Riesgo de accidente cerebrovascular en pacientes con aterosclerosis carotídea asintomática: ¿se debe tratar médicamente o quirúrgicamente?
DOI:
https://doi.org/10.24265/horizmed.2023.v23n3.11Palavras-chave:
accidente cerebrovascular, riesgo, enfermedades de las arterias carótidas, procedimientos quirúrgicos operativos, terapéuticaResumo
Los desórdenes cerebrovasculares siguen siendo la primera causa de morbilidad y mortalidad neurológica en el mundo, representando una de las entidades patológicas que genera mayor carga de enfermedad a nivel global. La aterosclerosis, o estenosis carotídea, es un potencial factor de riesgo para el ictus isquémico. La identificación y seguimiento estricto de esta condición son esenciales en la prevención secundaria de complicaciones a través de la atención primaria y el manejo especializado del riesgo cardiometabólico. No obstante, dependiendo de este riesgo y/o la presencia de sintomatología, es necesario realizar un manejo definitivo. Actualmente, existe controversia sobre si es mejor tratar la estenosis carotídea asintomática, ya sea médica o quirúrgicamente. Teniendo en cuenta la relevancia de esta entidad, el objetivo de esta revisión consiste en analizar la evidencia reciente sobre el riesgo de ictus isquémico en la aterosclerosis carotídea asintomática en adultos, y el potencial beneficio del manejo quirúrgico vs. farmacológico de esta condición. Para esto, se llevó a cabo una búsqueda bibliográfica en las bases de datos PubMed, ScienceDirect, Web of Science y MEDLINE, hasta el año 2023. Se evidenció que el riesgo de ictus asociado a estenosis carotídea asintomática es significativo (>10 %, aproximadamente), incluso en aquellos con terapia antiplaquetaria e hipolipemiante activa. En aquellos con manejo médico, la supervivencia a cinco años es alrededor del 80 %. Sin embargo, la progresión de la estenosis sucede en promedio en más del 60 % de los casos, y es significativa. Por el contrario, el stent carotídeo y la endarterectomía son intervenciones resolutivas. Pero existe un riesgo mayor comparado con la terapia médica, el cual se atribuye al periodo peri- y posoperatorio, así como a 30 días de aparición o recurrencia del ictus, infarto agudo de miocardio o muerte por cualquier causa; aunque el uso de la endarterectomía ha demostrado beneficios superiores a largo plazo en cuanto a estos mismos desenlaces. Entonces, la evidencia es heterogénea en cuanto a la superioridad del tratamiento quirúrgico comparado con la terapia farmacológica en el manejo de la aterosclerosis o estenosis carotídea asintomática. Sin embargo, parece ser que el manejo quirúrgico, específicamente la endarterectomía, podría impactar significativamente sobre la aparición o recurrencia del ictus ipsilateral y muerte a largo plazo, pero con resultados controversiales peri- y postoperatorios.
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Referências
GBD 2019 Stroke Collaborators. Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol [Internet]. 2021;20(10):795-820.
Krishnamurthi RV, Ikeda T, Feigin VL. Global, regional and countryspecific burden of ischaemic stroke, intracerebral haemorrhage and subarachnoid haemorrhage: A systematic analysis of the Global Burden of Disease Study 2017. Neuroepidemiology [Internet]. 2020;54(2):171-9.
Zhang T, Yin X, Zhang Y, Chen H, Man J, Li Y, et al. Global trends in mortality and burden of stroke attributable to lead exposure from 1990 to 2019. Front Cardiovasc Med [Internet]. 2022;9:870747.
Portegies ML, Koudstaal PJ, Ikram MA. Cerebrovascular disease. Handb Clin Neurol [Internet]. 2016;138:239-61.
Pan American Health Organization. Cardiovascular disease burden [Internet]. Disponible en: https://www.paho.org/en/enlace/cardiovascular-disease-burden
World Health Organization. Cerebrovascular disease [Internet]. Disponible en: https://platform.who.int/mortality/themes/themedetails/topics/indicator-groups/indicator-group-details/MDB/cerebrovascular-disease
Tong X, Yang Q, Ritchey MD, George MG, Jackson SL, Gillespie C, et al. The burden of cerebrovascular disease in the United States. Prev Chronic Dis [Internet]. 2019;16(180411):E52.
