Abstract
In recent years, there have been a number of advances in the pathogenesis and treatment of atherosclerosis and in assessing prognosis in carotid atherosclerosis. Risk stratification to improve vascular prevention by identifying patients most likely to benefit from intensive therapy is much improved by measuring carotid plaque burden. In patients with asymptomatic carotid stenosis, a number of modalities can be used to identify the 10-15% who could benefit from endarterectomy or stenting. Transcranial Doppler embolus detection, echolucency and ulceration on 3D ultrasound, intraplaque hemorrhage on magnetic resonance imaging (MRI), and reduced cerebrovascular reserve are useful already; new approaches including plaque texture on ultrasound and imaging of plaque inflammation and early calcification on positron emission tomography/computed tomography (PET/CT) are in development. The discovery that the intestinal microbiome produces vasculotoxic metabolites from dietary constituents such as carnitine in meat (particularly red meat) and phosphatidylcholine from egg yolk and other sources has revolutionized nutritional aspects of vascular prevention. Because many of these vasculotoxic metabolites are removed by the kidney, it is particularly important in patients with renal failure to limit their intake of red meat and egg yolk. A new approach to lowering low-density lipoprotein (LDL) cholesterol by blocking the action of an enzyme that destroys LDL receptors promises to revolutionize vascular prevention once less costly treatments are developed, and a new approach to vascular prevention—“treating arteries instead of risk factors”—shows promise but requires randomized trials. These advances all promise to help in the quest to prevent strokes in high-risk patients.
Highlights
In recent years, there have been important advances in the pathogenesis and treatment of atherosclerosis and in assessing prognosis in carotid atherosclerosis
Diet is much more important than most physicians suppose, and the intestinal microbiome has major effects on metabolic products derived from dietary constituents such as carnitine from meat and phosphatidylcholine from egg yolk
Avoidance of red meat and egg yolk is important in patients with impaired renal function
Summary
There have been important advances in the pathogenesis and treatment of atherosclerosis and in assessing prognosis in carotid atherosclerosis. In the United States, ~90% of carotid intervention is for asymptomatic stenosis, even though 90% of patients would be better treated with intensive medical therapy[12] This is being justified by an invalid extrapolation from the medical risks in randomized trials conducted decades ago to modern risks with CEA and CAS. Plaque characteristics and prediction of risk In patients with asymptomatic carotid stenosis, the presence of three or more ulcers in either or both carotid arteries carried a similar risk as the presence of microemboli: an 18% 3-year risk of stroke or death. Modalities to identify the few who could benefit from intervention should be in more widespread use; no patient with asymptomatic stenosis should be subjected to intervention without first being identified as being at a high enough risk of ipsilateral stroke to benefit from intervention
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