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Nguyen D, D'Andrea M, Joule D, Kulwin J, Rojas C, Zhou W. Barriers to Antiplatelet and Statin Adherence Following Major Vascular Intervention. Ann Vasc Surg 2024; 106:360-368. [PMID: 38821476 DOI: 10.1016/j.avsg.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/12/2024] [Accepted: 03/21/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Antiplatelets and statins therapies are associated with improved cardiovascular outcomes following major vascular intervention. Many vascular surgery institutions are reporting improved prescribing rates for aspirin (ASA), P2Y12 antagonists, and statins. Nevertheless, there remains limited publication describing rates and patient-perceived barriers for postoperative adherence. The purpose of this study is to investigate patient nonadherence to antiplatelet and statin therapies following major vascular intervention. METHODS A retrospective review of patients who underwent major vascular intervention at a single academic center was performed. The prescribing rates of ASA, P2Y12 antagonists, and statins were reviewed. Postoperative adherence, defined as consistent intake as prescribed, was evaluated at 1, 3, 6, 9, and 12 months using electronic documentation of both follow-up clinic appointments and phone call assessments, then corroborated with pharmacy fulfilment records. Patient-reported barriers to medication adherence were also examined. RESULTS A total of 101 subjects underwent major vascular intervention between January 2020 and July 2020, 98% of whom were discharged on at least 1 antiplatelet or statin agent. Approximately 90% of patients were discharged with ASA, 32% with a P2Y12 antagonist, and 96% with a statin. All patients who maintained adherence up to 6 months continued to report adherence at 9 and 12 months. Consistent adherence at 12 months was documented in 76% of patients on ASA, 81% on P2Y12 antagonism therapy, and 73% on statins. New adverse drug reactions represented the most common barrier to achieving adherence (37% [n = 20]). Preoperative therapy with ASA, P2Y12 antagonists, and statins were all independently predictive of postoperative adherence to the same regimen (P ≤ 0.001). The female gender was also associated with higher rates of adherence to postoperative P2Y12 antagonism therapy (P ≤ 0.05). CONCLUSIONS The current prescribing rates for antiplatelet and statin agents are promising, but postoperative nonadherence remains a multifaceted issue.
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Affiliation(s)
- Daniel Nguyen
- The University of Arizona College of Medicine - Tucson, Tucson, AZ.
| | - Melissa D'Andrea
- The University of Arizona College of Medicine - Tucson, Tucson, AZ
| | - Dylan Joule
- The University of Arizona College of Medicine - Tucson, Tucson, AZ
| | - Jeremy Kulwin
- The University of Arizona College of Medicine - Tucson, Tucson, AZ
| | - Connie Rojas
- Genome Center, The University of California, Davis, CA
| | - Wei Zhou
- The University of Arizona College of Medicine - Tucson, Tucson, AZ; Division of Vascular Surgery and Endovascular Therapy, The University of Arizona Department of Surgery, Tucson, AZ.
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Ait‐Aissa K, Guo X, Klemmensen M, Juhr D, Leng LN, Koval OM, Grumbach IM. Short-Term Statin Treatment Reduces, and Long-Term Statin Treatment Abolishes, Chronic Vascular Injury by Radiation Therapy. J Am Heart Assoc 2024; 13:e033558. [PMID: 38904226 PMCID: PMC11255702 DOI: 10.1161/jaha.123.033558] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 05/14/2024] [Indexed: 06/22/2024]
Abstract
BACKGROUND The incidental use of statins during radiation therapy has been associated with a reduced long-term risk of developing atherosclerotic cardiovascular disease. We examined whether irradiation causes chronic vascular injury and whether short-term administration of statins during and after irradiation is sufficient to prevent chronic injury compared with long-term administration. METHODS AND RESULTS C57Bl/6 mice were pretreated with pravastatin for 72 hours and then exposed to 12 Gy X-ray head-and-neck irradiation. Pravastatin was then administered either for an additional 24 hours or for 1 year. Carotid arteries were tested for vascular reactivity, altered gene expression, and collagen deposition 1 year after irradiation. Treatment with pravastatin for 24 hours after irradiation reduced the loss of endothelium-dependent vasorelaxation and protected against enhanced vasoconstriction. Expression of markers associated with inflammation (NFκB p65 [phospho-nuclear factor kappa B p65] and TNF-α [tumor necrosis factor alpha]) and with oxidative stress (NADPH oxidases 2 and 4) were lowered and subunits of the voltage and Ca2+ activated K+ BK channel (potassium calcium-activated channel subfamily M alpha 1 and potassium calcium-activated channel subfamily M regulatory beta subunit 1) in the carotid artery were modulated. Treatment with pravastatin for 1 year after irradiation completely reversed irradiation-induced changes. CONCLUSIONS Short-term administration of pravastatin is sufficient to reduce chronic vascular injury at 1 year after irradiation. Long-term administration eliminates the effects of irradiation. These findings suggest that a prospective treatment strategy involving statins could be effective in patients undergoing radiation therapy. The optimal duration of treatment in humans has yet to be determined.
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Affiliation(s)
- Karima Ait‐Aissa
- Department of Biomedical Sciences, College of Dental MedicineLincoln Memorial UniversityKnoxvilleTNUSA
| | - Xutong Guo
- Abboud Cardiovascular Research Center, Department of Internal Medicine, Carver College of MedicineUniversity of IowaIowa CityIAUSA
| | - Madelyn Klemmensen
- Abboud Cardiovascular Research Center, Department of Internal Medicine, Carver College of MedicineUniversity of IowaIowa CityIAUSA
| | - Denise Juhr
- Abboud Cardiovascular Research Center, Department of Internal Medicine, Carver College of MedicineUniversity of IowaIowa CityIAUSA
| | - Linette N. Leng
- Abboud Cardiovascular Research Center, Department of Internal Medicine, Carver College of MedicineUniversity of IowaIowa CityIAUSA
| | - Olha M. Koval
- Abboud Cardiovascular Research Center, Department of Internal Medicine, Carver College of MedicineUniversity of IowaIowa CityIAUSA
| | - Isabella M. Grumbach
- Abboud Cardiovascular Research Center, Department of Internal Medicine, Carver College of MedicineUniversity of IowaIowa CityIAUSA
- Free Radical and Radiation Biology Program, Department of Radiation Oncology, Carver College of MedicineUniversity of IowaIowa CityIAUSA
- Iowa City VA Healthcare SystemIowa CityIAUSA
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Said S, Dardik A, Ochoa Chaar CI. What are the benefits and drawbacks of statins in carotid artery disease? A perspective review. Expert Rev Cardiovasc Ther 2023; 21:763-777. [PMID: 37994875 DOI: 10.1080/14779072.2023.2286011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 11/16/2023] [Indexed: 11/24/2023]
Abstract
INTRODUCTION The prevalence of carotid artery stenosis in the general population is approximately 3%, but approximately 20% among people with acute ischemic stroke. Statins are recommended by multiple international guidelines as the drug of choice for lipid control in people with asymptomatic or symptomatic carotid artery stenosis due to their lipid-lowering and other pleiotropic effects. AREAS COVERED This review discusses the guidelines for statin usage as a cornerstone in the prevention and management of atherosclerotic carotid artery disease and the impact of statins on stroke incidence and mortality. Statin side effects, alternative therapy, and genetic polymorphisms are reviewed. EXPERT OPINION Statin therapy is associated with a decreased incidence of stroke and mortality as well as improved outcomes for patients treated with carotid revascularization. Statins are a safe and effective class of medications, but the initiation of therapy warrants close monitoring to avoid rare and potentially serious side effects. Lack of clinical efficacy or the presence of side effects suggests a need for treatment with an alternative therapy such as PCSK9 inhibitors. Understanding the interplay between the mechanisms of statins and PCSK9 inhibition therapies will allow optimal benefits while minimizing risks. Future research into genetic polymorphisms may improve patient selection for personalized therapy.
