CPC: A Case of Asymptomatic Carotid Stenosis in a Hypertensive Patient

CPC: A Case of Asymptomatic Carotid Stenosis in a Hypertensive Patient


On behalf of my co-chair, Professor Rhian Touyz and myself i would like to welcome you to this very special session. It is for
American Heart Association journal called Hypertension. Probably very
familiar to all of you. This is ran as clinical pathological conference and we
try and cover, our ambition is to be very similar to what you read i am sure every
week in New England Journal of Medicine So we filming, but differently to them, we
film it and then later publish a paper. All of you who will take part in
discussion will have a chance to contribute to the paper which will be
published in Hypertension. There is very important percent you need to know
and talk to after the session and she is at the back in the red top and that is
Denise Kuo and Denise runs Hypertension with us. She will make a
note of all discussions, including the email, so you can then be able to
contribute to the final paper. So without any further ado we would like to start
from our first case and first presenter. The case is of
asymptomatic carotid artery stenosis in a hypertensive patient. The presenter
comes here from Paris in France and is Dr. Calvet. Please. Good afternoon everyone. It’s really my pleasure to take part in
this clinical presentation session and of course i would like to thank the
organizing committee for inviting me and also Professor Dominiczak for
supporting this session. My case I’m going to present it about management of
a patient, of a hypertensive patient with an asymptomatic carotid stenosis.
As neurologists, it’s very very very common situation we have to
cope with that always needs to be discussed, and that’s exactly what we are
going to do together. This is my case. A 75 years old man with an history of
hypertension for 10 years, treated with amlodipine, 5 milligram once a day, and
perindopnl, 8 milligram once a day. His hypertension was considered as
controlled. He also had treated hyper- lipidemia for five years with Atorvastatin,
10 milligram once a day. His general practitioner wanted him to have
an Echo-Doppler of cervical, intracranial arteries as part of the systematic
screening because of these vascular risk factors. As you can see, this Echo-Doppler was
done and it showed atherosclerotic stenosis of the site of the left
bifurcation, or maybe just down to the bifurcation, which was estimated about
seventy percent according to the NASCET criteria in imagery. We got in gray
scale the plaque was uniformly echogenic rather homogeneous type four plaque
Regarding the sonographic NASCET index we had a peak velocity increase of
280. That translated to a high ratio, higher psv ratio of 4.5. Then the echographic
data and morphology data were very consistent
with severe carotid stenosis. Estimated about seventy
percent according to NASCET criteria. His general practitioner had already
decided to perform a CT Angiography to confirm the stenosis, and indeed,
the CT Angiography was very consistent It also show severe stenosis of the
bifurcation, a little calcified and just above the bifurcation and also estimated
using CT angiography to be about 70 percent. Then
we had two consistent investigations, Echo- Doppler Ultrasound and CT angiography
with severe stenosis in asymptomatic patients. Indeed, the patient really had
no previous history of cerebral vascular disease. His neurological examination
was normal. His blood pressure was a little high,
systolic blood pressure 160 and diastolic blood pressure 95. His recent last blood sample
showed LDL cholesterol zero point one gram per liter and is glomerular
filtration rate was normal. Maybe to start the discussion i would like to
conduct a kind of survey. And to start the first question is
about the risk of ischemic stroke in this patient. What do you think about this risk? Maybe
we can vote by show of hands. Do you think that the risk of ischemic
stroke, of course ipsilateral to the carotid stenosis, is less than one percent
per year? or between one and two percent per year? More than two per year and less than five? Yeah? Or more than five-percent per year?
ok so there is really a division of opinion. Respnse A maybe? One 1, 2? ok
Really a division of opinion. It is important because we are going to
discuss here about the need for revascularisation. We’re going to discuss
this concern that may justify prophylactic revascularization. Who thinks that revascularisation is needed? Nobody?

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nobody nobody but one percent okay so only one percent. two percent.
three. four. Ok. Change. ok. Any of you think that the revascularization should be
performed using surgery? Yeah. Or using stenting? yeah. a lot of stenting, or so.
and who think that no revascularization is needed? Almost all. Maybe some of you
are not sure. ok. So we are going to discuss these
two main concerns. ok that is really a huge concern. For
example, in France, I remind you the population is estimated about 60
million people and from the recent population census we have estimated that
almost 1 million French people have asymptomatic carotid stenosis of
fifty percent or more. Of course not all are aware of this condition. You can
imagine the concern. So what do we know about the need for
revascularization in patients with asymptomatic carotid stenosis? We have
two randomized clinical trials conducted in the nineties. The first was ACAS. It
was conducted in North America and it found that in addition to medical
treatment, surgery, vascularization performed by surgery reduced the
risk of ipsilateral ischemic stroke from eleven percent in
patients treated medically to five point one percent in those treated by
surgery, including of course the peripatetic risk of stroke of this.
