First question: Is the patient asymptomatic or symptomatic?
Asymptomatic Stenosis
Questions:
(1) Is the stenosis >= 60%?
(2) Is the surgical risk > 3%?
Patients with a surgical risk > 3% - one or more of the following:
(1) age > 79 years
(2) unstable cardiac disease
(3) experienced surgeon not available
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Patient Characteristics
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Management
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stenosis < 60%
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medical therapy
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stenosis >= 60%, surgical risk <= 3%
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endarterectomy and medical therapy
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stenosis >= 60%, surgical risk > 3%
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medical therapy
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Symptomatic Stenosis
Questions:
(1) What is the degree of stenosis?
(2) Does the patient have a higher risk of carotid stroke?
Person at higher risk of carotid stroke - one or more of the following:
(1) more severe stenosis
(2) age >= 75 years
(3) male sex
(4) stroke within last 3 months
(5) hemispheric symptoms
(6) intracranial stenosis present
(7) no microvascular ischemia
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Patient Characteristics
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Management
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stenosis < 50%
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medical therapy
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stenosis 50 - 69%, lower risk of carotid stroke
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medical therapy
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stenosis 50 - 69%, higher risk of carotid stroke
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endarterectomy and medical therapy
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stenosis >= 70%
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endarterectomy and medical therapy
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Management Issues
Medical therapy may include one or more of the following:
(1) control of risk factors (smoking cessation, weight control, exercise, atrial fibrillation, etc.)
(2) antiplatelet drugs
(3) statins
(4) angiotensin-converting-enzyme (ACE) inhibitors
Other factors may impact the recommendations given above. This may include the presence of other comorbid conditions, valvular heart disease, etc.