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Affiliation(s)
- Shreef Said
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Alan Dardik
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
- Department of Cellular and Molecular Physiology, Yale School of Medicine, New Haven, CT, USA
- Department of Surgery, VA Connecticut Healthcare Systems, West Haven, CT, USA
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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Boudreau H, Blakeslee-Carter J, Novak Z, Sutzko DC, Spangler EL, Passman MA, Scali ST, McFarland GE, Pearce BJ, Beck AW. Association of Statin and Antiplatelet Use with Survival in Patients with AAA with and without Concomitant Atherosclerotic Occlusive Disease. Ann Vasc Surg 2022; 83:70-79. [PMID: 35108555 PMCID: PMC9634438 DOI: 10.1016/j.avsg.2022.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/09/2022] [Accepted: 01/10/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND Statin therapy has been associated with improved clinical outcomes in patients undergoing treatment for vascular disease. Current guidelines do not address statin therapy in isolated abdominal aortic aneurysm (AAA) in the absence of other atherosclerotic cardiovascular disease (ASCVD). This study aims to elucidate effects of statin therapy, either as monotherapy or combined with antiplatelet agents, on the long-term mortality of patients with and without ASCVD who undergo elective AAA repair. METHODS A retrospective review was performed on all AAA patients treated electively with endovascular (EVAR) and open aortic repair (OAR) in the Society for Vascular Surgery Vascular Quality Initiative from 2003-2020. Long-term mortality was evaluated based on the presence of statin and antiplatelet medication use at discharge stratified by those with and without a history of ASCVD. Unadjusted survival was estimated by Kaplan Meier methodology. Cox proportional hazards modeling was used to determine mortality risk after adjusting for key factors. RESULTS A total of 47,012 AAA repairs were selected for analysis: 80.7% EVAR (N = 40,153) and 19.3% OAR (N = 6,859). EVAR patients on combined statin/antiplatelet (AP) therapy had significantly better survival irrespective of whether they had known ASCVD. In the presence of ASCVD, EVAR patients on statin alone had improved survival compared to those not on a statin (10.9 ± 0.5 vs. 10.5 ± 0.4 years, Log Rank < 0.001), with survival being even greater among those receiving combined statin/AP therapy (12.2 ± 0.2 vs. 10.5 ± 0.4 years, Log Rank < 0.001). In the absence of ASCVD, EVAR patients on statin alone also had better mean survival compared to patients not on a statin (8.7 ± 0.5 vs. 8.4 ± 0.4 years, Log Rank<.001), with higher survival among statin/AP therapy patients (9.4 ± 0.2 years vs. 8.7 ± 0.5 years, Log Rank < 0.001). Comparison of adjusted survival via Cox multivariable regression demonstrated a protective effect of statins (HR = 0.737, P = 0.04, vs. no medication) and combined statin/AP therapy (HR = 0.659, P = 0.001, vs no medication) in patients with ASCVD history. A similar protective effect (statin: HR 0.826, P = 0.05. Combination statin/AP: HR 0.726, P < 0.001, vs. no medication) was identified in patients without ASCVD history. Within the OAR cohort, statin therapy was not associated with improved survival among patients without ASCVD; however, combined statin/AP therapy had a protective effect for patients with a known ASCVD diagnosis. Based on KM analysis, OAR patients with ASCVD on combined statin/AP therapy had significantly higher mean survival compared to isolated statin therapy (12.7 ± 0.2 vs. 10.3 ± 0.65 years) and no medical therapy (10.5 ± 0.8 years, Log Rank < 0.001). In KM analysis, OAR patients without known ASCVD indications (N = 3591) had no significant survival differences based on the presence of combined statin/AP therapy (8.4 ± .07 vs. 8.5 ± .11 years, Log Rank = 0 638). CONCLUSION Isolated statin therapy and combined statin/AP therapy showed significant survival benefit in all EVAR and OAR patients with ASCVD indications, as well as among EVAR patients without a known ASCVD diagnosis. OAR patients without ASCVD did not have a significant survival benefit from statin therapy, but low numbers in this group may have confounded the findings. Combined statin/AP therapy appears to have significant post-repair survival benefits even in isolated AAA without ASCVD, as demonstrated in post-EVAR patients in this study. Expansion of statin use recommendations within aneurysm treatment guidelines may be warranted.
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Affiliation(s)
- Hunter Boudreau
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Juliet Blakeslee-Carter
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Zdenek Novak
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Danielle C Sutzko
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Emily L Spangler
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Marc A Passman
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Salvatore T Scali
- Division of Vascular Surgery and Endovascular Therapy, University of Florida College of Medicine, Gainesville, FL
| | - Graeme E McFarland
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL
| | - Adam W Beck
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, Birmingham, AL.
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Benefits and drawbacks of statins and non-statin lipid lowering agents in carotid artery disease. Prog Cardiovasc Dis 2022; 73:41-47. [DOI: 10.1016/j.pcad.2022.05.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Accepted: 05/15/2022] [Indexed: 11/18/2022]
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Akhavan A, Farghadani M, Emami H, Naderi Beni Z, Naderi Beni A. Effects of Neck Radiation on Result of Doppler Sonography of Carotid Arteries in Head and Neck Cancer Patients. J Stroke Cerebrovasc Dis 2021; 30:105607. [PMID: 33461025 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 12/28/2020] [Accepted: 01/03/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The aim of this study was to assess the effects of neck radiation on the results of Doppler sonography of carotid arteries in head and neck cancer patients. METHODS In this prospective, cross-sectional study, 25 consecutive patients with head and neck cancers were assessed for carotid artery stenosis (CAS) by carotid color Doppler sonography before external radiotherapy and six months after external radiotherapy. Main outcome measures were peak systolic velocity (PSVs), end-diastolic velocities (EDVs) of the internal carotid artery (ICA), ICA/common carotid (CCA) ratios, and degree of stenosis. RESULTS The age of the enrolled patients at the initiation of radiotherapy was 57.9±11.8 years (mean±SD; range, 43-91 years), and only 4 (16%) of the 25 patients were female. The findings showed significant changes in the plaque degree and stenosis degree, and plaque size before and after external radiotherapy (P<0.05). Changes in degree of stenosis were significantly correlated with age (p=0.021). CONCLUSION After neck irradiation changes in the carotid artery may occur and cause subsequent neurologic events.
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Affiliation(s)
- Ali Akhavan
- Department of radiation oncology, Isfahan university of medical sciences, Isfahan, Iran
| | - Maryam Farghadani
- Department of radiology, cancer prevention research center, school of medicine, Isfahan niversity of medical sciences, Isfahan, Iran
| | - Hamid Emami
- Department of radiation oncology, Isfahan university of medical sciences, Isfahan, Iran
| | - Zahra Naderi Beni
- Department of radiation oncology, Isfahan university of medical sciences, Isfahan, Iran.
| | - Afsaneh Naderi Beni
- Isfahan Eye Research Center, Department of Ophthalmology, Isfahan University of Medical Sciences, Isfahan, Iran
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Paraskevas KI, Veith FJ, Eckstein HH, Ricco JB, Mikhailidis DP. Cholesterol, carotid artery disease and stroke: what the vascular specialist needs to know. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:1265. [PMID: 33178797 PMCID: PMC7607102 DOI: 10.21037/atm.2020.02.176] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Hypercholesterolemia is a risk factor for carotid artery stenosis and stroke. Statins are the main drugs for the management of hypercholesterolemia and they are strongly recommended by international guidelines for the management of vascular patients. The present review will focus on the associations between cholesterol, carotid artery stenosis and stroke and will cover several topics, including the conservative and perioperative/periprocedural management of carotid patients, the effect of statins on contrast-induced nephropathy developing after endovascular carotid interventions, the role of statin loading prior to endovascular procedures, as well as the indirect beneficial effects of statin treatment on renal function. It will also discuss the topics of statin intolerance and alternative cholesterol-lowering options for statin-intolerant vascular patients. Cholesterol levels play a prognostic role in carotid patients with regards to both short- and long-term stroke and mortality rates. Physicians should keep in mind the pivotal role of cholesterol levels in determining cardiovascular outcomes and the pleiotropic beneficial effects associated with statin use and should not miss the opportunity for cardiovascular risk reduction with aggressive statin treatment.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of General and Vascular Surgery, Central Clinic of Athens, Athens, Greece
| | - Frank J Veith
- Division of Vascular Surgery, New York University Langone Medical Center, NY, USA.,Division of Vascular Surgery, The Cleveland Clinic, Cleveland, OH, USA
| | - Hans-Henning Eckstein
- Department of Vascular and Endovascular Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jean-Baptiste Ricco
- Department of Clinical Research, University of Poitiers, CHU de Poitiers, Poitiers, France
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
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Formanowicz D, Krawczyk JB. Controlling the thickness of the atherosclerotic plaque by statin medication. PLoS One 2020; 15:e0239953. [PMID: 33048950 PMCID: PMC7553348 DOI: 10.1371/journal.pone.0239953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 09/15/2020] [Indexed: 02/08/2023] Open
Abstract
Atherosclerosis, a chronic inflammatory disorder of the arterial wall, is a complex process whose dynamics are affected by multiple factors. The disease control consists of restraining it by administering statins. Slowing down or halting the plaque growth depends on the patient age at which the statin treatment begins and on the thickness of the intima-media (IMT) at that time. In this paper, we propose a mathematical model to estimate the sets of atherosclerosis states, from which the use of statins can restrain the disease. Our model is control-theoretic, and the estimated sets are the viability kernels, in the parlance of viability theory. To our best knowledge, this way of modelling the atherosclerosis progression is original. We compute two viability kernels, each for a different statin-treatment dose. Each kernel is composed of the vector [age, IMT] from which the disease can be restrained. By extension, the disease can’t be restrained from the kernel complements, this being mainly because of the disease and patient-age advancement. The kernels visualise tradeoffs between early and late treatments, which helps the clinician to decide when to start the statin treatment and which statin dose may be sufficient.
