Carotid artery stenosis secondary prevention

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Vascular Imaging in Patients With Vertebral Artery Disease

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Occlusive Disease of the Subclavian and Brachiocephalic Arteries

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Secondary prevention for carotid artery stenosis include the cessation of smoking. Other preventative methods which can also be treatment measures are tight control of blood pressure, management of diabetes, and management of lipids.

Secondary Prevention

2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS: Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease (DO NOT EDIT)[1]

Smoking Cessation (DO NOT EDIT)[1]

Class I
"1. Patients with extracranial carotid or vertebral atherosclerosis who smoke cigarettes should be advised to quit smoking and offered smoking cessation interventions to reduce the risks of atherosclerosis progression and stroke.[2][3][4][5] (Level of Evidence: B) "

Treatment of Hypertension (DO NOT EDIT)[1]

Class I
"1. Antihypertensive treatment is recommended for patients with hypertension and asymptomatic atherosclerotic ECVD to maintain blood pressure (BP) less than 140/90 mm Hg.[6][7][8][9][10] (Level of Evidence: A) "
Class IIa
"1. Except during the hyperacute period, antihypertensive treatment is probably indicated in patients with hypertension and symptomatic atherosclerotic ECVD, but the benefit of treatment to a specific BP has not been established in relation to the risk of exacerbating cerebral ischemia. (Level of Evidence: C) "

Control of Hyperlipidemia (DO NOT EDIT)[1]

Class I
"1. Treatment with a statin is recommended for all patients with atherosclerotic ECVD (Extracranial Carotid and Vertebral artery disease) to lower low density lipoprotein cholesterol to less than 100 mg/dL.[7][11][12] (Level of Evidence: B) "
Class IIa
"1. Treatment with a statin is reasonable for all patients with atherosclerotic ECVD who sustain ischemic stroke to reduce low-density lipoprotein cholesterol to a level less than or equal to 70 mg/dL.[11] (Level of Evidence: B) "
"2. If treatment with a statin (including trials of higher-dose statins and higher-potency statins) does not achieve the goal selected for a patient, intensifying LDL-lowering drug therapy with an additional drug from among those with evidence of improving outcomes (ie, bile acid sequestrants or niacin) can be effective.[13][14][15][16] (Level of Evidence: B) "
"3. For patients who do not tolerate statins, therapy with bile acid sequestrants and/or niacin is reasonable.[13][15][17] (Level of Evidence: B) "

Management of Diabetes Mellitus in Patients With Atherosclerosis of the Extracranial Carotid or Vertebral Arteries (DO NOT EDIT)[1]

Class IIa
"1. Diet, exercise, and glucose-lowering drugs can be useful for patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis. The stroke prevention benefit, however, of intensive glucose lowering therapy to a glycosylated hemoglobin A1c level less than 7.0% has not been established.[18][19] (Level of Evidence: A)"
"2. Administration of statin-type lipid-lowering medication at a dosage sufficient to reduce LDL cholesterol to a level near or below 70 mg/dL is reasonable in patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis for prevention of ischemic stroke and other ischemic cardiovascular events.[20] (Level of Evidence: B)"

Antithrombotic Therapy in Patients With Extracranial Carotid Atherosclerotic Disease Not Undergoing Revascularization (DO NOT EDIT)[1]

Class I
"1. Antiplatelet therapy with aspirin, 75 to 325 mg daily, is recommended for patients with obstructive or nonobstructive atherosclerosis that involves the extracranial carotid and/or vertebral arteries for prevention of myocardial infarction (MI) and other ischemic cardiovascular events, although the benefit has not been established for prevention of stroke in asymptomatic patients.[12][21][22][23] (Level of Evidence: A) "
"2. In patients with obstructive or nonobstructive extracranial carotid or vertebral atherosclerosis who have sustained ischemic stroke or TIA, antiplatelet therapy with aspirin alone (75 to 325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin plus extended-release dipyridamole (25 and 200 mg twice daily, respectively) is recommended (Level of Evidence: B) and preferred over the combination of aspirin with clopidogrel.[12][23][24][25][26][27] (Level of Evidence: B) Selection of an antiplatelet regimen should be individualized on the basis of patient risk factor profiles, cost, tolerance, and other clinical characteristics, as well as guidance from regulatory agencies.
"3. Antiplatelet agents are recommended rather than oral anticoagulation for patients with atherosclerosis of the extracranial carotid or vertebral arteries with[28][29] (Level of Evidence: B) or without (Level of Evidence: C) ischemic symptoms. (For patients with allergy or other contraindications to aspirin, see Class IIa recommendation #2, this section)
Class III (Harm)
"1. Full-intensity parenteral anticoagulation with unfractionated heparin or low-molecular-weight heparinoids is not recommended for patients with extracranial cerebrovascular atherosclerosis who develop transient cerebral ischemia or acute ischemic stroke.[30][31][32] (Level of Evidence: B) "
"2. Administration of clopidogrel in combination with aspirin is not recommended within 3 months after stroke or TIA. (Level of Evidence: B) "
Class IIa
"1. In patients with extracranial cerebrovascular atherosclerosis who have an indication for anticoagulation, such as atrial fibrillation or a mechanical prosthetic heart valve, it can be beneficial to administer a vitamin K antagonist (such as warfarin, dose adjusted to achieve a target international normalized ratio (INR) of 2.5 [range 2.0 to 3.0]) for prevention of thromboembolic ischemic events.[33] (Level of Evidence: C) "
"2. For patients with atherosclerosis of the extracranial carotid or vertebral arteries in whom aspirin is contraindicated by factors other than active bleeding, including allergy, either clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) is a reasonable alternative. (Level of Evidence: C) "


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