Patients with severely narrowed neck arteries have low risk of future stroke, study finds

The risk of having a future stroke caused by a severe blockage of an artery in the neck that currently causes no symptoms is so low that most patients with this disease -; asymptomatic carotid stenosis -; could potentially be treated with the newer drugs and may not require surgery, according to a new study from Kaiser Permanente.

The question of how best to treat patients with carotid artery narrowing without symptoms has been a long-standing research priority. We decided to take a step back and start our study by asking how likely these patients were to actually have a stroke related to their severe stenosis. Our analyzes have shown that this risk is so low that it seems that for most patients surgery is not necessary.”

Robert Chang, MD, research physician at Kaiser Permanente Division of Research and vascular surgeon at Permanente Medical Group

The study, published on May 24 in JAMAis considered the most important and current assessment of long-term stroke risk in this population.

Carotid stenosis occurs when plaque -; fatty cholesterol deposits -; collects in one or both large arteries on either side of the neck that carry blood to the brain, face and head. This narrowing of the artery is usually diagnosed after a patient exhibits symptoms of a stroke, but it can also be detected during a routine physical examination.

Randomized clinical trials conducted before 2010 concluded that surgery to remove the blockage was the best option for reducing the risk of stroke in patients with severe stenosis. But as medical treatments to reduce the risk of stroke have improved, doctors have begun to question whether surgery should remain the treatment of choice for asymptomatic patients.

To answer this question, Dr. Chang and colleagues identified 3,737 members of Kaiser Permanente in Northern California who had been diagnosed between 2008 and 2012 with severe asymptomatic carotid stenosis (70% to 99% blockage). None of these patients had been operated on before.

The research team first sought to see how the stenosis had been treated. Review of patients’ medical records showed that 1,423 patients had undergone surgery to treat the stenosis and 2,314 had not. The team also followed patients who were taking a statin, a drug used to help lower blood cholesterol, or medication to lower high blood pressure. Next, the team set out to see how many patients had a carotid-related stroke on the same side as the severe carotid stenosis, following patients through 2019.

A total of 133 strokes were diagnosed in 129 patients during the follow-up period. Statistical analyzes showed that unoperated patients had a 4.7% cumulative risk of having a stroke within 5 years of their diagnosis of carotid stenosis.

The study’s lead author, Mai N. Nguyen-Huynh, MD, a researcher at the Kaiser Permanente Division of Research and regional medical director for primary stroke at Permanente Medical Group, said the results didn’t have it. not surprised. “We suspected that we might find a low risk of stroke in these patients because there are now better stroke prevention treatments, including drugs to control blood pressure, prevent blood clots and lower cholesterol, than when original randomized trials have been done,” she says. “I believe our study will make many patients and their doctors think twice about having surgery if they can instead follow an effective and aggressive medical management program to reduce their risk of stroke due to asymptomatic carotid disease. .”

Dr. Chang and Dr. Nguyen-Huynh also currently lead a Research Division team affiliated with a nationwide randomized clinical trial, called CREST2, which is enrolling patients in a study comparing surgery or stenting to medical management in patients with asymptomatic severe carotid artery disease. stenosis. “This head-to-head comparison of carotid surgery versus medical management in a clinical trial is what we need to help us determine the appropriate approach,” Dr. Nguyen-Huynh said.


Journal reference:

Chang, RW, et al. (2022) Incidence of ischemic stroke in patients with asymptomatic severe carotid stenosis without surgery. JAMA.

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