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Affiliation(s)
- Dorota Formanowicz
- Department of Clinical Biochemistry and Laboratory Medicine, Poznan University of Medical Sciences, Poznan, Poland
- * E-mail: (DF); (JBK)
| | - Jacek B. Krawczyk
- School of Mathematics and Statistics, The University of Sydney, Sydney, NSW, Australia
- * E-mail: (DF); (JBK)
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Ratcliffe F, Rothwell PM. The case for statin use to reduce perioperative adverse cardiovascular and cerebrovascular events. Br J Anaesth 2020; 124:525-534. [PMID: 32111371 DOI: 10.1016/j.bja.2020.01.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 01/12/2020] [Accepted: 01/24/2020] [Indexed: 12/11/2022] Open
Abstract
Ischaemic heart disease and stroke are the leading causes of death worldwide at 119 per 100,000 and 85 per 100,000 population. For the USA, heart disease is leading cause of death at 165 per 100,000 population. In developed countries, strokes and acute myocardial infarction in the general population have fallen from smoking reduction, lifestyle modifications and therapeutic interventions including statins. In a population-based stroke study in the UK involving primary care practices, of in-hospital strokes 90% were ischaemic, and 37% occurred within 1 week of an operation. Approximately 50% of the patients were not on a statin. In the UK, there is a national screening initiative for the prevention of atherosclerotic cardiovascular disease (ASCVD) offered to people aged 40-74 yr old. The QRISK3 tool calculates the risk of developing heart disease or stroke over 10 yr, from which recommendations are made on interventions for the prevention of ASCVD up to age 84 yr, with similar screening and assessment tools in Europe and the US. If the QRISK3 score tool for calculating cardiovascular risk is considered sufficiently robust for population screening in primary care, should anaesthetists not use the same screening for secondary care? We present a case for statin use over the perioperative period, to reduce early vascular adverse events based on statins' early pleiotropic actions, using the primary care QRISK tool for screening of ASCVD risk.
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Affiliation(s)
- Fiona Ratcliffe
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Peter M Rothwell
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
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Shah VS, Kreatsoulas D, Dornbos D, Cua S, Powers CJ. The impact of pre-operative symptoms on carotid endarterectomy Outcomes: Analysis of the ACS-NSQIP carotid endarterectomy database. J Clin Neurosci 2020; 73:51-56. [PMID: 32019726 DOI: 10.1016/j.jocn.2020.01.077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 12/01/2019] [Accepted: 01/26/2020] [Indexed: 10/25/2022]
Abstract
Carotid artery stenosis accounts for up to 20% of ischemic strokes. Since the 1950 s, one of the primary surgical treatment for this condition is carotid endarterectomy (CEA). Because of improvement of medical therapy for carotid artery atherosclerosis and the increased use of carotid artery stents, CEA is indicated if the risk of stroke and death are low. The goal of this study is to characterize the impact of pre-operative stroke and stroke risk factors on post-operative CEA patient outcomes, using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Vascular Module on CEA. Using the Targeted Vascular Module of the ACS-NSQIP, 22,116 patients who underwent CEA were identified from 2011 to 2016. Univariate analysis and multivariable logistic regression analyses were conducted to identify significant risk factors that predispose patients to stroke. Patients with pre-operative stroke comprise 42.1% of the group, with post-operative stroke being the second most common complication (2.1%). Pre-operative stroke patients were also at a higher risk for transient ischemic attacks, post-operative restenosis, post-operative distal embolization, and other complications. Patients with pre-operative risk factors, including stroke or stroke-like symptoms, high risk physiologic factors, high risk anatomic factors, and contralateral internal carotid artery stenosis were at a higher risk of developing post-operative stroke and other complications. Patients with these pre-operative risk factors should be closely monitored for post-operative complications in an effort to improve patient outcomes.
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Affiliation(s)
- Varun S Shah
- The Ohio State University College of Medicine, Columbus, OH USA
| | - Daniel Kreatsoulas
- The Ohio State University Wexner Medical Center, Department of Neurological Surgery, Columbus, OH USA
| | - David Dornbos
- The Ohio State University Wexner Medical Center, Department of Neurological Surgery, Columbus, OH USA
| | - Santino Cua
- The Ohio State University College of Medicine, Columbus, OH USA
| | - Ciarán J Powers
- The Ohio State University Wexner Medical Center, Department of Neurological Surgery, Columbus, OH USA.
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Hypoglycemia does not affect the progression of preclinical atherosclerosis in subjects with type 2 diabetes. PLoS One 2019; 14:e0212871. [PMID: 30835778 PMCID: PMC6400373 DOI: 10.1371/journal.pone.0212871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 02/11/2019] [Indexed: 12/03/2022] Open
Abstract
Introduction Intensive treatment aimed at achieving optimal metabolic control to prevent the development of chronic diabetic complications is often associated with an increased rate of hypoglycemic events. Hypoglycemia is believed to be responsible for acute fatal and nonfatal cardiovascular events likely as a consequence of the activation of pro-inflammatory and pro-atherothrombotic pathways. Hypoglycemia has been reported to influence the development of preclinical atherosclerosis. The present study was designed to prospectively evaluate whether hypoglycemia influences the function and the morphology of the arteries in subjects with type 2 diabetes without complications and uncontrolled diabetes. Material and methods Seventy-six subjects underwent a noninvasive evaluation of carotid wall thickness and brachial artery function at baseline and after one year of treatment with the intent of obtaining optimal glycemic control. At the end of the observation time, subjects were divided in two groups: with hypoglycemia (H-group) or without hypoglycemia (C-group). Results Baseline characteristic were comparable between groups. HbA1c significantly decreased in both groups, and fasting plasma glucose was only significant in the H-group. Subjects with hypoglycemia showed a significant reduction of carotid wall thickness after one-year of treatment (H-groups: right baseline 834±141 vs. 1-year 770±132 μ p<0.05; C-group: 757±162 vs. 767±135 μ p = ns). Endothelial function remained unchanged during the study for both groups. Discussion The present findings demonstrate that hypoglycemia does not affect endothelial function. Furthermore, subjects who experience more hypoglycemia show significant reduction of carotid wall thickness. Optimal metabolic control should be pursued as soon as possible.
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12
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Lung YJ, Weng WC, Wu CL, Huang WY. Association Between Total Cholesterol and 5 year Mortality in Patients with Carotid Artery Stenosis and Poststroke Functional Dependence. J Stroke Cerebrovasc Dis 2019; 28:1040-1047. [PMID: 30642665 DOI: 10.1016/j.jstrokecerebrovasdis.2018.12.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 12/03/2018] [Accepted: 12/22/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Aggressive lipid-lowering treatment reduces the risk of cardiovascular events, but remains controversial in stroke patients. We investigate the influence of total cholesterol level on 5-year outcomes of ischemic stroke patients with high-grade internal carotid artery (ICA) stenosis and poststroke functional dependence. METHODS One-hundred and ninety-six acute ischemic stroke patients with high-grade ICA stenosis and modified Rankin Scale score ≥ 3 upon discharge were enrolled and prospectively observed for 5 years. Patients were divided into 2 groups according to total cholesterol level at admission: ≥200 mg/dL or <200 mg/dL. Demographic features, vascular risk factors, co-morbidities, and outcomes were compared between the 2 groups. RESULTS 117 (59.7%) patients had higher and 79 (40.3%) patients had lower total cholesterol levels. The prevalence of older age and atrial fibrillation was significantly higher in patients with lower total cholesterol; the prevalence of diabetes mellitus was higher in patients with higher total cholesterol. After adjusting for the established clinical predictors of adverse outcomes, the multivariate Cox regression revealed that lower total cholesterol level is a significant predictor of 5-year mortality (HR (hazard ratio) = 1.88, 95% CI (confidence interval) = 1.09-3.23, P = .023). CONCLUSIONS Lower total cholesterol level is associated with increased risk of 5-year mortality in ischemic stroke patients with high-grade ICA stenosis and post-stroke functional dependence. Aggressive treatment of hyperlipidemia should be carefully considered in these patients although it could reduce the risk of atherosclerotic cardiovascular diseases and stroke recurrence in some stroke patients.
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Affiliation(s)
- Yen-Ju Lung
- Department of Neurology, Chang-Gung Memorial Hospital, Keelung branch, Keelung, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Wei-Chieh Weng
- Department of Neurology, Chang-Gung Memorial Hospital, Keelung branch, Keelung, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Chia-Lun Wu
- Department of Neurology, Chang-Gung Memorial Hospital, Keelung branch, Keelung, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan
| | - Wen-Yi Huang
- Department of Neurology, Chang-Gung Memorial Hospital, Keelung branch, Keelung, Taiwan; Department of Medicine, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan.