Zhang Y, He Q, Zhang W, Xiong Y, Shen S, Yang J, et al. Non-linear associations between visceral adiposity index and cardiovascular and cerebrovascular diseases: Results from the NHANES (1999-2018). Front Cardiovasc Med [Internet]. 2022;9:908020.
Leal J, Luengo-Fernandez R. The economic burden of cerebrovascular diseases in the UK [Internet]. University of Oxford; 2009. Disponible en: https://www.herc.ox.ac.uk/research/disease-cost-studies-2/studies-28/the-economic-burden-of-cerebrovascular-diseases-inthe-uk-2
Becattini C, Dentali F, Camporese G, Sembolini A, Rancan E, Tonello C, et al. Carotid atherosclerosis and risk for ischemic stroke in patients with atrial fibrillation on oral anticoagulant treatment. Atherosclerosis [Internet]. 2018;271:177-81.
Iannuzzi A, Rubba P, Gentile M, Mallardo V, Calcaterra I, Bresciani A, et al. Carotid atherosclerosis, ultrasound and lipoproteins. Biomedicines [Internet]. 2021;9(5):521.
Selwaness M, Bos D, van den Bouwhuijsen Q, Portegies MLP, Ikram MA, Hofman A, et al. Carotid atherosclerotic plaque characteristics on magnetic resonance imaging relate with history of stroke and coronary heart disease. Stroke [Internet]. 2016;47(6):1542-7.
Bos D, Arshi B, van den Bouwhuijsen QJA, Ikram MK, Selwaness M, Vernooij MW, et al. Atherosclerotic carotid plaque composition and incident stroke and coronary events. J Am Coll Cardiol [Internet]. 2021;77(11):1426-35.
Parish S, Arnold M, Clarke R, Du H, Wan E, Kurmi O, et al. Assessment of the role of carotid atherosclerosis in the association between major cardiovascular risk factors and ischemic stroke subtypes. JAMA Netw Open [Internet]. 2019;2(5):e194873.
Song P, Fang Z, Wang H, Cai Y, Rahimi K, Zhu Y, et al. Global and regional prevalence, burden, and risk factors for carotid atherosclerosis: a systematic review, meta-analysis, and modelling study. Lancet Glob Health [Internet]. 2020;8(5):e721-9.
Finn C, Giambrone AE, Gialdini G, Delgado D, Baradaran H, Kamel H, et al. The association between carotid artery atherosclerosis and silent brain infarction: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis [Internet]. 2017;26(7):1594-601.
Dempsey RJ, Vemuganti R, Varghese T, Hermann BP. A review of carotid atherosclerosis and vascular cognitive decline: A new understanding of the keys to symptomology. Neurosurgery [Internet]. 2010;67(2):484-94.
Chang RW, Tucker L-Y, Rothenberg KA, Lancaster E, Faruqi RM, Kuang HC, et al. Incidence of ischemic stroke in patients with asymptomatic severe carotid stenosis without surgical intervention. JAMA [Internet]. 2022;327(20):1974-82.
Meschia JF, Klaas JP, Brown RD Jr, Brott TG. Evaluation and management of atherosclerotic carotid stenosis. Mayo Clin Proc [Internet]. 2017;92(7):1144-57.
Hobson RW 2nd, Mackey WC, Ascher E, Murad MH, Calligaro KD, Comerota AJ, et al. Management of atherosclerotic carotid artery disease: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg [Internet]. 2008;48(2):480-6.
Ederle J, Brown MM. The evidence for medicine versus surgery for carotid stenosis. Eur J Radiol [Internet]. 2006;60(1):3-7.
Ricotta JJ, Aburahma A, Ascher E, Eskandari M, Faries P, Lal BK et al. Updated Society for Vascular Surgery guidelines for management of extracranial carotid disease: executive summary. J Vasc Surg [Internet]. 2011;54(3):832-6.
Baek J-H. Carotid artery stenting for asymptomatic carotid stenosis: What we need to know for treatment decision. Neurointervention [Internet]. 2023;18(1):9-22.
Paraskevas KI, Eckstein H-H, Mansilha A, Ricco J-B, Geroulakos G, Di Lazzaro V, et al. Screening for asymptomatic carotid stenosis in patients with non-valvular atrial fibrillation. Int J Cardiol [Internet]. 2023;372:120-1.
