Hicks Caitlin W, Talbott Katherine, Canner Joseph K, Qazi Umair, Arhuidese Isibor, Glebova Natalia O, Freischlag Julie A, Perler Bruce A, Malas Mahmoud B
Division of Vascular and Endovascular Therapy, Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD; Division of Vascular and Endovascular Therapy, Department of Surgery, Johns Hopkins Hospital, Baltimore, MD.
Division of Vascular and Endovascular Therapy, Department of Surgery, Johns Hopkins Bayview Medical Center, Baltimore, MD.
Ann Vasc Surg. 2015 Jan;29(1):1-8. doi: 10.1016/j.avsg.2014.02.007. Epub 2014 Feb 12.
Because of improved medical therapy in contemporary practice, some have advocated that, most if not, all patients with asymptomatic carotid disease should be managed medically without intervention. Disease progression in this patient population is not well established, and data describing risk factors for disease progression in patients with moderate asymptomatic carotid artery stenosis (ASCAS) are lacking. The aim of our study was to determine the incidence of and risk factors for disease progression in this patient population.
All patients presenting to a tertiary center between January 2005 and May 2012 with moderate (50-69%) ASCAS as determined by carotid artery duplex were included. Outcomes including disease progression to severe stenosis (≥70%), incidence of symptoms, need for operative intervention, and all-cause mortality were recorded. Cox proportional hazard regression models were used to identify risk factors for disease progression.
A total of 282 carotid arteries in 258 patients with moderate ASCAS were identified from 1555 carotid duplex scans over the 7.5-year study period (mean age: 70.6 ± 0.55 years, 52% male). Mean follow-up time was 2.6 ± 0.10 years. Overall, disease progression to severe stenosis occurred in 25.2% (n = 71) and followed a linear trend. The incidence of symptoms including ipsilateral stroke (2.13%, n = 6) and transient ischemic attack (0.71%; n = 2) was low. Carotid endarterectomy was performed in 15.3% (n = 43) of patients, all with severe disease. Carotid stenting was performed in 3.90% (n = 11) patients. Risk of progression was higher in patients receiving dual antiplatelet therapy (Hazard Ratio [HR] 1.85, 95% confidence interval [CI] 1.09-3.15; P = 0.02) and smokers (HR 1.85, 95% CI 0.96-3.55; P = 0.05). Age, gender (women), hypertension, statin use, and aspirin use were not significant predictors of progression to severe stenosis. There was a nonsignificant trend toward increased mortality in patients who progressed compared with those who did not (HR 3.39, 95% CI 0.91-12.6; P = 0.07).
In our study, one-quarter of patients with moderate ASCAS progressed to severe disease, although the majority remained asymptomatic. Smoking and dual antiplatelet therapy are independent risk factors for disease progression. Patients with identifiable risk factors may warrant more careful follow-up.
由于现代医学治疗方法的改进，一些人主张，大多数（即便不是全部）无症状颈动脉疾病患者应接受药物治疗而非干预措施。该患者群体中的疾病进展情况尚未明确，且缺乏描述中度无症状颈动脉狭窄（ASCAS）患者疾病进展风险因素的数据。我们研究的目的是确定该患者群体中疾病进展的发生率及风险因素。
纳入2005年1月至2012年5月期间在一家三级中心就诊、经颈动脉双功超声检查确定为中度（50%-69%）ASCAS的所有患者。记录包括疾病进展至重度狭窄（≥70%）、症状发生率、手术干预需求及全因死亡率等结果。采用Cox比例风险回归模型确定疾病进展的风险因素。
在7.5年的研究期间，从1555次颈动脉双功超声扫描中识别出258例中度ASCAS患者的282条颈动脉（平均年龄：70.6±0.55岁，52%为男性）。平均随访时间为2.6±0.10年。总体而言，25.2%（n=71）的患者疾病进展至重度狭窄，且呈线性趋势。包括同侧卒中（2.13%，n=6）和短暂性脑缺血发作（0.71%；n=2）在内的症状发生率较低。15.3%（n=43）的患者接受了颈动脉内膜切除术，均为重度疾病患者。3.90%（n=11）的患者接受了颈动脉支架置入术。接受双联抗血小板治疗的患者（风险比[HR]1.85，95%置信区间[CI]1.09-3.15；P=0.02）和吸烟者（HR 1.85，95%CI 0.96-3.55；P=0.05）疾病进展风险更高。年龄、性别（女性）、高血压、他汀类药物使用及阿司匹林使用并非进展至重度狭窄的显著预测因素。与未进展患者相比，进展患者的死亡率有升高趋势，但差异无统计学意义（HR 3.39，95%CI 0.91-12.6；P=0.07）。
在我们的研究中，四分之一的中度ASCAS患者进展为重度疾病，尽管大多数患者仍无症状。吸烟和双联抗血小板治疗是疾病进展的独立风险因素。具有可识别风险因素的患者可能需要更密切的随访。
