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Mendes GN, Jacquin G, Katsanos AH, Singh N, Stotts G, Ferguson DB, Yip S, Poppe AY. Safety of acute internal carotid artery stenting during endovascular thrombectomy in patients with acute ischemic stroke: a retrospective analysis of the OPTIMISE registry. J Neurointerv Surg 2024:jnis-2024-021915. [PMID: 38937083 DOI: 10.1136/jnis-2024-021915] [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: 05/01/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The optimal management of tandem carotid lesions during endovascular thrombectomy (EVT) remains uncertain. The safety and efficacy of acute carotid artery stenting (aCAS) are debated, including safety concerns such as procedural complications and symptomatic intracerebral hemorrhage (sICH). We aimed to assess aCAS safety among EVT-treated patients using a large Canadian registry. METHODS We retrospectively analyzed the OPTIMISE registry and compared adult patients undergoing EVT and aCAS versus EVT only. The primary outcome was a composite of in-hospital death, long-term care facility destination at discharge, sICH, or any EVT-related procedural complications. Secondary outcomes included individual components of the primary outcome, EVT workflow times, final modified Thrombolysis in Cerebral Ischemia score and 90-day modified Rankin Scale score. Statistical significance was evaluated by a multivariate logistic regression model. RESULTS 4205 patients were included (330 with EVT-aCAS and 3875 with EVT-only). Both groups were similar with regard to baseline National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score and use of IV thrombolysis, but differed in age (EVT-aCAS group 67.2±12.1 years vs EVT-only group 71.3±14.1 years, P<0.001), proportion of women (28.2% vs 53.3%, P<0.001), and occlusion location (internal carotid artery terminus 44% vs 16%, P<0.001). The EVT-aCAS group showed a non-significant increase in odds of composite safety outcomes (adjusted OR 1.35 (95% CI 0.97 to 1.84), P=0.06) with a significantly higher proportion of procedural complications (10.0% vs 6.2%, P=0.002). CONCLUSION In a large national registry, EVT-aCAS was associated with a higher proportion of unfavorable safety outcomes, driven by more frequent procedural complications. Further research is needed to clarify the role of aCAS in tandem occlusion stroke.
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Affiliation(s)
- George Nilton Mendes
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
| | - Grégory Jacquin
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
| | - Aristeidis H Katsanos
- Medicine (Neurology), McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Nishita Singh
- Internal Medicine (Neurology), University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Grant Stotts
- Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Darren B Ferguson
- Diagnostic Radiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Samuel Yip
- Medicine (Neurology), The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexandre Y Poppe
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
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Huang Y, Shi W, He Q, Tan J, Tong J, Yu B. Racial and ethnic influences on carotid atherosclerosis: Epidemiology and risk factors. SAGE Open Med 2024; 12:20503121241261840. [PMID: 39045542 PMCID: PMC11265241 DOI: 10.1177/20503121241261840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Accepted: 05/28/2024] [Indexed: 07/25/2024] Open
Abstract
Carotid atherosclerosis-related stenosis, marked by atherosclerotic plaque formation in the carotid artery, significantly increases ischemic stroke risk. Its prevalence varies across ethnic groups, reflecting racial disparities. Epidemiological studies have highlighted different susceptibilities to carotid stenosis among racial groups. Native Americans and Whites show greater vulnerability, indicating genetic and environmental influences. The impact of carotid stenosis is more severe in Hispanic and Black populations, with a higher incidence of related brain injuries, underscoring the need for targeted interventions. Comparative imaging studies between Chinese and White individuals reveal unique patterns of carotid stenosis, enhancing understanding of its pathophysiology and management across ethnicities. This review also categorizes risk factors, distinguishing those with racial disparity (such as genetic loci, sleep apnea, and emotional factors, socioeconomic status) from those without. In summary, racial disparities affect carotid stenosis, leading to varying susceptibilities and outcomes among ethnic groups. Recognizing these differences is essential for developing effective prevention, diagnosis, and management strategies. Addressing these disparities is critical to reducing ischemic stroke's burden across populations. Continued research and targeted interventions are crucial to improve outcomes for individuals at risk of carotid stenosis and its complications.
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Affiliation(s)
- Yijun Huang
- Department of General Surgery, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Weihao Shi
- Department of General Surgery, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Qing He
- Department of General Surgery, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jinyun Tan
- Department of General Surgery, Huashan Hospital Affiliated to Fudan University, Shanghai, China
| | - Jindong Tong
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
- Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
| | - Bo Yu
- Department of General Surgery, Huashan Hospital Affiliated to Fudan University, Shanghai, China
- Department of Vascular Surgery, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
- Shanghai Key Laboratory of Vascular Lesions Regulation and Remodeling, Shanghai Pudong Hospital, Fudan University Pudong Medical Center, Shanghai, China
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Li R, Sidawy A, Nguyen BN. Comparative assessment of racial disparity in 30-day outcomes for Asian Americans undergoing carotid endarterectomy. J Vasc Surg 2024; 79:1132-1141. [PMID: 38142944 DOI: 10.1016/j.jvs.2023.12.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 11/29/2023] [Accepted: 12/19/2023] [Indexed: 12/26/2023]
Abstract
OBJECTIVE Carotid endarterectomy (CEA) is an effective treatment for carotid stenosis. All previous studies on racial disparity of CEA outcomes omitted Asian Americans. This study aimed to address this gap by investigating racial disparities in 30-day outcomes following CEA among Asian Americans. METHODS Asian American and Caucasian patients who underwent CEA were identified in the American College of Surgeons National Surgical Quality Improvement Program targeted database from 2011 to 2021. Patients with age less than 18 years old were excluded. Patients with symptomatic and asymptomatic carotid stenosis were examined separately. A 1:5 propensity-score matching was used to address preoperative differences. Thirty perioperative outcomes were assessed. RESULTS There were 380 Asian Americans (2.27%) and 13,250 Caucasians (79.18%) with symptomatic carotid stenosis who underwent CEA. Also, 289 Asian Americans (1.40%) and 18,257 Caucasians (88.14%) with asymptomatic carotid stenosis had CEA. Asian Americans undergoing CEA presented with higher comorbid burdens and more severe symptomology. Also, asymptomatic Asian Americans were more likely to undergo surgeries for mild stenosis (<50%), which is not in line with practice guidelines. After 1:5 propensity-matching, all symptomatic Asian Americans were matched to 1550 Caucasian patients, and all asymptomatic Asian Americans were matched to 1445 Caucasians; preoperative differences were addressed. Asian Americans exhibited low overall 30-day mortality (symptomatic, 1.61%; asymptomatic, 0.35%) and stroke (symptomatic, 2.26%; asymptomatic, 0.69%). All perioperative outcomes were comparable to Caucasians, with the exception that Asian Americans experienced longer operation times. CONCLUSIONS Evidence suggested that Asian Americans with asymptomatic stenosis were underrepresented in CEA. After propensity-score matching, Asian Americans demonstrated comparable 30-day outcomes to Caucasians. These suggest that, when afforded equal access to quality health care, CEA serves as an effective treatment for carotid stenosis among Asian Americans. Therefore, efforts may be aimed at addressing health care access, potentially in the screening for asymptomatic carotid stenosis in Asian Americans. This would ensure they have equitable benefits from CEA. Nevertheless, the exact preoperative differences and long-term CEA outcomes in Asian Americans should warrant further examination in future studies.
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Affiliation(s)
- Renxi Li
- The George Washington University School of Medicine and Health Sciences, Washington, DC.
| | - Anton Sidawy
- The George Washington University Hospital, Department of Surgery, Washington, DC
| | - Bao-Ngoc Nguyen
- The George Washington University Hospital, Department of Surgery, Washington, DC
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Harish KB, Speranza G, Rockman CB, Sadek M, Jacobowitz GR, Garg K, Teter KA, Maldonado TS. Natural history of internal carotid artery stenosis progression. J Vasc Surg 2024; 79:297-304. [PMID: 37925038 DOI: 10.1016/j.jvs.2023.10.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 10/23/2023] [Accepted: 10/30/2023] [Indexed: 11/06/2023]
Abstract
OBJECTIVE The aim of this study was to investigate the natural history of internal carotid artery (ICA) stenosis progression. METHODS This single-institution retrospective cohort study analyzed patients diagnosed with ICA stenosis of 50% or greater on duplex ultrasound from 2015 to 2022. Subjects were drawn from our institutional Intersocietal Accreditation Commission-accredited noninterventional vascular laboratory database. Primary outcomes were incidences of disease progression, and stroke or revascularization after index study. Progression was defined as an increase in stenosis classification category. Imaging, demographic, and clinical data was obtained from our institutional electronic medical record via a database mining query. Cases were analyzed at the patient and artery levels, with severity corresponding to the greatest degree of ICA stenosis on index and follow-up studies. RESULTS Of 577 arteries in 467 patients, mean cohort age was 73.5 ± 8.9 years at the time of the index study, and 45.0% (n = 210) were female. Patients were followed with duplex ultrasound for a mean of 42.2 ± 22.7 months. Of 577 arteries, 65.5% (n = 378) at the index imaging study had moderate (50%-69%) stenosis, 23.7% (n = 137) had severe (70%-99%) stenosis, and 10.7% (n = 62) were occluded. These three groups had significant differences in age, hypertension, hyperlipidemia prevalence, and proportion on best medical therapy. Of the 467-patient cohort, 56.5% (n = 264) were on best medical therapy, defined as smoking cessation, treatment with an antiplatelet agent, statin, and antihypertensive and glycemic agents as indicated. Mean time to progression for affected arteries was 28.0 ± 20.5 months. Of those arteries with nonocclusive disease at diagnosis, 21.3% (n = 123) progressed in their level of stenosis. Older age, diabetes, and a history of vasculitis were associated with stenosis progression, whereas antiplatelet agent use trended towards decreased progression rates. Of the 467 patients, 5.6% (n = 26) developed symptoms; of those, 38.5% (n = 10) had ischemic strokes, 26.9% (n = 7) had hemispheric transient ischemic attacks, 11.5% (n = 3) had amaurosis fugax, and 23.1% (n = 6) had other symptoms. A history of head and neck cancer was positively associated with symptom development. Of 577 affected arteries, 16.6% (n = 96) underwent intervention; 81% (n = 78) of interventions were for asymptomatic disease and 19% (n = 18) were for symptomatic disease. No patient-level factors were associated with risk of intervention. CONCLUSIONS A significant number of carotid stenosis patients experience progression of disease. Physicians should consider long-term surveillance on all patients with carotid disease, with increased attention paid to those with risk factors for progression, particularly those with diabetes and a history of vasculitis.
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Affiliation(s)
| | | | - Caron B Rockman
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Mikel Sadek
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Glenn R Jacobowitz
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Karan Garg
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Katherine A Teter
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY
| | - Thomas S Maldonado
- Division of Vascular Surgery, Department of Surgery, New York University Langone Health, New York, NY.
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Teramoto M, Kokubo Y, Arafa A, Kashima R, Nakao YM, Sheerah HA, Kataoka H. Common Carotid Artery Stenosis Degree as a Predictor of Cardiovascular Disease in a General Population: The Suita Study. J Am Heart Assoc 2024; 13:e030828. [PMID: 38116928 PMCID: PMC10863812 DOI: 10.1161/jaha.123.030828] [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: 05/02/2023] [Accepted: 10/31/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND The utility of screening for the degree of common carotid artery (CCA) stenosis as a predictor of cardiovascular disease (CVD) in a general population remains unclear. METHODS AND RESULTS We studied 4775 Japanese men and women whose CCA was measured using bilateral carotid ultrasonography at baseline (April 1994-August 2001). We calculated the degree of stenosis as a percentage of the stenotic area of the lumen in the cross-section perpendicular to the long axis. The Cox proportional hazards model was used to calculate multivariable-adjusted hazard ratios (HRs) with 95% CIs for incident CVD and its subtypes according to the degree of CCA stenosis. During the median 14.2 years of follow-up, 385 incident CVD events (159 coronary heart disease and 226 stroke) were documented. The degree of CCA stenosis was associated with increased risks of incident CVD, coronary heart disease, and stroke, with multivariable-adjusted HRs (95% CIs) for <25%, 25%-49%, and ≥50% stenosis with plaque compared with no CCA plaque of 1.37 (1.07-1.76), 1.72 (1.23-2.40), and 2.49 (1.69-3.67), respectively. Adding the CCA stenosis degree to traditional CVD risk factors increased Harrell's C statistics (0.772 [95% CI, 0.751-0.794] to 0.778 [95% CI, 0.758-0.799]; P=0.04) and improved the 10-year risk prediction ability (integrated discrimination improvement, 0.0129 [95% CI, 0.0078-0.0179]; P<0.001; continuous net reclassification improvement, 0.1598 [95% CI, 0.0297-0.2881]; P=0.01). CONCLUSIONS The degree of CCA stenosis may be used as a predictive marker for the development of CVD in the general population.
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Affiliation(s)
- Masayuki Teramoto
- Department of Preventive CardiologyNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Yoshihiro Kokubo
- Department of Preventive CardiologyNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Ahmed Arafa
- Department of Preventive CardiologyNational Cerebral and Cardiovascular CenterSuitaJapan
- Department of Public Health, Faculty of MedicineBeni‐Suef UniversityBeni‐SuefEgypt
| | - Rena Kashima
- Department of Preventive CardiologyNational Cerebral and Cardiovascular CenterSuitaJapan
- Department of Cardiovascular Pathophysiology and Therapeutics, Graduate School of MedicineOsaka UniversitySuitaJapan
| | - Yoko M. Nakao
- Leeds Institute of Cardiovascular and Metabolic MedicineUniversity of LeedsLeedsUnited Kingdom
| | - Haytham A. Sheerah
- Department of Preventive CardiologyNational Cerebral and Cardiovascular CenterSuitaJapan
| | - Hiroharu Kataoka
- Department of NeurosurgeryNational Cerebral and Cardiovascular CenterSuitaJapan
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Di Donna A, Muto G, Giordano F, Muto M, Guarnieri G, Servillo G, De Mase A, Spina E, Leone G. Diagnosis and management of tandem occlusion in acute ischemic stroke. Eur J Radiol Open 2023; 11:100513. [PMID: 37609048 PMCID: PMC10440394 DOI: 10.1016/j.ejro.2023.100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.
