Week 9: Even More Stroke, part 2

#21: Management of asymptomatic internal carotid artery stenosis

  • This article is a JAMA Grand Rounds that tries to answer the scenario in which a PCP hears a carotid bruit in an elderly patient, and ultrasound confirms high grade stenosis–should they be referred for intervention, or stick to medical therapy alone?
  • Spoiler: the evidence isn’t great.
  • 10-15% of strokes in the US are associated with ICA stenosis (symptomatic or asymptomatic)
  • 7-9% of patients older than 75 have asymptomatic ICA stenosis
  • The natural history of carotid disease has changed: in the 1980s, the stroke risk was 3% per year for >80% stenosis, 5%/yr for >90% stenosis, but these rates have significantly declined over the years
  • Statins are a magic drug: in patients with CAD or diabetes, simvastatin 40mg daily was associated with a 25% reduction in stroke risk; in patients with diabetes and additional risk factors, atorvastatin 10mg decreased stroke risk by 48% compared with placebo
  • Two older trials supported CEA (ACAS and ACST), but achieving similar results requires a perioperative risk of <3%, which is hard to achieve in the community
  • CREST evaluated stenting vs CEA in 2502 patients, including both symptomatic and asymptomatic patients, and found no difference, but stenting hasn’t become standard of care
  • The primary cause of mortality in patients with asymptomatic ICA stenosis is cardiac: having a carotid bruit increases your risk of heart attack by three, to 5% per year
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