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Högberg D, Mani K, Wanhainen A, Svensjö S. Clinical Effect and Cost-Effectiveness of Screening for Asymptomatic Carotid Stenosis: A Markov Model. Eur J Vasc Endovasc Surg 2018; 55:819-827. [PMID: 29636252 DOI: 10.1016/j.ejvs.2018.02.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Accepted: 02/24/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE/BACKGROUND The cost-effectiveness of screening depends on the cost of screening, prevalence of asymptomatic carotid artery stenosis (ACAS), and the potential effect of medical intervention in reducing the risk of stroke. The aim of the study was to determine the threshold values for these parameters in order for screening for ACAS to be cost-effective. METHODS The clinical effect and cost-effectiveness of ultrasound screening for ACAS with subsequent initiation of preventive therapy versus not screening was assessed in a Markov model with a lifetime perspective. Key parameters, including stroke risk, all cause mortality, and costs, were based on contemporary published data, population statistics, and data from an ongoing screening program in Uppsala county (population 300,000), Sweden. Prevalence of ACAS (2%) and the rate of best medical treatment (BMT; 40%) were based on data from a male Swedish population recently screened for ACAS. The required stroke risk reduction from BMT, incremental cost-efficiency ratio (ICER), absolute risk reduction for stroke (ARR), and number needed to screen (NNS) were calculated. RESULTS Screening was cost-effective at an ICER of €5744 per incremental quality adjusted life year (QALY) gained. ARR was 135 per 100,000 screened, NNS was 741, and QALYs gained were 6700 per 100,000 invited. At a willingness to pay (WTP) threshold of €50,000 per QALY the minimum required stroke risk reduction from BMT was 22%. The assumed degree of stroke risk reduction was the most important determinant of cost-efficiency. CONCLUSION A moderate (22%) reduction in the risk of stroke was required for an ACAS screening strategy to be cost-effective at a WTP of €50,000/QALY. Targeting populations with a higher prevalence of ACAS could further improve cost-efficiency.
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Affiliation(s)
- Dominika Högberg
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden; Department Hybrid and Interventional Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden.
| | - Kevin Mani
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden
| | - Sverker Svensjö
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University Hospital, Uppsala, Sweden; Department of Surgery, Falun County Hospital, Falun, Sweden; Centre for Clinical Research, Falun, Sweden
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Paraskevas KI, Cambria RP. Best Medical Treatment for Patients with Carotid Stenosis: Evidence-Based Medicine or Wishful Thinking? Angiology 2018; 69:97-99. [DOI: 10.1177/0003319717709860] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Affiliation(s)
- Kosmas I. Paraskevas
- Liverpool Vascular and Endovascular Services, Royal Liverpool University Hospital, Liverpool, UK
| | - Richard P. Cambria
- Division of Vascular and Endovascular Surgery, Thoracic Aortic Centre, Massachusetts General Hospital, Boston, MA, USA
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15
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Kim BJ, Kang HG, Lee SW, Jung J, Lee MH, Kang DW, Kim JS, Kwon SU. Changes in the Common Carotid Artery after Radiotherapy: Wall Thickness, Calcification, and Atherosclerosis. J Clin Neurol 2018; 14:35-42. [PMID: 29629538 PMCID: PMC5765254 DOI: 10.3988/jcn.2018.14.1.35] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/25/2017] [Accepted: 08/29/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Since the long-term survival rate has improved in laryngeal cancer patients who receive radiotherapy, concerns about postradiation complications (including carotid atherosclerosis) have increased. We followed changes in the common carotid artery (CCA) after radiotherapy and identified the underlying risk factors. METHODS Consecutive patients with laryngeal cancer who underwent radiotherapy between January 1999 and December 2009 and who had received computed tomography (CT) both pre- and postradiotherapy were enrolled. Changes in the wall thickness and in the vessel and lumen areas as well as the presence of calcification or atherosclerosis were investigated. Demographics and risk factors were compared between patients with and without atherosclerosis at follow-up CT. RESULTS In total, 125 patients were enrolled. The wall thickness had increased and the lumen area had decreased several months after radiotherapy. These changes were not associated with vascular risk factors and were not progressive. Calcification and atherosclerosis were observed in 37 (29.6%) and 71 (56.8%) patients, respectively. Diabetes was associated with calcification (p=0.02). The prevalence of hyperlipidemia was higher in patients with atherosclerosis (28.2% vs. 11.1%, p=0.02) and for a longer period postradiation [62.7±32.1 vs. 40.0±24.2 months (mean±SD), p<0.001]. Atherosclerosis occurred mostly in the middle portion of the CCA (n=31, 24.6%), followed by the proximal CCA at the intrathoracic level (n=26, 20.6%) and the distal CCA (n=6, 4.8%). Positive remodeling was also observed, but this was less common in patients with calcification (p=0.02). CONCLUSIONS Various types of postradiation changes occur in the CCA and can be easily observed in postradiation CT. The prevalence and burden of postradiation atherosclerosis increased in a close relationship with baseline cholesterol levels and the time after radiotherapy. Postradiation atherosclerosis was observed at unusual sites of the CCA.
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Affiliation(s)
- Bum Joon Kim
- Department of Neurology, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Seoul, Korea
| | - Hyun Goo Kang
- Department of Neurology, Chosun University Hospital, Gwangju, Korea
| | - Sang Wook Lee
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinhong Jung
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min Hwan Lee
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jong S Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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16
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Pothof AB, Zwanenburg ES, Deery SE, O'Donnell TFX, de Borst GJ, Schermerhorn ML. An update on the incidence of perioperative outcomes after carotid endarterectomy, stratified by type of preprocedural neurologic symptom. J Vasc Surg 2017; 67:785-792. [PMID: 29074118 DOI: 10.1016/j.jvs.2017.07.132] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 07/24/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Perioperative complications after carotid endarterectomy (CEA) have decreased over time. Therefore, we aimed to provide an update on 30-day outcomes after CEA, stratified by type of preprocedural neurologic symptom. METHODS We included all CEAs from the Targeted Vascular module of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP, 2011-2015) and stratified patients based on type of preprocedural neurologic symptom, that is, asymptomatic, ocular transient ischemic attack (TIA), hemispheric TIA, and stroke. We compared 30-day outcomes across the groups, with 30-day stroke/death as our primary endpoint. RESULTS Of 16,739 CEA patients, 9784 were asymptomatic (58%). Among the 6955 symptomatic patients, 1216 (17%) had a preprocedural ocular TIA, 2635 (38%) a preprocedural hemispheric TIA, and 3104 (45%) a preprocedural stroke. Preprocedural stroke patients had higher 30-day stroke/death rates compared with those with a preprocedural hemispheric TIA, or ocular TIA, or asymptomatic patients (5.0% vs 3.3%, 1.9%, and 1.8%, respectively; all P < .001), primarily owing to differences in perioperative 30-day stroke rates, with 4.1% vs 2.5%, 1.4%, and 1.3%, respectively (all P < .001). CONCLUSIONS Among symptomatic CEA patients, those with a preprocedural stroke had a high perioperative 30-day stroke/death rate, compared with those patients with either a preprocedural hemispheric or ocular TIA. Therefore, the common stratification applied to CEA patients, which groups all symptomatic patients, should be avoided, especially as the relative proportion of symptomatic patients with a preprocedural stroke vs those with a hemispheric or ocular TIA will affect the overall outcome for all symptomatic patients after CEA.
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Affiliation(s)
- Alexander B Pothof
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Emma S Zwanenburg
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Division of Vascular Surgery, Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Sarah E Deery
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Thomas F X O'Donnell
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass; Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Gert J de Borst
- Department of Vascular Surgery, University Medical Center, Utrecht, The Netherlands
| | - Marc L Schermerhorn
- Division of Vascular and Endovascular Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Volpe M, Volpe R, Gallo G, Presta V, Tocci G, Folco E, Peracino A, Tremoli E, Trimarco B. 2017 Position Paper of the Italian Society for Cardiovascular Prevention (SIPREC) for an Updated Clinical Management of Hypercholesterolemia and Cardiovascular Risk: Executive Document. High Blood Press Cardiovasc Prev 2017; 24:313-329. [PMID: 28523635 DOI: 10.1007/s40292-017-0211-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 05/07/2017] [Indexed: 12/15/2022] Open
Abstract
The benefits achieved by implementing cardiovascular prevention strategies in terms of reduced incidence of atherosclerotic diseases and mortality are accepted, worldwide. In particular, the clinical management of hypercholesterolemia has a fundamental role for all preventive strategies, both in primary and secondary prevention, at each stage of cardiovascular risk. Since the net clinical benefit of lipid-lowering therapy largely depends on baseline individual cardiovascular risk profile, the assessment of individual risk is essential to establish type and intensity of both preventive and therapeutic strategies. Thus, the real challenge in a setting of clinical practice is not only to identify whom to treat among individuals at low-to-moderate risk, but mostly how much and how long to treat high or very-high risk patients. This manuscript, which reflects concepts and positions that have been published in a more extensive document of the Italian Society for Cardiovascular Prevention (SIPREC), deals with the diagnostic and therapeutic management of patients with dyslipidaemia, with an evidence-based approach adapted and updated from recent guidelines of the European Society of Cardiology and very recent results of randomized clinical trials. The purpose is to suggest a multidimensional and integrated actions aimed at eliminating or minimizing the impact of cardiovascular diseases and their related disabilities and mortality in patients with hypercholesterolemia.
