150. [PMID: 35603781 DOI: 10.1177/17085381221093900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2023]
Abstract
OBJECTIVE The optimal medical management strategy in the periprocedural period for patients undergoing carotid artery interventions is not well described. Renin-angiotensin-system blocking (RASB) agents are considered to be among the first line anti-hypertensive agents; however, their role in the perioperative period is unclear. The objective of this study was to examine the relationship between the use of RASB agents on periprocedural outcomes in patients undergoing carotid interventions-carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS), and transcervical carotid artery revascularization (TCAR). METHOD The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing CAS, CEA, and TCAR between 2003 and 2020. Patients were stratified into two groups based upon their use of RASB agents in the periprocedural period. The primary endpoint was periprocedural neurologic events (including both strokes and transient ischemic attacks (TIAs)). The secondary endpoints were peri-procedural mortality and significant cardiac events, including myocardial infarction, dysrhythmia, and congestive heart failure. RESULTS Over 150,000 patients were included in the analysis: 13,666 patients underwent TCAR, 13,811 underwent CAS, and 125,429 underwent CEA for carotid artery stenosis. Overall, 52.2% of patients were maintained on RASB agents. Among patients undergoing CEA, patients on RASB agents had a significantly lower rate of periprocedural neurologic events (1.7% versus 2.0%, p =0.001). The peri-procedural neurological event rate in the TCAR cohort was similarly reduced in those treated with RASB agents, but did not reach statistical significance (2.0% vs 2.4%, p = 0.162). Among patients undergoing CAS, there was no difference in perioperative neurologic events between the RASB treated and untreated cohorts (3.4% vs 3.2%, p = 0.234); however, the use of RASB agents was significantly associated with lower mortality (1.2% vs 1.7%, p =0.001) with CAS. The use of preoperative RAS-blocking agents did not appear to affect the overall rates of adverse cardiac events with any of the three carotid intervention types, or periprocedural mortality following CEA or TCAR. On multivariable analysis, the use of RAS-blocking agents was independently associated with lower rates of post-procedural neurologic events in patients undergoing CEA (OR 0.819, CI 0.747-0.898; p = 0.01) and TCAR (OR 0.869, CI 0.768-0.984; p = 0.026), but not in those undergoing CAS (OR 0.967, CI 0.884-1.057; p = 0.461). CONCLUSION The use of peri-procedural RASB agents was associated with a significantly decreased rate of neurologic events in patients undergoing both CEA and TCAR. This effect was not observed in patients undergoing CAS. As carotid interventions warrant absolute minimization of perioperative complications in order to provide maximum efficacy with regard to stroke protection, the potential neuro-protective effect associated with RASB agents use following CEA and TCAR warrants further examination.
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Affiliation(s)
- Chong Li
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Caron Rockman
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Heepeel Chang
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Virendra I Patel
- Division of Vascular Surgery, Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston, MA, USA
| | - Neal Cayne
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Frank J Veith
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Jose L Torres
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Thomas S Maldonado
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | | | - Glenn Jacobowitz
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Karan Garg
- Division of Vascular and Endovascular Surgery, Department of Surgery, New York University Langone Health, New York, NY, USA
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3
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Lipshy KA, Itani K, Chu D, Bahadursingh A, Spector S, Raman K, Dardik A, Tzeng E, Ballantyne GH, John PR, Cmolik B, Maloney J, Kozol R, Longo WE. Sentinel Contributions of US Department of Veterans Affairs Surgeons in Shaping the Face of Health Care. JAMA Surg 2021; 156:380-386. [PMID: 33471058 DOI: 10.1001/jamasurg.2020.6372] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
The vast accomplishments of the US Department of Veterans Affairs (VA) during the past century have contributed to the advancement of medicine and benefited patients worldwide. This article highlights some of those accomplishments and the advantages in the VA system that promulgated those successes. Through its affiliation with medical schools, its formation of a structured research and development program, its Cooperative Studies Program, and its National Surgical Quality Improvement Program, the VA has led the world in the progress of health care. The exigencies of war led not only to the organization of VA health care but also to groundbreaking, landmark developments in colon surgery; surgical treatments for vascular disease, including vascular grafts, carotid surgery, and arteriovenous dialysis fistulas; cardiac surgery, including implantable cardiac pacemaker and coronary artery bypass surgery; and the surgical management of many conditions, such as hernias. The birth of successful liver transplantation was also seen within the VA, and countless other achievements have benefited patients around the globe. These successes have created an environment where residents and medical students are able to obtain superb education and postgraduate training and where faculty are able to develop their clinical and academic careers.
