Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada.
Department of Community Health Sciences, University of Calgary Cumming School of Medicine, Calgary, Canada.
Can J Neurol Sci. 2024 Mar;51(2):210-219. doi: 10.1017/cjn.2023.28. Epub 2023 Feb 21.
Whereas the beneficial effect of antiplatelet therapy for recurrent stroke prevention has been well established, uncertainties remain regarding the optimal antithrombotic regimen for recently symptomatic carotid stenosis. We sought to explore the approaches of stroke physicians to antithrombotic management of patients with symptomatic carotid stenosis.
We employed a qualitative descriptive methodology to explore the decision-making approaches and opinions of physicians regarding antithrombotic regimens for symptomatic carotid stenosis. We conducted semi-structured interviews with a purposive sample of 22 stroke physicians (11 neurologists, 3 geriatricians, 5 interventional-neuroradiologists, and 3 neurosurgeons) from 16 centers on four continents to discuss symptomatic carotid stenosis management. We then conducted thematic analysis on the transcripts.
Important themes revealed from our analysis included limitations of existing clinical trial evidence, competing surgeon versus neurologist/internist preferences, and the choice of antiplatelet therapy while awaiting revascularization. There was a greater concern for adverse events while using multiple antiplatelet agents (e.g., dual-antiplatelet therapy (DAPT)) in patients undergoing carotid endarterectomy compared to carotid artery stenting. Regional variations included more frequent use of single antiplatelet agents among European participants. Areas of uncertainty included antithrombotic management if already on an antiplatelet agent, implications of nonstenotic features of carotid disease, the role of newer antiplatelet agents or anticoagulants, platelet aggregation testing, and timing of DAPT.
Our qualitative findings can help physicians critically examine the rationale underlying their own antithrombotic approaches to symptomatic carotid stenosis. Future clinical trials may wish to accommodate identified variations in practice patterns and areas of uncertainty to better inform clinical practice.
抗血小板治疗预防复发性卒中的有益效果已得到充分证实，但对于近期有症状的颈动脉狭窄患者的最佳抗血栓治疗方案仍存在不确定性。我们旨在探讨卒中医生对有症状颈动脉狭窄患者抗血栓治疗管理的方法。
我们采用定性描述方法，探讨了医生对有症状颈动脉狭窄抗血栓治疗方案的决策方法和意见。我们对来自四大洲 16 个中心的 22 名卒中医生（11 名神经病学家、3 名老年病学家、5 名介入神经放射学家和 3 名神经外科医生）进行了半结构化访谈，以讨论有症状颈动脉狭窄的管理。然后，我们对转录本进行了主题分析。
我们的分析揭示了重要的主题，包括现有临床试验证据的局限性、外科医生与神经科医生/内科医生的偏好竞争以及在等待血运重建时选择抗血小板治疗。与颈动脉支架置入术相比，在接受颈动脉内膜切除术的患者中使用多种抗血小板药物（如双联抗血小板治疗（DAPT））时，对不良事件的担忧更大。区域差异包括欧洲参与者更频繁地使用单一抗血小板药物。不确定的领域包括已经使用抗血小板药物时的抗血栓治疗管理、颈动脉疾病非狭窄特征的影响、新型抗血小板药物或抗凝剂的作用、血小板聚集试验以及 DAPT 的时机。
我们的定性发现可以帮助医生批判性地检查他们自己有症状颈动脉狭窄抗血栓治疗方法的基本原理。未来的临床试验可能希望考虑到已确定的实践模式差异和不确定性领域，以更好地为临床实践提供信息。