Paraskevas KI, Spence JD, Mikhailidis DP, Antignani PL, Gloviczki P, Eckstein H-H, et al. Why do guidelines recommend screening for abdominal aortic aneurysms, but not for asymptomatic carotid stenosis? A plea for a randomized controlled trial. Int J Cardiol [Internet]. 2023;371:406-12.
Hogberg D, Mani K, Wanhainen A, Svensjo S. Clinical effect and cost-effectiveness of screening for asymptomatic carotid stenosis: A Markov model. Eur J Vasc Endovasc Surg [Internet]. 2018;55(6):81927.
Roh Y-N, Woo S-Y, Kim N, Kim S, Kim Y-W, Kim D-I. Prevalence of asymptomatic carotid stenosis in Korea based on health screening population. J Korean Med Sci [Internet]. 2011;26(9):1173-7.
Johansson EP, Ahlqvist J, Garoff M, Karp K, Jaghagen EL, Wester P. Ultrasound screening for asymptomatic carotid stenosis in subjects with calcifications in the area of the carotid arteries on panoramic radiographs: a cross-sectional study. BMC Cardiovasc Disord [Internet]. 2011;11(1):44.
Guirguis-Blake JM, Webber EM, Coppola EL. Screening for asymptomatic carotid artery stenosis in the general population: An evidence update for the U.S. Preventive Services Task Force [Internet]. Agency for Healthcare Research and Quality; 2021.
Conrad MF, Michalczyk MJ, Opalacz A, Patel VI, LaMuraglia GM, Cambria RP. The natural history of asymptomatic severe carotid artery stenosis. J Vasc Surg [Internet]. 2014;60(5):1218-26.
Naylor AR, Schroeder TV, Sillesen H. Clinical and imaging features associated with an increased risk of late stroke in patients with asymptomatic carotid disease. Eur J Vasc Endovasc Surg [Internet]. 2014;48(6):633-40.
Capoccia L, Sbarigia E, Rizzo A, Mansour W, Speziale F. Silent stroke and cognitive decline in asymptomatic carotid stenosis revascularization. Vascular [Internet]. 2012;20(4):181-7.
Weiner S, Benton MH, Guraziu B, Yange Y, He J, Chen YT, et al. High stroke rate in patients with medically managed asymptomatic carotid stenosis at an academic center in the southeastern United States. Ann Vasc Surg [Internet]. 2022;85:418-23.
Bir SC, Kelley RE. Carotid atherosclerotic disease: A systematic review of pathogenesis and management. Brain Circ [Internet]. 2022;8(3):127-36.
Gologorsky RC, Lancaster E, Tucker L-Y, Nguyen-Huynh MN, Rothenberg KA, Avins AL, et al. Natural history of asymptomatic moderate carotid artery stenosis in a large community-based cohort. Stroke [Internet]. 2022;53(9):2838-46.
Pini R, Faggioli G, Rocchi C, Fronterre S, Lodato M, Vacirca A, et al. Cerebral ischemic events ipsilateral to carotid artery stenosis. The Carotid Asymptomatic Stenosis (CARAS) observational study: First year preliminary results. J Stroke Cerebrovasc Dis [Internet]. 2022;31(8):106574.
Cheng TW, Pointer KE, Gopal M, Farber A, Jones DW, Eberhardt RT, et al. Natural history of non-operative management in asymptomatic patients with 70%-80% internal carotid artery stenosis by duplex criteria. Eur J Vasc Endovasc Surg [Internet]. 2020;60(3):339-46.
Conrad MF, Boulom V, Mukhopadhyay S, Garg A, Patel VI, Cambria RP. Progression of asymptomatic carotid stenosis despite optimal medical therapy. J Vasc Surg [Internet]. 2013;58(1):128-35.e1.
Durham CA, Ehlert BA, Agle SC, Mays AC, Parker FM, Bogey WM, et al. Role of statin therapy and angiotensin blockade in patients with asymptomatic moderate carotid artery stenosis. Ann Vasc Surg [Internet]. 2012;26(3):344-52.