That translated to a relative reduction of about fifty percent and in
Europe we had the ACST trial, conducted in Europe, but mainly in the UK, which found similar results with
similar kind of curve. You can see that the five-year absolute reduction
was about five percent with the benefits of the intervention which sustained
beyond the first five years. Then we have both procedure that
conclude, both study that concurred that the
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revsascularization, in addition to medical
treatment, is greatest in reducing the risk of ipsilateral ischemic stroke. However this pathway for
intervention. We have two randomized clinical trials with a similar
conclusion that there is really a large variation of practice. But why? You can
see on this line the VASCUNET, which is a very large registry from Europe,
Australia performing patients with revascularization for an asymptomatic
carotid stenosis. Most of them were treated using surgery and the graphs show the
proportion of patient revascularized for an asymptomatic carotid stenosis.
It’s not the proportion of patients revascularized, but the
proportion of patient with an asymptomatic stenosis who
were treated. We can see that the proportion range from only zero
percent in Denmark. No patient with an asymptomatic stenosis are revascularized in
Denmark at this time. To only seventeen percent in the UK. Up to 70 in Italy and
this proportion reach ninety percent in the United States. We do not have published
data in France, but probably we have a similar proportion of patient
revascularized for asymptomatic carotid stenosis. Why such variations?
Maybe you have some explanation for that. Probably not. But one probably is that
this procedure has question a lot because of the low risk of ischemic
stroke in patients treated medically. Indeed. We have a strong, great risk reduction,
about fifty percent, but we have a low absolute risk of ischemic stroke. So
we have a low absolute risk reduction confirmed by surgery and the absolute
risk reduction is only one percent per year. This translate into an ability
to treat, an ability to revascularize, to prevent one stroke in one year of
about 100 patients. Provided another way, 60 strokes are prevented in five
years for every 1,000 patients treated with surgery. For comparison, in patients
with asymptomatic carotid stenosis, we only need to revascularize
ten patients to avoid one stroke in one year. In a patient in AF, we only need to
give anti-coagulant to thirty patient to avoid one stroke in one year. It
can also be translated to the fact that about ninety-four percent of procedure auto-
matically can be consider as un- neccessary. Some have calculated
that these unnecessary procedures in the United States cost about two billion
dollars each year to U.S. care providers. We have also to bear in mind the
low population attributable risk. Indeed, if we could treat all carotid
stenoses, we could only prevent not more than four percent of all strokes. So
funding surgeries is not the only concern. The controversy have intensified
recently due to growing evidence that thanks to medical advances in
treatment for prevention of vascular risk factor, the risk of ischemic stroke
in patient with asymptomatic carotid stenosis has declined significantly
during the last 20 years. Yes, it has declined by about sixty percent since the
ACAS published their research in ’95. Even in the randomized clinical trial, we observe
that decline because in ACAS in the beginning, the ipsilateral risk of stroke was
about 2.2% in patient treated medically. Yes, declined by about two-thirds and in
ACST, in the second five year period of ACST, the ipsilateral stoke risk was only zero point
seven percent. That is currently un certain whether the benefits, the
potential benefit of carotid surgery, of carotid stenting, still justify the
peripatetic risk of stroke or deaths. Even so it’s right, the risk of
procedural stroke or death has also declined in the same period, from probably two or
three percent to no more than one point five percent. Recently we have also
recent cohorts of patients that have received optimal medical treatment
and meta-analysis which showed that the risk of patients with asymptomatic carotid
stenosis, risk of ipsilateral stroke is no more than 0.5 percent. That is currently
very low. Then of course we have to try to look on the medical treatment. Of
the best medical treatment. What can be the best medical treatment
and it’s interesting to have a look of what happened in ACST. That is the ACST
conducted in the ’90s, the last years. At the beginning of
ACST, the proportion of patient who received an antihypertensive
drug was not more than fifty percent, but at the end of the
study, the proportion of patient who had an antihypertensive drug was almost 90
percent. Of course, interesting. In that period we observe the proportion decreased.
