Neuroscience and Mental Health Institute, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
Centre for Heart Rhythm Disorders, South Australian Health and Medical Research Institute, Royal Adelaide Hospital, The University of Adelaide, Adelaide, South Australia, Australia.
JAMA Neurol. 2020 Dec 1;77(12):1524-1535. doi: 10.1001/jamaneurol.2020.2658.
There is an ongoing debate regarding the management of asymptomatic carotid stenosis. Previous studies have reported imaging features of high-risk plaques that could help to optimize the risk-benefit ratio of revascularization. However, such studies have not provided an accurate estimate of the prevalence of high-risk plaques and the associated annual incidence of ipsilateral ischemic cerebrovascular events to inform the design of clinical trials using a risk-oriented selection of patients before randomization.
To assess the relevance and feasibility of risk-oriented selection of patients for revascularization.
A systematic search of PubMed and Ovid Embase from database inception to July 31, 2019, was performed.
Prospective observational studies that reported prevalence of high-risk plaques and incidence of ipsilateral ischemic cerebrovascular events were included.
Aggregated data were pooled using random-effects meta-analysis. Data were analyzed from December 16, 2019, to January 15, 2020.
Prevalence of high-risk plaques and annual incidence of ipsilateral ischemic events.
Overall, 64 studies enrolling 20 751 participants aged 29 to 95 years (mean age range, 55.0-76.5 years; proportion of men, 45%-87%) were included in the meta-analysis. Among all participants, the pooled prevalence of high-risk plaques was 26.5% (95% CI, 22.9%-30.3%). The most prevalent high-risk plaque features were neovascularization (43.4%; 95% CI, 31.4%-55.8%) in 785 participants, echolucency (42.3%; 95% CI, 32.2%-52.8%) in 12 364 participants, and lipid-rich necrotic core (36.3%; 95% CI, 27.7%-45.2%) in 3728 participants. The overall incidence of ipsilateral ischemic cerebrovascular events was 3.2 events per 100 person-years (22 cohorts with 10 381 participants; mean follow-up period, 2.8 years; range, 0.7-6.5 years). The incidence of ipsilateral ischemic cerebrovascular events was higher in patients with high-risk plaques (4.3 events per 100 person-years; 95% CI, 2.5-6.5 events per 100 person-years) than in those without high-risk plaques (1.2 events per 100 person-years; 95% CI, 0.6-1.8 events per 100 person-years), with an odds ratio of 3.0 (95% CI, 2.1-4.3; I2 = 48.8%). In studies focusing on severe stenosis (9 cohorts with 2128 participants; mean follow-up period, 2.8 years; range, 1.4-6.5 years), the incidence of ipsilateral ischemic cerebrovascular events was 3.7 events per 100 person-years (95% CI, 1.9-6.0 events per 100 person-years). The incidence of ipsilateral ischemic cerebrovascular events was also higher in patients with high-risk plaques (7.3 events per 100 person-years; 95% CI, 2.0-15.0 events per 100 person-years) than in those without high-risk plaques (1.7 events per 100 person-years; 95% CI, 0.6-3.3 events per 100 person-years), with an odds ratio of 3.2 (95% CI, 1.7-5.9; I2 = 39.6%).
High-risk plaques are common in patients with asymptomatic carotid stenosis, and the associated risk of an ipsilateral ischemic cerebrovascular event is higher than the currently accepted estimates. Extension of routine assessment of asymptomatic carotid stenosis beyond the grade of stenosis may help improve risk stratification and optimize therapy.
无症状性颈动脉狭窄的治疗策略一直存在争议。先前的研究报告了高危斑块的影像学特征，这有助于优化血运重建的风险获益比。然而，这些研究并未提供高危斑块的准确发生率和同侧缺血性脑血管事件的年发生率，从而无法为临床试验提供信息，无法根据风险选择患者进行随机分组。
评估基于风险选择患者进行血运重建的相关性和可行性。
从数据库建立到 2019 年 7 月 31 日，对 PubMed 和 Ovid Embase 进行了系统检索。
纳入了报告高危斑块发生率和同侧缺血性脑血管事件发生率的前瞻性观察性研究。
使用随机效应荟萃分析汇总了汇总数据。数据分析于 2019 年 12 月 16 日至 2020 年 1 月 15 日进行。
高危斑块发生率和同侧缺血性事件的年发生率。
共有 64 项研究纳入了 20751 名年龄 29 岁至 95 岁的参与者（平均年龄范围为 55.0 岁至 76.5 岁；男性比例为 45%至 87%），进行了荟萃分析。在所有参与者中，高危斑块的总发生率为 26.5%（95%CI，22.9%至 30.3%）。最常见的高危斑块特征为 785 名参与者的新生血管形成（43.4%；95%CI，31.4%至 55.8%），12364 名参与者的回声不透明（42.3%；95%CI，32.2%至 52.8%）和 3728 名参与者的富含脂质的坏死核心（36.3%；95%CI，27.7%至 45.2%）。同侧缺血性脑血管事件的总发生率为每 100 人年 3.2 例（22 项队列共 10381 名参与者；平均随访时间为 2.8 年；范围，0.7 年至 6.5 年）。在有高危斑块的患者中，同侧缺血性脑血管事件的发生率更高（每 100 人年 4.3 例；95%CI，2.5 例至 6.5 例），而无高危斑块的患者发生率较低（每 100 人年 1.2 例；95%CI，0.6 例至 1.8 例），比值比为 3.0（95%CI，2.1 例至 4.3 例；I2=48.8%）。在关注严重狭窄的研究中（9 项队列共 2128 名参与者；平均随访时间为 2.8 年；范围，1.4 年至 6.5 年），同侧缺血性脑血管事件的发生率为每 100 人年 3.7 例（95%CI，1.9 例至 6.0 例）。在有高危斑块的患者中，同侧缺血性脑血管事件的发生率也更高（每 100 人年 7.3 例；95%CI，2.0 例至 15.0 例），而无高危斑块的患者发生率较低（每 100 人年 1.7 例；95%CI，0.6 例至 3.3 例），比值比为 3.2（95%CI，1.7 例至 5.9 例；I2=39.6%）。
无症状性颈动脉狭窄患者的高危斑块很常见，同侧缺血性脑血管事件的风险高于目前公认的估计。在常规评估无症状性颈动脉狭窄时，除狭窄程度外，还应评估高危斑块，这有助于改善风险分层，优化治疗策略。
