New stroke guidelines weigh stenting vs. endartectomy, ultrasound screening
“In general, people are gaining an awareness that atherosclerosis is a systemic disease that extends beyond patients who experience heart attacks, along with the disease complications including stroke,” Jonathan L. Halperin, MD, director of cardiology clinical services at the Zena and Michael A. Wiener Cardiovascular Institute at Mount Sinai Medical Center in New York City, told Cardiovascular Business News. “Also, these guidelines are particularly timely because an FDA committee recommended broadening the indications for carotid stenting, which heretofore were either used in research trials or those patients who were deemed inoperable candidates.
“Prior to these guidelines, there weren’t any widely accepted standards about when ultrasound assessment should occur, but we determined that it should be a part of routine screening, but reserved for patients with known disease that needs [assessment or presents with] clinical reason to be highly suspicious," offered Halperin, co-chair of the writing committee.
Some examples when ultrasound should be employed, according to the authors, are if a physician hears carotid bruit (abnormal sound in the neck that could indicate turbulent blood flow in the neck arteries), or if a patient has two or more risk factors for stroke, such as high cholesterol or a family history. Other stroke risk factors include age, family history of stroke, high blood pressure, high blood cholesterol, diabetes, obesity, atrial fibrillation, physical inactivity, sickle cell disease and other heart or blood vessel diseases.
Among dozens of recommendations, the writing committee concluded that the two often competing procedures—carotid stenting and carotid endartectomy—are both “reasonable and safe” when arteries are more than 50 percent blocked.
The guidelines took into account the two recent large-scale, randomized trials: CREST in the U.S. and the International Carotid Stenting Study. Because the two trials arrived at “slightly different conclusions,” Halperin said, the committee had to truly assess the strengths and weaknesses of both trial designs.
"The guidelines support carotid surgery as a tried-and-true treatment for most patients," said Thomas G. Brott, MD, committee co-chair and professor of neurology and director of research at the Mayo Clinic in Jacksonville, Fla. "However, for patients who have a strong preference for less invasive treatments, carotid stenting offers a safe alternative. Because of the anatomy of their arteries or other individual considerations, some patients may be more appropriate for surgery and others for stenting."
Also, Halperin stressed while both techniques may be viable options for many patients, operator experience is integral for success with either technique.
Finally, “all patients should be receiving optimal medical therapy whether they receive revascularization or not.” Medications offer a better alternative than either surgery or stenting for many patients, according to the guidelines. Based on the latest clinical trials comparing the procedures, all patients received optimal medical treatment but there were no medication-only groups.
In addition to the AHA, ASA and the ACC, the guidelines were developed with the American Association of Neuroscience Nurses, the American Association of Neurological Surgeons, the American Society of Neuroradiology, the American College of Radiology, the Congress of Neurological Surgeons, the Society for Atherosclerosis Imaging and Prevention, the Society for Cardiovascular Angiography and Interventions, the Society of Interventional Radiology, the Society for NeuroInterventional Surgery, the Society for Vascular Medicine and the Society for Vascular Surgery. The American Academy of Neurology and the Society of Cardiovascular Computed Tomography also collaborated in the process.