Probably the main change is the use of lipid-lowering therapy. Indeed, at the beginning of ACST, less than
10-percent of patients received lipid lowering therapy and this proportion rose to
more than 80 percent at the end of the study. So of course the relative effect
did not differ in the patient receiving or not a lipid lowering therapy, but the absolute
risk differs. The the benefit of surgery was lower in patients receiving lipid
lowering therapy and you can see that in the patient that were treated, the rate
of iipsilateral stroke was only one-point-three percent in those receiving lipid lowering
therapy, but it was 3.3 percent in those not receiving lipid-lowering therapy. Also in
the randomized clinical trials, in the large randomized clinical trial for
example in the Heart Protection study or in SPARCL, we know that the statin
reduced the risk of ischemic stroke by about one third. But it also halves the number of
patients requiring a revascularization in the trials. Probably there
is something to do with the stability of the plaque. To conclude on the study and effect,
maybe we can detail a little history, or the large study, which include three thousand
patients. They were seen in their clinic during the long term, during a
20 year period, and they were followed up with regular Doppler examination.
They identified more than 300 patients with a progression up to total occlusion.
Interestingly, almost ninety, eighty percent of occlusion occurred before
2002. So before the era of statin. So we have
to discuss the revascularisation maybe, and maybe have a look on the
guidelines. Maybe just read the guidelines on, for now, on the
revascularization. It is reasonable to consider performing a carotid endartectomy in asymptomatic patients who have a fifty
percent or more stenosis of the internal carotid artery. That’s exactly what we’re
doing. If the risk of peripatetic stroke, my- ocardial infarction, and death is low,
below three percent, of course, but however its effectiveness compared with
contemporary best medical management alone is not well established. Its not well
established at all. That’s really the the current concept
the concern. So what to do in 2016? Maybe we can try
to simulate some scenarios. If we took into account ipsilateral stroke risk of
two-percent per year, as found at the time of randomized clinical trials, then this is
gray dotted line. And if we consider the low risk of the periprocedural complications
found in CREST, recently permission in CREST, only one point four percent, and after, there is small
more risk thereafter. Of course, if we took into account this hypothesis that
surgery or the revascularization will be highly effective. But if we took into
account only 0.7 percent risk of ischemic stroke as found at the end of ACST,
follow. The number of ipsilateral stroke avoided for every
1,000 carotid endarterectomy performed will be only five at five years, increase only to 24 stroke avoided at
ten years. But if you do account smaller risk, as 0.5 percent as currently
found in cohorts of patients we would to to five strokes at five years. By
revascularizing patients. We have to bear in mind that this hypothesis.
I’ve only talked about carotid surgery because if we took into account
carotid stenting, with the the the same research reported increased in CREST, a small
procedural risk, only two point five percent in CREST. But the risk is too high.
You can see that we would cause stroke at five years, about 15 or 25
according to the medical hypothesis. But that is something we have to bear in
mind. So, have you change your mind regarding the need for revascularization?
Who would recommend revascularization for this patient? I think one new one. One yeah? No
revascularisation? Some of you has changed
your mind. Maybe some do not know if revascularization is needed? ok Of course, we do not compare
the revascularization with medical treatment. We compare optimal medical treatment
plus revascularization to the optimal medical treatment. So it’s really
important, if we decided not to treat the patient that to be sure that he is under
the best medical treatment. We have guidelines, we have this one. Patient with
asymptomatic carotid stenosis should be prescribed daily aspirin and
statin. Of course that’s consistent. Patient should also be screened for all the
treatable risk factor for stroke and appropriate medical therapies and
lifestyle changes should be instituted. Of course we have to be sure that the best
medical treatment is given. There are some guidelines specifically regarding
the medical treatment. For example, antihypertensive treatment. It is
recommended to treat of course to maintain blood pressure less than
140/90, or not specific target. Maybe except if we have a very very
serious stenosis, we have an occlusion, or patient with associated
intracranial stenosis, there is no good reason to change these simple targets.
Remember that our patient was already treated using Perindopril, Amlodopine.
At this stage, we don’t know what to do, in that condition if it’s better to
add a third antihypertensive drug or to increase the dose of one. Maybe
I ask you because I don’t know what to do. I ask you what to do in that case, what is
best? to add the third modicum or to…. Diruetic? ok The suggestion is to add
diruetic. okay. That’s what we should do and of course patients as we
have already said, who smoke, should be advised to quit and to offer cessation
intervention. And if we got hyperlipidemia, a treatment with statin
is recommended for all patients to lower LDL cholesterol level 1
gram per liter. The stroke target, that I remind you that most of these patients are
asymptomatic, had no previous history of course and now the target is
recommended if in case of diabetes zero point seven target. Of course
if the goal is not achieved it is recommended to intensify therapy. Of
course diet exercise recommended and glucose lowering drugs in case of
diabetes. It’s not clear whether it’s needed to really intensify or not. It is
not known if very strict control of diabetes is
useful. And of course we do not forget to add aspirin if the patient did not have
aspirin before. Then what we could do it depends on where he lives. We could
consider to enroll the patient in one ongoing randomized clinical trials. In
North America currently there are QUEST-2 study that assess whether optimal
medical treatment, current optimal medical treatment is as effective as
revascularization In the U.S. you could
enroll the patient in CREST-2 In Germany you could have enrolled the patient
in SPACE-2, but SPACE has just stopped because of a slow recruitment. In the UK
probably consider enrolling them in ECST2. And in Russia, I don’t know if other people from Russia
but there is also a trial in Russia. Name is AMTEC. I don’t know a lot on AMTEC,
but it’s the same kind of trials. So maybe those are another option.
