Carotid artery stenosis medical therapy: Difference between revisions
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/* Antithrombotic Therapy in Patients With Extracranial Carotid Atherosclerotic Disease Not Undergoing Revascularization{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AAN... |
/* Antithrombotic Therapy in Patients With Extracranial Carotid Atherosclerotic Disease Not Undergoing Revascularization{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=2011 ASA/ACCF/AHA/AANN/AAN... |
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| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | | colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]] | ||
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with extracranial cerebrovascular atherosclerosis who have an indication for anticoagulation, such as atrial fibrillation or a mechanical prosthetic heart valve, it can be beneficial to administer a vitamin K antagonist (such as warfarin, dose adjusted to achieve a target international normalized ratio [INR] of 2.5 [range 2.0 to 3.0]) for prevention of thromboembolic ischemic events. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' In patients with extracranial cerebrovascular atherosclerosis who have an indication for anticoagulation, such as [[atrial fibrillation]] or a mechanical prosthetic heart valve, it can be beneficial to administer a vitamin K antagonist (such as [[warfarin]], dose adjusted to achieve a target international normalized ratio ([[INR]]) of 2.5 [range 2.0 to 3.0]) for prevention of thromboembolic ischemic events. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | ||
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|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with atherosclerosis of the extracranial carotid or vertebral arteries in whom aspirin is contraindicated by factors other than active bleeding, including allergy, either clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) is a reasonable alternative. ([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | |bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' For patients with atherosclerosis of the extracranial carotid or vertebral arteries in whom aspirin is contraindicated by factors other than active bleeding, including allergy, either clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) is a reasonable alternative. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])'' <nowiki>"</nowiki> | ||
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Revision as of 00:53, 2 November 2012
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Carotid artery stenosis Microchapters |
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Diagnosis |
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Treatment |
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ACC/AHA Guideline Recommendations |
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Periprocedural Management of Patients Undergoing Carotid Endarterectomy |
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Atherosclerotic Risk Factors in Patients With Vertebral Artery Disease |
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Occlusive Disease of the Subclavian and Brachiocephalic Arteries |
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Case Studies |
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Carotid artery stenosis medical therapy On the Web |
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American Roentgen Ray Society Images of Carotid artery stenosis medical therapy |
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Risk calculators and risk factors for Carotid artery stenosis medical therapy |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Charmaine Patel, M.D. [2], Aarti Narayan, M.B.B.S [3]
Overview
Medical Therapy
- Assess global cardiovascular risk
- Aspirin, clopidogrel; aspirin + dipyridamole
- Blood pressure, lipid and diabetes management
- Surveillance ultrasound yearly
- Educate about symptoms of TIA or stroke
2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS: Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease (DO NOT EDIT)[1]
Treatment of Hypertension (DO NOT EDIT)[1]
| Class I |
| "1. Antihypertensive treatment is recommended for patients with hypertension and asymptomatic atherosclerotic ECVD to maintain blood pressure (BP) less than 140/90 mm Hg. (Level of Evidence: A) " |
| Class IIa |
| "1. Except during the hyperacute period, antihypertensive treatment is probably indicated in patients with hypertension and symptomatic atherosclerotic ECVD, but the benefit of treatment to a specific BP has not been established in relation to the risk of exacerbating cerebral ischemia. (Level of Evidence: C) " |
Control of Hyperlipidemia (DO NOT EDIT)[1]
| Class I |
| "1. Treatment with a statin is recommended for all patients with atherosclerotic ECVD (Extracranial Carotid and Vertebral artery Disease) to lower low density lipoprotein cholesterol to less than 100 mg/dL. (Level of Evidence: B) " |