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Affiliation(s)
- Antonio Di Donna
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluca Muto
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Massimo Muto
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluigi Guarnieri
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giovanna Servillo
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Antonio De Mase
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Emanuele Spina
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giuseppe Leone
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
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Bose S, McDermott KM, Keegan A, Black JH, Drudi LM, Lum YW, Zarkowsky DS, Hicks CW. Socioeconomic status fails to account for worse outcomes in non-Hispanic black patients undergoing carotid revascularization. J Vasc Surg 2023; 78:1248-1259.e1. [PMID: 37419427 PMCID: PMC10615195 DOI: 10.1016/j.jvs.2023.06.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/08/2023] [Accepted: 06/28/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE Previous studies have reported an association of Black race with worse carotid revascularization outcomes, but rarely include socioeconomic status as a confounding covariate. We aimed to assess the association of race and ethnicity with in-hospital and long-term outcomes following carotid revascularization before and after accounting for socioeconomic status. METHODS We identified non-Hispanic Black and non-Hispanic white patients who underwent carotid endarterectomy, transfemoral carotid stenting, or transcarotid artery revascularization between 2003 and 2022 in the Vascular Quality Initiative. Primary outcomes were in-hospital stroke/death and long-term stroke/death. Multivariable logistic regression and Cox proportional hazards models were used to assess the association of race with perioperative and long-term outcomes after adjusting for baseline characteristics using a sequential model approach without and with consideration of Area Deprivation Index (ADI), a validated composite marker of socioeconomic status. RESULTS Of 201,395 patients, 5.1% (n = 10,195) were non-Hispanic Black, and 94.9% (n = 191,200) were non-Hispanic white. Mean follow-up time was 3.4±0.01 years. A disproportionately high percentage of Black patients were living in more socioeconomically deprived neighborhoods relative to their white counterparts (67.5% vs 54.2%; P < .001). After adjusting for demographic, comorbidity, and disease characteristics, Black race was associated with greater odds of in-hospital (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.10-1.40) and long-term stroke/death (adjusted hazard ratio [aHR], 1.13; 95% CI, 1.04-1.23). These associations did not substantially change after additionally adjusting for ADI; Black race was persistently associated with greater odds of in-hospital (aOR, 1.23; 95% CI, 1.09-1.39) and long-term stroke/death (aHR, 1.12; 95% CI, 1.03-1.21). Patients living in the most deprived neighborhoods were at greater risk of long-term stroke/death compared with patients living in the least deprived neighborhoods (aHR, 1.19; 95% CI, 1.05-1.35). CONCLUSIONS Non-Hispanic Black race is associated with worse in-hospital and long-term outcomes following carotid revascularization despite accounting for neighborhood socioeconomic deprivation. There appears to be unrecognized gaps in care that prevent Black patients from experiencing equitable outcomes following carotid artery revascularization.
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Affiliation(s)
- Sanuja Bose
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Alana Keegan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
- Department of Surgery, Sinai Hospital of Baltimore, Baltimore, MD
| | - James H. Black
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Laura M. Drudi
- Division of Vascular Surgery, Department of Surgery, Centre Hospitalier de l’Université de Montréal, Montreal, Québec, Canada
| | - Ying-Wei Lum
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | | | - Caitlin W. Hicks
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
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Ferreira NV, Bertola L, Santos IS, Goulart AC, Bittencourt MS, Barreto SM, Giatti L, Caramelli P, Pereira A, Lotufo PA, Bensenor IM, Suemoto CK. Association between carotid intima-media thickness and cognitive decline differs by race. Alzheimers Dement 2023; 19:3528-3536. [PMID: 36825689 DOI: 10.1002/alz.12996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
INTRODUCTION Common carotid intima-media thickness (cIMT) is a marker of subclinical atherosclerosis and is associated with cognitive decline. Although carotid atherosclerosis is more frequent in White than in Black participants, little is known whether race modifies the association between cIMT and cognitive decline. METHODS In this longitudinal analysis of the ELSA-Brasil, we assessed cIMT using ultrasound and cognitive performance using different domain tests. We used linear mixed models, interaction analysis, and race stratified analyses. RESULTS Baseline high IMT values were associated with memory (p < 0.001), verbal fluency (p < 0.001), TMT-B (p < 0.001)), and global cognitive decline (p < 0.001). Race was an effect modifier in the association between IMT and global cognitive decline (0.043), with stronger association in White (p < 0.001) than in Black (p = 0.009) participants. DISCUSSION Baseline IMT was associated with global and domain-specific cognitive decline and race modified this relationship, with stronger associations in White participants. HIGHLIGHTS Carotid intima-media thickness (cIMT) was associated with cognitive decline. cIMT and cognitive decline association was stronger in White than in Black participants. We used inverse probability weighting to address attrition bias.
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Affiliation(s)
- Naomi Vidal Ferreira
- Center for Clinical and Epidemiological Research, Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil
- Adventist University of Sao Paulo, Engenheiro Coelho, Sao Paulo, Brazil
- Amazonia Adventist College, Benevides, Pará, Brazil
| | - Laiss Bertola
- Department of Psychiatry, Escola Paulista de Medicina, Universidade Federal de Sao Paulo, Sao Paulo, Brazil
| | - Itamar S Santos
- Center for Clinical and Epidemiological Research, Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil
- Department of Internal Medicine, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Alessandra C Goulart
- Center for Clinical and Epidemiological Research, Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Marcio S Bittencourt
- Division of Cardiology, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Sandhi Maria Barreto
- Departamento de Medicina Preventiva e Social, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Luana Giatti
- School of Medicine and Clinical Hospital, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Paulo Caramelli
- Behavioral and Cognitive Research Group, Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
| | - Alexandre Pereira
- Heart Institute, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Paulo Andrade Lotufo
- Center for Clinical and Epidemiological Research, Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil
- Department of Internal Medicine, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Isabela M Bensenor
- Center for Clinical and Epidemiological Research, Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil
- Department of Internal Medicine, University of Sao Paulo Medical School, Sao Paulo, Brazil
| | - Claudia Kimie Suemoto
- Division of Geriatrics, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Sao Paulo, Brazil
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Banks CA, Pearce BJ. Interventions in Carotid Artery Surgery: An Overview of Current Management and Future Implications. Surg Clin North Am 2023; 103:645-671. [PMID: 37455030 DOI: 10.1016/j.suc.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Atherosclerotic carotid artery disease has been well studied over the last half-century by multiple randomized controlled trials attempting to elucidate the appropriate modality of therapy for this disease process. Surgical techniques have evolved from carotid artery endarterectomy and transfemoral carotid artery stenting to the development of hybrid techniques in transcarotid artery revascularization. In this article, the authors provide a review of the available literature regarding operative and medical management of carotid artery disease.
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Affiliation(s)
- Charles Adam Banks
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA
| | - Benjamin J Pearce
- Division of Vascular Surgery and Endovascular Therapy, University of Alabama at Birmingham, 1808 7th Avenue South, Boshell Diabetes Building 652, Birmingham, AL 35294, USA.
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Tuwar MN, Chen WH, Chiwaya AM, Yeh HL, Nguyen MH, Bai CH. Brain-Derived Neurotrophic Factor (BDNF) and Translocator Protein (TSPO) as Diagnostic Biomarkers for Acute Ischemic Stroke. Diagnostics (Basel) 2023; 13:2298. [PMID: 37443691 DOI: 10.3390/diagnostics13132298] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/11/2023] [Accepted: 07/04/2023] [Indexed: 07/15/2023] Open
Abstract
Brain-derived neurotrophic factor (BDNF) interacts with tropomyosin-related kinase B (TrkB) to promote neuronal growth, survival, differentiation, neurotransmitter release, and synaptic plasticity. The translocator protein (TSPO) is known to be found in arterial plaques, which are a symptom of atherosclerosis and a contributory cause of ischemic stroke. This study aims to determine the diagnostic accuracy of plasma BDNF and TSPO levels in discriminating new-onset acute ischemic stroke (AIS) patients from individuals without acute ischemic stroke. A total of 90 AIS patients (61% male, with a mean age of 67.7 ± 12.88) were recruited consecutively in a stroke unit, and each patient was paired with two age- and gender-matched controls. The sensitivity, specificity, and area of the curve between high plasma BDNF and TSPO and having AIS was determined using receiver operating characteristic curves. Furthermore, compared to the controls, AIS patients exhibited significantly higher levels of BDNF and TSPO, blood pressure, HbA1c, and white blood cells, as well as higher creatinine levels. The plasma levels of BDNF and TSPO can significantly discriminate AIS patients from healthy individuals (AUC 0.76 and 0.89, respectively). However, combining the two biomarkers provided little improvement in AUC (0.90). It may be possible to use elevated levels of TSPO as a diagnostic biomarker in patients with acute ischemic stroke upon admission.
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Affiliation(s)
- Mayuri N Tuwar
- School of Public Health, College of Public Health, Taipei Medical University, Taipei 106236, Taiwan
| | - Wei-Hung Chen
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111045, Taiwan
| | - Arthur M Chiwaya
- CLIME Group, Department of Biomedical Sciences, Division of Molecular Biology and Human Genetics, FMHS, Stellenbosch University, Francie Van Zijl Drive, Tygerberg, Cape Town 7505, South Africa
| | - Hsu-Ling Yeh
- Department of Neurology, Shin Kong Wu Ho-Su Memorial Hospital, Taipei 111045, Taiwan
| | - Minh H Nguyen
- School of Preventive Medicine and Public Health, Hanoi Medical University, Hanoi 100000, Vietnam
| | - Chyi-Huey Bai
- School of Public Health, College of Public Health, Taipei Medical University, Taipei 106236, Taiwan
- School of Medicine, College of Medicine, Taipei Medical University, Taipei 106236, Taiwan
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11
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Ismail A, Ravipati S, Gonzalez-Hernandez D, Mahmood H, Imran A, Munoz EJ, Naeem S, Abdin ZU, Siddiqui HF. Carotid Artery Stenosis: A Look Into the Diagnostic and Management Strategies, and Related Complications. Cureus 2023; 15:e38794. [PMID: 37303351 PMCID: PMC10250083 DOI: 10.7759/cureus.38794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/09/2023] [Indexed: 06/13/2023] Open
Abstract
Carotid stenosis (CS) is a buildup of atherosclerotic plaque within the artery leading to a wide range of symptoms, from mild symptoms, including blurred vision and confusion, to much more life-threatening presentations, including paralysis due to stroke. The presentation is insidious, with symptoms exhibiting predominantly at severe stenosis; hence the emphasis is placed on the importance of early diagnosis, treatment, and lifestyle modifications. CS is seen undergoing almost the same pathogenesis of any atherosclerotic plaque formation, from endothelial damage of the artery lumen to the formation of a fibrous cap with a foam cell, lipid-filled core. The findings of our review article were consistent with the recent literature, depicting that comorbid hypertension, diabetes, and chronic kidney disease (CKD), and lifestyle aspects, including smoking and diet, played the most salient role in plaque development. Among several imaging modalities, duplex ultrasound (DUS) imaging is the widely preferred method in clinical practice. Carotid endarterectomy (CEA) and carotid stenting are the primarily advocated procedures for symptomatic severe stenosis, with similar long-term outcomes. Although, earlier clinical trials showed promising results in mitigating the risk of stroke among asymptomatic severe CS with surgical intervention. However, recent advancements have shifted the focus to medical management alone due to comparable results among the asymptomatic population. Both surgical and medical regimens are beneficial in treating patients, but it is still an ongoing debate as to which is predominantly superior. The currently advancing trials and research will help elucidate definitive guidelines. However, the massive impact of lifestyle modifications advocates some degree of individualized multidisciplinary management strategies.
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Affiliation(s)
- Aqsa Ismail
- Department of Medicine, United Medical and Dental College, Karachi, PAK
| | - Shivani Ravipati
- Department of Medicine, Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Vijayawada, IND
| | | | - Hashim Mahmood
- Department of Medicine, University College of Medicine and Dentistry, University of Lahore, Lahore, PAK
| | - Alizay Imran
- Department of Surgery, Windsor University School of Medicine, Chicago, USA
| | - Eduardo J Munoz
- Department of General Medicine, Montemorelos University, Montemorelos, MEX
| | - Saad Naeem
- Department of Internal Medicine, Faisalabad Medical University, Faisalabad, PAK
- Department of Internal Medicine, Punjab Social Security Hospital, Faisalabad, PAK
| | - Zain U Abdin
- Department of Medicine, District Head Quarters Hospital, Faisalabad, PAK
| | - Humza F Siddiqui
- Department of Medicine, Jinnah Sindh Medical University, Karachi, PAK
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12
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Miura Y, Suzuki H. Hypertriglyceridemia and Atherosclerotic Carotid Artery Stenosis. Int J Mol Sci 2022; 23:ijms232416224. [PMID: 36555866 PMCID: PMC9785250 DOI: 10.3390/ijms232416224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Both fasting and non-fasting hypertriglyceridemia have emerged as residual risk factors for atherosclerotic disease. However, it is unclear whether hypertriglyceridemia increases the risks of the progression of carotid artery stenosis. Statins are well known to prevent carotid plaque progression and improve carotid plaque instability. In addition, statin therapy is also known to reduce cerebrovascular events in patients with carotid artery stenosis and to improve clinical outcomes in patients undergoing revascularization procedures. On the other hand, there have been no randomized controlled trials showing that the combination of non-statin lipid-lowering drugs with statins has additional beneficial effects over statin monotherapy to prevent cerebrovascular events and stenosis progression in patients with carotid artery stenosis. In this article, the authors demonstrate the mechanisms of atherosclerosis formation associated with hypertriglyceridemia and the potential role of lipid-lowering drugs on carotid artery stenosis. The authors also review the articles reporting the relationships between hypertriglyceridemia and carotid artery stenosis.