Maybe you would like to have additional investigation to better know about the
potential risk of ischemic stroke. We will be happy to have additional investigations
for these patients. Ok, maybe an assessment of cerebral vascular
plasticity? One person. Or a potential detection of microembolic
signal? A lot. Would you be happy to have some data on the plaque structure
itself? Yeah. Or that maybe I don’t know if you’re yeah I would be happy to do so.
I’m Gian Paolo Rossi from University of Padova Italy. Among the tests that
i would like to have, there are at least two having in mind that this plaque
is a sign of atherosclerosis which could be elsewhere. Many years ago 1994 we
reported that patients with arterio sclerotic renovascular hypertension had
an excess rate of carotid plaques and the same applies to coronary artery
disease so in the evaluation of the patient I think you need to look at more
than just one vascular path. The other thing is that i would like to see
is that you’ve stated that this patient was asymptomatic and that’s kind of scaring to me because
symptoms cannot tell that all the story. If you do for example an MRI of
the brain you might see signals of previous ischemic events that were
totally asymptomatic and in that case I wonder if the definition of
asymptomatic is still really there. ok so this is a very good point and we
would like some answers to those yeah I’ve just been reminded by Professor Touyz
very rightly that we have plenty of time so don’t panic we have an hour for
each case which is very good but we would like to have audience involvement
because that’s how this feels the best ok so could we tackle all these
points from Professor Rossi? Regarding what a patient asymptomatic
or not is, it refers to clinical symptoms. Did the patient have a stroke
or not? The stroke means you have a symptom of a stroke. But of course many of these
patients have silent infarcts, and then.. it was my last slide maybe. I try to show you sorry. We have some study that uses
CT to try to assess silent infarct of that kind of patients. I chose this
study because it’s rather a large number of patients almost 1,000 patients
with asymptomatic carotid stenosis and they found silent infarct on many of
them. It’s very interesting to think that their rate of ischemic stroke in that
patient with silent infarct was quite high at 3.6 per year. Compared with those with no
silent infarct which was then below one per year. Probably the patient developed
something that can be used but the concern that there is no definition of an infarct in a CT. Probably it’s more
easy using a MRI, but we do not have such kind of data with MRI.
Probably something that be made at the patient level. Regarding the
question about the extent of atherosclerosis that’s true that it is
also a marker of atherosclerosis and we will know that the patient with the
asymptomatic carotid stenosis have high risk of other vascular event, which have
marked infarction. That’s why the medical treatment is very useful. By
revascularization we would only avoid the stroke, the kind of stroke related to
the stenosis. We know that inhibition with asymptomatic carotid
stenosis halve the stroke that have an indentative cause. That’s why the preventive
treatment is very, of importance. ok we have another question here from
Professor Touyz, my co-chair Thank you. Just to follow up I guess the
question that really arises at this point is these are patients who are
asymptomatic by definition, yet the GP has undergone all these tests. I think
the question that i would like to ask is who do with screen? when do we screen? and
should we screen? Because surely this is what is absolutely fundamental for all
these patients are apparently asymptomatic. yeah and before you answer this, Could I add to
this? In your huge variety between the way various European countries treat
these patients this is very very interesting but I wonder if you have or
somebody has the data whether the primary referral is to surgeons or
physicians. Because i think the level of activity, of aggression, very much
depends you know how aggressive the treatment is very much depends whether
it’s physician or surgeon. I know that in the United Kingdom vast majority
of these patients would be with physician and never see the surgeon and
that’s why it’s below eighteen percent that’s good whilst in the US I presume
and maybe in France they all go to vascular surgeon and then the aggressive
treatment follows because we know surgeons like to use the knife and be
more aggressive. So I think it would be extremely interesting to know where
clearly where they referred for specialist care. This is not the first referral but the
second our third referral center. Is that known in these studies? it’s not
well-known. of courses.. But i think we have an opportunity as European
Society of Hypertension to maybe mount such a study because i think it would be
interesting it could be a simple questionnaire to our ESH centers of
excellence perhaps how you know what is the
referral pattern depending to type of aggressiveness of treatment i think it
will be very interesting so now you can tackle Rhian’s questions
so Do you remember? Screening. yeah yeah To screen or not. The issue that we still
don’t know if revascularization is needed or not, so I would be happy to
screen patients for this if I was sure that is interesting to screen because I
would have something to do. So far as we do not really know not sure the
screening can be recommended. It’s not currently recommended. But I’m going
to tell you just after that I would be happy to know because we have ongoing
