Department of Hospital Medicine, Medicine Institute, Cleveland Clinic, 9500 Euclid Avenue, M2-Annex, Cleveland, OH, 44195, USA,
Curr Cardiol Rep. 2014 Jan;16(1):440. doi: 10.1007/s11886-013-0440-9.
Based on several randomized clinical trials, carotid revascularization has been shown to reduce future stroke risk among individuals with severe asymptomatic carotid stenosis. However, a well-recognized problem with such prophylactic intervention is the risk of periprocedural stroke, death, or myocardial infarction. If actual stroke risk with asymptomatic carotid stenosis can be reduced significantly by aggressive medical management, carotid revascularization may yield marginal benefit or even cause harm especially in those with limited life expectancy. Based on recent observational data, it is becoming apparent that the stroke risk in this population has been declining with better medical management alone. This has prompted a few to avoid carotid revascularization for asymptomatic carotid stenosis altogether. Others feel such conclusions cannot be made with observational data alone. In the midst of this controversy, it is important that clinicians perform carotid revascularization on a case by case basis while ensuring optimal medical management in all patients. An algorithmic approach to decision making based on available evidence will enable clinicians to personalize patient management with efficiency.
基于几项随机临床试验，颈动脉血运重建术已被证明可降低严重无症状颈动脉狭窄患者的未来卒中风险。然而，这种预防性介入的一个公认问题是围手术期卒中、死亡或心肌梗死的风险。如果无症状颈动脉狭窄的实际卒中风险可以通过积极的药物治疗显著降低，那么颈动脉血运重建术可能只会带来边际获益，甚至可能造成伤害，尤其是在预期寿命有限的患者中。基于最近的观察性数据，越来越明显的是，随着更好的药物治疗，该人群的卒中风险单独下降。这促使一些人完全避免对无症状颈动脉狭窄进行颈动脉血运重建术。另一些人则认为仅凭观察性数据无法得出这样的结论。在这场争议中，重要的是，临床医生应根据具体情况进行颈动脉血运重建术，同时确保所有患者都接受最佳的药物治疗。基于现有证据的决策算法方法将使临床医生能够有效地对患者进行个体化管理。
