Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.
Department of Neurology, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago, Chile.
J Vasc Surg. 2020 Jan;71(1):257-269. doi: 10.1016/j.jvs.2019.04.490. Epub 2019 Sep 26.
Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal.
We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017.
Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit for ACS only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with ACS using medical intervention alone are overall lower than for those who had CEA or CAS in randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention.
Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.
医学干预（风险因素识别、生活方式指导和药物治疗）在预防中风方面取得了显著进展。现在，可能只有不超过 5.5%的患有严重无症状颈动脉狭窄（ACS）的人在其一生中会从颈动脉手术中受益。然而，一些人对仅采用医学干预的方法是否足够提出了质疑，并提出使用高中风风险标志物来干预颈动脉内膜切除术（CEA）和/或颈动脉血管成形术/支架置入术（CAS）。我们的目的是检验这一建议的科学性和意义。
我们回顾了单独使用医学干预或在 ACS 患者中联合使用 CEA 或 CAS 的证据。我们还回顾了使用通常引用的高中风风险标志物来选择此类患者进行 CEA 或 CAS 的有效性证据，包括欧洲血管外科学会在 2017 年提出的标志物。
单独使用医学干预与额外 CEA 的随机试验仅表明，对于符合北美症状性颈动脉内膜切除术试验标准的年龄在 75 至 80 岁以下、狭窄程度为 60%或以上的特定平均手术风险男性，ACS 仅具有明确的统计学显著 CEA 中风预防益处。然而，使用单独医学干预的 ACS 最新中风发生率测量值总体上低于随机试验中接受 CEA 或 CAS 的患者。ACS 患者中 CEA 与 CAS 的随机试验的效力不足。然而，趋势是 CAS 的中风和死亡率更高。目前没有与比较当前最佳医学干预与 CEA 或 CAS 相关的随机试验结果。与 ACS 相关的高中风风险的常用标志物特异性不足，尚未与当前最佳医学干预联合评估，并且在随机试验中也没有表明它们可识别除当前最佳医学干预之外还需要颈动脉手术的患者。
医学干预在当前 ACS 患者的常规管理中具有既定的作用。使用当前最佳医学干预的中风风险分层研究是确定可能从增加颈动脉手术中受益的患者的最高研究优先级。
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