Hicks CW, Talbott K, Canner JK, Qazi U, Arhuidese I, Glebova NO, et al. Risk of disease progression in patients with moderate asymptomatic carotid artery stenosis: implications of tobacco use and dual antiplatelet therapy. Ann Vasc Surg [Internet]. 2015;29(1):18.
Kolos I, Troitskiy A, Balakhonova T, Shariya M, Skrypnik D, Tvorogova T, et al. Modern medical treatment with or without carotid endarterectomy for severe asymptomatic carotid atherosclerosis. J Vasc Surg [Internet]. 2015;62(4):914-22.
Reiff T, Eckstein H-H, Mansmann U, Jansen O, Fraedrich G, Mudra H, et al. Carotid endarterectomy or stenting or best medical treatment alone for moderate-to-severe asymptomatic carotid artery stenosis: 5-year results of a multicentre, randomised controlled trial. Lancet Neurol [Internet]. 2022;21(10):877-88.
Bai X, Feng Y, Li L, Yang K, Wang T, Luo J, et al. Treatment strategies for asymptomatic carotid artery stenosis in the era of lipid-lowering drugs: protocol for a systematic review and network meta-analysis. BMJ Open [Internet]. 2020;10(7):e035094.
Hu X, Hu Y, Sun X, Li Y, Zhu Y. Effect of aspirin in patients with established asymptomatic carotid atherosclerosis: A systematic review and meta-analysis. Front Pharmacol [Internet]. 2022;13:1041400.
Reiff T, Eckstein HH, Mansmann U, Jansen O, Fraedrich G, Mudra H, et al. Angioplasty in asymptomatic carotid artery stenosis vs. endarterectomy compared to best medical treatment: One-year interim results of SPACE-2. Int J Stroke [Internet]. 2019;15(6):1747493019833017.
Galyfos G, Sachsamanis G, Anastasiadou C, Sachmpazidis I, Kikiras K, Kastrisios G, et al. Carotid endarterectomy versus carotid stenting or best medical treatment in asymptomatic patients with significant carotid stenosis: A meta-analysis. Cardiovasc Revasc Med [Internet]. 2019;20(5):413-23.
Kakkos SK, Kakisis I, Tsolakis IA, Geroulakos G. Endarterectomy achieves lower stroke and death rates compared with stenting in patients with asymptomatic carotid stenosis. J Vasc Surg [Internet]. 2017;66(2):607-17.
Hicks CW, Nejim B, Aridi HD, Black JH 3rd, Malas MB. Transfemoral carotid artery stents should be used with caution in patients with asymptomatic carotid artery stenosis. Ann Vasc Surg [Internet]. 2019;54:1-11.
Cui L, Han Y, Zhang S, Liu X, Zhang J. Safety of stenting and endarterectomy for asymptomatic carotid artery stenosis: A metaanalysis of randomised controlled trials. Eur J Vasc Endovasc Surg [Internet]. 2018;55(5):614-24.
Kim MJ, Ha S-K. Outcomes following carotid endarterectomy and carotid artery stenting in patients with carotid artery stenosis: A retrospective study from a single center in South Korea. Med Sci Monit [Internet]. 2023;29:e939223.
Poorthuis MHF, Kappelle LJ, de Borst GJ. A research agenda for selective screening for asymptomatic carotid artery stenosis. Int J Cardiol [Internet]. 2023;370:421-2.
Ravindranath V, Dang H-M, Goya RG, Mansour H, Nimgaonkar VL, Russell VA, et al. Regional research priorities in brain and nervous system disorders. Nature [Internet]. 2015;527(7578):S198-206.
Thakur KT, Albanese E, Giannakopoulos P, Jette N, Linde M, Prince MJ, et al. Neurological Disorders. In: Disease Control Priorities, Third Edition (Volume 4): Mental, Neurological, and Substance Use Disorders. The World Bank; 2016.
Kolappa K, Seeher K, Dua T. Brain health as a global priority. J Neurol Sci [Internet]. 2022;439(120326):120326.
Winkler AS. The growing burden of neurological disorders in lowincome and middle-income countries: priorities for policy making. Lancet Neurol [Internet]. 2020;19(3):200-2.
Feigin VL, Vos T, Nichols E, Owolabi MO, Carroll WM, Dichgans M, et al. The global burden of neurological disorders: translating evidence into policy. Lancet Neurol [Internet]. 2020;19(3):255-65.
