December 1st, 2011
Heart Over Head or Head Over Heart?
Anju Nohria, MD and James Fang, MD
A 52-year-old man presented with 3 episodes of transient dysarthria and right-sided facial numbness within a 2-week period. A carotid ultrasound revealed >70% stenosis of the left-internal carotid artery and 50%–69% stenosis of the right coronary artery.
At age 40, the man had been diagnosed with non-Hodgkin lymphoma, which was treated with cranial radiation and anthracyclines, followed by total-body irradiation and an allogeneic stem-cell transplant. His post-transplant course has been complicated by end-stage renal disease, requiring dialysis.
While being evaluated for renal transplantation last year, the patient had an echocardiogram and an exercise MIBI stress test. The echo showed an LV ejection fraction of 55% with no regional wall-motion abnormalities and no significant valvular disease. He exercised to a workload of 10 Mets without any chest pain or shortness of breath. His EKG, however, showed 1-mm horizontal ST depressions in leads V4–6. A subsequent cardiac catheterization revealed noncritical three-vessel coronary artery disease, and the patient was medically managed with aspirin, statins, and a beta-blocker.
As part of a perioperative assessment for left-carotid endarterectomy, the patient was again referred for an exercise MIBI. He exercised, without significant EKG changes, to a workload of 8.4 Mets, then stopped from fatigue. The MIBI images showed large reversible areas of ischemia in the mid-anterior, septal, apical, and lateral walls (summed stress score, 27); the post-stress reduction in LV ejection fraction was from 45% to 32%. The patient was again sent for a left-heart catheterization, which revealed small, diffusely diseased coronary vessels without any clear-cut focal lesions.
A CT angiogram of the neck and aortic arch revealed no acute intracranial abnormality. Severe narrowing of the proximal left-internal carotid artery, along an approximately 1-cm length and with heterogeneous density, was consistent with lipid/thrombus. The CT angiogram also revealed focal moderate narrowing of the proximal right-internal carotid artery, approximately 2 cm from the bifurcation; a circumferential plaque and luminal irregularity at the origin of the right-internal carotid artery; and “a web versus intimal” flap, approximately 1 cm from the carotid bifurcation.
Questions:
1. Given the patient’s preoperative cardiac assessment, would you clear him for surgery?
2. Given the carotid imaging data, would you recommend carotid-artery stenting or endarterectomy?
3. How would you communicate the pros and cons of your decision to the patient and his family?
Response:
December 14, 2011
This middle-aged man is having TIAs due to unstable left common carotid disease and should be managed urgently. Revascularization has been shown to decrease the risk for subsequent stroke in this clinical setting; the greatest risk for stroke is in the first few days after presentation. A reasonable case could be made to admit this patient for heparin anticoagulation, particularly in light of the angiographic findings. However, the evidence base for acute anticoagulation in this setting is not robust.
Although the patient has provokable ischemia (which increases his operative risk), such situations can be managed effectively with medical therapy, as shown in the CARP trial. I also wonder about the accuracy of the stress-test findings 1 year apart, given how different they are. In fact, ACC/AHA guidelines do not recommend repeat testing within 3 years if there is no interval clinical change (and up to 5 years after revascularization). The widespread scintigraphic ischemia without EKG changes or hemodynamic compromise after >8 METs — and no change in angiographic appearance of the epicardial anatomy — would be unusual, even for microvascular angina. However, the >8 METs of work is reassuring regardless of the scintigraphic findings.
In light of the coronary and carotid angiographic results, I would proceed with surgical management (e.g., carotid endarterectomy [CEA]). Randomized trials of CEA versus carotid stenting have generally favored CEA (SPACE, EVA-3S, ICSS) or have shown that the two strategies are generally equivalent in the proper hands (SAPPHIRE, CAVATAS, and CREST). Despite distal protection devices, ipsilateral stroke is still an issue with stenting. The cumulative evidence to date has also been difficult to reconcile in light of variable rates of relevant outcomes. Probably the most important lesson from these trials and registries is that local expertise, whatever the technique, is the most overriding consideration when deciding on a method of revascularization. Moreover, in this patient on dialysis, long-term dual antiplatelet therapy has a substantial chance of being complicated by clinically important bleeding.
Therefore, I conclude:
1. This man’s operative risk is elevated but acceptable, as long as surgical expertise is available.
2. I favor CEA over carotid stenting, as discussed. If there is local expertise, stenting could be offered, with the limitations I described above.
3. I would explain to the patient and his family that the optimal approach is surgical (again, assuming the local expertise), albeit with some increased CV risk. Stenting could be offered as an alternative, but only if the patient (or family) refused operative therapy.
Update:
December 29, 2011
The patient’s anatomical features on CT angiography suggested a higher risk for periprocedural stroke with carotid stenting than with endarterectomy. However, surgery presented a greater risk for a periprocedural cardiac event. The patient was presented with the risks and benefits of both options. He chose surgery,which was performed successfully in the presence of aspirin and beta-blockade. He recovered from the procedure without any perioperative complications. Nevertheless, given his extensive coronary artery disease and lack of nonmedical treatment options, his candidacy for renal transplantation remains unclear.
