Thursday, October 23, 2014

Carotid Stenosis and Stroke - "Once upon a time".

By: Gary S Roubin MD PhD with Cardiovascular Associates, a Brookwood Medical Partner.

There are many “once upon a time” stories in medicine! The extraordinary development of science and technology in cardiovascular medicine has dramatically changed the way life-threatening diseases are treated. We rightly call the recommendations and treatment guidelines, based on rigorous scientific studies and expert consensus opinion, “ Best Practice”. And they are constantly changing! “Once upon a time” – 2 to 3 decades ago, rigorous studies showed that a surgical operation to remove blockages in the neck arteries feeding blood to the brain was effective in preventing stroke.

Then some 20 years ago pioneering work at the University of Alabama at Birmingham provided physicians with a considerably less invasive method of treating the blockages, a procedure that became known as carotid stenting. In 2010 the Federal National Institute of Neurological Diseases and Stroke (NINDS) completed a major 2500 patient, prospective multicenter study comparing Surgery and Stenting. This trial confirmed that these two procedures were equally safe and effective in preventing stroke from carotid stenosis - albeit stenting is done without an operation.

But time and medical science march on! And over the last 20 years we have also seen incredible advances in the medications used to treat this condition. Cholesterol lowering drugs that stabilize the blockages, antiplatelet drugs that prevent blood clot in the blockages and blood pressure medicines that all effectively reduce the risk of stroke. We have also made great strides in reducing tobacco use, managing diabetes, and improving our diet and exercise patterns all of which are known to reduce stroke.

So now physicians have not 2 but 3 options to manage carotid disease in patients with significant blockage but who are quite asymptomatic. (Patients who have specific neurologic symptoms are still best treated with surgery or stenting). Some experts in the field are convinced that surgery and stenting are unnecessary, potentially harmful and unnecessarily costly. Other experts fervently disagree! An expert panel at the NINDS has examined all the available evidence and concluded that given the advances in medicine, stenting and surgery this important question needs to be resolved in a rigorous scientific study. They have commissioned the CREST2 Trial that will begin enrolling patients in the coming months.

All patients in this study will receive the best medical therapy available including advice on medication compliance and risk factor management. Depending on a variety of now well-established factors that determine if a patient is best suited for stenting or surgery; half of the group will be treated with either one of these therapies in addition to the medication program. All treatment strategies will carry a very low risk of a stroke occurring and accordingly patients will be followed with stringent care for a minimum of 4 years. Patients in Alabama are fortunate to have centers participating in this important trial and access to physicians with vast experience in treating carotid disease.

Gary S Roubin MD PhD practices cardiovascular medicine with Cardiovascular Associates, a Brookwood Medical Partner. He is recognized as an international expert in the procedure of carotid stenting and is the lead stenting investigator in the NINDS CREST2 trial. Visit for more information or call (205) 510-5000 to refer a patient.

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