Best management unclear for patients needing carotid revascularisation

By Eleanor McDermid, Senior medwireNews Reporter

Research highlights the vulnerability of patients with symptomatic carotid stenosis to stroke while awaiting revascularisation.

The study authors – Elisa Cuadrado-Godia (IMIM-Hospital del Mar, Barcelona, Spain) and team – note that urgent carotid revascularisation (within 48–72 hours) has been linked to a high rate of periprocedural events.

However, they found a high rate of recurrent stroke within the currently advised 14-day intervention period, leading them to call for formal comparisons of the risks associated with urgent versus subacute carotid revascularisation.

The study, which appears in Neurology, included 377 patients with symptomatic carotid stenosis of 50–99% treated in one of three centres in Sweden, Ireland and Spain. During the first 14 days after their presenting event, 11.5% of these patients had an ipsilateral ischaemic event (stroke or retinal artery occlusion), rising to 18.8% in those who did not undergo revascularisation within 90 days.

At 3 days after presentation, 6.6% of the patients had experienced a recurrent event, and just 2.7% had done so within 1 day. Older age was the only factor to independently predict recurrence.

In a linked editorial, Seemant Chaturvedi (University of Miami Miller School of Medicine, Florida, USA) and Peter Rothwell (John Radcliffe Hospital, Oxford, UK) argue that the effects of optimal medical therapy are unclear in these patients.

The trials demonstrating the benefits of revascularisation over medical therapy were conducted a quarter of a century ago, they say, and medical therapy has moved on since then. They highlight a study that reported a large fall in recurrent events among patients awaiting carotid surgery, from 29% to 2.5%, after the introduction of early optimised therapy, consisting of dual antiplatelet therapy and statin treatment.

Most patients in the current study received antithrombotic therapy within 48 hours, but just 21% of these received dual antiplatelet treatment, and the rates of early statin treatment ranged from 64% to 81% depending on the centre.

Chaturvedi and Rothwell also note that optimised medical therapy “proved to be the best option for patients with intracranial stenosis and there is reason to believe that it could also prove to be so for some patients with extracranial disease as well.”

They conclude: “Clinicians and patients deserve an answer to this important question.”

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