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Affiliation(s)
- Kenneth A Lipshy
- Department of Surgery, W. G. (Bill) Hefner Veterans Affairs (VA) Health Care System, Salisbury, North Carolina.,Department of Surgery, Wake Forest University, Winston-Salem, North Carolina.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Kamal Itani
- Department of Surgery, VA Boston Health Care System, Boston, Massachusetts.,Department of Surgery, Boston University, Boston, Massachusetts.,Department of Surgery, Harvard Medical School, Boston, Massachusetts
| | - Danny Chu
- Department of Surgery, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania.,Department of Cardiothoracic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anil Bahadursingh
- Department of Surgery, Kansas Veterans Affairs Medical Center (VAMC), Kansas City, Missouri.,Department of Surgery, University of Missouri, Kansas City
| | - Seth Spector
- Department of Surgery, Miami VAMC, Miami, Florida.,Department of Surgery, University of Miami School of Medicine, Miami, Florida
| | - Kathleen Raman
- Department of Surgery, University of Rochester School of Medicine, Rochester, New York
| | - Alan Dardik
- Department of Surgery, West Haven VAMC, West Haven, Connecticut.,Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Edith Tzeng
- Department of Surgery, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | | | - Preeti R John
- VA Maryland Health Care System, Baltimore.,Department of Surgery, University of Maryland School of Medicine, Baltimore
| | - Brian Cmolik
- Department of Surgery, Cleveland VAMC, Cleveland, Ohio
| | - James Maloney
- Department of Surgery, Madison VAMC, Madison, Wisconsin.,Department of Surgery, University of Wisconsin, Madison
| | | | - Walter E Longo
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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4
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Papanikolaou P, Antonopoulos AS, Mastorakou I, Angelopoulos A, Kostoula E, Mystakidi XV, Simantiris S, Galiatsatos N, Oikonomou E, Tousoulis D. Antithrombotic Therapy in Carotid Artery Disease. Curr Pharm Des 2020; 26:2725-2734. [PMID: 32418521 DOI: 10.2174/1381612826666200518111359] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 05/08/2020] [Indexed: 12/19/2022]
Abstract
The management of asymptomatic atherosclerotic carotid artery disease and the role of antithrombotic therapy is of increasing importance for stroke prevention. Non-invasive imaging of carotid plaques can identify high-risk plaque features that are associated with the risk of plaque rupture. Carotid plaque necrosis, hemorrhage, fibrous cap thinning, and the presence of foam cells have all been correlated with the risk of rupture and onset of neurological symptoms in patients with carotid stenosis. Antiplatelets are currently recommended for patients with a history of ischemic stroke and/or significant carotid artery stenosis, with aspirin and clopidogrel being the most widely used and studied agents. The role of dual antiplatelet therapy remains controversial. Moreover, there is scarce evidence on the role of newer anticoagulant agents in stable patients with carotid artery stenosis. In this review article, we discuss the pathophysiology of carotid atherosclerosis, the use of non-invasive imaging for detecting the vulnerable carotid plaque and summarize the existing clinical evidence on the use of antiplatelet and antithrombotic agents in carotid artery disease.