trials in this topic and we need to know the real answer. That to get an answer
we need patients to enroll, to enroll patients in randomized trial. too early know what to
do but the screening there is nothing in guide lines for screen patient for asymptomatic
as we don’t know what to do when they have asymptomatic, where they have
asymptomatic Stenosis. So any of these. Do you want to ask the
audience all these questions or we’ve already worked on this so
we can move to next slide or quiz. Oh, there is a question at the
microphone on on our right yeah. I have a question
basically the point you’re taking is drugs can do very good but problem is
that we have all other stations telling patients don’t take drugs. So the study
shows that if you follow the patients and give them the good drugs then
basically maybe we don’t need to revas- cularize, but in the real life you
just…patients are lost to follow-up and so are there any studies that just
looked at that? yeah but the data we have so far refers
to patients treated with medical treatment. I don’t know if they have
really this medical treatment or not but this is a risk we observe
in patient with prescribed anti- hypertensive drug or statin. Probably
not all are very compliant with that but that we observed even in cohort study.
In the randomized clinical trial we don’t know exactly to what extent the patient is
treated or not. But that means a patient where we prescribe optimal medical
treatment one objective of the trial also is to know to what extent we can
achieve the goals of course. So we have Professor Laurent on the left microphone. yeah thank you David for this
beautiful case and explanation in my opinion it’s a little bit biased because
the aging parameter seems to be lacking of course with 65, 75, and 80 for life expectancy is
different and you are balancing a perioperative and postoperative risk
around two to three percent With an increased risk of cerebrovascular events
depending on your age because everything is presented as if the risk of a simple
event was the same at 65, 75, or 85 so you are playing with different parameters
Seventy percent of a threshold for taking a decision and starting
discussion ok but what is the age? what is the risk
according to the age and the comorbidities? of course you’ve chosen
very simply no other co- mobidity except hypertension and cholesterol but how
will you will you deal with aging of the patients? yeah I thank you for the questions.
I can swear we did not discuss before because my next slide is about
that. The risk according to the age and because maybe we can also try to
identify which persons are more likely to benefit and of course it has been
shown that a patient less than 75 or men rather than women benefit, greatly
benefit, from carotid revascularization. Women and patients older than 75 do not
significantly benefit from the procedure but it’s maybe a question of
life expectancy and it’s shown that any condition that will reduce it the life expectancy may limit the
potential benefit if any. So for that we will need a model to predict life
expectancy and we have one. I propose one. This is a large study that assess the
factors associated with the final survival following endarterectomy
in patient with asymptomatic internal carotid stenosis. So exactly the kind of
patient we have. And they identified different patterns of patients in
different risk profile. For example we have a high risk profile with patients
with low survival. At 5 years. The kind of patient with measures, factors,
which have age more than 80 or insulin dependent diabetes or dialysis
dependence or patient with severe ipsilateral stenosis. That kind of
patients are not likely to survive long enough to
benefit from the procedure but in contrast those with low risk and profile
for example for our patient, they are really expected to live long enough to
potentially benefit. So of course the life expectancy is really a critical
factor in the decision making. ok so we can go directly to the right
microphone and then we come back to the left microphone please identify yourself i’m dr. moodley from durban south africa where I come from there’s a lot of
type 2 diabetes and we get the patients that would routinely do a
glucose tolerance test. we would routinely also do CT scanning of the
brain because when if we find previously lesions that will move us more towards
intervening and thirdly just a comment with the aspirin
prevention on going. Do you use 75, 80, 150 or 300 milligrams of aspirin in a
patient like this? yeah we’re getting data In which patients? aspirin
prevention what dose do you the recommended that is the usual order I mean meet between 75 up to a 300 mill
igram what’s the preferred dose? Because you know
there’s a mobility associated with the use of aspirin yeah i will recommend the
lower dose of aspirin. Is it better, known that the lower dose like 75 or 80
milligrams is just as good as the 150 or 300? We do not have specific data
that compare the different doses of aspirin. Sure we have to to give aspirin
but we never we have no study that have compared the different dose of aspirin
in that condition and we do not have any study that really measure the use of
aspirin. Aspririn is recommended because of the vascular risk including the
myochardial infarction risk and other vascular risk that we do not have
specific data about what extent the aspririn is useful that’s that’s intuitive. Just a final
comment with the improved study coming out recently would you say that a patient like this
here once you go for the way we work in different units but would you say that
