Lim Sungho, Mora-Pinzon Maria, Park Taeyoung, Yoon William, Crisostomo Paul R, Cho Jae S
Department of Vascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA.
School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA.
Int Angiol. 2019 Oct;38(5):372-380. doi: 10.23736/S0392-9590.19.04143-9. Epub 2019 Jul 24.
Recent advances in best medical therapy (BMT) has been associated with reduced risk of stroke similar to that observed following surgical carotid revascularization (CR). Thus, it remains uncertain which subset(s) of patients would benefit from prophylactic CR+BMT for asymptomatic carotid stenosis (ACS) over BMT alone. The purpose of this study was to analyze the contemporary experience in the management of >70% ACS in an academic institution, to compare the short- and long-term outcomes of BMT alone against CR+BMT, and to identify risk factors for the development of future cerebrovascular events.
A retrospective review of all patients with severe ACS between January 2005 and December 2012 at Loyola University Medical Center and its affiliated Edward Hines Jr. Veterans Administration Hospital was conducted. Baseline patient characteristics, medications, and follow-up data were collected from electronic medical records, and treatment outcomes were compared. The random forest method was performed to select potential important variables for the development of late stroke. The recursive partitioning regression analysis (RPRA) was performed to identify the patient subgroup at increased risk of future stroke.
Of 409 patients identified; 247 were treated with CR and 162 with BMT. Between these groups with CR+BMT and BMT alone, the mean age was 69.1±8.2 versus 75.5±9.0, respectively (P<0.01). Mean follow-up was 60.7±37.5 months. Early (30-day) outcomes of stroke, acute myocardial infarction or mortality did not differ between the treatment modalities (2.0% CR vs. 0.6% BMT, P=0.41). Probability of freedom from ipsilateral stroke, and any stroke at 1- and 5-year follow-up were also comparable between CR+BMT and BMT alone. However, random forest method and RPRA demonstrated that patients with history of diabetes and remote stroke treated with BMT alone were at a high risk for future stroke (36.4% in total, 7.2% per year). The diabetics with contralateral carotid stenosis >50% who are active smokers are at the highest risk for stroke after CR (20.0% in total, 4.0% per year).
Prophylactic CR+BMT does not provide overall late stroke prevention compared with BMT alone. Diabetics with a history of stroke, in particular, are at an increased risk of stroke despite BMT. Timely CR+BMT for high-risk patients is still indicated.
最佳药物治疗（BMT）的最新进展与卒中风险降低相关，这与颈动脉外科血管重建术（CR）后的情况相似。因此，对于无症状性颈动脉狭窄（ACS）患者，哪些亚组能从预防性CR+BMT而非单纯BMT中获益仍不确定。本研究的目的是分析一所学术机构中＞70% ACS患者的当代管理经验，比较单纯BMT与CR+BMT的短期和长期结局，并确定未来脑血管事件发生的危险因素。
对2005年1月至2012年12月在洛约拉大学医学中心及其附属爱德华·H·小欣斯退伍军人管理医院的所有重度ACS患者进行回顾性研究。从电子病历中收集患者基线特征、用药情况及随访数据，并比较治疗结局。采用随机森林法选择可能对晚期卒中发生有重要影响的变量。采用递归划分回归分析（RPRA）确定未来卒中风险增加的患者亚组。
共纳入409例患者；247例接受CR治疗，162例接受BMT治疗。在CR+BMT组和单纯BMT组之间，平均年龄分别为69.1±8.2岁和75.5±9.0岁（P<0.01）。平均随访时间为60.7±37.5个月。两种治疗方式的早期（30天）卒中、急性心肌梗死或死亡结局无差异（CR组为2.0%，BMT组为0.6%，P=0.41）。CR+BMT组和单纯BMT组在1年和5年随访时同侧无卒中及任何卒中的概率也相当。然而，随机森林法和RPRA显示，单纯接受BMT治疗的糖尿病和既往有卒中史的患者未来发生卒中的风险较高（总计36.4%，每年7.2%）。对侧颈动脉狭窄＞50%且为现吸烟者的糖尿病患者在接受CR治疗后发生卒中的风险最高（总计20.0%，每年4.0%）。
与单纯BMT相比，预防性CR+BMT并不能提供总体的晚期卒中预防。特别是有卒中史的糖尿病患者，尽管接受了BMT，其卒中风险仍增加。对于高危患者，仍建议及时进行CR+BMT。
