International Stroke Conference
February 6–8, 2019

Deepak Gulati, MD

There has been significant improvement in medical management in the last decade leading to various options in 2019 as compared to the era when earlier clinical trials on carotid stenosis were performed.

Dr. Seemant Chaturvedi from the University of Maryland presented on multi-modal treatment of carotid stenosis. Statins plays an important role by reducing LDL being the primary focus of treatment. In the SPARCL study, 32% risk reduction was seen with statins. The cardioprotective mechanisms of physical activity includes psychological, anti-arrhythmic, anti-thrombotic, anti-atherosclerotic and improved hemodynamics. Various studies/guidelines support the encouragement of regular exercise as a stroke prevention strategy and should be emphasized to patients. Physical activity is often found to be a ‘neglected prescription.’ Exercise volumes of 150 min/week of moderate-intensity or 75 min/week of vigorous-intensity aerobic exercise further reduce CVD mortality. Several diets have been proposed for CV risk reduction, including the DASH diet and Mediterranean diet. Being DM as one of the major vascular risk factor, stroke physicians should be aware of recent advances in anti-hyperglycemic drugs. Some newer antihyperglycemic agents have an FDA indication for reduction of either CV death or CV events. The use of dual antiplatelet therapy has been increasing based on the CHANCE and POINT trial. Some of the newer strategies include PCSK9 inhibitors, ezetimibe and TG reduction. Our current management of symptomatic carotid stenosis is based on the NASCET trial published in 1991. Given the recent advances in multimodal medical treatment, there appears to be a strong need of new clinical trials in patients with carotid stenosis.

Blood pressure target in the setting of carotid stenosis has been an area of uncertainty. Dr. Philip Bath from the University of Nottingham presented on blood pressure control in symptomatic carotid stenosis. As per the data presented, blood pressure reduction overall appears to be safer. BP control also lead to reduction of intimal medial thickness. Reducing very high BP is more effective than reducing moderately high BP. Lowering the BP in the setting of bilateral carotid stenosis could be detrimental.

Dr. Wei Zhou from the University of Arizona presented the data showing significant improvement in medical management and surgical techniques for carotid stenosis in the last two decades. She mentioned cognition as an important outcome measure of carotid disease and carotid interventions. There is a need to redefine symptomatic carotid artery disease and also to design clinical trials to include neurocognitive outcome measures.