Manejo pacientes con estenosis carotidea
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Transcript of Manejo pacientes con estenosis carotidea
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de Weerd, Stroke 2009
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Sposato, Neurol Arg 2010, en prensa
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1: Vasa 2006;35:232 | 2: Cochrane Systematic Review 2008 | 3: Stroke 2010;41:e55 | 4: Stroke 1998;19:1485
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Complic. en
Sintomáticos
OR 1.62
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CAVATAS Investigators, Lancet 2001
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CAVATAS Investigators, Lancet 2001
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Bonati, Lancet Neurol 2009
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Bonati, Lancet Neurol 2009
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Eckstein, Lancet Neurol 2008
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Bonati, Lancet Neurol 2009
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Mas, New Eng J Med 2006
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Bonati, Lancet Neurol 2009
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Gurm, New Eng J Med 2008
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Gurm, New Eng J Med 2008
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Gurm, New Eng J Med 2008
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Bonati, Lancet Neurol 2009
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CREST Investigators, New Eng J Med 2010
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ANGIO Doppler TC/RMN
Sintomáticos ≥ 50% ≥ 70% > 70%
Asintomáticos ≥ 60% ≥ 70% > 80%
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CASn=1262
CEAn=1240
2.3%
4.1%
2.3%
1.1%
0.3%
0.7% 5.2%
4.5%
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CASn=1262
CEAn=1240
2.3%
4.4%
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CASn=1262
CEAn=1240
12.6%
11.3%
7.9%
10.2% 7.2%
6.8%
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CASn=1262
CEAn=1240
4.7%
6.4%
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P=0.07P=0.14
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Estimated impact of peri-procedural events (stroke, MI) on the SF-36
physical and mental component summary scales at 1 year
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Estimated impact of peri-procedural events on the individual SF-36
subscales at 1 year
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Stroke 2011
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Stroke 2011
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Stroke 2011
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ICSS Investigators, Lancet 2010
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Meier, Expert Rev Cardiovasc Ther 2010
Bonati, Lancet 2010
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Stroke 2011
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Stroke 2011
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Marquardt, Stroke 2010
-2% Riesgo A
-80% Riesgo R
20081983
2.5%
0.5%
25 años
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Goodney, J Vasc Surg 2008 | Kang, J Vasc Surg 2009 | ACST, Lancet 2004 | ACAS, JAMA 1995
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Abbott, Stroke 2009
Reducción absoluta del riesgo de stroke ipsilateral desde 1985 a 2007: 1.4%
Reducción absoluta del riesgo de cualquier stroke desde 1985 a 2007: 2.3%
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Abbott, Stroke 2009
2010200019901980
Décadas
Stroke
Ipsilateral
Cualquier
Stroke/AIT
Cualquier
Stroke
EDAD HTA
TBQ EVPECo
7.7 5.5
15
37
11
Cambios en Prevalencia
Últimos 25 años
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Jackevicius, CMAJ 2009
Clopidogrel o
Ticlopidina
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¿Hay algún paciente asintomático que
deba ser intervenido?
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Reiff, Int J Stroke 2009
3640 p con estenosis carotídea ≥70% (x DVC) sin
síntomas en los últimos 180 días (50-85 años )
Endarterectomía + MTM Stenting + MTMMTM
Endpoints
1º de Seguridad
Stroke o muerte a 30 días
1º de Eficacia
Stroke o muerte a 30 días +
Stroke a 5 años
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Calvillo-King, Stroke 2010
La endarterectomía es más riesgosa en mujeres asintomáticas
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Rothwell, Lancet 2004
La CEA NO reduce el riesgo de stroke en mujeres asintomáticas
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Bond, Cerebrovasc Dis 2005
Aumento de la mortalidad y el stroke perioperatorios con
la edad
Nagaki, J Neurosurg 2009
No. de años ajustados por calidad
de vida ganados por la CEA para ≠
edades y grados de comorbilidad
ACST, Lancet 2004
La CEA no previene el stroke en ≥ 75 años
asintomáticos
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ACST, Lancet 2004 | ACST, Lancet 2010
El beneficio de la endarterectomía en asintomáticos no es evidente antes de los 5 años de la cirugía
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ACST, Lancet 2004 | ACAS, JAMA 1995
Tanto ACST como ACAS
incluyeron pacientes con
estenosis ≥ 60%En ninguno de los dos estudios
hubo diferencias en el outcome
a grados crecientes de
estenosis.
Mackey, Neurology 1997
750 pacientes con estenosis
asintomática seguidos prospectivamente
durante un promedio de 3.6 años
Asymptomatic Cervical Bruit Study Group, Canada
Podría no haber beneficio en
estenosis < 80%
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Sabeti, Stroke 2005 Sabeti, Stroke 2007
La progresión del grado de estenosis es un marcador de riesgo de stroke en asintomáticos
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Markus, Lancet Neurol 2010 | Spence, Arch Neurol 2010
Las embolias asintomáticas detectadas por DTC son un marcador de riesgo de stroke
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Nighoghossian, Stroke 2005 | U-King-Im, Lancet Neurol 2009
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Riccio, Neurol Arg 2010
203 p sometidos a CEA
entre 2006 y 2009
Sintomáticos
n = 28
Asintomáticos
n = 175
Anatomía Patológica
Core lipídico-necrótico
Calcio
Hemorragia
Inflamación
Trombo
Úlcera
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Riccio, Neurol Arg 2010
Los pacientes con placas vulnerables (úlcera principalmente) tendrían un mayor riesgo de stroke
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