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Gologorsky RC, Lancaster E, Tucker LY, Nguyen-Huynh MN, Rothenberg KA, Avins AL, Kuang HC, Chang RW. Natural History of Asymptomatic Moderate Carotid Artery Stenosis in a Large Community-Based Cohort. Stroke 2022; 53:2838-2846. [DOI: 10.1161/strokeaha.121.038426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Moderate carotid artery stenosis is a poorly defined risk factor for ischemic stroke. As such, practice recommendations are lacking. In this study, we describe the long-term risk of stroke in patients with moderate asymptomatic stenosis in an integrated health care system.
Methods:
All adult patients with asymptomatic moderate (50%–69%) internal carotid artery stenosis between 2008 and 2012 were identified, with follow-up through 2017. The primary outcome was acute ischemic stroke attributed to the ipsilateral carotid artery. Stroke rates were calculated using competing risk analysis. Secondary outcomes included disease progression, ipsilateral intervention, and long-term survival.
Results:
Overall, 11 614 arteries with moderate stenosis in 9803 patients were identified. Mean age was 74.2±9.9 years with 51.4% women. Mean follow-up was 5.1±2.9 years. There were 180 ipsilateral ischemic strokes (1.6%) identified (crude annual risk, 0.31% [95% CI, 0.21%–0.41%]), of which thirty-one (17.2%) underwent subsequent intervention. Controlling for death and intervention as competing risks, the cumulative incidence of stroke was 1.2% (95% CI, 1.0%–1.4%) at 5 years and 2.0% (95% CI, 1.7%–2.4%) at 10 years. Of identified strokes, 50 (27.8%) arteries had progressed to severe stenosis or occlusion. During follow-up, there were 17 029 carotid studies performed in 5951 patients, revealing stenosis progression in 1674 (14.4%) arteries, including 1614 (13.9%) progressing to severe stenosis and 60 (0.5%) to occlusion. The mean time to stenosis progression was 2.6±2.1 years. Carotid intervention occurred in 708 arteries (6.1%). Of these, 66.1% (468/708) had progressed to severe stenosis. The overall mortality rate was 44.5%, with 10.5% of patients lost to follow-up.
Conclusions:
In this community-based sample of patients with asymptomatic moderate internal carotid artery stenosis followed for an average of 5 years, the cumulative incidence of stroke is low out to 10 years. Future research is needed to optimize management strategies for this population.
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Affiliation(s)
- Rebecca C. Gologorsky
- Department of Surgery, University of California, San Francisco, East Bay, Oakland (R.C.G., K.A.R.)
| | | | - Lue-Yen Tucker
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
| | - Mai N. Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
- Department of Surgery, The Permanente Medical Group, Inc, Walnut Creek, CA (M.N.N.-H.,)
| | - Kara A. Rothenberg
- Department of Surgery, University of California, San Francisco, East Bay, Oakland (R.C.G., K.A.R.)
| | - Andrew L. Avins
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
- Departments of Medicine and Epidemiology and Biostatistics, University of California, San Francisco (A.L.A.)
| | - Hui C. Kuang
- Department of Surgery, The Permanente Medical Group, San Francisco, CA (H.C.K.)
| | - Robert W. Chang
- Division of Research, Kaiser Permanente Northern California, Oakland (L.-Y.T., M.N.N.-H., A.L.A., R.W.C.)
- Department of Surgery, The Permanente Medical Group, South San Francisco, CA (R.W.C.)
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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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Bluth E, Mohammed A, Fort D, Bouche R, Collins J, Price-Haywood EG. Differential rates of progression of low-grade carotid stenosis detected by follow-up ultrasound: A single institution experience. Clin Imaging 2020; 67:170-176. [PMID: 32798965 DOI: 10.1016/j.clinimag.2020.06.048] [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: 04/03/2020] [Revised: 06/27/2020] [Accepted: 06/29/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The growing body of evidence suggesting that lifestyle changes and aggressive medical management reduce the risk of strokes in patients with carotid stenosis has fostered interest in noninvasive screening. The objective of this study was to develop recommendations for follow-up carotid ultrasound surveillance of patients with <60% carotid stenosis. METHODS This retrospective observational cohort study includes 2956 patients seen between August 1998 and March 2015 in 4440 visits. Data analysis was restricted to 7710 carotid ultrasounds. Primary outcome was progression of carotid stenosis as defined by the "bulb" method: baseline stenosis of 0%-39% progressed to 40%-59% on subsequent examination, baseline stenosis of 0%-39% progressed to ≥60%, or baseline of 40%-59% progressed to ≥60%. Progression was estimated using Cox proportional hazard ratios and the Kaplan-Meier method. RESULTS More than 10% of patients progressed in the 40%-59% baseline group within 12 months compared to 78 months for the 0%-39% baseline group. Patients who progressed had a higher proportion of peripheral vascular disease, and current/former smoking compared to those who did not. While there were statistically significant correlations between medication classes and comorbidities, none of the medications studied appeared to slow carotid stenosis progression. CONCLUSIONS In our experience, for patients with a 0%-39% carotid stenosis, follow-up examination should be performed at 6-year intervals. For patients with 40%-59% carotid stenosis, follow-up should be obtained annually to identify those who progress to a level requiring intervention. Future studies should examine whether study findings can be replicated using other approaches for determining carotid stenosis.