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Affiliation(s)
| | - Hidenori Suzuki
- Correspondence: ; Tel.: +81-59-232-1111; Fax: +81-59-231-5212
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13
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Lee M, Ahmed ZV, Huang J, Brice A, Arham A, Castro-Dominguez Y, Aboian E, Nagpal S, Smolderen KG, Mena-Hurtado C. Antiplatelet regimens following carotid artery revascularization. Am Heart J 2022; 253:48-52. [PMID: 35863439 DOI: 10.1016/j.ahj.2022.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 07/06/2022] [Accepted: 07/07/2022] [Indexed: 06/15/2023]
Abstract
Dual antiplatelet therapy (DAPT) is indicated following carotid artery stenting (CAS) and single antiplatelet therapy (SAPT) following carotid endarterectomy (CEA), but it remains unknown how providers adhere to these guidelines in real-world clinical practice. Using the Vascular Quality Initiative New England data, we found that of 12,257 patients, 82% patients were discharged on DAPT following CAS and 66% were discharged on SAPT following CEA. While a high percentage of patients undergoing CAS appropriately receive DAPT, the use of SAPT following CEA exists with more variability and lower adherence rates.
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Affiliation(s)
- Megan Lee
- Yale School of Medicine, Yale New Haven Health System, CT
| | - Zain V Ahmed
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Jiaming Huang
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Aaron Brice
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Ahmad Arham
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Yulanka Castro-Dominguez
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Edouard Aboian
- Department of Vascular Surgery, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Sameer Nagpal
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Kim G Smolderen
- Department of Vascular Surgery, Yale New Haven Health System, Yale School of Medicine, New Haven, CT; Department of Psychiatry, Yale New Haven Health System, Yale School of Medicine, New Haven, CT
| | - Carlos Mena-Hurtado
- Department of Cardiovascular Medicine, Yale New Haven Health System, Yale School of Medicine, New Haven, CT.
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14
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MicroRNA and Hemostasis Profile of Carotid Atherosclerosis. Int J Mol Sci 2022; 23:ijms231810974. [PMID: 36142883 PMCID: PMC9500617 DOI: 10.3390/ijms231810974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 11/24/2022] Open
Abstract
Carotid atherosclerosis (CA) is an important risk factor for ischemic stroke. We described the miRNA and hemostasis profile of patients with moderate and advanced stages of carotid atherosclerosis and elucidated potential correlations with hemostatic activation. A prospective case-control study included 61 patients with evidence of carotid atherosclerosis (via ultrasound). The study population was divided into groups depending on the degree of carotid artery stenosis: 60% or more (advanced) and <60% (moderate). All patients underwent the following blood tests: general blood test, hemostatic parameters and microRNA. Extraction of microRNA was performed using Leukocyte RNA Purification Kit (NORGEN Biotec Corp., Thorold, ON, Canada); miRNA quantification was performed via RT-PCR. Statistical analysis was performed in R programming language (v. 4.1.0) using RSudio. MicroRNA expression profile was different depending on CA degree. MiR-33a-5p/3p levels were higher in patients with ≥60% carotid stenosis (42.70 and 42.45 versus 38.50 and 38.50, respectively, p < 0.05). Almost complete separation can be visualized with the levels of miR-126-5p: 9.50 in the moderate CA group versus 5.25 in the advanced CA (p < 0.001). MiR-29-5p was higher in the moderate CA group: 28.60 [25.50;33.05] than in advanced CA group: 25.75 [24.38;29.50] (p = 0.086); miR-29-3p was also higher in the moderate CA group: 10.36 [8.60;14.99] than in advanced CA group: 8.46 [7.47;10.3] (p = 0.001). By-group pairwise correlation analyses revealed at least three clusters with significant positive correlations in the moderate CA group: miR-29-3p with factors V and XII (r = 0.53 and r = 0.37, respectively, p < 0.05); miR-21-5p with ADAMTS13, erythrocyte sedimentation rate and D-dimer (r = 0.42, r = 0.36 and r = 0.44, respectively, p < 0.05); stenosis degree with miR-33a-5p/3p and factor VIII levels (r = 0.43 (both) and r = 0.62, respectively, p < 0.05). Hemostasis parameters did not reveal significant changes in CA patients: the only statistically significant differences concerned factor VIII, plasminogen and (marginally significant) ADAMTS-13 and protein C. Down-regulation of miR-126-5p expression has been identified as a promising biomarker of advanced carotid atherosclerosis with high specificity and sensitivity. Correlation cluster analysis showed potential interplay between miRNAs and hemostatic activation in the setting of carotid atherosclerosis.
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15
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Carcel C, Caso V, Aguiar de Sousa D, Sandset EC. Sex differences in neurovascular disorders. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2022; 164:69-99. [PMID: 36038210 DOI: 10.1016/bs.irn.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Neurovascular disorders is a heterogenous group of diseases, including one of the most time critical disorders in emergency medicine; stroke. Sex differences are extensively described in neurovascular disorders, ranging from differences in symptom presentation, risk factors, treatment and outcomes. For example, women with stroke, more often present with generalized weakness, reduced consciousness and headache than men. Furthermore, there are differences in risk factors, outcomes and in the effect of secondary prevention. Women have a higher risk of cerebral venous thrombosis and developing cerebral aneurysms. In general, women have been underrepresented in trials on neurovascular disorders. This chapter provides an extensive overview of sex differences in stroke in general and in the differences specially seen in ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage and in cerebral venous thrombosis.
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Affiliation(s)
- Cheryl Carcel
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; Sydney School of Public Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Valeria Caso
- Stroke Unit, Santa Maria della Misericordia Hospital University of Perugia, Perugia, Italy
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital, Lisbon, Portugal; CEEM and Institute of Anatomy, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Else Charlotte Sandset
- Department of Neurology, Oslo University Hospital, Oslo, Norway; The Norwegian Air Ambulance Foundation, Oslo, Norway.
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16
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Tang ASP, Chan KE, Quek J, Xiao J, Tay P, Teng M, Lee KS, Lin SY, Myint MZ, Tan B, Sharma VK, Tan DJH, Lim WH, Kaewdech A, Huang D, Chew NWS, Siddiqui MS, Sanyal AJ, Muthiah M, Ng CH. Non-alcoholic fatty liver disease increases risk of carotid atherosclerosis and ischemic stroke: An updated meta-analysis with 135,602 individuals. Clin Mol Hepatol 2022; 28:483-496. [PMID: 35232007 PMCID: PMC9293613 DOI: 10.3350/cmh.2021.0406] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 03/02/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/AIMS Non-alcoholic fatty liver disease (NAFLD) is associated with the development of cardiovascular disease. While existing studies have examined cardiac remodeling in NAFLD, there has been less emphasis on the development of carotid atherosclerosis and stroke. We sought to conduct a meta-analysis to quantify the prevalence, risk factors, and degree of risk increment of carotid atherosclerosis and stroke in NAFLD. METHODS Embase and Medline were searched for articles relating to NAFLD, carotid atherosclerosis, and stroke. Proportional data was analysed using a generalized linear mixed model. Pairwise meta-analysis was conducted to obtain odds ratio or weighted mean difference for comparison between patients with and without NAFLD. RESULTS From pooled analysis of 30 studies involving 7,951 patients with NAFLD, 35.02% (95% confidence interval [CI], 27.36-43.53%) had carotid atherosclerosis with an odds ratio of 3.20 (95% CI, 2.37-4.32; P<0.0001). Pooled analysis of 25,839 patients with NAFLD found the prevalence of stroke to be 5.04% (95% CI, 2.74-9.09%) with an odds ratio of 1.88 (95% CI, 1.23-2.88; P=0.02) compared to non-NAFLD. The degree of steatosis assessed by ultrasonography in NAFLD was closely associated with risk of carotid atherosclerosis and stroke. Older age significantly increased the risk of developing carotid atherosclerosis, but not stroke in NAFLD. CONCLUSION This meta-analysis shows that a stepwise increment of steatosis of NAFLD can significantly increase the risk of carotid atherosclerosis and stroke development in NAFLD. Patients more than a third sufferred from carotid atherosclerosis and routine assessment of carotid atherosclerosis is quintessential in NAFLD.
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Affiliation(s)
- Ansel Shao Pin Tang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Kai En Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jingxuan Quek
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Jieling Xiao
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Phoebe Tay
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Margaret Teng
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
| | - Keng Siang Lee
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Snow Yunni Lin
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - May Zin Myint
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin Tan
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Darren Jun Hao Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Wen Hui Lim
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Apichat Kaewdech
- Gastroenterology and Hepatology Unit, Division of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Daniel Huang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
| | - Nicholas WS Chew
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, National University Hospital, Singapore
| | - Mohammad Shadab Siddiqui
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Arun J Sanyal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University, Richmond, VA, USA
| | - Mark Muthiah
- Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Singapore
- National University Centre for Organ Transplantation, National University Health System, Singapore
- Mark Muthiah Division of Gastroenterology and Hepatology, Department of Medicine, National University Hospital, Tower Block Level 10, 1E Kent Ridge Road, Singapore 119228, Singapore Tel: +65 6772 4354, Fax: +65 6775 1518, E-mail:
| | - Cheng Han Ng
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Corresponding author : Cheng Han Ng Yong Loo Lin School of Medicine, National University of Singapore, Singapore 10 Medical Dr, Singapore 117597, Singapore Tel: +65 6772 3737, Fax: +65 6778 5743, E-mail:
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17
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Gender, Racial, and Ethnic Disparities in Index Hospitalization Operations for Symptomatic Carotid Stenosis in Texas Hospitals. J Vasc Surg 2022. [DOI: 10.1016/j.jvs.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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18
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Abstract
The goal of the current review is to examine the hazards and benefits of carotid interventions in women and to provide recommendations for the indications for carotid intervention in female patients. Stroke and cerebrovascular disease are prevalent in women. There are inherent biological and other differences in men and women, which affect the manifestations and outcome of stroke, with women experiencing worse disability and higher mortality following ischemic stroke than men. Due to the underrepresentation of female patients in most clinical trials, the ability to make firm but alternative recommendations for women specifically on the management of carotid stenosis is challenging. Although some data suggest that women might have worse periprocedural outcomes as compared to men following all carotid revascularization procedures, there is also an abundance of data to support a similar risk for carotid procedures in men and women, especially with carotid endarterectomy and transcarotid artery revascularization. Therefore, the indications for carotid revascularization are the same in women as they are in men. The choice of a carotid revascularization procedure in women is based upon the same factors as in men and requires careful evaluation of a particular patient's risk profile, anatomic criteria, plaque morphology, and medical comorbidities that might favor one technique over the other. When performing carotid revascularization procedures in women, tailored techniques and procedures to address the small diameter of the female artery are warranted.
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Affiliation(s)
- Caron Rockman
- Division of Vascular Surgery, NYU Grossman School of Medicine, New York, NY (C.R.)
| | - Valeria Caso
- Department of Cardiovascular Medicine, Santa Maria Della Misericordia Hospital, University of Perugia, Italy (V.C.)
| | - Peter A Schneider
- Division of Vascular and Endovascular Surgery, University of California San Francisco (P.A.S.)
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Mallela DP, Canner JK, Zarkowsky DS, Haut ER, Abularrage CJ, Hicks CW. Association between Race and Perioperative Outcomes after Carotid Endarterectomy for Asymptomatic Carotid Artery Stenosis in NSQIP. J Am Coll Surg 2022; 234:65-73. [PMID: 35213462 PMCID: PMC9860456 DOI: 10.1097/xcs.0000000000000016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Previous studies have documented that Black patients have worse outcomes after lower extremity revascularization procedures compared with White patients. However, the association of race on carotid endarterectomy (CEA) outcomes is not well described. The aim of this study was to compare perioperative outcomes of CEA for Black vs White patients with asymptomatic carotid artery stenosis. STUDY DESIGN All patients who underwent CEA for asymptomatic carotid stenosis in the ACS-NSQIP targeted vascular database (2011-2019) were included. Perioperative (30-day) outcomes were compared for Black vs White patients using multivariable logistic regression adjusting for age/sex, comorbidities, and disease characteristics. RESULTS Of 16,764 asymptomatic CEA patients, 95.2% (N = 15,960) were White and 4.8% (N = 804) were Black. Black patients were slightly younger (mean age 71.4 ± 0.1 vs 69.9 ± 0.3 years, P < 0.001) and more frequently had high-grade carotid artery stenosis compared to White patients (79.5% vs 74.0%, p = 0.001). Comorbidities including hypertension, diabetes, kidney disease, congestive heart failure, and coronary artery disease were all more prevalent among Black patients (p ≤ 0.01). Crude perioperative stroke (2.4% vs 1.3%, p = 0.007) and stroke/death (2.6% vs 1.4%, p = 0.003) were higher for Black patients, but myocardial infarction (1.7% vs 1.5%, p = 0.67) and death (0.4% vs 0.2%, p = 0.12) were similar. After adjusting for baseline differences between groups, the risk of perioperative stroke (odds ratio 1.66, 95% CI 1.01 to 2.73) and stroke/death (odds ratio 1.75, 95% CI 1.10 to 2.81) remained significantly higher for Black patients compared with White patients. CONCLUSIONS Black patients undergoing CEA for asymptomatic carotid artery stenosis had more severe stenosis, more comorbidities, and worse perioperative outcomes compared to White patients. Overall, our data suggest substantial differences in the treatment and outcomes of asymptomatic carotid artery stenosis based on race.