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Affiliation(s)
- Paraskevi Papanikolaou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Alexios S Antonopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Irene Mastorakou
- Imaging Department - Onassis Cardiac Surgery Centre, Athens, Greece
| | - Andreas Angelopoulos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | | | - Xara-Vasiliki Mystakidi
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Spyros Simantiris
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Nikolaos Galiatsatos
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Evangelos Oikonomou
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
| | - Dimitris Tousoulis
- First Department of Cardiology, Hippokration Hospital, Athens Medical School, Athens, Greece
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Jusufovic M, Skagen K, Krohg-Sørensen K, Skjelland M. Current Medical and Surgical Stroke Prevention Therapies for Patients with Carotid Artery Stenosis. Curr Neurovasc Res 2019; 16:96-103. [PMID: 30706783 DOI: 10.2174/1567202616666190131162811] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 01/16/2019] [Accepted: 01/23/2019] [Indexed: 01/22/2023]
Abstract
Carotid Artery Stenosis (CAS) is a marker of systemic atherosclerosis and patients with CAS are at high risk of vascular events in multiple vascular locations, including ipsilateral ischemic stroke. Both medical and surgical therapies have been demonstrated effective in reducing this risk. The optimal management for patients with asymptomatic carotid artery stenosis remains controversial. In patients with symptomatic CAS ≥70%, CEA has been demonstrated to reduce the risk of stroke. With the risk of recurrent stroke being particularly high in the first 2 weeks after the first event, Carotid Endarterectomy (CEA) or carotid angioplasty with stenting provides maximal benefits to patients with symptomatic CAS ≥70% if performed within this «2-week» target. Several large ongoing trials are currently comparing the risks and benefits of carotid revascularization versus medical therapy alone.
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Affiliation(s)
- Mirza Jusufovic
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Karolina Skagen
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Kirsten Krohg-Sørensen
- Department of Cardiothoracic Surgery, Oslo University Hospital, Rikshospitalet, Oslo, Norway.,Institute of Clinical Medicine, Faculty of Medicine University of Oslo, Oslo, Norway
| | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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6
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Mizuno T, Nakamura M, Satoh N, Tsukada H, Matsumoto A, Hamasaki Y, Kume H, Nangaku M. Patency with antiplatelet treatment after vascular access intervention therapy: a retrospective observational study. RENAL REPLACEMENT THERAPY 2018. [DOI: 10.1186/s41100-018-0184-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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7
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Nicolaides A, Thomas D. Asymptomatic Carotid Stenosis and Risk of Stroke: A Natural History Study. Clin Appl Thromb Hemost 2016. [DOI: 10.1177/107602969500100305] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In patients with asymptomatic carotid stenosis >70% diameter, the annual incidence of ipsilateral stroke is 3-4%. Multicentre randomised studies such as the asymptomatic carotid atherosclerosis study (ACAS) in the U.S.A. and the ACST in Europe aim to answer the question whether carotid endarterectomy can reduce the incidence of stroke in such patients. If the surgical risk is too close to benefit or if a high proportion of patients not at risk of stroke are entered into the ACAS or ACST studies, the latter may fail to demonstrate the benefit of carotid endarterectomy (CE). The need to identify a high risk stroke group (ipsilateral stroke >7% per annum) with randomisation of this group to a subsequent study will then become apparent. If the ACAS and ACST studies indicate that the risk of stroke is reduced by 50% (i.e., from 4 to 2%), it has been calculated that the cost of preventing one stroke will be 1.2 million US dollars because of the large number of operations required. It will still be necessary to identify a high-risk group or, better, a low-risk group in order to spare many patients unnecessary operation. A multicentre, natural history study has been set up under the auspices of the International Union of Angiology and monitored from St Mary's Hospital Medical School in London with over 50 centres taking part. Patients with asymptomatic carotid stenosis 50-70% and 70-90% are entered in a ratio of 1 to 2, a number of noninvasive tests are performed, and the patients are followed for 5 years. The tests performed are (a) Grading the degree of internal carotid stenosis using duplex scanning; (b) grading the opposite side; (c) plaque characterisation; (d) presence of ultrasonic ulceration; (e) plaque thickness (mm); (f) cerebral reactivity to CO2using velocity of internal carotid artery and (optional) middle cerebral artery ; (g) CT brain scan for the presence of silent infarction ; (h) intima-media thickness of the common carotid; and (i) identification of conventional risk factors: hypertension, hypercholeterolaemia, smoking, family history, diabetes. The key end points are stroke (including fatal stroke) and ipsilateral stroke. Patients who die from cardiovascular death other than stroke or noncardiovascular death and patients who develop hemispheric transient ischaemic attacks followed by CE are considered to have reached an exit end point. Because this is a natural history study, the clinician in charge of all patients is free to treat them in any way considered appropriate. Patients in the Medical Limb of the ACST study may be entered into the Natural History (ACSRS) study.
