Antithrombotic therapy in carotid artery stenosis: an update
Maurizio Paciaroni1, Julien Bogousslavsky
1Stroke Unit and Division of Cardiovascular Medicine, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy.
Insights
Optimal management of carotid artery stenosis involves lifestyle changes and medications to reduce stroke risk. Antiplatelet therapy is more beneficial for symptomatic patients than asymptomatic ones, with specific recommendations for surgical procedures.
Area of Science:
- Vascular Medicine
- Neurology
- Cardiology
Background:
- Carotid stenosis poses significant risks for stroke and vascular events.
- Effective management strategies are crucial for both symptomatic and asymptomatic patients.
Purpose of the Study:
- To review optimal management strategies for carotid artery stenosis.
- To evaluate the role of antiplatelet therapy in preventing stroke and managing stenosis progression.
- To outline perioperative antithrombotic therapy recommendations for carotid revascularization procedures.
Main Methods:
- Literature review of studies on carotid stenosis management.
- Analysis of evidence regarding antiplatelet therapy efficacy.
- Examination of guidelines for perioperative antithrombotic treatment in carotid endarterectomy and stenting.
Main Results:
- Lifestyle modifications and medications are key to controlling atheroma and reducing embolic events.
- Antiplatelet therapy shows robust evidence for secondary stroke prevention in symptomatic patients.
- Asymptomatic patients have limited evidence supporting antiplatelet therapy for stroke prevention or stenosis progression.
- Perioperative aspirin is recommended for carotid endarterectomy; clopidogrel addition is case-dependent.
- Dual antiplatelet therapy (aspirin plus clopidogrel) is recommended for carotid stenting.
Conclusions:
- Comprehensive management of carotid stenosis requires a multi-faceted approach including risk factor control and judicious use of antiplatelet agents.
- Antiplatelet therapy is essential for secondary prevention in symptomatic carotid stenosis.
- Specific antithrombotic regimens are vital for patients undergoing carotid revascularization procedures.
Abstract:
Carotid stenosis is generally associated with high risks of stroke and vascular events. In asymptomatic and symptomatic patients, with or without revascularization, optimal managements of carotid artery stenosis require the use of medications or lifestyle modifications (stopping smoking and monitoring hypertension, hyperlipidemia, and diabetes) to control the processes associated with atheroma to reduce the risk of embolic events. Moreover, antiplatelet therapy should be considered. There is little evidence that antiplatelet therapy is beneficial in preventing stroke or the progression of stenosis in asymptomatic patients, whereas, evidence of a benefit from antiplatelet therapy for secondary prevention of recurrent stroke in symptomatic patients with carotid atherosclerosis is more robust. Also, in patients undergoing carotid endarterectomy, perioperative antithrombotic therapy should include aspirin, while the addition of clopidogrel should be decided case-by-case. Furthermore, perioperative antithrombotic therapy in patients undergoing carotid stenting should consist a combination of aspirin plus clopidogrel.
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