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Determining Risk Factors Associated With Failure Of Best Medical Therapy In Carotid Stenosis
Elisa Caron, MD1, Randall Bloch, MD
1, Stephen Caron, PhD candidate
2, Katie Shean, MD
1, Scott Prushik, MD
1, Marc L. Schermerhorn, MD
3, Mark Conrad, MD
1;
1St Elizabeth's Medical Center, Boston, MA, USA,
2Boston University Department of Biology, Boston, MA, USA,
3Beth Israel Deaconess Medical Center, Boston, MA, USA
OBJECTIVES: There is level 1 evidence that supports Carotid Endarterectomy (CEA) for the prevention of stroke in patients with severe carotid stenosis. A recent meta-analysis of statin trials concluded that the risk of stroke in patients taking statins is so low that most patients should be managed medically. However, patients continue to present with carotid-related Stroke or TIA despite medical therapy. The goal of this study is to determine which risk factors are associated with the failure of medical therapy.
METHODS: All patients who underwent carotid revascularization (CEA or TCAR) were identified at a single institution from 2017-2021 and were stratified by symptomatic status. Patients were reviewed to determine who was on best medical therapy (BMT) prior to revascularization. BMT included antiplatelet therapy, a statin, and smoking cessation. All patients met NASCET criteria for severe stenosis of 70% or had high-risk plaque features.
RESULTS: There were 240 patients,79(33%) symptomatic, 161(67% asymptomatic). Of these, 52% were on BMT prior to Presentation. Best medical therapy was protective against symptoms, (aOR 0.4, P=0.004) after adjusting for prior surgical and medical history. A history of a prior major amputation was associated with an increased risk of stroke or TIA (aOR 3.98, P=0.002), however, a history of prior vascular intervention reduced the odds of symptomatic presentation (aOR 0.3, P=0.008). Subgroup analysis of only patients on BMT at the time of presentation showed the same trend, with a prior amputation associated with increased risk of failure of BMT, and a prior vascular procedure was associated with a trend towards decreased risk ( aOR 2.83, 0.3, P=0.043,P=0.061).
CONCLUSIONS: There is a continued role for CEA in the management of severe carotid artery stenosis. It is plausible that the decrease in risk for Stroke or TIA in patients with prior vascular interventions suggests that those patients are more likely to receive screening duplex, whereas patients with a prior amputation likely had poorer access to or utilization of the health care system. While this represents a small number of patients it suggests that patients with vascular disease in other areas would likely benefit from screening.
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