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Affiliation(s)
| | - D. Thomas
- St. Mary's Hospital Medical School, London, U.K
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8
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Abbott AL, Bladin CF, Levi CR, Chambers BR. What Should We Do with Asymptomatic Carotid Stenosis? Int J Stroke 2016; 2:27-39. [DOI: 10.1111/j.1747-4949.2007.00096.x] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The benefit of prophylactic carotid endarterectomy (CEA) for patients with asymptomatic severe carotid stenosis in the major randomised surgical studies was small, expensive and may now be absorbed by improvements in best practice medical intervention. Strategies to identify patients with high stroke risk are needed. If surgical intervention is to be considered the complication rates of individual surgeons should be available. Clinicians will differ in their interpretation of the same published data. Maintaining professional relationships with clinicians from different disciplines often involves compromise. As such, the management of a patient will, in part, depend on what kind of specialist the patient is referred to. The clinician's discussion with patients about this complex issue must be flexible to accommodate differing patient expectations. Ideally, patients prepared to undergo surgical procedures should be monitored in a trial setting or as part of an audited review process to increase our understanding of current practice outcomes.
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Affiliation(s)
- Anne L. Abbott
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
| | - Christopher F. Bladin
- Department of Neuroscience, Box Hill Hospital, Nelson Road, Box Hill, Melbourne Vic., 3128, Australia
| | - Christopher R. Levi
- Department of Neuroscience, John Hunter Hospital, Lookout Road, Lambton Heights, Newcastle, NSW, 2035, Australia
| | - Brian R. Chambers
- National Stroke Research Institute, Austin Health, Melbourne, Vic. 3081, Australia
- The University of Melbourne, Melbourne, Vic., Australia
- Neurology Department, Austin Health, Melbourne, Vic., Australia
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9
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Agayeva N, Topcuoglu MA, Arsava EM. The Interplay between Stroke Severity, Antiplatelet Use, and Aspirin Resistance in Ischemic Stroke. J Stroke Cerebrovasc Dis 2015; 25:397-403. [PMID: 26576697 DOI: 10.1016/j.jstrokecerebrovasdis.2015.10.011] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 08/22/2015] [Accepted: 10/10/2015] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The issue of whether prior antiplatelet use favorably affects stroke severity is currently unresolved. In this study, we evaluated the effect of antiplatelet use on clinical stroke severity and ischemic lesion volume, and assessed the confounding effect of laboratory-defined aspirin resistance on this relationship. METHODS Admission National Institutes of Health Stroke Scale (NIHSS) score, ischemic lesion volumes on diffusion-weighted imaging (DWI), and in vitro aspirin resistance, in addition to other pertinent stroke features, were determined in a series of ischemic stroke patients. Univariate and multivariate analyses were performed to compare clinical and imaging markers of stroke severity among patients with and without prior antiplatelet use, taking into consideration the presence or absence of aspirin resistance. RESULTS Antiplatelet users experienced more severe strokes, per NIHSS score, in comparison to antiplatelet-naive patients (P = .007). No significant difference was observed with respect to admission DWI lesion volume. When analyses were repeated after adjustment for stroke subtype and other confounders, no association was observed between antiplatelet use and stroke severity. On the other hand, NIHSS scores were significantly higher in aspirin-unresponsive patients than in both aspirin responders (P = .049) and aspirin nonusers (P = .005). CONCLUSION We were unable to demonstrate a substantial positive influence of prestroke antiplatelet usage on stroke severity. Although the presence of more severe strokes among patients with laboratory resistance suggests a protective influence of aspirin sensitivity on stroke severity, the hypothesis could not be validated as no difference was observed among aspirin-naive and aspirin-sensitive patients with respect to admission NIHSS score or DWI lesion volume.