the elders should be moved closer to 1.4 millimoles per liter? or would you say
we still stick at 1.8 millimoles? Because you know it’s a similar type of
patient. I know there’s no data but what would you do? Would you be more
aggressive with the LDL level? Not too aggressive. We do not know
exactly what to do. So I’m not sure if we can we can maybe we cannot recommend that
a very aggressive strategy in that condition. ok so we move to the left microphone Please
I’m Guillaume Turc from Paris, France. thank you for this great talk and you focused on carotid artery
surgery, however and as compared to surgery stenting was associated with
a lower risk of procedural myocardial infarction in the CREST study. Don’t you
think that this should be taken into account? yeah thank you yes of course stenting,
carotid stenting is a real option, but especially with asymptomatic carotid stenosis
the issue is to know in which patient maybe the carotid stenting
can be as safe and effective. In that kind of patient, asymptomatic carotid stenosis, the
issue is to know whether revascularisation as performed by surgery
or by stenting is effective and compared with medical treatment. But it is also
a question of do we include myocardial infarction in the safety, in the composite
safety outcome. In a trial that can be done in trial for asymptomatic
stenosis. I have a slide on this. For example in CREST. I’ve been discussing
a lot in CREST and it’s true that in CREST, the higher peri-procedural
risk of stroke or death in patients treated with stenting was partly offset by a
lower risk of myocardial infarction. But as you can see the proportion of
patient with myocardial infarction during the procedure period is much higher
in CREST than in European trials so maybe that can reflect enrollment of
different kind of patients with more cardiac disease but also a different
screening for myocardial infarction and unlike European trials, in CREST,
the myocardial infarction do not justify the clinical symptoms. About 40
patients have clinically asymptomatic MI, so we can include asymptomatic brain infarction in safety outcome, but in that condition we should also include a symptomatic brain
infarction. It has been well described
in the substudy of ICSS. So again in symptomatic patients, the clinic found that
patients treated with stenting had much more higher risk of asymptomatic lesions
as you can see on MRI like this than patients with the surgery they were five
times more likely to have asymptomatic lesions. so we can take it into
account but in that condition we should also take into account more
asymptomatic brain infarction and probably another factor why including MI
maybe is debatable is that patients do not value stroke and MI to a similar
extent. For example in CREST again they found that the stroke had a
greater impact on quality of life one year after procedure, than MI. So it’s
not really the same thing to have stroke to have an MI, in particular if
the MI is asymptomatic, if the stroke is symptomatic. So we can take both but we
have to take into account symptomatic event only I think. ok so we have professor gary Jennings
from Melbourne Australia on the Left microphone thank you I’d like to add some support
for medical therapy along two lines number one is most of the data we’ve
talked about relates to rates of ip silateral stroke and you’ve already
talked about the fact that quite often people go on to have myocardial
infarction they also have contralateral stroke
quite often too and that kind of takes away the argument for local treatment of
a systemic disease a second point is we’ve kind of gone along with the idea
with the logic that if somebody’s got, with an asymptomatic disease, has got
MRI lesions of previous involvement that that leads you towards being more likely
to want to intervene but if you really believe that medical contemporary
medical therapy works there could be just as much an argument for that as being a
useful strategy for preventing future strokes. yes of course that’s why we have to do
the optimal medical treatment with or without surgery and we do not compare
surgery with optimal medical treatment the optimal medical treatment should
also be given in patients treated with surgery I focus on ipsilateral stroke
that kind of stroke that we can try to avoid with surgery. of course we
won’t be able to avoid a contralateral stroke using carotid surgery and
contralateral but that’s what we try to avoid in this kind of patient the
higher-risk of ipsilateral stenosis of course okay that’s great we have on the right
microphone professor Tom Guzik from Glasgow. Discussing the sort of
procedural complications i think the point raised by Professor Laurent regarding age
is a very important aspect and I think it’s worth commenting but I came here to
to ask about additional investigations that your list did not contain serial
ultrasound testing for progression of the disease what do you think is there a place for
that in such patients? Of course, there is a place for that and it has been
done in ACST, the UK trial because patients who were not treated were
followed-up using Echo-Doppler ultrasound they found that patient with CV and
rapid progression had a higher risk of ipsilateral stroke so rapid means within
one year and Severe mean that really quick progression. They had a lot of
categories in this study and when patients quit one particularly they were
associated with increased risk. If patient would quit one category and were four
times more more likely to have ipsilateral stroke, it’s a huge predictive
factor but in practice very few patients have that kind of severe and rapid progression.