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Affiliation(s)
- Deepthi P Mallela
- From the Division of Vascular Surgery and Endovascular Therapy (Mallela, Abularrage, Hicks), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Joseph K Canner
- the Department of Surgery, Yale University School of Medicine, New Haven, CT (Canner)
| | - Devin S Zarkowsky
- the Division of Vascular Surgery, University of Colorado School of Medicine, Aurora, CO (Zarkowsky)
| | - Elliott R Haut
- the Division of Acute Care Surgery (Haut), Johns Hopkins University School of Medicine, Baltimore, MD
- the Department of Anesthesiology and Critical Care Medicine (Haut), Johns Hopkins University School of Medicine, Baltimore, MD
- the Department of Emergency Medicine (Haut), Johns Hopkins University School of Medicine, Baltimore, MD
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD (Haut)
- the Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD (Haut)
| | - Christopher J Abularrage
- From the Division of Vascular Surgery and Endovascular Therapy (Mallela, Abularrage, Hicks), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Caitlin W Hicks
- From the Division of Vascular Surgery and Endovascular Therapy (Mallela, Abularrage, Hicks), Johns Hopkins University School of Medicine, Baltimore, MD
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20
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Gender, racial and ethnic disparities in index hospitalization operations for symptomatic carotid stenosis in Texas hospitals. Ann Vasc Surg 2021; 80:152-157. [PMID: 34687890 DOI: 10.1016/j.avsg.2021.08.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Recent literature and societal recommendations support early revascularization of symptomatic carotid patients over the traditional six-week period. Nonetheless, the timing of these interventions can vary widely among populations. The goal of this study is to identify any factors influencing carotid revascularization during the index hospitalization for patients with symptomatic disease. METHODS The Texas Department of State Health Services database was queried to identify all patients > 45 years old admitted to nonfederal Texas Hospitals between 2009 to 2013 with an admission diagnosis of carotid artery stenosis and either transient ischemic attack (TIA), cerebrovascular accident (CVA), or amaurosis fugax. Diagnoses codes and demographic data were also used to adjust for clinical, social, and demographic factors (including area of residence and treatment). Descriptive statistics and multivariable logistic regression were used to identify significant factors for index admission revascularization. RESULTS A total of 29,046 symptomatic patients were identified among the 153,484 patients who had an eligible admission diagnosis. This included 16,244 (55.9%) males and 12,802 (44.1%) females. Only 4,594 (15.8%) patients were revascularized during the index hospitalization. The majority of these patients presented with amaurosis (OR 5.58; 95% CI 4.84-6.44) instead of CVAs (OR 0.48; 95% CI 0.45-0.51) or TIAs . Adjusting for hospital volume, insurance coverage, residence, and other clinical factors, rates of index admission carotid intervention remained significantly lower for women (OR 0.85; 95% CI 0.79-0.91), persons categorized as black (OR 0.60; 95% CI 0.53-0.69), and persons categorized as Hispanic (OR 0.77; 95% CI 0.70-0.86). CONCLUSIONS Gender, race and ethnicity appear to correlate with rates of carotid intervention at index hospitalization despite thorough risk adjustment for clinical, social and demographic factors. Efforts should be directed towards reducing these disparities.
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21
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Mettananda KCD, Eshani MDP, Wettasinghe LM, Somaratne S, Nanayakkkara YP, Sathkorala W, Upasena A, Sirigampola C, Tilakaratna PMY, Pathmeswaran A, Ranawaka UK. Prevalence and correlates of carotid artery stenosis in a cohort of Sri Lankan ischaemic stroke patients. BMC Neurol 2021; 21:385. [PMID: 34607563 PMCID: PMC8489097 DOI: 10.1186/s12883-021-02415-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 09/21/2021] [Indexed: 01/04/2023] Open
Abstract
Background Large artery atherosclerotic disease is an important cause of stroke, accounting for 15–46% of ischaemic strokes in population-based studies. Therefore, current guidelines from west recommend urgent carotid imaging in all ischaemic strokes or transient ischaemic attacks and referral for carotid endarterectomy. However, the clinical features and epidemiology of stroke in Asians are different from those in Caucasians and therefore the applicability of these recommendations to Asians is controversial. Data on the prevalence of carotid artery stenosis (CAS) among South Asian stroke patients is limited. Therefore, we sought to determine the prevalence and associated factors of significant CAS in a cohort of Sri Lankan patients with ischaemic stroke. Methods We prospectively studied all ischaemic stroke patients who underwent carotid doppler ultrasonography admitted to the stroke unit of a Sri Lankan tertiary care hospital over 5 years. We defined carotid stenosis as low (< 50%), moderate (50–69%) or severe (70–99%) or total-occlusion (100%) by North American Symptomatic Trial Collaborators (NASCET) criteria. We identified the factors associated with CAS ≥ 50% and ≥ 70% by stepwise multiple logistic regression analysis. Results A total of 550 ischaemic stroke patients (326 (59.3%) male, mean age was 58.9 ± 10.2 years) had carotid doppler ultrasonography. Of them, 528 (96.0%) had low-grade, 12 (2.2%) moderate and 7 (1.3%) severe stenosis and 3 (0.5%) had total occlusion. On multivariate logistic regression, age was associated with CAS ≥ 50% (OR 1.12, p = 0.001) and CAS ≥ 70% (OR 1.14, p = 0.016), but none of the other vascular risk factors studied (sex, hypertension, diabetes mellitus, smoking, past history of TIA, stroke or ischemic heart disease) showed significant associations. Conclusions Carotid stenosis is a minor cause of ischemic stroke in Sri Lankans compared to western populations with only 4.0% having CAS ≥ 50 and 3.5% eligible for carotid endarterectomy. Our findings have implications for the management of acute strokes in Sri Lanka.
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Affiliation(s)
- K C D Mettananda
- Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Talagolla Road, Ragama, Sri Lanka. .,Stroke Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka.
| | - M D P Eshani
- Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Talagolla Road, Ragama, Sri Lanka.,Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - L M Wettasinghe
- Department of Pharmacology, Faculty of Medicine, University of Kelaniya, Talagolla Road, Ragama, Sri Lanka.,Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - S Somaratne
- Stroke Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka
| | | | - W Sathkorala
- Radiology Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | - A Upasena
- Radiology Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | - C Sirigampola
- Stroke Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka
| | - P M Y Tilakaratna
- Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.,University Medical Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
| | - A Pathmeswaran
- Department of Public Health, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
| | - U K Ranawaka
- Stroke Unit, Colombo North Teaching Hospital, Ragama, Sri Lanka.,Department of Medicine, Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka.,University Medical Unit, North Colombo Teaching Hospital, Ragama, Sri Lanka
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22
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SOCIETY FOR VASCULAR SURGERY CLINICAL PRACTICE GUIDELINES FOR MANAGEMENT OF EXTRACRANIAL CEREBROVASCULAR DISEASE. J Vasc Surg 2021; 75:4S-22S. [PMID: 34153348 DOI: 10.1016/j.jvs.2021.04.073] [Citation(s) in RCA: 201] [Impact Index Per Article: 67.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 04/20/2021] [Indexed: 11/22/2022]
Abstract
Management of carotid bifurcation stenosis in stroke prevention has been the subject of extensive investigations, including multiple randomized controlled trials. The proper treatment of patients with carotid bifurcation disease is of major interest to vascular surgeons and other vascular specialists. In 2011, the Society for Vascular Surgery published guidelines for treatment of carotid artery disease. At the time, several randomized trials, comparing carotid endarterectomy (CEA) and carotid artery stenting (CAS), were published. Since that publication, several studies and a few systematic reviews comparing CEA and CAS have been published, and the role of medical management has been re-emphasized. The current publication updates and expands the 2011 guidelines with specific emphasis on five areas: is carotid endarterectomy recommended over maximal medical therapy in low risk patients; is carotid endarterectomy recommended over trans-femoral carotid artery stenting in low surgical risk patients with symptomatic carotid artery stenosis of >50%; timing of carotid Intervention in patients presenting with acute stroke; screening for carotid artery stenosis in asymptomatic patients; and optimal sequence for intervention in patients with combined carotid and coronary artery disease. A separate implementation document will address other important clinical issues in extracranial cerebrovascular disease. Recommendations are made using the GRADE (Grades of Recommendation Assessment, Development and Evaluation) approach, as has been done with other Society for Vascular Surgery guidelines. The committee recommends CEA as the first-line treatment for symptomatic low risk surgical patients with stenosis of 50% to 99% and asymptomatic patients with stenosis of 70% to 99%. The perioperative risk of stroke and death in asymptomatic patients must be <3% to ensure benefit for the patient. In patients with recent stable stroke (modified Rankin 0-2), carotid revascularization is considered appropriate in symptomatic patients with greater than 50% stenosis and is recommended and performed as soon as the patient is neurologically stable after 48 hours but definitely before 14 days of onset of symptoms. In the general population, screening for clinically asymptomatic carotid artery stenosis in patients without cerebrovascular symptoms or significant risk factors for carotid artery disease is not recommended. In selected asymptomatic patients who are at increased risk for carotid stenosis, we suggest screening for clinically asymptomatic carotid artery stenosis as long as the patients would potentially be fit for and willing to consider carotid intervention if significant stenosis is discovered. In patients with symptomatic carotid stenosis 50-99%, who require both CEA and CABG, we suggest CEA before or concomitant with CABG to potentially reduce the risk of stroke and stroke/death. The sequencing of the intervention depends on clinical presentation and institutional experience.
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23
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Lal BK, Meschia JF, Brott TG, Jones M, Aronow HD, Lackey A, Howard G. Race Differences in High-Grade Carotid Artery Stenosis. Stroke 2021; 52:2053-2059. [PMID: 33940957 PMCID: PMC8154708 DOI: 10.1161/strokeaha.120.032723] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background and Purpose Despite a higher incidence of stroke and a more adverse cardiovascular risk factor profile in Blacks and Hispanics compared with Whites, carotid artery revascularization is performed less frequently among these subpopulations. We assessed racial differences in high-grade (≥70% diameter-reducing) carotid stenosis. Methods Consecutive clients in a Nationwide Life Line for-Profit Service to screen for vascular disease, 2005 to 2019 were evaluated in a cross-sectional study. The prevalence of high-grade stenosis, defined by a carotid ultrasound peak systolic velocity of ≥230 cm/s, was assessed. Participants self-identified as White, Black, Hispanic, Asian, Native American, or other. Race/ethnic differences were assessed using Poisson regression. The number of individuals in the United States with high-grade stenosis was estimated by applying prevalence estimates to 2015 US Census population estimates. Results The prevalence of high-grade carotid stenosis was estimated in 6 130 481 individuals. The prevalence of high-grade stenosis was higher with increasing age in all race-sex strata. Generally, Blacks and Hispanics had a lower prevalence of high-grade stenosis compared with Whites, while Native Americans had a higher prevalence. For example, for men aged 55 to 65, the relative risk of stenosis compared with Whites was 0.40 (95% CI, 0.29–0.55) and 0.61 (95% CI, 0.46–0.81) for Blacks and Hispanics, respectively; and 1.53 (95% CI, 1.12–2.10) for Native Americans. When these prevalence estimates were applied to the Census estimates of the US population, an estimated 327 721 individuals have high-grade stenosis, of whom 7% are Black, 7% Hispanic, and 43% women. Conclusions Despite their having a more adverse cardiovascular risk profile, there was a lower prevalence of high-grade carotid artery stenosis for both the Black and Hispanic relative to the White clients. This lower prevalence of high-grade stenosis is a potential contributor to the lower use of carotid revascularization procedures in these minority populations.
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Affiliation(s)
- Brajesh K Lal
- University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD
| | | | | | | | | | - Angelica Lackey
- University of Maryland School of Medicine and Baltimore VA Medical Center, Baltimore, MD
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24
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Yang T, Yoshida K, Maki T, Fushimi Y, Yamada K, Okawa M, Yamamoto Y, Takayama N, Suzuki K, Miyamoto S. Prevalence and site of predilection of carotid webs focusing on symptomatic and asymptomatic Japanese patients. J Neurosurg 2021; 135:1370-1376. [PMID: 33668027 DOI: 10.3171/2020.8.jns201727] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Accepted: 08/28/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Carotid webs (CWs) have increasingly been recognized as a cause of recurrent ischemic stroke. However, the natural history and clinical course of CWs remain unclear. The authors aimed to clarify the prevalence, imaging features, and optimal treatment of CWs in a Japanese cohort study. METHODS A series of 444 consecutive Japanese patients who had undergone CTA of the head and neck between April 2011 and October 2016 was retrospectively reviewed. CW was diagnosed on CT angiograms as a membrane-like intraluminal filling defect along the posterior wall of the carotid bulb or the origin of the internal carotid artery (ICA) on oblique sagittal images and a corresponding thin septum on axial images. RESULTS Two patients with CWs were identified among 132 patients with suspected stroke. The prevalence of CWs among symptomatic patients with suspected stroke was 1.5%. The prevalence of asymptomatic CWs was 2.2% (7 of 312 cases). The CWs were located in the posterior wall of the carotid bulb in 7 patients and just distal to the ICA origin in 2 patients. There were no apparent differences in the location or lesion length between symptomatic and asymptomatic CWs. Four of the 7 asymptomatic CWs remained asymptomatic for at least 2 years of follow-up. Two patients with symptomatic CWs developed recurrent cerebral infarction and transient ischemic attack despite being on a regimen of oral antiplatelet agents, and carotid endarterectomy was performed as radical treatment. Patients with CWs were younger than controls (median age 55 vs 69 years, p = 0.003) and were less frequently male than controls (33% vs 72%, p = 0.025). CW cases showed significantly fewer common atherosclerosis risk factors than the control group (p < 0.05). CONCLUSIONS Although limited to CTA patients, this study reported on the prevalence and common site of CWs, focusing on symptomatic and asymptomatic Japanese patients. Extensive cross-sectional and prospective observational studies are warranted to elucidate the overall prevalence and natural history of CWs.
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Affiliation(s)
| | | | | | - Yasutaka Fushimi
- 3Diagnostic Imaging and Nuclear Medicine, Kyoto University Graduate School of Medicine, Kyoto, Japan
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25
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Abstract
Atherosclerotic carotid artery disease is a significant cause of stroke in the United States and globally. Its prevalence increases with age and it is more prevalent in men and White and Native-American populations. However, the outcomes related to carotid disease are worse in women and Black patients. Research suggests the disparities exist due to a multitude of factors, including disease pathophysiology, access to care, provider bias, and socioeconomic status. The prevalence of carotid stenosis in the general population is low (3%), and routine screening for carotid stenosis is not recommended in adults. Randomized clinical trials have shown benefits of stroke risk reduction with surgery (carotid endarterectomy or stenting) for symptomatic patients. Management is controversial in asymptomatic patients, as modern medical management has results equivalent to those of surgery and ongoing randomized clinical trials will address this important question. Carotid surgery is not appropriate in asymptomatic patients with limited life expectancy. Future work should explore comprehensive care models for care of patients with carotid disease and assessment of patient-reported outcomes to measure quality of care.