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Affiliation(s)
- Nergiz Agayeva
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | | | - Ethem Murat Arsava
- Department of Neurology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
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10
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Thrombi of Different Pathologies: Implications for Diagnosis and Treatment. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 12:274-91. [DOI: 10.1007/s11936-010-0075-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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11
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Schellinger P, Ringleb P, Hacke W. Leitlinien zum Management von Patienten mit akutem Hirninfarkt oder TIA der Europäischen Schlaganfallorganisation 2008. DER NERVENARZT 2008; 79:1180-4, 1186-8, 1190-201. [DOI: 10.1007/s00115-008-2532-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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12
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Sobel M, Verhaeghe R. Antithrombotic Therapy for Peripheral Artery Occlusive Disease. Chest 2008; 133:815S-843S. [DOI: 10.1378/chest.08-0686] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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13
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Abstract
BACKGROUND Millions of people around the world regularly consume aspirin, but its value in determining stroke severity is still not clear. It has been stated that prior aspirin use might reduce the severity of ischemic stroke by reducing the size of fibrin-platelet emboli or by ameliorating platelet hyperaggregability that occurs in the microcirculation. However there are only few large studies focusing on the early outcome of stroke patients including both ischemic stroke and primary intracerebral hemorrhage patients with prior aspirin therapy. REVIEW SUMMARY We retrospectively analyzed the medical records of 2509 consecutive stroke patients who were hospitalized in the 2nd Neurology Clinic of Haydarpaşa Numune Education and Research Hospital, Istanbul, Turkey, during the period of 1993-2003. We compared the early mortality rates in the patients with prior aspirin use versus the patients without. Of the patients without prior aspirin use, 20.1% died during the first 3 weeks of the stroke, while only 11.5% of the patients with prior aspirin use died during the same period. The difference in early mortality rate between 2 groups was extremely significant (P = 0.0008). Logistic regression analysis indicated that aspirin use was a significant (P < 0.01) and independent predictor of early stroke mortality. CONCLUSION Daily low dose (100-300 mg) aspirin has a protective effect in reducing the risk of early death in stroke.
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Affiliation(s)
- Geysu Karlikaya
- Haydarpasa Numune Research Hospital, 2nd Neurology Clinic, Istanbul, Turkey.
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14
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Clagett GP, Sobel M, Jackson MR, Lip GYH, Tangelder M, Verhaeghe R. Antithrombotic Therapy in Peripheral Arterial Occlusive Disease. Chest 2004; 126:609S-626S. [PMID: 15383487 DOI: 10.1378/chest.126.3_suppl.609s] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
This chapter about antithrombotic therapy for peripheral arterial occlusive disease is part of the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy: Evidence Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs, and Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004;126:179S-187S). Among the key recommendations in this chapter are the following: For patients with chronic limb ischemia, we recommend lifelong aspirin therapy in comparison to no antiplatelet therapy in patients with clinically manifest coronary or cerebrovascular disease (Grade 1A) and in those without clinically manifest coronary or cerebrovascular disease (Grade 1C+). We recommend clopidogrel over no antiplatelet therapy (Grade 1C+) but suggest that aspirin be used instead of clopidogrel (Grade 2A). For patients with disabling intermittent