A new scoring system to assess the risk of stroke and heart attacks in patients with narrowed arteries could prevent unnecessary surgical procedures, according to a study published in The Lancet Neurology.
Atherosclerosis is a medical condition that causes blood vessels to narrow and harden. This is likely due to plaque buildup and can affect important vessels, such as the carotid arteries, which carry blood from the heart to the brain. As such, atherosclerosis significantly increases the risk of strokes and heart attacks.
This condition is common in patients over 65, as well as those who smoke, have high cholesterol, hypertension, or a family history of heart problems. It is believed that atherosclerosis causes up to 20% of strokes. As a preventative measure, many patients get a stent to prevent strokes resulting from atherosclerosis. However, these procedures also carry risks of causing strokes and other serious complications at the time of the intervention.
In the new study, a team from UCL, UK, collaborating with colleagues at the Amsterdam University Medical Centre and the University of Basel, found that using the Carotid Artery Risk (CAR) scoring system is a safer alternative. This system identifies patients who can be treated with medications and lifestyle changes instead of surgery.
“While further follow-up and additional trials are needed to confirm these findings, we recommend using the CAR score to identify patients with carotid narrowing who can be managed with optimised medical therapy alone. This approach emphasises personal assessment and intensive treatment of vascular risk factors, potentially sparing many patients from the discomfort and risks of carotid surgery or stenting. Additionally, this method could lead to substantial cost savings for health services,” said senior author Emeritus Professor Martin Brown (UCL Queen Square Institute of Neurology).
For this study, the team conducted a clinical trial to evaluate the effectiveness of the CAR score with 428 patients across 30 centres in the UK, Europe, and Canada. All participants were over 18 and had a significant narrowing of their carotid arteries, which was detected before it caused any major symptoms.
The patients were divided into two groups: One group received medication and advice on lifestyle changes, including a recommendation to follow a low cholesterol diet, a cholesterol-lowering medication, treatment to lower blood pressure, antithrombotic therapy (a treatment that helps prevent blood clots from forming or growing), and regular checks to adjust the medication as necessary. In addition to the same treatment, the second group also received additional carotid surgery or stenting.
Over the first two years, patients who were treated with medication and advice alone had very low rates of recurrent strokes and heart attacks. In addition, those who underwent surgery or stenting did not experience significant benefits, considering the associated risks of these procedures.
“Atherosclerosis is a common condition and a major risk factor for heart disease and stroke. Whilst medical therapy is the first line of treatment, many of those who have medical therapy then need surgery or stenting, which can lead to complications including an increased risk of stroke and other unpleasant side effects,” said Dr. Louise Flanagan, Head of Research at the Stroke Association.
“The CAR risk score offers the opportunity to take away the downsides of surgery and stenting by using medical therapy alone as well as combining medical therapy with surgery. The Stroke Association is pleased to have funded this trial, which indicates that some people with atherosclerosis could see the same benefits from medication and lifestyle changes that previously required surgery. The medical therapies used to reduce the risk of stroke from atherosclerosis work by treating risk factors for stroke, including high cholesterol and raised blood pressure, which we are putting at the heart of our recommendations for the Government’s 10 Year Health Plan. Whilst we welcome the results of this study, we note the need for more research to confirm or refute these findings, so we look forward to further developments.”
Donners, et al. Optimised medical therapy alone versus optimised medical therapy plus revascularisation for asymptomatic or low-to-intermediate risk symptomatic carotid stenosis (ECST-2): 2-year interim results of a multicentre randomised trial. The Lancet Neurology, Volume 24, Issue 5, 389 – 399