2011 ASA/ACCF/AHA/AANN/AANS/ACR/CNS/SAIP/SCAI/SIR/ SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease

Perspective:

The following are 10 points to remember about the guideline on management of patients with extracranial carotid and vertebral artery disease:

1. The initial evaluation of patients with transient retinal or hemispheric neurological symptoms of possible ischemic origin should include noninvasive imaging for the detection of extracranial carotid stenosis.

2. Antihypertensive treatment is recommended for patients with hypertension and asymptomatic extracranial carotid or vertebral atherosclerosis to maintain blood pressure below 140/90 mm Hg.

3. Patients with extracranial carotid or vertebral atherosclerosis who smoke cigarettes should be advised to quit smoking and offered smoking cessation interventions to reduce the risks of atherosclerosis progression and stroke.

4. Treatment with a statin medication is recommended for all patients with extracranial carotid or vertebral atherosclerosis to reduce low-density lipoprotein cholesterol below 100 mg/dl.

5. Antiplatelet therapy with aspirin, 75-325 mg daily, is recommended for patients with obstructive or nonobstructive atherosclerosis that involves the extracranial carotid and/or vertebral arteries for prevention of myocardial infarction and other ischemic cardiovascular events, although the benefit has not been established for prevention of stroke in asymptomatic patients.

6. In patients with obstructive or nonobstructive extracranial carotid or vertebral atherosclerosis who have sustained ischemic stroke or transient ischemic attack, antiplatelet therapy with aspirin alone (75-325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin plus extended-release dipyridamole (25-200 mg twice daily, respectively) is recommended and preferred over the combination of aspirin with clopidogrel.

7. Patients at average or low surgical risk who experience nondisabling ischemic stroke or transient cerebral ischemic symptoms including hemispheric events or amaurosis fugax within 6 months (symptomatic patients) should undergo carotid endarterectomy (CEA) if the diameter of the lumen of the ipsilateral internal carotid artery is reduced more than 70% as documented by noninvasive imaging, or more than 50% as documented by catheter angiography, and the anticipated rate of perioperative stroke or mortality is less than 6%.

8. Carotid stenting is indicated as an alternative to CEA for symptomatic patients at average or low risk of complications associated with endovascular intervention when the diameter of the lumen of the internal carotid artery is reduced by more than 70% as documented by noninvasive imaging, or more than 50% as documented by catheter angiography, and the anticipated rate of periprocedural stroke or mortality is less than 6%.

9. Before and for a minimum of 30 days after carotid stenting, dual antiplatelet therapy with aspirin (81-325 mg daily) plus clopidogrel (75 mg daily) is recommended. For patients intolerant of clopidogrel, ticlopidine (250 mg twice daily) may be substituted.

10. Percutaneous endovascular angioplasty and stenting are reasonable for patients with symptomatic posterior cerebral or cerebellar ischemia caused by subclavian artery stenosis (subclavian steal syndrome), who are at high risk of surgical complications.

Clinical Topics: Dyslipidemia, Prevention, Lipid Metabolism, Nonstatins, Statins, Hypertension, Smoking

Keywords: Vertebral Artery, Stroke, Myocardial Infarction, Ischemic Attack, Transient, Platelet Aggregation Inhibitors, Smoking, Cholesterol, Drug Combinations, Hypertension, Smoking Cessation, Dipyridamole


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