claudication who do not respond to conservative measures and who are not candidates for surgical or catheter-based intervention, we suggest cilostazol (Grade 2A). We suggest that clinicians not use cilostazol in patients with less-disabling claudication (Grade 2A). In these patients, we recommend against the use of pentoxifylline (Grade 1B). We suggest clinicians not use prostaglandins (Grade 2B). In patients with intermittent claudication, we recommend against the use of anticoagulants (Grade 1A). In patients with acute arterial emboli or thrombosis, we recommend treatment with immediate systemic anticoagulation with unfractionated heparin (UFH) [Grade 1C]. We also recommend systemic anticoagulation with UFH followed by long-term vitamin K antagonist (VKA) in patients with embolism [Grade 1C]). For patients undergoing major vascular reconstructive procedures, we recommend UFH at the time of application of vascular cross-clamps (Grade 1A). In patients undergoing prosthetic infrainguinal bypass, we recommend aspirin (Grade 1A). In patients undergoing infrainguinal femoropopliteal or distal vein bypass, we suggest that clinicians do not routinely use a VKA (Grade 2A). For routine patients undergoing infrainguinal bypass without special risk factors for occlusion, we recommend against VKA plus aspirin (Grade 1A). For those at high risk of bypass occlusion and limb loss, we suggest VKA plus aspirin (Grade 2B). In patients undergoing carotid endarterectomy, we recommend aspirin preoperatively and continued indefinitely (Grade 1A). In nonoperative patients with asymptomatic or recurrent carotid stenosis, we recommend lifelong aspirin (Grade 1C+). For all patients undergoing extremity balloon angioplasty, we recommend long-term aspirin (Grade 1C+).
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Affiliation(s)
- G Patrick Clagett
- Division of Vascular Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75235-9157, USA.
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15
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Wilterdink JL, Bendixen B, Adams HP, Woolson RF, Clarke WR, Hansen MD. Effect of prior aspirin use on stroke severity in the trial of Org 10172 in acute stroke treatment (TOAST). Stroke 2001; 32:2836-40. [PMID: 11739983 DOI: 10.1161/hs1201.099384] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Although the efficacy of aspirin in reducing stroke incidence is clear, its role in reducing stroke severity is disputed. This study compares stroke severity between patients who did or did not take aspirin in the week before stroke and enrollment in the Trial of Org 10172 in Acute Stroke Treatment (TOAST). METHODS Of 1275 patients randomized, 509 reported aspirin use in the week before stroke; 766 did not. Clinical stroke severity was assessed with the National Institutes of Health Stroke Scale (NIHSS) and the Supplementary Motor Examination (SME) at trial entry and at 3 months. Using these scales, we compared the categorization of stroke severity (mild, moderate, and severe) and mean scores between aspirin users and nonusers. RESULTS The difference in distribution of baseline NIHSS scores was statistically significant between aspirin users and nonusers (P=0.006), with a greater percentage of milder strokes among aspirin users. The difference in mean baseline NIHSS scores was also significantly lower in aspirin users (8.2) and nonusers (9.3) (P=0.003). The distribution of baseline SME scores and mean SME scores also showed lower stroke severity in aspirin users than in nonusers (P=0.048 and P=0.004, respectively). At 3 months, differences in stroke severity measured by the SME but not the NIHSS remained statistically significant. Seven-day and 3-month mortality did not differ significantly. CONCLUSIONS In this study aspirin use is associated with milder clinical deficits at stroke onset. These deficits may affect prognosis and influence response to treatment. Future clinical trials should ensure that prestroke aspirin use is comparable in study groups.
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Affiliation(s)
- J L Wilterdink
- Department of Clinical Neurosciences, Brown Medical School, Providence, RI, USA.