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Affiliation(s)
- Massimo Volpe
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy. .,IRCCS Neuromed, Pozzilli, IS, Italy.
| | - Roberto Volpe
- Health and Safety Office, Italian National Research Council, Rome, Italy
| | - Giovanna Gallo
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Vivianne Presta
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy
| | - Giuliano Tocci
- Division of Cardiology, Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sant'Andrea Hospital, University of Rome Sapienza, Rome, Italy.,IRCCS Neuromed, Pozzilli, IS, Italy
| | - Emanuela Folco
- Italian Heart Foundation-Fondazione Italiana Per il Cuore (FIPC), Milan, Italy
| | - Andrea Peracino
- Italian Heart Foundation-Fondazione Italiana Per il Cuore (FIPC), Milan, Italy
| | - Elena Tremoli
- Italian Heart Foundation-Fondazione Italiana Per il Cuore (FIPC), Milan, Italy
| | - Bruno Trimarco
- Division of Cardiology, Department of Advanced Biomedical Sciences, Hypertension Research Centre, University of Napoli "Federico II", Naples, Italy
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18
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Morris DR, Ayabe K, Inoue T, Sakai N, Bulbulia R, Halliday A, Goto S. Evidence-Based Carotid Interventions for Stroke Prevention: State-of-the-art Review. J Atheroscler Thromb 2017; 24:373-387. [PMID: 28260723 PMCID: PMC5392474 DOI: 10.5551/jat.38745] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 02/01/2017] [Indexed: 12/28/2022] Open
Abstract
Carotid artery stenosis is responsible for between 10-20% of all ischaemic strokes. Interventions, such as carotid endarterectomy and carotid stenting, effectively reduce the risk of stroke in selected individuals. This review describes the history of carotid interventions, and summarises reliable evidence on the safety and efficacy of these interventions gained from large randomised clinical trials.Early trials comparing carotid endarterectomy to medical therapy alone in symptomatic patients, and asymptomatic patients, demonstrated that endarterectomy halved the risk of stroke and perioperative death in these two unique populations. The absolute risk reduction was smaller in the asymptomatic carotid trials, consistent with their lower absolute stroke risk. More recent trials in symptomatic patients, suggest that carotid stenting has similar long term durability to carotid endarterectomy, but possibly has higher procedural hazards dominated by non-disabling strokes. The Asymptomatic Carotid Surgery Trial-2, along with individual patient data meta-analysis of all asymptomatic trials, will provide reliable evidence for the choice of intervention in asymptomatic patients in whom a decision has been made for carotid revascularisation. Given improvements in effective cardiovascular medical therapy, in particular lipid-lowering medications, there is renewed uncertainty as to whether carotid interventions still provide meaningful net reductions in stroke risk in asymptomatic populations. Four large trials in Europe and the US are currently underway, and are expected to report long-term results in the next decade.It is essential that surgeons, interventionalists, and physicians continue to randomise large numbers of patients from around the world to clarify current uncertainty around the management of asymptomatic carotid stenosis.
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Affiliation(s)
- Dylan R. Morris
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK
| | - Kengo Ayabe
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
| | - Takashi Inoue
- Department of Neurosurgery, Sendai Medical Center, Sendai, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, KCGH Comprehensive Stroke Center, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies Unit, University of Oxford, Oxford, UK
| | - Alison Halliday
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Shinya Goto
- Department of Medicine (Cardiology), Tokai University School of Medicine, Kanagawa, Japan
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Paraskevas KI, Veith FJ, Mikhailidis DP, Liapis CD. Appropriate Patient Selection for Carotid Revascularization Procedures is Urgently Needed. Angiology 2017; 69:12-16. [PMID: 28078914 DOI: 10.1177/0003319716687870] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The identification/selection of appropriate patient subgroups with asymptomatic carotid artery stenosis and the performance of prophylactic carotid endarterectomy (CEA)/carotid artery stenting (CAS) exclusively on these asymptomatic patient subgroups is currently one of the "hottest" topics in vascular surgery. It is now clear that offering CEA/CAS to asymptomatic carotid patients based only on the degree of carotid stenosis is unjustified and scientifically flawed. On the other hand, offering only best medical therapy to every asymptomatic patient, irrespective of certain high-risk criteria (such as the detection of microemboli by transcranial Doppler, intraplaque hemorrhage, silent embolic infarcts on brain computed tomography/magnetic resonance imaging, elevated biomarkers, family history), is equally wrong. The validation of specific measures to identify those asymptomatic patients at high risk for developing symptoms is crucial to achieve optimal use of carotid interventions and avoid wasting stroke prevention resources.
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Affiliation(s)
- Kosmas I Paraskevas
- 1 Northern Vascular Centre, Freeman Hospital, Newcastle Upon Tyne, NHS Foundation Trust, UK
| | - Frank J Veith
- 2 Divisions of Vascular Surgery, New York University Langone Medical Center and Cleveland Clinic, New York, NY and Cleveland, OH, USA
| | - Dimitri P Mikhailidis
- 3 Department of Clinical Biochemistry, Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, UK
| | - Christos D Liapis
- 4 Vascular and Endovascular Clinic, Athens Medical Center, Athens, Greece
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20
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Högberg D, Dellagrammaticas D, Kragsterman B, Björck M, Wanhainen A. Simplified ultrasound protocol for the exclusion of clinically significant carotid artery stenosis. Ups J Med Sci 2016; 121:165-9. [PMID: 27379448 PMCID: PMC4967261 DOI: 10.1080/03009734.2016.1201177] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2022] Open
Abstract
OBJECTIVES To evaluate a simplified ultrasound protocol for the exclusion of clinically significant carotid artery stenosis for screening purposes. MATERIAL AND METHODS A total of 9,493 carotid arteries in 4,748 persons underwent carotid ultrasound examination. Most subjects were 65-year-old men attending screening for abdominal aortic aneurysm. The presence of a stenosis on B-mode and/or a mosaic pattern in post-stenotic areas on colour Doppler and maximum peak systolic velocity (PSV) in the internal carotid artery (ICA) were recorded. A carotid stenosis was defined as The North American Symptomatic Carotid Endarterectomy Trial (NASCET) >20% and a significant stenosis as NASCET >50%. The kappa (κ) statistic was used to assess agreement between methods. Sensitivity, specificity, positive predictive (PPV), and negative predictive (NPV) values were calculated for the greyscale/mosaic method compared to conventional assessment by means of PSV measurement. RESULTS An ICA stenosis was found in 121 (1.3%) arteries; 82 (0.9%) were graded 20%-49%, 16 (0.2%) were 50%-69%, and 23 (0.2%) were 70%-99%. Eighteen (0.2%) arteries were occluded. Overall, the greyscale/mosaic protocol showed a moderate agreement with ICA PSV measurements for the detection of carotid artery stenosis, κ = 0.455. The sensitivity, specificity, PPV, and NPV for detection of >20% ICA stenosis were 91% (95% CI 0.84-0.95), 97% (0.97-0.98), 31% (0.26-0.36), and 97% (0.97-0.97), respectively. The corresponding figures for >50% stenosis were 90% (0.83-0.95), 97% (0.97-0.98), 11% (0.08-0.15), and 100% (0.99-1.00). CONCLUSION Compared with PSV measurements, the simplified greyscale/mosaic protocol had a high negative predictive value for detection of >50% carotid stenosis, suggesting that it may be suitable as a screening method to exclude significant disease.
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Affiliation(s)
- Dominika Högberg
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
- Department of Surgery, NU Hospital Organization, Trollhättan, Sweden
- CONTACT Dominika Högberg Department of Surgery, NU-sjukvården, NÄL, SE-461 85 Trollhättan, Sweden
| | | | - Björn Kragsterman
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Martin Björck
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
| | - Anders Wanhainen
- Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden
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21
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Li Y, Liu N, Huang Y, Wei W, Chen F, Zhang W. Risk Factors for Silent Lacunar Infarction in Patients with Transient Ischemic Attack. Med Sci Monit 2016; 22:447-53. [PMID: 26864634 PMCID: PMC4754089 DOI: 10.12659/msm.895759] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Lacunar infarctions represent 25% of ischemic strokes. Lacunar stroke and transient ischemic attack (TIA) share a number of symptoms. This study aimed to assess the potential risk factors for lacunar infarction in patients with TIA. Material/Methods This was a retrospective study performed at the Beijing Military General Hospital in patients with TIA admitted between March 2010 and December 2011. Patients were grouped according to lacunar vs. no lacunar infarction. All patients were diagnosed using diffusion-weighted imaging (DWI) on brain magnetic resonance imaging (MRI). Brain angiography (computed tomography and MRI) was used to measure intracranial stenosis. Carotid artery stenosis was measured by ultrasound. Results Patients with TIA and lacunar infarction (n=298) were older than those without lacunar infarction (n=157) (69.4±10.0 vs. 58.9±9.0 years, P<0.001) and showed a higher frequency of males (51.7% vs. 41.4%, P=0.037), hypertension (75.3% vs. 45.9%, P<0.001), diabetes (32.6% vs. 21.0%, P=0.010), hyperlipidemia (53.4% vs. 29.3%, P<0.001), carotid stenosis (73.2% vs. 40.1%, P<0.001), and intracranial stenosis (55.6% vs. 31.9%, P<0.001), but a lower frequency of alcohol drinking (8.1% vs. 14.0%, P=0.045). Lacunar infarction mostly involved the anterior circulation (62.8%). Multivariate analysis showed that age (odds ratio (OR)=1.085, 95% confidence interval (95%CI): 1.054–1.117, P<0.001), hypertension (OR=1.738, 95%CI: 1.041–2.903, P=0.035), hyperlipidemia (OR=2.169, 95%CI: 1.307–3.601, P=0.003), and carotid stenosis (OR=1.878, 95%CI: 1.099–3.206, P=0.021) were independently associated with lacunar infarction. Conclusions Age, hypertension, hyperlipidemia, and carotid stenosis were independently associated with silent lacunar infarction in patients with TIA.
