INTERVENTIONS FOR STROKE PREVENTION: WHAT IS A CARDIOLOGIST TO DO?
James D. Marsh, M.D., University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
Atherosclerosis in the carotid artery is a common cause of stroke in North America. For those with a prior transient ischemic attack (TIA) or minor stroke, data from 20 years ago indicates a high 90 day risk of recurrence of 12-20%. However, recent registry data (2009-2011) which includes patients on contemporary treatment for atherosclerosis shows a 12 month recurrence rate of <7%. Medical therapy has improved, with compelling data for patients with symptomatic carotid disease: aspirin + clopidogrel therapy reduces recurrence and is superior to aspirin alone if started within 24 hours of symptom onset, with no increase in risk of hemorrhage. To compare the safety and efficacy of carotid artery endarterectomy (CEA) with carotid artery stenting (CAS) in patients with both symptomatic and asymptomatic carotid stenosis, the CREST trial was undertaken at 108 US and 9 Canadian sites. The primary endpoint (up to 4 years) was any stroke, MI or death within the periprocedural period and ipsilateral stroke thereafter. Both procedures, in expert hands, were relatively safe with similar net outcome. The effects were durable over 10 year follow-up.A major question remains regarding optimal management of patients with asymptomatic carotid disease. With the marked improvement in the medical management of atherosclerosis, in asymptomatic patients is there a difference in outcome for intense medical management vs. CEA, or intense medical management vs. CAS? The CREST 2 Trial was launched to answer this question. An important secondary outcome measure is cognitive function at four years. The trial is ongoing with projected enrollment completion in 2020. At this point, intensive medical management is appropriate for all patients with symptomatic or asymptomatic carotid disease, there are good carotid intervention options for symptomatic disease and the relative value of mechanical interventions in asymptomatic disease will be known soon.