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Schmid-Elsaesser R, Medele RJ, Steiger HJ. Reconstructive surgery of the extracranial arteries. Adv Tech Stand Neurosurg 2001; 26:217-329. [PMID: 10997201 DOI: 10.1007/978-3-7091-6323-8_6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
The first carotid endarterectomy (CEA) is usually accredited to Eastcott who reported in 1954 the successful incision of a diseased carotid bulb with end-to-end anastomosis of the internal carotid artery (ICA) to the common carotid artery (CCA). During the following years surgeons were quick to adopt and improve the intuitively attractive procedure. But by the early to mid 1980s several leading neurologists began to question the growing number of CEAs performed at that time. Six major CEA trials were then designed which are now completed or nearing completion. Most conclusive data are available from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) for symptomatic carotid disease, and from the Asymptomatic Carotid Atherosclerosis Study (ACAS) for asymptomatic carotid disease. The key result of these studies is that CEA is beneficial to high grade symptomatic and asymptomatic carotid stenosis. While the benefit in symptomatic disease is clear, it may be negligible in asymptomatic patients suffering from other medical conditions, the most important being coronary artery disease. Since the conclusions from the different studies vary significantly, guidelines and recommendations with regard to CEA have been issued by a number of interest groups, so-called consensus conferences. The best known guidelines are published by the American Heart Association (AHA). However, the practice of interest groups to issue guidelines is currently being criticized, the main reason being that interest groups have different ideas and all claim the right to issue guidelines. At present we recommend CEA for symptomatic high-grade stenosis in patients without significant coincident disease. With regard to asymptomatic stenosis we suggest surgery to otherwise healthy patients if the stenosis is very narrow or progressive. Preoperative evaluation has changed over the years. Currently we recommend duplex sonography in combination with intra- and extracranial magnetic resonance angiography (MRA). Concurrent coronary artery disease is a major consideration in the perioperative management, and the use of a specific algorithm is recommended. Surgery is performed under general anaesthesia with intraoperative monitoring such as electroencephalography (EEG) and transcranial Doppler (TCD). A temporary intraluminal shunt is used selectively if after cross-clamping the flow velocity in the middle cerebral artery (MCA) falls to below 30 to 40% of baseline. For years we employed routine barbiturate neuroprotection during cross-clamping. At the present time we use barbiturate selectively, if the flow velocity in the MCA falls to below 30 to 40% of baseline and if the use of a temporary intraluminal shunt is not possible due to difficult anatomic conditions. The reason to abandon systematic barbiturate protection was to accelerate recovery from anaesthesia. Our patients are monitored overnight on the ICU or a surveillance unit. Routine hospitalization after surgery is 5 to 7 days with a control duplex sonography being performed prior to discharge. A number of details with regard to surgical technique and perioperative management are a matter of discussion. Our surgical routine is described here step by step. Such management resulted in 6 major complications among the 402 cases with 4 of cardiopulmonary and 2 of cerebrovascular origin. For the future we can expect the development of percutaneous transluminal techniques competing with standard carotid endarterectomy. At the present time several comparative studies are under way. Irrespective of the technical approach to treat carotid stenosis, several other issues have to be clarified before long. One of the major unresolved items is the timing of treatment after completed stroke. In this regard prospective trials need to be performed. Although numerically not as important as carotid stenosis, vertebral artery (VA) and subclavian artery (SA) stenoses are more and more accepted as indication for surgical
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Affiliation(s)
- R Schmid-Elsaesser
- Department of Neurosurgery, Ludwig-Maximilians-Universität, Klinikum Grosshadern, Munich, Germany
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Fleck JD, Biller J. Choices in medical management for prevention of acute ischemic stroke. Curr Neurol Neurosci Rep 2001; 1:33-8. [PMID: 11898498 DOI: 10.1007/s11910-001-0075-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Stroke is a leading cause of death and disability. Although advances are being made in the treatment of acute ischemic stroke, its prevention is equally as important. Identification and management of risk factors are essential. Medical therapy is also helpful in the secondary prevention of ischemic stroke. There are currently four platelet-antiaggregating agents used to prevent ischemic stroke: aspirin, aspirin plus dipyridamole, clopidogrel, and ticlopidine. The relevant studies proving their efficacy are noted, as are some of their similarities and differences. The use of warfarin is also discussed.
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Affiliation(s)
- J D Fleck
- Department of Neurology, Indiana University School of Medicine, 541 Clinical Drive, CL 365, Indianapolis, IN 46202, USA.
