Athérome carotidien

et

Prévention des AVC

AMCAR 2015

Serge Kownator

« Centre Cardiologique et Vasculaire »

Thionville

A propos d’AVC

• Environ 150 000 nouveaux cas/an en France

• Responsable de 60 000 décès

• Conséquences

– 1ère cause de handicap physique acquis

– 2ème cause de démence

– 3ème cause de mortalité

• 70 à 80% des survivants rentrent chez eux

– Mais handicap pour la moitié d’entre eux

• Coût majeur pour la société

3

Etiologie des AVC/ AIT

Athérosclérose

Plaque aortique

Cardiopathies

emboligènes

Plaque embolie

Sténose carotide

Fibrillation Atriale

Maladie Valvulaire

Thrombus du Ventricule gauche

Athérosclérose

Intracrânienne

25%

30% : Cause rare ou cause non identifiée German Stroke Data Bank, Stroke 2001, 32 : 2559-66

Maladie des petites

artères

20%

25%

25%

Risk factors for stroke

Interstroke

O’Donnell MJ et al. the INTERSTROKE study. Lancet 2010; 376: 112–23

Carotid atherosclerosis

Definitions – Intima media thickness

• “Double line” pattern between the luminal edge of the artery and the

boundary between media and adventitia

– Plaque

• Focal structure encroaching in the lumen

• > 0.5mm or > 50 % of the surrounding IMT

• Or > 1.5 mm wall thickness

– Stenosis

• Plaque leading to an obstruction ≥ 50 %

Touboul PJ et al. Cerebrovasc Dis. 2012;34(4):290-6.

Hypertension increases atherogenic

lipoprotein content of arterial vessel walls

Sposito AC. Eur Heart J Suppl. 2004;6(suppl G):G8-G12.

BP

Atherogenic

VLDL, VLDL-R,

IDL, LDL

Intima- Enhanced – LP penetration

media – LP retention

– Pressure-induced distension

– Stretching

Intima-

media

Pressure-driven

convection

Relation of Common Carotid Intima-Media

Thickness With First-Time Myocardial

Infarction or Stroke Across Studies

• Hazard ratios are per 0.1 mm increase in CCA-IMT

Den Ruijter DM et al. JAMA. 2012;308(8):796-803

EIM et AVC

Bots et al Circulation 1997; 96: 1432–37.

<0.75 0.75 0.82

0.83 0.91

>= 0.92

Common CIMT (mm)

10

9

8

7

6

5

4

3

2

1

0

Rela

tive r

isk

(9

5%

CI)

Relationship between IMT & Plaque EVA study

• IMT value as a predictor

of 4 years atheromatous

plaque occurrence:

– OR = 2.6 for mid IMT

value

– OR = 3.6 for high IMT

value

Zureik et al. Arterioscl Thromb Vasc Biol 2000;20:1622-9

Carotid atherosclerotic plaque

• Strong predictor of risk

MI Stroke

Salonen JT et al . Arterioscler Thromb 1991;11:1245-9.

Marjolein de Weerd et al. Stroke. 2010;41:1294-1297

Prevalence of Asymptomatic Carotid Artery

Stenosis in the General Population

Severe stenosis in subgroups.

Asymptomatic carotid stenosis

and risk of ipsilateral stroke

Marquardt L et al. Stroke. 2010;41:e11-e17;

Prevention of Stroke/TIA

– Medical Rx

– Revasc

Abbott et al. Stroke 2009;40:e573-e583.

Effet du traitement médical Ipsilateral stroke Any territory stroke

Falls coincide with: (1) Gains in vascular disease understanding (2) Lowering or expansion of thresholds used to define and treat diabetes, hypertension,

hyperlipidemia (3) Progressive use of antiplatelet drugs, blood pressure-lowering drugs, and statins

Courtesy E Touze - Caen

Medical RX

• Antiplatelet therapy

• Blood pressure reduction

• Statin therapy

• Life-style modification

2011 ASA/ACCF/AHA/AANN/

AANS/ACR/ASNR/CNS/SAIP/SCAI/

SIR/SNIS/SVM/SVS Guideline on the

Management of Patients With Extracranial

Carotid and Vertebral Artery Disease

Developed in Collaboration with the American Academy of Neurology and Society of Cardiovascular Computed Tomography

Antiplatelet therapy with aspirin, 75 to 325 mg

daily, is recommended for patients with

obstructive or nonobstructive atherosclerosis

that involves the extracranial carotid and/or

vertebral arteries for prevention of MI and other

ischemic cardiovascular events, although the

benefit has not been established for

prevention of stroke in asymptomatic

patients.