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Affiliation(s)
- Ying Li
- Postgraduate School, The Third Millitary Medical University, Chongqing, China (mainland)
| | - Nan Liu
- Postgraduate School, Third Military Medical University, Chongqing, China (mainland)
| | - Yonghua Huang
- Department of Neurology, Beijing Military General Hospital, Beijing, China (mainland)
| | - Wei Wei
- Department of Neurology, Beijing Military General Hospital, Beijing, China (mainland)
| | - Fei Chen
- Department of Neurology, Beijing Military 254 Hospital, Tianjin, China (mainland)
| | - Weiwei Zhang
- Department of Neurology, Beijing Military General Hospital, Beijing, China (mainland)
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22
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Paraskevas KI, Mikhailidis DP, Veith FJ. Critical Issues and Controversies in the Management of Patients With Carotid Artery Stenosis. Angiology 2016; 67:405-7. [PMID: 26838712 DOI: 10.1177/0003319716629320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, Southampton University Hospital, Southampton, United Kingdom
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, United Kingdom
| | - Frank J Veith
- Divisions of Vascular Surgery, New York University Langone Medical Center and The Cleveland Clinic, New York, NY, USA
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23
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Paraskevas KI, Mikhailidis DP, Veith FJ, Spence JD. Definition of Best Medical Treatment in Asymptomatic and Symptomatic Carotid Artery Stenosis. Angiology 2015; 67:411-9. [PMID: 26721504 DOI: 10.1177/0003319715624526] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Implementation of best medical treatment (BMT) is the cornerstone of the management of patients with either asymptomatic or symptomatic carotid artery stenosis. We review the literature to define the components of BMT. Smoking cessation, maintaining a healthy body weight, moderate exercise, and a Mediterranean diet are essential lifestyle measures. Moderate alcohol consumption may also be beneficial but recommending it to patients may be hazardous if they consume too much. The importance of lifestyle measures is largely underestimated by both physicians and patients. Blood pressure and diabetes control, antiplatelet agents, and lipid-lowering treatment with statins/ezetimibe comprise the pharmacological components of BMT. Initiation of an intensive regimen of BMT is a sine qua non for patients with carotid artery stenosis whether or not they are offered or undergo an invasive revascularization procedure.
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Affiliation(s)
- Kosmas I Paraskevas
- Department of Vascular Surgery, Southampton University Hospital, Southampton, United Kingdom
| | - Dimitri P Mikhailidis
- Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College London Medical School, University College London (UCL), London, United Kingdom
| | - Frank J Veith
- Division of Vascular Surgery, New York University Langone Medical Center, New York, NY, USA Division of Vascular Surgery, The Cleveland Clinic, Cleveland, OH, USA
| | - J David Spence
- Stroke Prevention & Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada
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24
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Moore WS. Issues to Be Addressed and Hopefully Resolved in the Carotid Revascularization Endarterectomy Versus Stenting Trial 2. Angiology 2015; 67:408-10. [PMID: 26460327 DOI: 10.1177/0003319715611281] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The superiority of carotid endarterectomy (CEA) plus best medical treatment (BMT) over BMT alone for the management of patients with asymptomatic carotid stenosis is based on randomized controlled trials that recruited patients up to 30 years ago. Best medical treatment has improved considerably since that time with respect to stroke prevention. Furthermore, a new carotid intervention has emerged during the last 2 decades and has gradually become established, that is, carotid artery stenting (CAS). Consequently, the efficacy of current BMT alone needs to be compared not only with CEA plus BMT but also with CAS plus BMT to determine which strategy achieves the optimal stroke prevention rates. This article highlights the purpose of the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) 2 and discusses the issues that CREST-2 will hopefully provide answers to.
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Affiliation(s)
- Wesley S Moore
- Division of Vascular and Endovascular Surgery, UCLA Medical Center, Los Angeles, CA, USA
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25
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Poredos P, Jezovnik MK. Do the Effects of Secondary Prevention of Cardiovascular Events in PAD Patients Differ from Other Atherosclerotic Disease? Int J Mol Sci 2015; 16:14477-89. [PMID: 26121301 PMCID: PMC4519853 DOI: 10.3390/ijms160714477] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Revised: 05/08/2015] [Accepted: 05/11/2015] [Indexed: 01/08/2023] Open
Abstract
Atherosclerosis is considered a generalized disease. Similar or identical etiopathogenetic mechanisms and risk factors are involved in various atherosclerotic diseases, and the positive effects of preventive measures on atherogenesis in different parts of the arterial system were shown. However, until know, great emphasis has been placed on the aggressive pharmacological management of coronary artery disease (CHD), while less attention has been devoted to the management of peripheral arterial disease (PAD), despite its significant morbidity and mortality. Data on the efficacy of preventive measures in PAD patients have mostly been gained from subgroup analyses from studies devoted primarily to the management of coronary patients. These data have shown that treatment of risk factors for atherosclerosis with drugs can reduce cardiovascular events also in patients with PAD. The effects of some preventive procedures in PAD patients differ from coronary patients. Aspirin as a basic antiplatelet drug has been shown to be less effective in PAD patients than in coronary patients. The latest Antithrombotic Trialists' Collaboration (ATC) meta-analysis demonstrates no benefit of aspirin in reducing cardiovascular events in PAD. Statins reduce cardiovascular events in all three of the most frequently presented cardiovascular diseases, including PAD to a comparable extent. Recent studies indicate that in PAD patients, in addition to a reduction in cardiovascular events, statins may have some hemodynamic effects. They prolong walking distance and improve quality of life. Similarly, angiotensin enzyme inhibitors are also effective in the prevention of cardiovascular events in coronary, cerebrovascular, as well as PAD patients and show positive effects on the walking capacity of patients with intermittent claudication. In PAD patients, the treatment of hypertension and diabetes also effectively prevents cardiovascular morbidity and mortality. As PAD patients are at a highest risk of cardiovascular complications, the risk factors of atherosclerosis should be treated intensively in this group of patients. Most of the preventive measures, including the drugs used for prevention of CHD, are also effective in PAD patients.
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Affiliation(s)
- Pavel Poredos
- Department of Vascular Disease, University Medical Centre Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia.
| | - Mateja Kaja Jezovnik
- Department of Vascular Disease, University Medical Centre Ljubljana, Zaloska 7, 1000 Ljubljana, Slovenia.
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Pillay B. HIV-associated large-vessel vasculopathy: a review of the current and emerging clinicopathological spectrum in vascular surgical practice. Cardiovasc J Afr 2015; 26:70-81. [PMID: 25940120 PMCID: PMC4832607 DOI: 10.5830/cvja-2015-017] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Accepted: 01/27/2015] [Indexed: 12/13/2022] Open
Abstract
An established relationship exists between human immunodeficiency virus (HIV) and the vascular system, which is characterised by clinical expressions of aneurysmal and occlusive disease that emanate from a common pathological process. The exact pathogenesis is currently unknown; attempts to implicate opportunistic pathogens have been futile. Theories converge on leucocytoclastic vasculitis with the vaso vasora as the vasculopathic epicentre. It is thought that the virus itself or viral proteins trigger the release of inflammatory mediators that cause endothelial dysfunction and smooth muscle proliferation leading to vascular injury and thrombosis. The beneficial effects of highly active anti-retroviral therapy alter the natural history of the disease profile and promote longevity but are negated by cardiovascular complications. Atherosclerosis is an emerging challenge. Presently patients are managed by standard surgical protocols because of non-existent universal surgical interventional guidelines. Clinical response to treatment is variable and often compounded by complications of graft occlusion, sepsis and poor wound healing. The clinical, imaging and pathological observations position HIV-associated large-vessel vasculopathy as a unique entity. This review highlights the spectrum of HIV-associated large-vessel aneurysmal, occlusive and atherosclerotic disease in vascular surgical practice.