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Affiliation(s)
- M R Jackson
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas 75235-9157, USA
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Biasi GM, Sampaolo A, Mingazzini P, De Amicis P, El-Barghouty N, Nicolaides AN. Computer analysis of ultrasonic plaque echolucency in identifying high risk carotid bifurcation lesions. Eur J Vasc Endovasc Surg 1999; 17:476-9. [PMID: 10375482 DOI: 10.1053/ejvs.1999.0789] [Citation(s) in RCA: 104] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVES to confirm that plaque echogenicity evaluated by computer analysis, as suggested by preliminary studies, can identify plaques associated with a high incidence of strokes. MATERIALS AND METHODS a series of 96 patients with carotid stenosis in the range of 50-99% were studied retrospectively (41 with TIAs and 55 asymptomatic). Carotid plaque echogenicity was evaluated using a computerised measurement of the median grey scale value (GSM). All patients had a CT brain scan to determine the presence of infarction in the carotid territory. RESULTS the incidence of ipsilateral brain CT infarctions was 16% in the asymptomatic and 32% in the symptomatic plaques (p =0.076). It was 20% for <70% stenosis and 25% for >70% stenosis (p =0.52). It was 9% for plaques which had a GSM >50 and 40% in those with GSM <50 (p <0.001) with a relative risk of 4.6 (95% CI 1.8 to 11.6). CONCLUSIONS the results confirm that computer analysis of plaque echogenicity is better than the degree of stenosis in identifying plaques associated with an increased incidence of CT brain-scan infarction and consequently useful for identifying individuals at high risk of stroke. What is required is a form of image standardisation in order to apply this method to natural history studies with stroke as the endpoint.
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Affiliation(s)
- G M Biasi
- Division of Vascular Surgery, Bassini Teaching Hospital, Italy
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Affiliation(s)
- M R Jackson
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas 75235-9157, USA
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Renton S, Hornick P, Taylor KM, Grace PA. Rational approach to combined carotid and ischaemic heart disease. Br J Surg 1997. [DOI: 10.1002/bjs.1800841105] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Abstract
Since its introduction 40 years ago, the value of carotid endarterectomy has been controversial. In the early 1980s, several clinical trials were initiated to determine the efficacy of this operation in patients with carotid stenoses who were either symptomatic or asymptomatic for retinal or hemispheric ischemia. In 1991, interim results were published for the North American Symptomatic Carotid Endarterectomy Trial (NASCET) and the European Carotid Surgery Trial (ECST), both reporting efficacy for surgery in patients with symptomatic carotid artery stenosis of greater than 70%. Subgroup analyses revealed variable risk groups. The Veterans Administration (VA) Symptomatic Trial (Cooperative Studies Program 309 of the Department of Veterans Affairs) terminated early because of these results and its findings were consistent with the results of the larger trials. NASCET and ECST continue for symptomatic patients with carotid stenoses between 30% and 69%. The results of three trials in asymptomatic patients, the Mayo asymptomatic trial, the Carotid Artery Stenosis with Asymptomatic Narrowing: Operation Versus Aspirin trial, and the VA Asymptomatic Trial (Cooperative Studies Protocol 167 of the Department of Veterans Affairs), have been reported. None showed a statistically significant benefit for surgery in the prevention of stroke or death. However, none was sufficiently large to exclude such a benefit. The large Asymptomatic Carotid Atherosclerosis Study is in progress. Differences in the results and design of these trials are discussed as are restrictions in the applicability of their results.
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Affiliation(s)
- J D Easton
- Department of Clinical Neurosciences, Brown University, Rhode Island Hospital, Providence 02903
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Cohen SN, Hobson RW, Weiss DG, Chimowitz M. Death associated with asymptomatic carotid artery stenosis: Long-term clinical evaluation. J Vasc Surg 1993. [DOI: 10.1016/0741-5214(93)90555-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Hobson RW. Treatment of asymptomatic carotid stenosis. Platelets 1993; 4:15-7. [PMID: 21043680 DOI: 10.3109/09537109309013248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- R W Hobson
- Section of Vascular Surgery, Department of SurgeryUMDNJ-NJMS, 185 South Orange Avenue, MSB G-532, Newark, New Jersey, 07103, USA
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