Recommendations for Antithrombotic

Therapy

I IIa IIb III

In patients with obstructive or nonobstructive extracranial carotid or vertebral atherosclerosis who have sustained ischemic stroke or TIA, antiplatelet therapy with aspirin alone (75 to 325 mg daily), clopidogrel alone (75 mg daily), or the combination of aspirin plus extended-release dipyridamole (25 and 200 mg twice daily, respectively) is recommended and preferred over the combination of aspirin with clopidogrel. Selection of an antiplatelet regimen should be individualized on the basis of patient risk factor profiles, cost, tolerance, and other clinical characteristics, as well as guidance from regulatory agencies.

Recommendations for Antithrombotic

Therapy (continued)

I IIa IIb III

Antiplatelet agents are recommended rather than

oral anticoagulation for patients with

atherosclerosis of the extracranial carotid or

vertebral arteries with ischemic symptoms…

or without ischemic symptoms.

Recommendations for Antithrombotic

Therapy (continued)

I IIa IIb III

I IIa IIb III

Stroke Related Mortality and SBP

Lewington S et al. Lancet. 2002 Dec 14;360(9349):1903-13

Antihypertensive drugs and stroke reduction

Law MR. BMJ 2009;338:b1665

Statins and Carotid IMT

Adapté de Amarenco P et al. Stroke. 2004;35:2902-2909.

Meteor CCA

Statins and stroke prevention

• Relationship between ORs for stroke events and corresponding LDL-C reduction

Amarenco P et al, Lancet, 2009;8:453-63.

Statins and stroke prevention

• Meta analysis: 121000 pts

– Stroke RR : 0.84 (95% CI 0.79-0.91).

O’Regan C et al. The American Journal of Medicine (2008) 121, 24-33

Treatment with a statin medication is

recommended for all patients with extracranial

carotid or vertebral atherosclerosis to reduce low-

density lipoprotein (LDL) cholesterol below 100

mg/dL.

Treatment with a statin medication is reasonable

for all patients with extracranial carotid or

vertebral atherosclerosis who sustain ischemic

stroke to reduce LDL-cholesterol to a level near

or below 70 mg/dL.

Control of Hyperlipidemia

I IIa IIb III

I IIa IIb III

Statins and carotid

revascularisation

Study Follow-up Statin Placebo Relative Risk reduction

Heart Protection Study (simvastatine 40 mg/d)

4.6 yrs

All patients 0.4% 0.8% 50%

Prior history of stroke 1.0% 2.3% 56%

SPARCL (atorvastatine 80 mg/d)

5 yrs

Known carotid stenosis 3.2% 7.2% 56%

HPS. Lancet 2004;363:757-67 – Sillesen H et al. Stroke 2008;39:3297-3302.

Algorithm for the management of extracranial

carotid artery disease

ESC Guidelines 2012

Symptomatic stenosis Endarterectomy vs. Medical treatment

Ipsilateral ischemic stroke and any operative stroke or death

Rothwell PM for the CETC. Lancet 2003;361:107-16.

70-99% 50-69%

Operative risks: mortality=1.1% - stroke or death=7.1%

Algorithm for the management of extracranial

carotid artery disease

Asymptomatic Carotid stenosis

Beyond the degree of stenosis

• Clinical features

• Hypoechoic, heterogenous plaque

• Surface irregularity

• Progression of the degree of stenosis

Longstreth WT et al Stroke 1998;29:2371-6

Liapis CD et al. Stroke. 2001;32:2782-2786.

Conclusion

• Les lésions athéroscléreuses des

carotides sont un marqueur du risque

cardiovasculaire global et en particulier de

celui d’AVC

• La prise en charge est médicale avant tout

et devient chirurgicale en cas de lésion

symptomatique