| "2. For patients (mother or father) with HCM, genetic counseling is indicated before planned conception. (Level of Evidence: C) " |
| "3. In women with HCM and resting or provocable LVOT (Left Ventricular Outflow Tract) obstruction greater than or equal to 50 mm Hg and/or cardiac symptoms not controlled by medical therapy alone, pregnancy is associated with increased risk, and these patients should be referred to a high-risk obstetrician. (Level of Evidence: C) " |
| "4. The diagnosis of HCM among asymptomatic women is not considered a contraindication for pregnancy, but patients should be carefully evaluated in regard to the risk of pregnancy. (Level of Evidence: C) " |
| Class IIa |
| "1. Treatment with a statin is reasonable for all patients with atherosclerotic ECVD who sustain ischemic stroke to reduce low-density lipoprotein cholesterol to a level less than or equal to 70 mg/dL. (Level of Evidence: B) " |
| "2. If treatment with a statin does not achieve the goal, intensifying therapy with an additional drug from among those with evidence of improving outcomes can be effective. (Level of Evidence: B) " |
| "3. For patients who do not tolerate statins, therapy with bile acid sequestrants and/or niacin is reasonable. (Level of Evidence: B) " |
Management of Diabetes Mellitus in Patients With Atherosclerosis of the Extracranial Carotid or Vertebral Arteries (DO NOT EDIT)[1]
| Class IIa |
| "1. Diet, exercise, and glucose-lowering drugs can be useful for patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis. The stroke prevention benefit, however, of intensive glucose lowering therapy to a glycosylated hemoglobin A1c level less than 7.0% has not been established. (Level of Evidence: A)" |
| "2. Administration of statin-type lipid-lowering medication at a dosage sufficient to reduce LDL cholesterol to a level near or below 70 mg/dL is reasonable in patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis for prevention of ischemic stroke and other ischemic cardiovascular events. (Level of Evidence: B)" |
Antithrombotic Therapy in Patients With Extracranial Carotid Atherosclerotic Disease Not Undergoing Revascularization[1] (DO NOT EDIT)
| Class I |
| "1. Antiplatelet therapy with aspirin, 75 to 325 mg daily, is recommended for patients with obstructive or nonobstructive atherosclerosis that involves the extracranial carotid and/or vertebral arteries for prevention of myocardial infarction (MI) and other ischemic cardiovascular events, although the benefit has not been established for prevention of stroke in asymptomatic patients. (Level of Evidence: A) " |
| "2. In patients with obstructive or nonobstructive extracranial carotid or vertebral atherosclerosis who have sustained ischemic stroke or TIA, antiplatelet therapy with aspirin alone (75 to 325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin plus extended-release dipyridamole (25 and 200 mg twice daily, respectively) is recommended (Level of Evidence: B) and preferred over the combination of aspirin with clopidogrel. (Level of Evidence: B) Selection of an antiplatelet regimen should be individualized on the basis of patient risk factor profiles, cost, tolerance, and other clinical characteristics, as well as guidance from regulatory agencies. (Level of Evidence: C) " |
| "3. Antiplatelet agents are recommended rather than oral anticoagulation for patients with atherosclerosis of the extracranial carotid or vertebral arteries with (Level of Evidence: B) or without (Level of Evidence: C) ischemic symptoms. (For patients with allergy or other contraindications to aspirin, see Class IIa recommendation #2, this section.)(Level of Evidence: C) " |
| Class III (Harm) |
| "1. Full-intensity parenteral anticoagulation with unfractionated heparin or low-molecular-weight heparinoids is not recommended for patients with extracranial cerebrovascular atherosclerosis who develop transient cerebral ischemia or acute ischemic stroke. (Level of Evidence: B) " |
| "2. Administration of clopidogrel in combination with aspirin is not recommended within 3 months after stroke or TIA. (Level of Evidence: B) " |
| Class IIa |
| "1. In patients with extracranial cerebrovascular atherosclerosis who have an indication for anticoagulation, such as atrial fibrillation or a mechanical prosthetic heart valve, it can be beneficial to administer a vitamin K antagonist (such as warfarin, dose adjusted to achieve a target international normalized ratio (INR) of 2.5 [range 2.0 to 3.0]) for prevention of thromboembolic ischemic events. (Level of Evidence: C) " |
| "1. For patients with atherosclerosis of the extracranial carotid or vertebral arteries in whom aspirin is contraindicated by factors other than active bleeding, including allergy, either clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) is a reasonable alternative. (Level of Evidence: C) " |
References
- ↑ 1.0 1.1 1.2 1.3 1.4 Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL; et al. (2011). "2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery". Circulation. 124 (4): 489–532. doi:10.1161/CIR.0b013e31820d8d78. PMID 21282505.