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Affiliation(s)
- Shernaz Dossabhoy
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway M121-P, MC 5639, Stanford, CA 94305
| | - Shipra Arya
- Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Drive, Alway M121-P, MC 5639, Stanford, CA 94305.
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26
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Kespi Kpuduwei S, Fawehinmi H, Oladipo G. Establishing sexual dimorphism in diameter of carotid arteriesamong normotensive adult Nigerians. NIGERIAN JOURNAL OF MEDICINE 2021. [DOI: 10.4103/njm.njm_6_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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27
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McGee BT, Kim S, Aycock DM, Hayat MJ, Seagraves KB, Custer WS. Medicaid Expansion and Racial/Ethnic Differences in Readmission After Acute Ischemic Stroke. INQUIRY: THE JOURNAL OF HEALTH CARE ORGANIZATION, PROVISION, AND FINANCING 2021; 58:469580211062438. [PMID: 34914563 PMCID: PMC8695744 DOI: 10.1177/00469580211062438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
To examine whether rates of 30-day readmission after acute ischemic stroke
changed differentially between Medicaid expansion and non-expansion states, and
whether race/ethnicity moderated this change, we conducted a
difference-in-differences analysis using 6 state inpatient databases (AR, FL,
GA, MD, NM, and WA) from the Healthcare Cost and Utilization Project. Analysis
included all patients aged 19-64 hospitalized in 2012–2015 with a principal
diagnosis of ischemic stroke and a primary payer of Medicaid, self-pay, or no
charge, who resided in the state where admitted and were discharged alive
(N=28 330). No association was detected between Medicaid expansion and
readmission overall, but there was evidence of moderation by race/ethnicity. The
predicted probability of all-cause readmission among non-Hispanic White patients
rose an estimated 2.6 percentage points (or 39%) in expansion states but not in
non-expansion states, whereas it increased by 1.5 percentage points (or 23%) for
non-White and Hispanic patients in non-expansion states.
Therefore, Medicaid expansion was associated with a rise in readmission
probability that was 4.0 percentage points higher for non-Hispanic Whites
compared to other racial/ethnic groups, after adjustment for covariates. Similar
trends were observed when unplanned and potentially preventable readmissions
were isolated. Among low-income stroke survivors, we found evidence that 2 years
of Medicaid expansion promoted rehospitalization, but only for White patients.
Future studies should verify these findings over a longer follow-up period.
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Affiliation(s)
- Blake T. McGee
- Byrdine F. Lewis College of Nursing & Health Professions, Georgia State University, Atlanta, GA, USA
| | - Seiyoun Kim
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Dawn M. Aycock
- Byrdine F. Lewis College of Nursing & Health Professions, Georgia State University, Atlanta, GA, USA
| | - Matthew J. Hayat
- Department of Population Health Sciences, School of Public Health, Georgia State University, Atlanta, GA, USA
| | | | - William S. Custer
- Robinson College of Business, Georgia State University, Atlanta, GA, USA
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28
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Zhang K, Lin Q, Zhang T, Guo D, Cao L. Contemporary Prevalence and risk factors of carotid artery stenosis in asymptomatic low-income Chinese individuals: a population-based study. Postgrad Med 2020; 132:650-656. [PMID: 32590917 DOI: 10.1080/00325481.2020.1788319] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Carotid artery stenosis (CAS) is an established risk factor for cerebrovascular disease. However, the contemporary prevalence and risk factors of CAS in asymptomatic rural Chinese individuals, especially low-income populations, remains unclear. Therefore, we aimed to explore the present prevalence and risk factors of CAS in a low-income Chinese population. METHODS A total of 3126 people aged ≥ 45 years without history of stroke or cardiovascular disease were recruited for this study. B-mode ultrasonography was performed to evaluate the presence of CAS. We used multivariate analysis to determine potential risk factors for CAS. RESULTS The overall prevalence of CAS in this population was 6.7%, with a prevalence of 8.8% for men and 5.0% for women. The risk of CAS increased with older age and a higher level of low-density lipoprotein cholesterol (LDL-C), systolic blood pressure (SBP), and fasting blood glucose (FBG) (all P < 0.05). Each 1-mmHg increase in SBP increased the risk of CAS by 0.011 times, each 1-mmol/L increase in LDL-C increased the risk of CAS by 0.192 times, and each 1-mmol/L increase in FBG increased the risk of CAS by 0.067 times. In addition, the risk of CAS increased 52.9% in men compared to that in women, increased 100.2% in current drinkers compared to that in never drinkers, and increased 38.9% in patients with diabetes compared to those without diabetes (all P < 0.05). CONCLUSIONS These findings suggest that the prevalence of CAS remains high in low-income individuals. Male sex, older age, current drinking, diabetes, and high levels of LDL-C, SBP, and FBG increase the risk of CAS. Thus, to prevent cerebrovascular disease and reduce the severe disease-associated burden for low-income individuals, there is a definitive need to control the risk factors of CAS.
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Affiliation(s)
- Kai Zhang
- Department of Geriatrics, Tianjin Medical University General Hospital , Tianjin, China
| | - Qiuxing Lin
- Department of Neurology, Tianjin Medical University General Hospital , Tianjin, China.,Laboratory of Epidemiology, Tianjin Neurological Institute , Tianjin, China.,Tianjin Neurological Institute, Key Laboratory of Post-Neuroinjury Neuro-repair and Regeneration in Central Nervous System, Ministry of Education and Tianjin City , Tianjin, China
| | - Tianyu Zhang
- Department of Geriatrics, Tianjin Medical University General Hospital , Tianjin, China
| | - Dandan Guo
- Centre of Ultrasound, Tianjin Medical University General Hospital , Tianjin, China
| | - Li Cao
- Department of Geriatrics, Tianjin Medical University General Hospital , Tianjin, China
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Global and regional prevalence, burden, and risk factors for carotid atherosclerosis: a systematic review, meta-analysis, and modelling study. LANCET GLOBAL HEALTH 2020; 8:e721-e729. [PMID: 32353319 DOI: 10.1016/s2214-109x(20)30117-0] [Citation(s) in RCA: 327] [Impact Index Per Article: 81.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/02/2020] [Accepted: 03/18/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND Estimation of the epidemiological burden of carotid atherosclerosis can serve as a basis for prevention and management of cardiovascular disease. We aimed to provide the first estimation on the prevalence, number of cases, and risk factors for carotid atherosclerosis in the general population globally and regionally. METHODS In this systematic review, meta-analysis, and modelling study, we searched PubMed, MEDLINE, Embase, Global Health, and China National Knowledge Infrastructure for articles published from database inception until May 7, 2019, with no language restrictions, for population-based studies that quantified prevalence of carotid atherosclerosis by means of increased carotid intima-media thickness, carotid plaque, and carotid stenosis. Studies were eligible if they included bilaterally scanned carotid arteries using ultrasonography and defined increased carotid intima-media thickness as a thickness of 1·0 mm or more, carotid plaque as a focal carotid intima-media thickness of 1·5 mm or more encroaching into the lumen or at least 0·5 mm or 50% compared with the surrounding carotid intima-media thickness values, and carotid stenosis as 50% or more stenosis. Studies were excluded if the sample was not representative of the general population. We also included studies identified in our previous systematic review and meta-analysis of the prevalence of carotid atherosclerosis in China. We estimated age-specific and sex-specific prevalences of increased carotid intima-media thickness, carotid plaque, and carotid stenosis. We used UN population data to generate the number of people affected in 2000, 2015, and 2020. We did random-effects meta-analyses to assess the effects of risk factors for increased carotid intima-media thickness and carotid plaque. We derived regional numbers of people living with increased carotid intima-media thickness and carotid plaque in 2015 using a risk factors-based model by WHO region. All analyses were done in populations aged 30-79 years due to availability of data. This systematic review and meta-analysis is registered online on PROSPERO, CRD42019134709. FINDINGS We identified 8632 articles through our database search, of which 515 were eligible for full-text review, including 37 articles from our previous study, and 59 articles were eligible for inclusion in our systematic review and meta-analysis. Overall, in people aged 30-79 years in 2020, the global prevalence of increased carotid intima-media thickness is estimated to be 27·6% (95% CI 16·9-41·3), equivalent to 1066·70 million affected people and a percentage change of 57·46% from 2000; of carotid plaque is estimated to be 21·1% (13·2-31·5), equivalent to 815·76 million affected people and a percentage change of 58·97% from 2000; and carotid stenosis is estimated to be 1·5% (1·1-2·1), equivalent to 57·79 million affected people and a percentage change of 59·13% from 2000. The prevalence of increased carotid intima-media thickness, carotid plaque, and carotid stenosis increased consistently with age and was higher in men than in women. Current smoking, diabetes, and hypertension were common risk factors for increased carotid intima-media thickness and carotid plaque. In 2015, the Western Pacific region had the largest share of global cases of increased carotid intima-media thickness (317·62 million [33·36%] of 952·13 million affected people) and carotid plaque (240·77 million [33·20%] of 725·25 million), whereas the African region had the smallest share of cases of increased carotid intima-media thickness (59·08 million [6·21%]) and the Eastern Mediterranean region had the smallest share of carotid plaque cases (44·59 million [6·15%]). INTERPRETATION A substantial global burden of carotid atherosclerosis exists. Effective strategies are needed for primary prevention and management of carotid atherosclerosis. High-quality epidemiological investigations on carotid atherosclerosis are needed to better address the global burden of carotid atherosclerosis at finer levels. FUNDING None.
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30
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Safri LS, Lip HTC, Saripan MI, Huei TJ, Krishna K, Md Idris MA, Harunarashid H. Older age and duration of exposure to type 2 diabetes in selective screening of asymptomatic carotid artery stenosis for primary stroke prevention-A single institution experience. Prim Care Diabetes 2020; 14:364-369. [PMID: 31744790 DOI: 10.1016/j.pcd.2019.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Revised: 10/06/2019] [Accepted: 10/08/2019] [Indexed: 12/19/2022]
Abstract
AIMS To evaluate the incidence and risk factors for carotid artery stenosis amongst asymptomatic type 2 diabetes from a single Malaysian tertiary institution. METHODS This is a prospective cross-sectional study of asymptomatic type 2 diabetics selected from the outpatient ophthalmology and endocrine clinics for carotid duplex ultrasound scanning performed by a single radiologist. The duplex ultrasound criteria were based on the North American Symptomatic Carotid Endarterectomy Trial (NASCET) classification of carotid artery stenosis. Univariate and multivariate analysis was performed to identify possible risk factors of carotid artery stenosis. RESULTS Amongst the 200 patients, the majority were males (56%) and Malay predominance (58.5%). There were 12/200 patients (6%) with mean age of 69.2 years identified to have carotid artery stenosis. Univariate analysis of patients with asymptomatic carotid artery stenosis identified older age of 69.2 years (p=0.027) and duration of exposure to diabetes of 17.9 years (p=0.024) as significant risk factors. CONCLUSION Patients with longer exposure of diabetes and older age were risk factors of carotid artery stenosis in asymptomatic type 2 diabetics. These patients should be considered for selective screening of carotid artery stenosis during primary care visit for early identification and closer surveillance for stroke prevention.
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Affiliation(s)
- Lenny Suryani Safri
- Vascular Surgery Unit, Department of General Surgery, Faculty of Medicine, National University of Malaysia Medical Centre, 50603 Kuala Lumpur, Malaysia.
| | - Henry Tan Chor Lip
- Vascular Surgery Unit, Department of General Surgery, Faculty of Medicine, National University of Malaysia Medical Centre, 50603 Kuala Lumpur, Malaysia; Department of Surgery, Hospital Sultanah Aminah, Johor Bahru, Malaysia.
| | - M Iqbal Saripan
- Department of Computer and Communication Systems Engineering, Faculty of Engineering, Universiti Putra Malaysia.
| | - Tan Jih Huei
- Vascular Surgery Unit, Department of General Surgery, Faculty of Medicine, National University of Malaysia Medical Centre, 50603 Kuala Lumpur, Malaysia; Department of Surgery, Hospital Sultanah Aminah, Johor Bahru, Malaysia.
| | - K Krishna
- Vascular Surgery Unit, Department of General Surgery, Faculty of Medicine, National University of Malaysia Medical Centre, 50603 Kuala Lumpur, Malaysia.
| | - Mohamad Azim Md Idris
- Vascular Surgery Unit, Department of General Surgery, Faculty of Medicine, National University of Malaysia Medical Centre, 50603 Kuala Lumpur, Malaysia.
| | - Hanafiah Harunarashid
- Vascular Surgery Unit, Department of General Surgery, Faculty of Medicine, National University of Malaysia Medical Centre, 50603 Kuala Lumpur, Malaysia.
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31
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Nakaya H, Yokoyama N, Watanabe Y, Kataoka A, Konno K, Kozuma K. Prevalence and Predictors of Atherosclerotic Peripheral Arterial Obstructive Disease in Severe Heart Valve Diseases. Int Heart J 2020; 61:727-733. [PMID: 32684599 DOI: 10.1536/ihj.20-009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Despite witnessing an upsurge in heart valve diseases (HVDs), the correlation between HVDs and atherosclerotic peripheral arterial obstructive disease (PAOD) remains unclear. This study aims to investigate the prevalence and predictors of PAOD in HVDs.In this study, a total of 245 consecutive patients were examined: 153 with severe aortic valve stenosis (AS), 66 with severe primary mitral valve regurgitation (MR), and 26 with severe pure native aortic valve regurgitation (AR). All patients underwent ultrasound scan of the carotid artery to ascertain the presence of internal carotid artery stenosis (ICAS). ICAS was defined as a peak systolic velocity ≥ 125 cm/second and/or ≥ 50% reduction in diameter. In addition, we measured the ankle-brachial index in each leg using a volume plethysmograph. A result of ≤ 0.9 was considered lower extremity artery disease (LEAD).The presence of ICAS was statistically more frequent in patients with severe AS than in patients with severe MR and AR (11.1% versus 1.5% versus 3.8%; P = 0.038). LEAD was present in patients with severe AS (17.6%) and MR (10.6%) but not in patients with severe AR (P = 0.037). The multivariate analysis revealed that the presence of severe AS (OR, 5.6 [1.3-24.9]; P = 0.023) was an independent predictor for ICAS, while history of coronary artery disease (OR, 4.8 [2.2-10.5]; P < 0.001) was an independent predictor for LEAD.The prevalence of PAOD varies depending on each valvular disease. Individual screening should be considered on the basis of atherosclerotic risk factors, especially for patients with severe AS.