10 Responses to “Heart Over Head or Head Over Heart?”
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If he has radiation-induced carotid scarring, and in light of his age and symptomatic CAS, he would be a more ideal candidate for stenting than for endarterectomy. As well, he would be at high risk for a perioperative coronary event (or worse) with CEA. These data come from CREST and ICSS. He should be treated lifelong with dual antiplatelet therapy, a high dose potent statin and an ACE inhibitor (preferably ramipril or perindopril). If he has mixed dyslipidemia, I would add fenofibrate. I would track his plaque serially with high-resolution scanning post-procedure. If he advances, I would intensify medical therapy with additional lipid and BP modification. How are his Lp(a), OGTT, etc? Another consideration would be adding eplerenone. The data from NASCET suggests benefit from carotid intervention degrades as you go out from the procedure (>2 weeks in women, >12 weeks in men), so time is of the essence!
I would advise carotid surgery after these 3 TIA as soon as possible.
The ischemic heart disease is stable and the workload of 8,4 Mets tolerated seems acceptable for that kind of surgery.
Competing interests pertaining specifically to this post, comment, or both:
No conflict of interest.
I would recommend going ahead with surgery , endarterectomy likely.
At 52 , with all he has gone through, a cerebral event would be devastating, and might alter his chances of receiving a transplant.
Competing interests pertaining specifically to this post, comment, or both:
none
(Not sure why this comment came through as anonymous)
If he has radiation-induced carotid scarring, and in light of his age and because of his symptomatic CAS, he would be a more ideal candidate for stenting than for endarterectomy. As well, he would be at high risk for a perioperative coronary event (or worse) with CEA. These data come from CREST and ICSS. He should be treated lifelong with dual antiplatelet therapy, a high dose potent statin and an ACE inhibitor (preferably ramipril or perindopril). If he has mixed dyslipidemia, I would add fenofibrate. I would track his plaque serially with high-resolution scanning post-procedure. If he advances, I would intensify medical therapy with additional lipid and BP modification. How are his Lp(a), OGTT, etc? Another consideration would be adding eplerenone. The data from NASCET suggests benefit from carotid intervention degrades as you go out from the procedure (>2 weeks in women, >12 weeks in men), so time is of the essence!
Hi!: Am I right when remembering that is was shown medical treatment has a better outcome profile than endarterectomy in carotid atherosclerotic disease ?. The patient file doesn’t point to any cardiovascular risk factor that may explain his deep atherosclerotic involvement. As a matter of doubt, I’ll send him to an OGTT, several studies pointed that ischemic heart disease patients, that are not known diabetics, are more or less one third diabetics, one third IOGTT, and the last third with no carbohydrate metabolism abnormalities. The radiation therapy this patient had is a known risk factor for CV disease, but it would be wise looking for others, the others being easier to influence. An intense cholesterol lowering drug policy should be started in this patient, as it improves the outcomes even in the absence of high cholesterol levels, or of a bad LDL / HDL ratio. The situation of end stage renal disease introduces another complex issue in this case, but for example, a combination of Rosuvastatin and Aspirin with Dypiridamole, would be a good starting point, to be discussed with his nephrologist. I’m not a vascular surgeon, so I can’t explain the risk of any CV interventional procedure for this pt, but as my first choice would be a medical approach, I would ask the patient to start drug therapy and reassess the situation in some 3 or 6 months, pointing that he is at high risk, because the Radiation Therapy risk factor has no known intervention to improve it. No coronary artery intervention would help this patient now, and I see no better solution than drug therapy and watchful waiting. Salut +
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This patient had crescendo TIAs over a 2 week period attributable to a high-grade carotid stenosis containing thrombus overlaid on vulnerable plaque. If anyone deserves an intervention, it is this patient. From NASCET, the NNT would be under 10 to prevent a disabling stroke. We can argue about the form of intervention (stenting vs surgery), but not the need for it.
Yeah ! a greater than 70% stenosis is an indication for a fast surgical approach, may be the indication for medical therapy is for intracranial disease.
Competing interests pertaining specifically to this post, comment, or both:
Nay
Interesting. Sounds like he had three thromboembolic large artery TIAs on aspirin – unclear why, post-CEA, he would be maintained on this failed antiplatelet strategy – why not switch him to clopidogrel or aggrenox?
I vaguely remember, perhaps from an Annual ASCO meeting educational book or abstract, about the possibility of using Angiotensin Converting Enzyme Inhibitors as a preventive measure for the very much increased cardiovascular risk in patients having received chest or H&N Radiation Therapy, but I’ve been unable to retrieve the reference. Anyway, ACEIs are probably worth trying in a trial in patients having received RT, as it is a known efficacious risk-reducing prescription in other cardiovascular diseases, and with the exception of women in fertile ages, some point that a possibility exists that the fetal harm linked to ACEIs use during pregnancy is caused by the hypertension, and not by the drug, a preventive use of this drugs, specially those who cross the blood-brain barrier, and have a long half-life and a dual excretion way may be not a fool idea. Salut +
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If this pt received curative cervical radiorx to the neck, you are very lucky that his wound is healing and he didnt wind up with a nerve palsy post op. Did the surgeon know about the radiorx? Was the pt informed about the possible need for skin grafting?. Hands down this is a stent case in my opinion.