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MESH Headings
- Aneurysm/etiology
- Aneurysm/therapy
- Animals
- Atherosclerosis/etiology
- Atherosclerosis/therapy
- Blood Vessels/immunology
- Blood Vessels/virology
- Endothelium, Vascular/immunology
- Endothelium, Vascular/surgery
- Endothelium, Vascular/virology
- HIV Infections/complications
- HIV Infections/therapy
- Humans
- Myocytes, Smooth Muscle/immunology
- Myocytes, Smooth Muscle/pathology
- Myocytes, Smooth Muscle/virology
- Practice Guidelines as Topic
- Thrombosis/etiology
- Thrombosis/therapy
- Vascular Surgical Procedures
- Vasculitis, Leukocytoclastic, Cutaneous/etiology
- Vasculitis, Leukocytoclastic, Cutaneous/therapy
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Affiliation(s)
- Balasoobramanien Pillay
- Department of Vascular/Endovascular Surgery, Nelson R Mandela School of
Medicine, Durban, South Africa
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Vavra AK, Eskandari MK. Treatment options for symptomatic carotid stenosis: Timing and approach. Surgeon 2015; 13:44-51. [DOI: 10.1016/j.surge.2014.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Revised: 08/04/2014] [Accepted: 09/02/2014] [Indexed: 10/24/2022]
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Best evidence for medical therapy for carotid artery stenosis. J Vasc Surg 2013; 58:1129-39. [PMID: 24075112 DOI: 10.1016/j.jvs.2013.06.085] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 05/01/2013] [Accepted: 06/24/2013] [Indexed: 11/22/2022]
Abstract
Carotid atheromatous disease is an important cause of stroke and represents a key target in stroke prevention. Randomized trials have shown the efficacy of carotid endarterectomy in secondary stroke prevention. Carotid stenting presents a less invasive alternative to surgical intervention. Advances in medical management, if compliance can be ensured, are leading to improvement in outcomes when implemented as sole therapy in the treatment of atherosclerotic carotid stenosis. This includes lifestyle modification, blood pressure control, and antiplatelet and statin therapy. Over the last 20 years, the annual rate of ipsilateral stroke associated with asymptomatic carotid stenosis has decreased from 2% to 4% to less than 1%. This is largely due to improvements in medical therapy. However, despite numerous trials and years of clinical research, the optimal management of symptomatic and asymptomatic carotid disease remains controversial. This article presents and summarizes the evidence supporting best medical treatment for carotid artery stenosis.
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Paraskevas KI, Liapis CD, Veith FJ. Identifying Asymptomatic Carotid Stenosis Patients at High Risk of Cerebrovascular Events. Angiology 2012; 63:489-91. [DOI: 10.1177/0003319712449513] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Christos D. Liapis
- Department of Vascular Surgery, “Attiko” University Hospital, Athens University Medical School, Athens, Greece
| | - Frank J. Veith
- Divisions of Vascular Surgery, New York University Medical Center, NY, USA
- The Cleveland Clinic, Cleveland, OH, USA
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Catapano AL, Reiner Z, De Backer G, Graham I, Taskinen MR, Wiklund O, Agewall S, Alegria E, Chapman MJ, Durrington P, Erdine S, Halcox J, Hobbs R, Kjekshus J, Filardi PP, Riccardi G, Storey RF, Wood D. ESC/EAS Guidelines for the management of dyslipidaemias The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Atherosclerosis 2012; 217:3-46. [PMID: 21882396 DOI: 10.1016/j.atherosclerosis.2011.06.028] [Citation(s) in RCA: 441] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Reiner Ž, Catapano AL, De Backer G, Graham I, Taskinen MR, Wiklund O, Agewall S, Alegría E, Chapman MJ, Durrington P, Erdine S, Halcox J, Hobbs RH, Kjekshus JK, Perrone Filardi P, Riccardi G, Storey RF, David W. [ESC/EAS Guidelines for the management of dyslipidaemias]. Rev Esp Cardiol 2011; 64:1168.e1-1168.e60. [PMID: 22115524 DOI: 10.1016/j.recesp.2011.09.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Accepted: 09/16/2011] [Indexed: 01/15/2023]
Affiliation(s)
- Željko Reiner
- University Hospital Center Zagreb, School of Medicine, University of Zagreb, Salata 2, 10 000 Zagreb, Croacia.
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Koo BK. The Association between Carotid Atherosclerosis and Glucose. Diabetes Metab J 2011; 35:466-8. [PMID: 22111037 PMCID: PMC3221021 DOI: 10.4093/dmj.2011.35.5.466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Bo Kyung Koo
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
- Department of Internal Medicine, Boramae Medical Center, Seoul, Korea
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Reiner Z, Catapano AL, De Backer G, Graham I, Taskinen MR, Wiklund O, Agewall S, Alegria E, Chapman MJ, Durrington P, Erdine S, Halcox J, Hobbs R, Kjekshus J, Filardi PP, Riccardi G, Storey RF, Wood D. ESC/EAS Guidelines for the management of dyslipidaemias: The Task Force for the management of dyslipidaemias of the European Society of Cardiology (ESC) and the European Atherosclerosis Society (EAS). Eur Heart J 2011; 32:1769-818. [PMID: 21712404 DOI: 10.1093/eurheartj/ehr158] [Citation(s) in RCA: 1942] [Impact Index Per Article: 149.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Paraskevas KI, Mikhailidis DP, Veith FJ. Optimal statin type and dosage for vascular patients. J Vasc Surg 2011; 53:837-44. [PMID: 21215572 DOI: 10.1016/j.jvs.2010.10.114] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 10/14/2010] [Accepted: 10/23/2010] [Indexed: 12/29/2022]
Abstract
Statins are an essential component of the management of patients suffering from vascular diseases. As there is neither any consensus nor any guidelines regarding this issue, we aimed to define the optimal statin type and dosage for these patients. MEDLINE was searched for studies comparing different statin types and dosages for vascular patients. In the absence of adverse effects, rosuvastatin or atorvastatin ≥ 20 mg/d is the optimal statin type and dosage for vascular patients. The management of statin-induced adverse events and the options for statin-intolerant patients are also discussed. Routine statin treatment is associated with several beneficial effects in vascular patients whether managed conservatively or undergoing open vascular surgery/endovascular interventions. If possible, statins should not be discontinued before open or endovascular procedures and treatment should be resumed as soon as possible. Future studies should evaluate the effects of an increased statin loading dose prior to vascular procedures.
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Paraskevas KI, Katsiki N, Tzovaras AA, Koupidis SA, Mikhailidis DP. Peripheral arterial disease and HIV-positive patients. Angiology 2011; 62:7-9. [PMID: 21134992 DOI: 10.1177/0003319710386473] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Makris GC, Lavida A, Nicolaides AN, Geroulakos G. The effect of statins on carotid plaque morphology: A LDL-associated action or one more pleiotropic effect of statins? Atherosclerosis 2010; 213:8-20. [DOI: 10.1016/j.atherosclerosis.2010.04.032] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Revised: 04/26/2010] [Accepted: 04/27/2010] [Indexed: 10/19/2022]
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Paraskevas KI, Mikhailidis DP, Veith FJ. Mechanisms to explain the poor results of carotid artery stenting (CAS) in symptomatic patients to date and options to improve CAS outcomes. J Vasc Surg 2010; 52:1367-75. [DOI: 10.1016/j.jvs.2010.04.019] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 03/30/2010] [Accepted: 04/07/2010] [Indexed: 11/25/2022]
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Paraskevas KI, Mikhailidis DP, Nicolaides AN, Veith FJ. Interpreting the Carotid Revascularization Endarterectomy Versus Stent Trial (CREST): Additional Trials Are Needed. Vascular 2010; 18:247-9. [DOI: 10.2310/6670.2010.00063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Kosmas I. Paraskevas
- *Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; †Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College Medical School, University College London, London, UK; ‡Academic Department of Vascular Surgery, Imperial College, London, UK; §Divisions of Vascular Surgery, New York University Medical Center, New York, NY, and The Cleveland Clinic, Cleveland, OH
| | - Dimitri P. Mikhailidis
- *Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; †Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College Medical School, University College London, London, UK; ‡Academic Department of Vascular Surgery, Imperial College, London, UK; §Divisions of Vascular Surgery, New York University Medical Center, New York, NY, and The Cleveland Clinic, Cleveland, OH
| | - Andrew N. Nicolaides
- *Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; †Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College Medical School, University College London, London, UK; ‡Academic Department of Vascular Surgery, Imperial College, London, UK; §Divisions of Vascular Surgery, New York University Medical Center, New York, NY, and The Cleveland Clinic, Cleveland, OH
| | - Frank J. Veith
- *Department of Vascular Surgery, Red Cross Hospital, Athens, Greece; †Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Hospital Campus, University College Medical School, University College London, London, UK; ‡Academic Department of Vascular Surgery, Imperial College, London, UK; §Divisions of Vascular Surgery, New York University Medical Center, New York, NY, and The Cleveland Clinic, Cleveland, OH
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Paraskevas KI, Anastasakis E, Andrikopoulou M, Mikhailidis DP. Radial Artery Catheterization for Percutaneous Vascular or Coronary Interventions: An Innocent Procedure? Angiology 2009; 61:5-7. [DOI: 10.1177/0003319709353169] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | | | | | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry (Vascular Disease Prevention Clinics), Royal Free Campus, University College London Medical School, University College London (UCL), London, United Kingdom,
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Bountouris I, Paraskevas KI, Koutouzis M, Tzavara V, Nikolaou N, Nomikos A, Barbatis C, Andrikopoulos V, Mikhailidis DP, Andrikopoulou M, Kyriakides ZS, Georgopoulos S, Michail PO, Bastounis E. Serum leptin levels in patients undergoing carotid endarterectomy: a pilot study. Angiology 2009; 60:698-704. [PMID: 19825871 DOI: 10.1177/0003319709350133] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Elevated serum leptin levels are associated with cardiovascular events. We investigated the role of serum leptin in patients undergoing carotid endarterectomy (CEA). METHODS A total of 74 patients (55 men; 38 symptomatic and 36 asymptomatic; mean age 66.9 +/- 8.2 years) undergoing CEA for >70% carotid artery stenosis were enrolled. RESULTS Serum leptin levels were lower in symptomatic compared with asymptomatic patients (7.1 +/- 1.3 vs 14.4 +/- 4.7 ng/dL; P < .001). Interleukin-6 (IL-6) levels were higher in symptomatic compared with asymptomatic patients (4.3 +/- 1.7 vs 3.3 +/- 1.1 pg/dL; P = .017). Symptomatic patients had more intense macrophage accumulation (0.7% +/- 0.1% vs 0.3% +/- 0.1%; P < .001). Serum leptin and serum IL-6 levels were independently associated with the presence of symptoms in multivariate analysis. CONCLUSION Serum leptin levels were decreased in symptomatic carotid artery disease. This finding requires further investigation in larger studies.