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Affiliation(s)
- Hiroaki Nakaya
- Department of Cardiology, Division of Cardiology, Teikyo University School of Medicine
| | - Naoyuki Yokoyama
- Department of Cardiology, Division of Cardiology, Teikyo University School of Medicine
| | - Yusuke Watanabe
- Department of Cardiology, Division of Cardiology, Teikyo University School of Medicine
| | - Akihisa Kataoka
- Department of Cardiology, Division of Cardiology, Teikyo University School of Medicine
| | - Kumiko Konno
- Department of Cardiology, Division of Cardiology, Teikyo University School of Medicine
| | - Ken Kozuma
- Department of Cardiology, Division of Cardiology, Teikyo University School of Medicine
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Poppe AY, Jacquin G, Roy D, Stapf C, Derex L. Tandem Carotid Lesions in Acute Ischemic Stroke: Mechanisms, Therapeutic Challenges, and Future Directions. AJNR Am J Neuroradiol 2020; 41:1142-1148. [PMID: 32499251 DOI: 10.3174/ajnr.a6582] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 03/17/2020] [Indexed: 11/07/2022]
Abstract
Approximately 15% of patients undergoing endovascular thrombectomy for anterior circulation acute ischemic stroke have a tandem lesion, defined as a severe stenosis or occlusion of the cervical internal carotid artery ipsilateral to its intracranial occlusion. Patients with tandem lesions have worse outcomes than patients with isolated intracranial occlusions, but the optimal management of their carotid lesions during endovascular thrombectomy remains controversial. The main options commonly used in current practice include acute stent placement in the carotid lesion versus thrombectomy alone without definitive revascularization of the carotid artery. While treatment decisions for these patients are often complex and strategies vary according to clinical, anatomic, and technical considerations, only results from randomized trials comparing these approaches are likely to strengthen current recommendations and optimize patient care.
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Affiliation(s)
- A Y Poppe
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.) .,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - G Jacquin
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - D Roy
- Radiology (Neuroradiology) (D.R.), Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - C Stapf
- From the Departments of Medicine (Neurology) (A.Y.P., G.J., C.S.).,Neurovascular Group (A.Y.P., G.J., C.S.), Axe Neurosciences, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - L Derex
- Stroke Center (L.D.), Department of Neurology, Neurological Hospital, Hospices Civils de Lyon, Lyon, France.,EA 7425 HESPER (L.D.), Health Services and Performance Research, Claude Bernard Lyon 1 University, Lyon, France
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Joh JH, Cho S. Cardiovascular risk of carotid atherosclerosis: global consensus beyond societal guidelines. LANCET GLOBAL HEALTH 2020; 8:e625-e626. [PMID: 32353304 DOI: 10.1016/s2214-109x(20)30132-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 04/01/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Jin Hyun Joh
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul 05278, South Korea.
| | - Sungsin Cho
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul 05278, South Korea
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Poorthuis MHF, Halliday A, Massa MS, Sherliker P, Clack R, Morris DR, Clarke R, de Borst GJ, Bulbulia R, Lewington S. Validation of Risk Prediction Models to Detect Asymptomatic Carotid Stenosis. J Am Heart Assoc 2020; 9:e014766. [PMID: 32310014 PMCID: PMC7428515 DOI: 10.1161/jaha.119.014766] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 02/07/2020] [Indexed: 12/27/2022]
Abstract
Background Significant asymptomatic carotid stenosis (ACS) is associated with higher risk of strokes. While the prevalence of moderate and severe ACS is low in the general population, prediction models may allow identification of individuals at increased risk, thereby enabling targeted screening. We identified established prediction models for ACS and externally validated them in a large screening population. Methods and Results Prediction models for prevalent cases with ≥50% ACS were identified in a systematic review (975 studies reviewed and 6 prediction models identified [3 for moderate and 3 for severe ACS]) and then validated using data from 596 469 individuals who attended commercial vascular screening clinics in the United States and United Kingdom. We assessed discrimination and calibration. In the validation cohort, 11 178 (1.87%) participants had ≥50% ACS and 2033 (0.34%) had ≥70% ACS. The best model included age, sex, smoking, hypertension, hypercholesterolemia, diabetes mellitus, vascular and cerebrovascular disease, measured blood pressure, and blood lipids. The area under the receiver operating characteristic curve for this model was 0.75 (95% CI, 0.74-0.75) for ≥50% ACS and 0.78 (95% CI, 0.77-0.79) for ≥70% ACS. The prevalence of ≥50% ACS in the highest decile of risk was 6.51%, and 1.42% for ≥70% ACS. Targeted screening of the 10% highest risk identified 35% of cases with ≥50% ACS and 42% of cases with ≥70% ACS. Conclusions Individuals at high risk of significant ACS can be selected reliably using a prediction model. The best-performing prediction models identified over one third of all cases by targeted screening of individuals in the highest decile of risk only.
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Affiliation(s)
- Michiel H. F. Poorthuis
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- Department of Vascular SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Alison Halliday
- Nuffield Department of Surgical SciencesJohn Radcliffe HospitalUniversity of OxfordUnited Kingdom
| | - M. Sofia Massa
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Paul Sherliker
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Rachel Clack
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Dylan R. Morris
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Robert Clarke
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Gert J. de Borst
- Department of Vascular SurgeryUniversity Medical Center UtrechtUtrechtThe Netherlands
| | - Richard Bulbulia
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
| | - Sarah Lewington
- Clinical Trial Service Unit and Epidemiological Studies UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
- MRC Population Health Research UnitNuffield Department of Population HealthUniversity of Oxford,United Kingdom
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Kokkinidis DG, Chaitidis N, Giannopoulos S, Texakalidis P, Haider MN, Aronow HD, Giri JS, Armstrong EJ. Presence of Contralateral Carotid Occlusion Is Associated With Increased Periprocedural Stroke Risk Following CEA but Not CAS: A Meta-analysis and Meta-regression Analysis of 43 Studies and 96,658 Patients. J Endovasc Ther 2020; 27:334-344. [PMID: 32066317 DOI: 10.1177/1526602820904163] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To investigate the prognostic role of contralateral carotid artery occlusion (CCO) in perioperative outcomes of patients undergoing carotid artery endarterectomy (CEA) vs carotid artery stenting (CAS). Materials and Methods: The PubMed, Scopus, and Cochrane databases were searched up to September 2018 to identify observational or randomized studies that compared outcomes of carotid revascularization in patients with vs without CCO. Forty-three studies (46 arms) comprising 96,658 patients were selected (75,857 CEA and 20,801 CAS). The CCO group included 9258 patients. Heterogeneity was assessed with the Higgins I2 test. I2>75% indicated significant heterogeneity. A random effects model was used to account for heterogeneity among studies. The results were reported as the odds ratios (ORs) with the 95% confidence intervals (CIs). Meta-regression analysis examined potential confounders. Publication bias was quantified by the Egger method. Results: Carotid revascularization in patients with CCO was associated with an increased risk of 30-day mortality (OR 1.75, 95% CI 1.38 to 2.23, p<0.001; I2=0%), stroke (OR 1.77, 95% CI 1.41 to 2.22, p<0.001; I2=46%), transient ischemic attack (TIA) (OR 2.10, 95% CI 1.34 to 3.27, p=0.001; I2=15%), and the composite endpoint of stroke/death (OR 1.78, 95% CI 1.54 to 2.05, p<0.001; I2=0%). No difference was noted in the risk of perioperative myocardial infarction (OR 0.81, 95% CI 0.50 to 1.31; p=0.388; I2=0%). Subgroup analysis demonstrated that CEA in patients with CCO was associated with an increased risk of stroke (OR 2.07, 95% CI 1.72 to 2.49, p<0.001; I2=14%), death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I2=0%), TIA (OR 2.18, 95% CI 1.38 to 3.45, p<0.001; I2=13%), and stroke/death (OR 1.80, 95% CI 1.55 to 2.10, p<0.001; I2=0%), whereas CCO patients who were treated with CAS were at an increased risk for death (OR 1.65, 95% CI 1.07 to 2.60, p=0.023; I2=0%) but not stroke (OR 0.94, 95% CI 0.61 to 1.47; p=0.080; I2=31%) or TIA (OR 1.18, 95% CI 0.18 to 7.55; p=0.861; I2=43%). The meta-regression analysis did not find any significant association for any of the outcomes, and there was no evidence of publication bias. Conclusion: Carotid revascularization outcomes are adversely affected by the presence of CCO. Patients with CCO have a significantly higher risk of periprocedural stroke, death, and TIA. CEA in patients with CCO is associated with an increased risk of perioperative stroke, death, TIA, and death/stroke, while CAS in the presence of a CCO is associated with an increased risk of periprocedural death but not stroke or TIA.
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Affiliation(s)
- Damianos G Kokkinidis
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA.,Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nikos Chaitidis
- Department of Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Stefanos Giannopoulos
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
| | - Pavlos Texakalidis
- Division of Neurological Surgery, Emory University Hospital, Atlanta, GA, USA
| | - Moosa N Haider
- Vascular Center and Division of Cardiovascular Medicine, University of California, Davis, Sacramento, CA, USA
| | - Herbert D Aronow
- The Warren Alpert Medical School of Brown University and Lifespan Cardiovascular Institute, Providence, RI, USA
| | - Jay S Giri
- Penn Cardiovascular Outcomes, Quality, & Evaluative Research Center, Cardiovascular Medicine Division, Department of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ehrin J Armstrong
- Division of Cardiology, Rocky Mountain Regional VA Medical Center, University of Colorado, Denver, CO, USA
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36
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Shaheen MA, Albelali AA, AlKanhal RM, AlSaqabi MK, AlTurki RM, AlAskar RS, Khan AH, Khatri IA. Frequency, risk factors, and outcomes in patients with significant carotid artery disease admitted to King Abdulaziz Medical City, Riyadh with Ischemic Stroke. NEUROSCIENCES 2019; 24:264-268. [PMID: 31872804 DOI: 10.17712/nsj.2019.4.20190046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To determine the frequency, risk factors, and outcomes of significant carotid artery disease (CAD) in patients with ischemic stroke. METHODS The frequency of significant CAD in patients admitted to the Stroke Unit between January 2014 and December 2015 was determined from radiological data. Outcomes were determined clinically and radiologically. RESULTS Among 435 patients, 273 were men (62.8%), with a mean age of 57.4+/-12.2 years. Significant CAD was found in 48 vessels in 40 (9.2%) patients, of which 30 patients were symptomatic. Nine of these patients were treated with carotid artery stenting, one underwent carotid endarterectomy, and 3 underwent an urgent thrombectomy, without stenting. Seventeen symptomatic patients were not treated for the following reasons: patient/family refusal (n=2), contraindications (n=5), and complete occlusion (n=10). One (7.7%) of the 13 treated patients had an ipsilateral stroke on follow up, one (7.7%) had contralateral transient ischemic attack (TIA), 9 (69.2%) had no recurrence, and no clinical data were available for 2 patients. Among the 17 untreated patients, one (5.9%) had an ipsilateral stroke, 7 (41.2%) had no recurrence, and 9 (52.9%) were lost to follow up. CONCLUSION Significant carotid artery disease is uncommon in our cohort found in less than 10% of patients. Vascular risk factors are more or less similar between patients with or without CAD except obesity which appears to have inverse relation with CAD. A small number of patients received carotid intervention with no recurrence of stroke at limited follow up.
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Affiliation(s)
- Misealreem A Shaheen
- King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
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Rojsanga W, Sawanyawisuth K, Chotmongkol V, Tiamkao S, Kongbonkiat K, Kasemsap N. Clinical risk factors predictive of thrombotic stroke with large cerebral infarction. Neurol Int 2019; 11:7941. [PMID: 31281599 PMCID: PMC6589642 DOI: 10.4081/ni.2019.7941] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 12/05/2018] [Indexed: 12/13/2022] Open
Abstract
Large cerebral infarctions have high morbidity and mortality. Patients with large cerebral infarctions may have recurrent ischemia as high as 8.1% within 7 days; highest among other types of strokes. Data regarding risk factors for large cerebral infarction in Asian populations are still scant. All adult (age ≥15 years old) patients with the diagnosis of thrombotic ischemic stroke who were treated at Srinagarind Hospital, Khon Kaen University, Thailand from January 2012 to December 2013 were studied. Large cerebral infarctions are defined by clinical criteria of having cerebral cortical impairment, brain stem or cerebellar dysfunction with infarction sizes of more than 1.5 cm. The association of various stroke risk factors and large infarction strokes were calculated using multiple logistic regression analysis. There were 276 thrombotic stroke patients who met the study criteria; classified as large cerebral infarctions in 59 patients (21.38%) and small cerebral infarctions in 217 patients (78.62%). Baseline characteristics and risk factors for stroke were comparable between both groups. The large cerebral infarction group had a significantly larger proportions of right internal carotid artery stenosis, plaques on the left side, left internal carotid artery stenosis, and internal carotid artery stenosis at any side than the small cerebral infarction group. Among various stroke risk factors, only internal carotid artery stenosis at any side was the only significant factor associated with large cerebral infarction with an adjusted odds ratio of 11.14 (95% CI: 3.46, 35.82). In conclusion, significant internal carotid artery stenosis is associated with large cerebral infarction.