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Affiliation(s)
- Edward Bluth
- Ochsner Clinic Foundation, New Orleans, LA, USA; Ochsner Clinical School, University of Queensland, New Orleans, LA, USA.
| | - Alaa Mohammed
- Ochsner Health System Center for Outcomes and Health Services Research, New Orleans, LA, USA.
| | - Daniel Fort
- Ochsner Health System Center for Outcomes and Health Services Research, New Orleans, LA, USA.
| | - Rhett Bouche
- Ochsner Clinical School, University of Queensland, New Orleans, LA, USA
| | - Johnathon Collins
- Ochsner Clinical School, University of Queensland, New Orleans, LA, USA
| | - Eboni G Price-Haywood
- Ochsner Clinic Foundation, New Orleans, LA, USA; Ochsner Clinical School, University of Queensland, New Orleans, LA, USA; Ochsner Health System Center for Outcomes and Health Services Research, New Orleans, LA, USA.
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Ji R, Yu K, Li G, Liu X, Yan Y, Gao S, Yang H, Qin S, Li F, Zhang G, Yang B, He Y, Zhao Y, Li E, Xu L, Zhang N, Fan D, Liu D. ECAS progression score: a web-based model to predict progression of extracranial carotid artery stenosis. Neurol Res 2019; 41:456-465. [PMID: 30759062 DOI: 10.1080/01616412.2019.1576375] [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: 10/27/2022]
Abstract
BACKGROUND AND PURPOSE To develop and validate a risk model (Extracranial Carotid Artery Stenosis progression score, ECAS-PS) and to predict risk of ECAS progression. METHODS The ECAS-PS was developed based on the Renqiu Stroke Screening Study (RSSS), in which eligible participants were randomly divided into derivation (60%) and validation (40%) cohorts. ECAS at baseline and follow-up was diagosed by carotid duplex ultrasound according to the published criteria. ECAS progression was defined as an increase in ECAS to≥50% for those with a baseline of <50% or as an increase to a higher category of stenosis if the baseline stenosis was ≥50%. Independent predictors of ECAS progression were obtained using multivariable logistic regression. The area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow test were used to assess model discrimination and calibration. RESULTS A total of 4111 participants were included and the mean age was 64.3. A total number of 29 (0.7%), 24 (0.6%) and 48 (1.2%) patients progressed during 2-year follow-up for left, right and bilateral (either left or right) carotid artery, respectively. The ECAS-PS was developed from a set of predictors of ECAS progression. The ECAS-PS demonstrated good discrimination in both the derivation and validation cohorts (AUROC range: 0.824-0.917). The Hosmer-Lemeshow tests of ECAS progression score were not significant in the derivation and validation cohorts (all P > 0.05). CONCLUSION The ECAS progression score is a valid model for predicting the risk of ECAS progression. Further validation of the ECAS-PS in different populations and larger samples is warranted.
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Affiliation(s)
- Ruijun Ji
- a Department of Neurology, Tiantan Hospital , Capital Medical University , Beijing , China.,b Department of rehabilitation medicine (Neurorehabilitation), Tiantan Hospital , Capital Medical University , Beijing , China.,c China National Clinical Research Center for Neurological Diseases , Beijing , China.,d Center of Stroke , Beijing Institute for Brain Disorders , Beijing , China.,e Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease , Beijing , China.,f Beijing Key Laboratory of Brain Function Reconstruction , Beijing , China
| | - Kai Yu
- g Department of Neurology , Kangji Hospital , Hebei , China
| | - Guoyang Li
- a Department of Neurology, Tiantan Hospital , Capital Medical University , Beijing , China.,b Department of rehabilitation medicine (Neurorehabilitation), Tiantan Hospital , Capital Medical University , Beijing , China.,c China National Clinical Research Center for Neurological Diseases , Beijing , China.,d Center of Stroke , Beijing Institute for Brain Disorders , Beijing , China.,e Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease , Beijing , China.,f Beijing Key Laboratory of Brain Function Reconstruction , Beijing , China
| | - Xinyu Liu
- a Department of Neurology, Tiantan Hospital , Capital Medical University , Beijing , China.,b Department of rehabilitation medicine (Neurorehabilitation), Tiantan Hospital , Capital Medical University , Beijing , China.,c China National Clinical Research Center for Neurological Diseases , Beijing , China.,d Center of Stroke , Beijing Institute for Brain Disorders , Beijing , China.,e Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease , Beijing , China.,f Beijing Key Laboratory of Brain Function Reconstruction , Beijing , China
| | - Yinglin Yan
- g Department of Neurology , Kangji Hospital , Hebei , China
| | - Suying Gao
- g Department of Neurology , Kangji Hospital , Hebei , China
| | - Hongna Yang
- g Department of Neurology , Kangji Hospital , Hebei , China
| | - Shangmin Qin
- h Department of Ultrasonography , Kangji Hospital , Hebei , China
| | - Fang Li
- g Department of Neurology , Kangji Hospital , Hebei , China
| | - Guangbo Zhang
- g Department of Neurology , Kangji Hospital , Hebei , China
| | - Bo Yang
- i Department of Cardiology , Kangji Hospital , Hebei , China
| | - Yan He
- j Department of Endocrinology , Kangji Hospital , Hebei , China
| | - Yongna Zhao
- g Department of Neurology , Kangji Hospital , Hebei , China
| | - Enjing Li
- i Department of Cardiology , Kangji Hospital , Hebei , China
| | - Lihua Xu
- g Department of Neurology , Kangji Hospital , Hebei , China
| | - Na Zhang
- g Department of Neurology , Kangji Hospital , Hebei , China
| | - Dongna Fan
- i Department of Cardiology , Kangji Hospital , Hebei , China
| | - Dongliang Liu
- i Department of Cardiology , Kangji Hospital , Hebei , China
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