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Paraskevas KI, Giannoukas AD, Mikhailidis DP. Irradiation-induced carotid artery stenosis: a preventable complication of neck radiotherapy? Angiology 2009; 60:273-5. [PMID: 19622531 DOI: 10.1177/0003319709336419] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Paraskevas KI, Mikhailidis DP, Bell PR. The GALA Trial: Will It Influence Clinical Practice? Vasc Endovascular Surg 2009; 43:429-32. [DOI: 10.1177/1538574409340589] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The General Anesthesia vs. Local Anesthesia for Carotid Surgery (GALA) trial did not show a difference in 30-day postoperative stroke, myocardial infarction and death rates between patients undergoing carotid endarterectomy (CEA) under local vs. general anesthesia. The present article discusses some limitations of the GALA trial. Firstly, the expected stroke and death rates following CEA is so low, that it was unlikely that the GALA trial would show any significant difference between local and general anesthesia. Secondly, preoperative statin use was not recorded. Thirdly, intraoperative shunt usa ge rates (a possible parameter for the development of stroke) varied considerably between the 2 groups (43% vs. 14%, for general vs. local anesthesia, respectively; P < .0001), as well as between UK and non-UK surgeons who always (73.6% vs. 20.8%, respectively; P < .0001), never (4.2% vs. 26%, respectively; P < .0002), or selectively (22.2% vs. 53.2%, respectively; P < .0001) used a shunt. Furthermore, no information was provided regarding the type of shunts used; for example, atraumatic shunts may be associated with lower perioperative stroke rates. These limitations could influence the interpretation of the results of the GALA trial. Due to lack of differences between the 2 groups and the presence of the above limitations, it seems likely that this trial will have little effect on clinical practice.
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Affiliation(s)
| | - Dimitri P. Mikhailidis
- Department of Clinical Biochemistry (Vascular Disease Prevention Clinic), Royal Free Hospital Campus, University College London (UCL), University of London, London, United Kingdom,
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Paraskevas KI, Bessias N, Perdikides TP, Mikhailidis DP. Statins and venous thromboembolism: a novel effect of statins? Curr Med Res Opin 2009; 25:1807-9. [PMID: 19505206 DOI: 10.1185/03007990903052591] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Statins play a key role in the management of hypercholesterolemia and other dyslipidemias. However, statins exert several other actions, often referred to as 'pleiotropic'. This Editorial looks at the JUPITER trial (Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin), examining, in particular, the occurrence of venous thromboembolism in the rosuvastatin and placebo groups, and discussing these findings in the context of the current literature. The authors conclude that statin use could perhaps be associated with reductions in the risk of venous thromboembolism, and call for further appropriately designed studies.
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Vikan T, Johnsen SH, Schirmer H, Njølstad I, Svartberg J. Endogenous testosterone and the prospective association with carotid atherosclerosis in men: the Tromsø study. Eur J Epidemiol 2009; 24:289-95. [DOI: 10.1007/s10654-009-9322-2] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2008] [Accepted: 02/23/2009] [Indexed: 11/30/2022]
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Effect of pravastatin on experimental diabetic wound healing. J Surg Res 2009; 161:336-40. [PMID: 20031169 DOI: 10.1016/j.jss.2009.01.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2008] [Revised: 01/13/2009] [Accepted: 01/16/2009] [Indexed: 12/24/2022]
Abstract
BACKGROUND Impaired wound healing in diabetes has been associated with abnormalities in wound nitric oxide (NO) and nitric oxide synthase (NOS) availability. Efforts to alter the profile of NO expression in the wound microenvironment have proven to be successful in partially restoring wound healing deficits. We investigated the effects of pravastatin, a HMG Co A reductase inhibitor on endothelial nitric oxide synthase (eNOS) expression, NO production, and wound healing in a diabetic acute wound healing model. MATERIALS AND METHODS Of 70 male Sprague Dawley rats injected with streptozocin, 62 were confirmed diabetic after 1 wk. Animals were randomized into two groups: (1) diabetic control and (2) diabetic treated with pravastatin. Pravastatin sodium was gavaged at 0.4 mg/kg/d for 5 d, after which all animals underwent dorsal incision with insertion of subcutaneous sponges. Breaking strengths and hydroxyproline were measured on days 1, 3, and 10 post-wounding. Wound fluid was analyzed for nitrate/nitrite production. Tissue samples were analyzed for eNOS expression. RESULTS We demonstrated enhanced wound breaking strengths, hydroxyproline accumulation, an up-regulation in eNOS expression, and elevated NO levels in the pravastatin treated group. CONCLUSION We have shown that pravastatin, in an experimental model of diabetes may through up-regulation of eNOS and NO expression improve wound healing.
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Paraskevas KI, Psathas C, Dragios T, Chatzis DG, Mikhailidis DP, Kyriakides ZS. The impact of novel treatment modalities on the therapeutic approach of cardiovascular diseases. Angiology 2009; 60:5-7. [PMID: 19190028 DOI: 10.1177/0003319708328923] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Brevetti G, Sirico G, Giugliano G, Lanero S, De Maio JI, Luciano R, Laurenzano E, Chiariello M. Prevalence of hypoechoic carotid plaques in coronary artery disease: relationship with coexistent peripheral arterial disease and leukocyte number. Vasc Med 2009; 14:13-9. [DOI: 10.1177/1358863x08097066] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract In coronary artery disease (CAD), a concomitant peripheral arterial disease (PAD) entails a more severe coronary atherosclerosis. We hypothesized that the severity of carotid artery disease is greater in CAD+PAD than in CAD alone. In 90 CAD and 79 CAD+PAD patients, carotid plaque echolucency was measured by gray-scale median (GSM), and the degree of carotid stenosis by routine Doppler criteria. Plaques were absent in 20 (22.2%) CAD and 8 (10.1%) CAD+PAD patients ( p = 0.035), while the prevalence of carotid stenosis ≥ 50% was 16.7% and 25.3%, respectively ( p = 0.166). The GSM score was 45.1 [21.7–67.7] in CAD+PAD vs 60.1 [44.9–83.1] in CAD alone ( p < 0.001). Consistently, hypoechoic plaques (GSM < 25th percentile) were more common in CAD+PAD than in CAD patients (38.0% vs 11.4%, p < 0.001). On multivariate analysis, CAD+PAD was the only variable significantly associated with hypoechoic plaques (OR = 4.16, 95% CI 1.68–10.28). However, when the leukocyte count was added to the model, it showed the strongest association with hypoechoic plaques (OR = 6.70, 95% CI 2.13–21.10). In conclusion, compared with CAD alone patients, those with concomitant PAD showed a greater prevalence of plaques with characteristics of instability. Thus, our data suggest that in CAD+PAD, evaluation of carotid plaque echogenicity could contribute to improve clinical decision-making and differentiate treatments for individual patients.
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Affiliation(s)
- Gregorio Brevetti
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University of Naples ‘Federico II’, Naples, Italy
| | - Giusy Sirico
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University of Naples ‘Federico II’, Naples, Italy
| | - Giuseppe Giugliano
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University of Naples ‘Federico II’, Naples, Italy
| | - Simona Lanero
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University of Naples ‘Federico II’, Naples, Italy
| | - Julieta Isabel De Maio
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University of Naples ‘Federico II’, Naples, Italy
| | - Rossella Luciano
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University of Naples ‘Federico II’, Naples, Italy
| | - Eugenio Laurenzano
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University of Naples ‘Federico II’, Naples, Italy
| | - Massimo Chiariello
- Department of Clinical Medicine and Cardiovascular and Immunological Sciences, University of Naples ‘Federico II’, Naples, Italy
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50
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The benefit of statins in non-cardiac vascular surgery patients. J Vasc Surg 2009; 49:260-5. [DOI: 10.1016/j.jvs.2008.11.070] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2008] [Revised: 11/06/2008] [Accepted: 11/06/2008] [Indexed: 11/22/2022]
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