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Affiliation(s)
- Worapot Rojsanga
- Department of Medicine, Faculty of Medicine, Khon Kaen University.,Sleep Apnea Research Group, Research Center in Back, Neck, Other Joint Pain and Human Performance; Sleep Apnea Research Group; Research and Training Center for Enhancing Quality of Life of Working Age People, and Research and Diagnostic Center for Emerging Infectious Diseases, Khon Kaen University
| | - Kittisak Sawanyawisuth
- Department of Medicine, Faculty of Medicine, Khon Kaen University.,Sleep Apnea Research Group, Research Center in Back, Neck, Other Joint Pain and Human Performance; Sleep Apnea Research Group; Research and Training Center for Enhancing Quality of Life of Working Age People, and Research and Diagnostic Center for Emerging Infectious Diseases, Khon Kaen University
| | - Verajit Chotmongkol
- Department of Medicine, Faculty of Medicine, Khon Kaen University.,Sleep Apnea Research Group, Research Center in Back, Neck, Other Joint Pain and Human Performance; Sleep Apnea Research Group; Research and Training Center for Enhancing Quality of Life of Working Age People, and Research and Diagnostic Center for Emerging Infectious Diseases, Khon Kaen University
| | - Somsak Tiamkao
- Department of Medicine, Faculty of Medicine, Khon Kaen University.,Integrated Epilepsy Research Group, Khon Kaen University
| | - Kannikar Kongbonkiat
- Department of Medicine, Faculty of Medicine, Khon Kaen University.,North-Eastern Stroke Research Group, Khon Kaen University, Thailand
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Uchiyama S, Hoshino T, Sissani L, Linsay MT, Kamiyama K, Nakase T, Kitagawa K, Minematsu K, Todo K, Okada Y, Nakagawara J, Nagata K, Yamagami H, Yamaguchi T, Amarenco P. Japanese Versus Non-Japanese Patients with Transient Ischemic Attack or Minor Stroke: Subanalysis of TIA registry.org. J Stroke Cerebrovasc Dis 2019; 28:2232-2241. [PMID: 31178360 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 05/05/2019] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND TIAregistry.org is an international cohort of patients with transient ischemic attack (TIA) or minor stroke within 7 days before enrollment in the registry. Main analyses of 1-year follow-up data have been reported.5 We conducted subanalysis on the baseline and 1-year follow-up data of Japanese patients. METHODS The patients were classified into 2 groups based on Japanese ethnicity, Japanese (345) and non-Japanese (3238), and their baseline data and 1-year event rates were compared. We also determined risk factors and predictors of 1-year stroke. RESULTS Current smoking, regular alcohol drinking, intracranial arterial stenosis, and small vessel occlusion; and hypertension, dyslipidemia, coronary artery disease, and extracranial arterial stenosis were more and less common among Japanese patients, respectively. Stroke risk was higher and TIA risk was lower at 1-year follow-up among Japanese patients. The baseline risk factors for recurrent stroke were diabetes, alcohol drinking, and large artery atherosclerosis. Independent predictors of 1-year stroke risk were prior congestive heart failure and alcohol consumption. CONCLUSIONS The two populations of patients featured differences in risk factors, stroke subtypes, and outcome events. Predictors of recurrent stroke among Japanese patients included congestive heart failure and regular alcohol drinking. Strategies to attenuate residual risk of stroke aside from adherence to current guidelines should take our Japanese-patient specific findings into account.
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Affiliation(s)
- Shinichiro Uchiyama
- Clinical Research Center, International University of Health and Welfare, Center for Brain and Cerebral Vessels, Sanno Hospital and Sanno Medical Center, Tokyo, Japan.
| | - Takao Hoshino
- Department of Neurology and Stroke Center, Bichat Hospital, Paris, France
| | - Leila Sissani
- Department of Neurology and Stroke Center, Bichat Hospital, Paris, France
| | | | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Taizen Nakase
- Department of Neurology and Stroke Science, Research Institute of Brain and Blood Vessels Akita, Akita, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | | | - Ken Nagata
- Yokohama General Hospital, Yokohama, Japan
| | | | | | - Pierre Amarenco
- Department of Neurology and Stroke Center, Bichat Hospital, Paris, France
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Faigle R, Cooper LA, Gottesman RF. Lower carotid revascularization rates after stroke in racial/ethnic minority-serving US hospitals. Neurology 2019; 92:e2653-e2660. [PMID: 31101741 DOI: 10.1212/wnl.0000000000007570] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 01/26/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We sought to determine whether the use of carotid revascularization procedures after stroke due to carotid stenosis differs between minority-serving hospitals and hospitals serving predominantly white patients. METHODS We identified ischemic stroke cases due to carotid disease, identified by ICD-9-CM codes, from 2007 to 2011 in the Nationwide Inpatient Sample. The use of carotid endarterectomy (CEA) and carotid artery stenting (CAS) was recorded. Hospitals with ≥40% racial/ethnic minority patients (minority-serving hospitals) were compared to hospitals with <40% minority patients (predominantly white hospitals [hereafter, abbreviated to white]). Logistic regression was used to evaluate the use of CEA/CAS among minority-serving and white hospitals. RESULTS Of the 26,189 ischemic stroke cases meeting inclusion criteria, 20,870 (79.7%) were treated at 1,113 white hospitals and 5,319 (20.3%) received care at 325 minority-serving hospitals. Compared to patients in white hospitals, patients in minority-serving hospitals were less likely to undergo CEA/CAS (17.6%, 95% confidence interval [CI] 16.6%-18.6%, in minority-serving vs 21.2%, 95% CI 20.7%-21.8%, in white hospitals; p < 0.001). In fully adjusted logistic regression models, the odds of CEA/CAS were lower in minority-serving compared to white hospitals (odds ratio 0.81, 95% CI 0.70-0.93), independent of individual patient race/ethnicity and other measured hospital characteristics. White and Hispanic individuals had significantly lower odds of CEA/CAS in minority-serving compared to white hospitals. Patient-level racial/ethnic differences in the use of carotid revascularization procedures remained within each hospital stratum. CONCLUSION The odds of carotid revascularization after stroke is lower in minority- compared to white-serving hospitals, suggesting system-level factors as a major contributor to explain race disparities in the use of carotid revascularization.
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Affiliation(s)
- Roland Faigle
- From the Departments of Neurology (R.F., R.F.G.) and Medicine (L.A.C.), Johns Hopkins University School of Medicine, Baltimore, MD.
| | - Lisa A Cooper
- From the Departments of Neurology (R.F., R.F.G.) and Medicine (L.A.C.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rebecca F Gottesman
- From the Departments of Neurology (R.F., R.F.G.) and Medicine (L.A.C.), Johns Hopkins University School of Medicine, Baltimore, MD
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40
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Chu WF, Lee HJ, Lin CJ, Chang FC, Guo WY, Chen LW, Lin YY, Luo CB. Fluoroscopic angiography quantifies delay in cerebral circulation time and requires less radiation in carotid stenosis patients: A pilot study. J Chin Med Assoc 2019; 82:396-400. [PMID: 30893249 DOI: 10.1097/jcma.0000000000000046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Quantitative digital subtraction angiography (DSA) facilitates in-room assessment of flow changes in various cerebrovascular diseases and improves patient safety. The purpose of this study was to compare the diagnostic accuracy of quantitative fluoroscopic angiography (FA) and DSA. METHODS Twenty-two patients with >70% carotid stenosis according to NASCET criteria were prospectively included in the study. All patients received DSA and FA (ArtisZee, Siemens Healthcare, Forchheim, Germany) before and after carotid stenting in the same angiosuite. The regions of interest (ROIs) included the extracranial internal carotid artery (eICA), first segment of the middle cerebral artery (MCA1), and sigmoid sinus in the anterior-posterior view; cavernous portion of the ICA (cICA), parietal vein, and jugular vein in the lateral views. The time-to-peak (TTP) for all ROIs and cerebral circulation time (CCT) were measured from FA and DSA scans. TTP, CCT, and radiation doses from DSA were compared with those from FA. RESULTS The mean age of the patients were 69 ± 9.5 years old. The average stenosis was 89.7% ± 7.8% before stenting and 31% ± 3.6% after stenting. No patient suffered from periprocedural stroke. The intermethod correlation for TTP for all ROIs except the eICA and cICA ranged from 0.46 to 0.65 before stenting and 0.57 to 0.73 after stenting, and that for CCT was 0.65 before stenting and 0.57 after stenting. The radiation doses were significantly lower for FA than for DSA regardless of views or periprocedural timing (p < 0.001). CONCLUSION Stenosis facilitated the creation of a bolus by manual injection and therefore increased the accuracy of cerebral flow quantification in FA. Cerebral hemodynamic assessment by FA is quicker and associated with less radiation.
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Affiliation(s)
- Wei-Fa Chu
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Han-Jui Lee
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Chung-Jung Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Feng-Chi Chang
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Wan-Yuo Guo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Liang-Wei Chen
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
| | - Yi-Yang Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Interventional Radiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Chao-Bao Luo
- School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC
- Department of Radiology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC
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41
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Mitrović V, Marić R, Filipović-Danić S, Petrović N. Extracranial carotid atherosclerosis in genesis infarction brain in the border zones supratentorial localization. PRAXIS MEDICA 2019. [DOI: 10.5937/pramed1901015m] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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42
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Association Between Stroke Severity and 5-Year Mortality in Ischemic Stroke Patients with High-Grade Stenosis of Internal Carotid Artery. J Stroke Cerebrovasc Dis 2018; 27:3365-3372. [PMID: 30154052 DOI: 10.1016/j.jstrokecerebrovasdis.2018.07.042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 07/16/2018] [Accepted: 07/24/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The clinical presentations and outcomes of patients with high-grade stenosis of internal carotid artery (ICA) are highly variable. We investigate the influence of different stroke severity on outcomes of ischemic stroke patients with high-grade stenosis of ipsilateral ICA. METHODS 372 acute first-ever ischemic stroke patients with high-grade stenosis (70%-99%) or occlusion of ipsilateral ICA were enrolled and followed up for 5years. Stroke severities of the enrolled patients were grouped according to the Oxfordshire Community Stroke Project classification system as total anterior circulation infarcts (TACI) or non-TACI. Demographic features, vascular risk factors, comorbidities, and outcomes were compared between the 2 groups. RESULTS A total of 71 patients (19.1%) were presented with TACI. Of laboratory data, the values of white blood cell count and high-sensitivity C-reactive protein were significantly higher in patients with TACI (P = .008 and P = .003, respectively). Of clinical course, the occurrence of initial impaired conscious, stroke-in-evolution, pneumonia, gastrointestinal bleeding, and urinary tract infection were significantly higher in patients with TACI. The prevalence of dependent functional status was higher in patients with TACI. Multivariate Cox regression revealed that TACI is a significant predictor of 5-year all-cause mortality in first-ever ischemic stroke patients with high-grade stenosis of ipsilateral ICA (HR [hazard ratio] = 3.66, 95% confidence interval = 2.23-6.00, P < .001). CONCLUSIONS TACI is associated with increased risk of 5-year mortality in ischemic stroke patients with high-grade stenosis of ipsilateral ICA. Intensive medical treatment for stroke prevention in patients with severe carotid artery stenosis is warranted.
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43
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Song P, Xia W, Zhu Y, Wang M, Chang X, Jin S, Wang J, An L. Prevalence of carotid atherosclerosis and carotid plaque in Chinese adults: A systematic review and meta-regression analysis. Atherosclerosis 2018; 276:67-73. [PMID: 30036743 DOI: 10.1016/j.atherosclerosis.2018.07.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/10/2018] [Accepted: 07/13/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIMS The national representative prevalence of carotid atherosclerosis (CAS) or carotid plaque (CP) in the general Chinese population has never been estimated. We aim to generate the prevalence and number of people with CAS and CP in the general Chinese population. METHODS We searched China National Knowledge Infrastructure, Wanfang Data, VIP Database for Chinese Technical Periodical, PubMed, Embase and Medline. Articles reporting the prevalence of CAS or CP in the general Chinese population were included. A multilevel mixed-effects logistic regression was used to estimate the age- and gender-specific prevalence of CAS and CP. The effects of risk factors for CAS were assessed by a random-effects meta-analysis. RESULTS The prevalence of CAS and CP increased with advanced age. Males had a higher prevalence of CAS and CP than females consistently across all age groups. Overall, 27.22% and 20.15% of Chinese people aged 30-79 years were with CAS and CP, respectively, in 2010, equivalent to 207.73 million and 153.82 million affected individuals. With demographic ageing, the number of people affected by CAS and CP will increase to 267.25 million and 199.83 million, respectively, by 2020. In addition, current smoking, hypertension and diabetes were found to be risk factors for CAS. More than 70% of the national CAS cases were in rural China in 2010. CONCLUSIONS CAS and CP are highly prevalent in China. The huge disease burden of CAS and CP calls for efforts on effective preventive health strategies and early-detection of CVDs in people with CAS or CP, especially in rural areas.
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Affiliation(s)
- Peige Song
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China; Centre for Global Health Research, University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Wei Xia
- School of Nursing, University of Hong Kong, Hong Kong, China
| | - Yajie Zhu
- George Institute for Global Health, University of Oxford, Oxford, United Kingdom
| | - Manli Wang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Xinlei Chang
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China
| | - Shuai Jin
- School of Nursing, Peking University, Beijing, China
| | - Jingpin Wang
- School of Nursing, Peking University, Beijing, China
| | - Lin An
- Department of Maternal and Child Health, School of Public Health, Peking University, Beijing, China.