How often would you think, when would the next, once we started screening we we would when would you do the second
test in this patient? Probably at least once a year okay that’s great and we have another
question on the left microphone yes Gregor Bilo from Milan. My first
question was already anticipated my second question was what about
the cases which are maybe not so common but you can see them often,
bilateral stenosis, does it influence your management if you find in the
industry in the second artery, a moderate or severe stenosis? yeah contralateral stenosis
occlusion it’s a predictive factor of higher risk, of procedural risk but also of
course of ipsilateral stroke. Maybe you have seen that this is a
major risk factor also for life expectancy then that kind of patient
have a higher risk of dying before the end of the follow up in the studies so
we have to also consider why this patient have a cv arteriosclerosis and
maybe also refers to a higher risk of vascular disease At the same
time a risk factor for stroke but also for vascular or risk of vascular
event like this. There is another question on the left
microphone please thank you Dr. Barigou from Paris i have question about the
use of anticoagulants in this condition. When we have an important plaque
on the carotid artery and with micro- embolic signals on the MRI should it be
recommended to use anticoagulant drugs and plan to replace anti-aggregants? and the second question
would be about the blood pressure targets. You say that we should be below
140 over 90 millimeters of mercury but many study showed that in the outcome
stroke the lower is the better in many studies so should we not target less
than 130 over 85 millimeter mercury and now should we not provide the
treatment by diuretics like other person in this room state? thank you thank you yeah I agree the
lower is better provided we do not have too severe a stenosis but again I think
that is no reason why we should give a different target for that kind of
patients except in those with hypoperfusion to very serious
target recommendation. so I think we have to intensify therapy maybe with
diuretics if needed that kind of patient and regarding micro embolic signal
MRI in not sure the slide or the figure yes the micro embolic signal is very very
useful It can also identify a subset of patients with a very very high risk
of ipsilateral stroke and in this large study you can see that the
increased risk was high with regard to ratio about 5.3 in patient with at least only
one micro embolic. Now compare we do with those without and it’s very consistent
with that analysis we found consistent data and it’s very very specific
Circulating emboli show direction with a high-density micro embolic signal and
it is accompanied by a shocking sound maybe we can try to listen okay very specific sound and when you have
this kind of micro embolic signal you have identified a person with very
high risk of future ipsilateral stroke then maybe we can consider this predicitive
factor but nobody has shown that if you revasularize that kind of patient it’s also
benefit but its primarily in that kind of patient that something can be a problem
ok sorry we need you at the microphone because otherwise you we won’t capture the
question let him ask his question the question was about the use
of anticoagulants in this kind of patients Anticoagulants? sorry? there is
no data that can recommend anticoagulant in that kind of patients that were one study that
were two tier therapy that found in patient for example with
micro embolic signal patients treated with aspirin and clopidogrel at the lower
proportion of micro embolic signal than those treated only with aspirin. but we do not
have any data regarding the risk because that kind of study we are conducting
in patients with symptomatic stenosis, so they were revascularized shortly okay
and another question on the left. Yuri Sharabi from Tel Aviv so we made the
progress we look at age the comorbities, the progression of the
plaque, but i was wondering how much emphasis you put on the plaque itself? for
example the PLOS talked about meta-analysis, talked about carotid
distensibility, how it adds to the restratification. Do you put a lot of
weight on the structure, the distensibility, the plaque itself in in decision-making?