Khandelwal S, Avode G, Baingana F, Conde B, Cruz M, Deva P, et al. Mental and neurological health research priorities setting in developing countries. Soc Psychiatry Psychiatr Epidemiol [Internet]. 2010;45(4):487-95.
Safri LS, Lip HTC, Saripan MI, Huei TJ, Krishna K, Md Idris MA, et al. Older age and duration of exposure to type 2 diabetes in selective screening of asymptomatic carotid artery stenosis for primary stroke prevention-A single institution experience. Prim Care Diabetes [Internet]. 2020;14(4):364-9.
Mastrorilli D, D'Oria M, Lepidi S, Mezzetto L, Calvagna C, Taglialavoro J, et al. Prediction of long-term mortality for patients with severe asymptomatic de novo carotid stenosis undergoing carotid endarterectomy (PREMY2SE-CEA): Derivation and validation of a novel risk score. J Vasc Surg [Internet]. 2023;77(3):804-810.e3.
Lozada-Martinez ID, Vargas-Rodriguez M, Alarcon-Pacheco GV, ArdilaAcuna LY, Ortega-Sierra MG. Neurogenomics and neuroimaging genetics: the advance of predictive clinical models and risk stratification for cerebrovascular diseases. J Neurosurg Sci [Internet]. 2022;66(4):379-80.
Geiger HJ. Racial and ethnic disparities in diagnosis and treatment: A review of the evidence and a consideration of causes. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care; 2003. Disponible en: https://www.ncbi.nlm.nih.gov/books/NBK220337/
Pan American Health Organization. Considerations on Indigenous Peoples, Afro-Descendants, and Other Ethnic Groups during the COVID-19 Pandemic, 4 June 2020 [Internet]. Disponible en: https://iris.paho.org/handle/10665.2/52251
Costa JC, Mujica OJ, Gatica-Dominguez G, Del Pino S, Carvajal L, Sanhueza A, et al. Inequalities in the health, nutrition, and wellbeing of Afrodescendant women and children: A cross-sectional analysis of ten Latin American and Caribbean countries. Lancet Reg Health Am [Internet]. 2022;15(100345):100345.
Powe NR. The pathogenesis of race and ethnic disparities: Targets for achieving health equity. Clin J Am Soc Nephrol [Internet]. 2021;16(5):806-8.
Javed Z, Haisum Maqsood M, Yahya T, Amin Z, Acquah I, ValeroElizondo J, et al. Race, racism, and cardiovascular health: Applying a social determinants of health framework to racial/ethnic disparities in cardiovascular disease. Circ Cardiovasc Qual Outcomes [Internet]. 2022;15(1):e007917.
Jilani MH, Javed Z, Yahya T, Valero-Elizondo J, Khan SU, Kash B, et al. Social determinants of health and cardiovascular disease: Current state and future directions towards healthcare equity. Curr Atheroscler Rep [Internet]. 2021;23(9):55.
Devareddy A, Sarraju A, Rodriguez F. Health disparities across the continuum of ASCVD risk. Curr Cardiol Rep [Internet]. 2022;24(9):1129-37.
Fabi SG, Hernandez C, Montes JR, Cotofana S, Dayan S. Aesthetic considerations when treating the Latin American patient: Thriving in diversity international roundtable series. J Cosmet Dermatol [Internet]. 2023;22(2):593-602.
Lozada-Martinez ID, Bolano-Romero MP, Picon-Jaimes YA, MoscoteSalazar LR, Narvaez-Rojas AR. Quality or quantity? Questions on the growth of global scientific production. Int J Surg [Internet]. 2022;105(106862):106862.
Lozada-Martinez ID, Suarez-Causado A, Solana-Tinoco JS. Ethnicity, genetic variants, risk factors and cholelithiasis: The need for ecoepidemiologic studies and genomic analysis in Latin American surgery. Int J Surg [Internet]. 2022;99(106589):106589.
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Copyright (c) 2023 Roberth Nixon Moreno Muñoz, Richard Adrián Vergara Trujillo, German Andrés Guevara Lizarazo, Patrick Junior Brett Cano, Dalila Andrea León Cuervo, Adriana Marcela Puerta Lidueñas, Mariana Sarmiento Figueroa, Michael Ortega Sierra
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