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Xu Y, Li D, Yuan C, Zhou Z, He L, Li R, Cui Y, Li Q, Zheng Z, Zhao X. Association of severity between carotid and intracranial artery atherosclerosis. Ann Clin Transl Neurol 2018; 5:843-849. [PMID: 30009201 PMCID: PMC6043773 DOI: 10.1002/acn3.590] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 01/23/2023] Open
Abstract
Objective This study sought to investigate the relationship of atherosclerosis between intracranial and extracranial carotid arteries using three‐dimensional multicontrast magnetic resonance (MR) vessel wall imaging. Methods Patients with recent cerebrovascular symptoms in anterior circulation were recruited and underwent MR vessel wall imaging for intracranial and extracranial carotid arteries. The plaque burden, including maximum wall thickness (Max WT) and stenosis, and presence of intraplaque hemorrhage (IPH) were assessed. The correlation of the plaque characteristics between intracranial and extracranial carotid arteries was determined. Results In total, 107 patients (mean age: 57.0 ± 11.1 years, 69 males) were recruited. In discriminating intracranial severe stenosis (≥50% stenosis), the odds ratio (OR) of Max WT of extracranial carotid arteries was 1.41 (95% confidence interval [CI], 0.94–2.11, P = 0.095) and 1.72 (95% CI, 1.04–2.83, P = 0.034) before and after adjusting for confounding factors, respectively. The OR of stenosis of extracranial carotid arteries with increment of 10% was 1.26 (95% CI, 0.99–1.60, P = 0.054) and 1.37 (95% CI, 1.03–1.82, P = 0.033) before and after adjusting for confounding factors, in discriminating intracranial severe stenosis respectively. Receiver operating characteristic analysis revealed that the area under the curve (AUC) of Max WT, stenosis, and IPH of extracranial carotid artery plaques was 0.641, 0.605, and 0.603 in discriminating intracranial severe stenosis, respectively. After adjusting for confounding factors, the AUC of Max WT, stenosis, and presence of IPH in extracranial carotid artery plaques increased to 0.812, 0.817 and 0.781, respectively. Interpretation Carotid artery plaque burden is significantly associated with severe intracranial artery stenosis, suggesting that extracranial carotid plaque burden might be an independent indicator for severity of intracranial artery atherosclerosis.
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Affiliation(s)
- Yilan Xu
- Department of RadiologyBeijing Tsinghua Changgung HospitalSchool of Clinical MedicineTsinghua UniversityBeijingChina
| | - Dongye Li
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
- Center for Brain Disorders ResearchCapital Medical University and Beijing Institute for Brain DisordersBeijingChina
| | - Chun Yuan
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
- Department of RadiologyUniversity of WashingtonSeattleWashington
| | - Zechen Zhou
- Philips Research North AmericaCambridgeMassachusetts
| | - Le He
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
| | - Rui Li
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
| | - Yuanyuan Cui
- Department of RadiologyPLA General HospitalBeijingChina
| | - Qing Li
- Department of NeurologyPeople's Hospital of Xinjiang Vygur Autonomous RegionUrumqiChina
| | - Zhuozhao Zheng
- Department of RadiologyBeijing Tsinghua Changgung HospitalSchool of Clinical MedicineTsinghua UniversityBeijingChina
| | - Xihai Zhao
- Center for Biomedical Imaging ResearchDepartment of Biomedical EngineeringTsinghua University School of MedicineBeijingChina
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Park HK, Bae HJ. Response by Park and Bae to Letter Regarding Article, "One-Year Outcomes After Minor Stroke or High-Risk Transient Ischemic Attack: Korean Multicenter Stroke Registry Analysis". Stroke 2018; 49:e130. [PMID: 29438076 DOI: 10.1161/strokeaha.117.019815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Hong-Kyun Park
- Department of Neurology, Ilsan Paik Hospital, Inje University, Goyang, Korea
| | - Hee-Joon Bae
- Department of Neurology, Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
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46
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Chou CL, Wu YJ, Hung CL, Liu CC, Wang SD, Wu TW, Wang LY, Yeh HI. Segment-specific prevalence of carotid artery plaque and stenosis in middle-aged adults and elders in Taiwan: A community-based study. J Formos Med Assoc 2018; 118:64-71. [PMID: 29395388 DOI: 10.1016/j.jfma.2018.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2017] [Revised: 11/18/2017] [Accepted: 01/05/2018] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Plaque in carotid arteries (CAs) is a major factor of systemic atherosclerosis and cardiovascular disease (CVD). The left and right CAs have different anatomic and geometric features and may influence the predictability of CVD. However, the site- and segment-specific prevalence of carotid plaques (CP) and study on severity of carotid atherosclerosis with CVD risks was very limited. METHODS We enrolled 1539 healthy residents aged 40-to-74 years from two northern districts in Taiwan. All volunteers received high resolution B-mode carotid ultrasound scans and CVD risk factors evaluations. RESULTS The prevalence rate of extracranial CP was 21.9% in females and 33.8% in males. Carotid bifurcation is the most affected segment. As compared with the right CAs, the age-sex-adjusted matched odds ratio of having plaques in the left CAs was 1.32 (95% confidence interval = 1.02-1.73). The proportions of subjects had a total plaque number≥2, maximum stenosis≥30%, and plaque score≥3 were 8.9, 10.3, and 7.2%, respectively, in females and were 17.7, 17.2, and 15.1%, respectively, in males. Among subjects with moderate and severe carotid atherosclerosis, the mean ± SD of estimated 10-year CVD risk was 19.1 ± 14.6% and more than 65% of them need intensive blood pressure, lipids, or sugar controls. CONCLUSION We found that bifurcation was the most prevalent segment, and left CAs was more likely to form plaque than right CAs. The major CVD risk factors were highly prevalent and the estimated CVD risks were high in subjects with more advanced carotid atherosclerosis. The study provides further direction for CVD prevention and treatment.
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Affiliation(s)
- Chao-Liang Chou
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Department of Neurology, Mackay Memorial Hospital, New Taipei City, Taiwan
| | - Yih-Jer Wu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan; Institute of Biomedical Sciences, Mackay Medical College, New Taipei City, Taiwan
| | - Chung-Lieh Hung
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Chun-Chieh Liu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
| | - Shwun-De Wang
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Tzu-Wei Wu
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan
| | - Li-Yu Wang
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Institute of Biomedical Sciences, Mackay Medical College, New Taipei City, Taiwan.
| | - Hung-I Yeh
- Department of Medicine, Mackay Medical College, New Taipei City, Taiwan; Division of Cardiology, Department of Internal Medicine, Mackay Memorial Hospital, Taipei, Taiwan
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Controversies and evidence for cardiovascular disease in the diverse Hispanic population. J Vasc Surg 2017; 67:960-969. [PMID: 28951154 DOI: 10.1016/j.jvs.2017.06.111] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 06/23/2017] [Indexed: 01/29/2023]
Abstract
OBJECTIVE Hispanics account for approximately 17% of the U.S. POPULATION They are one of the fastest growing racial/ethnic groups, second only to Asians. This heterogeneous population has diverse socioeconomic conditions, making the prevention, diagnosis, and management of vascular disease difficult. This paper discusses the cultural, racial, and social aspects of the Hispanic community in the United States and assesses how they affect vascular disease within this population. Furthermore, it explores risk factors, medical and surgical treatments, and outcomes of vascular disease in the Hispanic population; generational evolution of these conditions; and the phenomenon called the Hispanic paradox. METHODS A systematic search of the literature was performed to identify all English-language publications from 1991 to 2014 using PubMed, which draws from the National Institutes of Health and U.S. National Library of Medicine, with the words "cardiovascular disease," "prevalence," "vascular," and "Hispanic." An additional search was performed using "cardiovascular disease and Mexico," "cardiovascular disease and Cuba," "cardiovascular disease and Puerto Rico," and "cardiovascular disease and Latin America" as well as for complications, management, outcomes, surgery, vascular disease, and Hispanic paradox. The resulting publications were queried for generational data (spanning multiple well-defined age groups) regarding cardiovascular disease, and cross-references were obtained from their bibliographies. Results are segmented by country of origin. RESULTS Compared with non-Hispanic whites, Hispanics face higher risks of cardiovascular diseases because of a high prevalence of high blood pressure, obesity, diabetes mellitus, and ischemic stroke. However, the incidence of peripheral arterial disease and carotid disease appears to be significantly lower than in whites. The Hispanic paradox (lower mortality in spite of higher cardiovascular risk factors) may relate to challenges in ascribing life expectancy and cause of death in this diverse population. Low socioeconomic status and high prevalence of concomitant diseases negatively influence the outcomes of all patients, independent of being Hispanic. CONCLUSIONS Understanding the cultural diversity in Hispanics is important in terms of targeting preventive measures to modify cardiovascular risk factors, which affect development and outcomes of vascular disease. The available literature regarding vascular disease in the Hispanic population is limited, and further longitudinal study is warranted to improve health care delivery and outcomes in this group.
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48
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Medical Management of Asymptomatic Carotid Artery Stenosis. Prog Cardiovasc Dis 2017; 59:585-590. [PMID: 28539213 DOI: 10.1016/j.pcad.2017.05.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 05/19/2017] [Indexed: 11/22/2022]
Abstract
Carotid artery atherosclerosis is a major risk factor for both stroke and cardiovascular disease. Appropriate management of asymptomatic patients with carotid artery stenosis (CAS) remains unclear. Although several randomized clinical trials support revascularization in asymptomatic patients with severe CAS to reduce stroke risk, the participants in these trials did not receive optimal medical therapy (OMT) by today's standards. For many individuals, medical therapy may provide excellent risk reduction without the periprocedural risk of endarterectomy or stenting. In this review, we discuss the risk factors for CAS and stroke and examine the data for each component of OMT in these patients.
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Newman JD, Rockman CB, Kosiborod M, Guo Y, Zhong H, Weintraub HS, Schwartzbard AZ, Adelman MA, Berger JS. Diabetes mellitus is a coronary heart disease risk equivalent for peripheral vascular disease. Am Heart J 2017; 184:114-120. [PMID: 28224925 DOI: 10.1016/j.ahj.2016.09.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Accepted: 09/08/2016] [Indexed: 10/21/2022]
Abstract
Diabetes mellitus (diabetes) is associated with significantly increased risk of peripheral vascular disease. Diabetes is classified as a coronary heart disease (CHD) risk equivalent, but it is unknown whether diabetes is a CHD risk equivalent for peripheral vascular disease. The objective was to evaluate the odds of peripheral arterial disease (PAD) or carotid artery stenosis (CAS) among participants with diabetes, CHD, or both, compared with participants without diabetes or CHD, in a nationwide vascular screening database. We hypothesized that diabetes and CHD would confer similar odds of PAD and CAS. METHODS A cross-sectional analysis of all eligible Life Line Screening Inc participants age 30 to 90 years with ankle brachial indices for PAD (ankle brachial index <0.9 in either leg) and carotid artery duplex ultrasonographic imaging for CAS (internal CAS ≥50%) was performed (N=3,522,890). RESULTS Diabetes and CHD were present in 372,330 (10.7%) and 182,760 (5.8%) of participants, respectively; PAD and CAS were present in 155,000 (4.4%) and 130,347 (3.7%) of participants. After multivariable adjustment, PAD odds were 1.56 (95% CI 1.54-1.59) and 1.69 (95% CI 1.65-1.73) for participants with diabetes or CHD, respectively. Participants with both diabetes and CHD had 2.75-fold increased odds of PAD (95% CI 2.66-2.85). Findings were similar for CAS; compared with no diabetes or CHD, CAS odds increased for participants with diabetes alone (1.53, 95% CI 1.50-1.56), CHD alone (1.72, 95% CI 1.68-1.76), and both diabetes and CHD (2.57, 95% CI 2.49-2.66). Findings were consistent for women and men. CONCLUSION In a large database of more than 3.5 million self-referred participants, diabetes was a CHD risk equivalent for PAD and CAS, and participants with comorbid diabetes and CHD had an especially robust association with PAD and CAS. Counseling regarding screening and prevention of peripheral vascular disease may be useful for patients with diabetes.
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50
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Woo SY, Joh JH, Han SA, Park HC. Prevalence and risk factors for atherosclerotic carotid stenosis and plaque: A population-based screening study. Medicine (Baltimore) 2017; 96:e5999. [PMID: 28121957 PMCID: PMC5287981 DOI: 10.1097/md.0000000000005999] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Atherosclerotic carotid stenosis (ACS) is a major cause of ischemic stroke. Screening for asymptomatic ACS is important to identify the patients who require longitudinal surveillance, medication, or endovascular surgery. The aim of this study was to assess the prevalence and risk factors for ACS and carotid plaque (CP) in Korea using a population-based screening study.We recruited participants during visits to several community welfare centers in Korea. The baseline characteristics of the study population were collected. All patients underwent duplex ultrasonography to examine their bilateral carotid arteries. ACS was defined as the presence of plaque with ≥50% vessel diameter reduction and peak systolic velocity (PSV) ≥125 cm/s or PSV ratio ≥2.0. CP was defined as the presence of plaque with <50% vessel diameter reduction. The Mann-Whitney test, χ test, Fisher exact test, and logistic regression were used in the statistical analysis.A total of 3030 participants were enrolled in this study (male 43.7% and female 56.3%). The prevalence of ACS and CP was 1.1% and 5.7%, respectively. Significant risk factors for CP included age ≥80 years (odds ratio [OR], 8.11; 95% confidence interval [CI], 3.45-18.93), male sex (OR, 2.16; 95% CI, 1.29-3.61), hypertension (OR, 1.72; 95% CI, 1.21-2.45), and hyperlipidemia (OR, 1.84; 95% CI, 1.30-2.62). The presence of ACS was significantly associated with age (OR, 1.07; 95% CI, 1.03-1.12), hypertension (OR, 3.16; 95% CI, 1.34-7.46), and being an ex-smoker (OR, 6.81; 95% CI, 1.66-27.93) or current smoker (OR, 6.97; 95% CI, 1.78-27.31) after adjusting for confounding factors.This population-based screening study revealed that ACS was uncommon and had a prevalence of 1.1% in the study population. Age, hypertension, and smoking were risk factors for ACS. Further investigations into the prevalence and risk factors of ACS are required, as are studies on the cost-effectiveness of a national screening program.
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Affiliation(s)
- Shin Young Woo
- Vascular Center, Heart Vascular and Stroke Institute, Samsung Medical Center
| | - Jin Hyun Joh
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Sang-Ah Han
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
| | - Ho-Chul Park
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, Korea
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