yeah of course yes the plaque itself we can try to assess the
plaque structure itself it’s not easy in routine, imaging, but that can
be done here using MRI and not using MRI of course we can have the severity of
the narrowing using contrast imagery photography but we can also try to have assessment
of the plaque itself it’s well known you have internal disease, seven studies, almost
700 patients it was including patients with asymptomatic
stenosis. When you can identify for example hemorrhage within the plaque
it’s a predictive factor of ipsilateral stroke again that doesn’t mean that this
percent needs to be revascularized but that patient have a higher risk of
future ischemic stroke. For other potential predictive factor all of course the
patient level everything needs to be taken into account but in that condition if
you have to decide if the patient needs or not to be revascularized, probably we should focus on the
stenosis itself because that’s why what we can remove. Ok. Rhian. Thank you
IM just going back to the question about the aspirin and do you have any comments
regarding blood pressure control and initiation of aspirin usage? because
there are some guidelines in terms of using aspirin only when blood pressure
is actually controlled so in this patient where you’ve still got very high
blood pressure would you still start aspirin? yeah i think that we do not have really
the data to justify that but it’s sure that aspirin is recommended again not
only for the plaque itself but for the vascular risk control and regarding the
pressure also we have to achieve a better target as recommended but you
have seen it’s a very general guidelines we do not have specific data
specifically on this patient so it’s quite hard to directly answer the question. ok so i would like to come back to the
patient you described and ask you what precisely happened to this
particular patient? so what have you done and what’s been the outcome as far as we
know with this particular patient. that’s my question. And my question two,
which is sort of under family and friends management type of question, how many times would
you normally do detailed MRI in a patient like that? because I accept that
your data from the CT but in 2016 I would send the patient for MRI and
maybe more than once and I would like to know what you would do to your family
and friends that’s a very good test in medicine. okay
thank you very much for your questions. i’m going to give you my proposal for
these patients because we think that the time’s come in France to try to
implement that practice for the predictive factors, the MRI
parameters in randomized control trial and this is randomized clinical trial I am going to
start in France within a few weeks. My proposal would be to enroll this patient
so of course if you have at least one micro embolic signal of you have a cerebral
vascular reason or if you have an intra-plaque hemorrhage or
rapid size progression. so if it’s estimated at higher than average risk of
ipsilateral stroke, i’ll be happy to enroll the patient in that trial. The
objective of the trial, the spirit of the trial is to assess whether revascularization
as performed by surgery in addition to a optimal treatment is
effective in reducing the risk of ipsilateral stroke. Though for the patient
we are going to assess all the predictive factor. if we
identify at least one I would be really happy to enroll the patient in the trial.
Regarding the second question of course we are
also we are performing currently MRI. and for the identification of
intra-plaque hemorrhage sometimes it’s needed to have a
high-resolution MRI that justify, or high expertise, but now it’s
probably possible to identify intra-plaque hemorrhage at the same time of the
contrast trans craniel doppler so for my friend or
for my patients i would recommend to try to do a TCD. TCD is widely available
it is quite inexpensive and we can know if the cerebro-vascular reserve is
decreased or not we can know if the patient has micro embolic signal and with
the MRI or the MRA which either can be done quickly and we have a lot of data to
decide. okay that’s very good i think there is a question one at the right
two at the right but first the right microphone first person and then we go
to the left. Right. In the protocol and also for the patient so what is rapid
stenosis progression? because you say we have to… ya rapid progression means within
one year old that’s right what has been done in HD so
any what is recommended if you don’t treat the patient is recommended to have
a follow-up using a echograph, ultrasound and so at least once a year to be able to
identify a patient with rapid progression and the CV, as I have shown you
before if the patient have a rapid increase for example at the 50-percent up to more
than 70 or between 50 and 70, up to 90 so we have a CV and rapid
progression ok so the left microphone. I have two
questions regarding this study which proportion of patients with severe
carotid stenosis do you expect to be eligible for this study that’s the first
question. We have three minutes to the end of the this case so we want quick
questions and fast answers right. Yeah, quick are probably about twenty percent of
patients but we do not know if the this all predictive factors are independently
associated or not we just know that micro embolic signal and intra-plaque hemorrhage
were independently associated with increased risk in patients with symptomatic
stenosis, so probably it would be the same thing for asymptomatic but for the other
i don’t know. Probably a rapid progression is probably associated with
intra-plaque hemorrhage, but I know it’s possible probably micro embolic signal and intra-plaque hemorrhage are really two
additional or interesting predictive factors okay we have only time for one more
question the lady at the right microphone i’m afraid the rest in the
break over coffee please yes indeed in this study do you take into account echographic parameters of the plaque, like …characteristic yeah not directly
for the eligibility of patients, probably in the similar study of course at the
patient level it is really of interest and for the decision making it is useful, if you
have a very heterogenous plaque the issue is the definition of heterogenous plaque,
not all will agree with the same definition so in a trial that is not
very easy to use this parameter, but at the patient level that’s something that can
be taken into account. great i think this completes this case we
are very grateful to the presenter I think this was very
stimulating the discussion was great we also thank all discussants and please
give your names to Denise because the paper in hypertension is a valuable
addition to your cv so thank you very much Dr. Calvet. This was very very good

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