Carotid artery stenosis medical therapy: Difference between revisions

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*Conservative treatment can include the use of [[Antiplatelet drug]]s
*Conservative treatment can include the use of [[Antiplatelet drug]]s


==Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Treatment of Hypertension<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=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: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref> (DO NOT EDIT)==
===Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Treatment of Hypertension<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=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: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref> (DO NOT EDIT)===
{{cquote|
{{cquote|
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]====
# Antihypertensive treatment is recommended for patients with hypertension and asymptomatic atherosclerotic ECVD to maintain blood pressure (BP) less than 140/90 mmHg. (Level of Evidence: A)
# Antihypertensive treatment is recommended for patients with hypertension and asymptomatic atherosclerotic ECVD to maintain blood pressure (BP) less than 140/90 mmHg. (Level of Evidence: A)
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]====
Except during the hyperacute period, antihypertensive treatment is probably indicated in patients with hypertension and symptomatic
Except during the hyperacute period, antihypertensive treatment is probably indicated in patients with hypertension and symptomatic
atherosclerotic ECVD, but the benefit of treatment to a specific BP has not been established in relation to
atherosclerotic ECVD, but the benefit of treatment to a specific BP has not been established in relation to
the risk of exacerbating cerebral ischemia. (Level ofEvidence: C)}}
the risk of exacerbating cerebral ischemia. (Level ofEvidence: C)}}


==Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease:Control of Hyperlipidemia<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=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: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref> (DO NOT EDIT)==
===Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease:Control of Hyperlipidemia<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=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: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref> (DO NOT EDIT)===
{{cquote|
{{cquote|
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]====
# Treatment with a statin is recommended for all patients with atherosclerotic ECVD to lower lowdensity lipoprotein cholesterol to less than 100 mg/dL. (Level of Evidence: B)
# Treatment with a statin is recommended for all patients with atherosclerotic ECVD to lower lowdensity lipoprotein cholesterol to less than 100 mg/dL. (Level of Evidence: B)
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]====
# Treatment with a statin is reasonable for all patients with atherosclerotic ECVD who sustain ischemic stroke to reduce low-density lipoprotein cholesterol to a level less than or equal to 70 mg/dL. (Level of Evidence: B)
# Treatment with a statin is reasonable for all patients with atherosclerotic ECVD who sustain ischemic stroke to reduce low-density lipoprotein cholesterol to a level less than or equal to 70 mg/dL. (Level of Evidence: B)
# If treatment with a statin does not achieve the goal, intensifying therapy with an additional drug from among those with evidence of improving outcomes can be effective. (Level of Evidence: B)
# If treatment with a statin does not achieve the goal, intensifying therapy with an additional drug from among those with evidence of improving outcomes can be effective. (Level of Evidence: B)
# For patients who do not tolerate statins, therapy with bile acid sequestrants and/or niacin is reasonable. (Level of Evidence: B)}}
# For patients who do not tolerate statins, therapy with bile acid sequestrants and/or niacin is reasonable. (Level of Evidence: B)}}


==Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Management of Diabetes Mellitus in Patients With Atherosclerosis of the Extracranial Carotid or Vertebral Arteries<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=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: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref> (DO NOT EDIT)==
===Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Management of Diabetes Mellitus in Patients With Atherosclerosis of the Extracranial Carotid or Vertebral Arteries<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=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: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref> (DO NOT EDIT)===
{{cquote|
{{cquote|
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]====
# Diet, exercise, and glucose-lowering drugs can be useful for patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis. The stroke prevention benefit, however, of intensive glucose lowering therapy to a glycosylated hemoglobin A1c level less than 7.0% has not been established. (Level of Evidence: A)
# Diet, exercise, and glucose-lowering drugs can be useful for patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis. The stroke prevention benefit, however, of intensive glucose lowering therapy to a glycosylated hemoglobin A1c level less than 7.0% has not been established. (Level of Evidence: A)
# Administration of statin-type lipid-lowering medication at a dosage sufficient to reduce LDL cholesterol to a level near or below 70 mg/dL is reasonable in patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis for prevention of ischemic stroke and other ischemic cardiovascular events. (Level of Evidence: B)
# Administration of statin-type lipid-lowering medication at a dosage sufficient to reduce LDL cholesterol to a level near or below 70 mg/dL is reasonable in patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis for prevention of ischemic stroke and other ischemic cardiovascular events. (Level of Evidence: B)
}}
}}


==Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Recommendations for Antithrombotic Therapy in Patients With Extracranial Carotid Atherosclerotic Disease Not Undergoing Revascularization<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=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: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref> (DO NOT EDIT)==
===Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Recommendations for Antithrombotic Therapy in Patients With Extracranial Carotid Atherosclerotic Disease Not Undergoing Revascularization<ref name="pmid21282505">{{cite journal| author=Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL et al.| title=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: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. | journal=Circulation | year= 2011 | volume= 124 | issue= 4 | pages= 489-532 | pmid=21282505 | doi=10.1161/CIR.0b013e31820d8d78 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21282505  }} </ref> (DO NOT EDIT)===
{{cquote|
{{cquote|
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]===
====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]====
# 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 myocardial infarction (MI) and other ischemic cardiovascular events, although the benefit has not been established for prevention of stroke in asymptomatic patients. (Level of Evidence: A)
# 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 myocardial infarction (MI) and other ischemic cardiovascular events, although the benefit has not been established for prevention of stroke in asymptomatic patients. (Level of Evidence: A)
# 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 (Level of Evidence: B) and preferred over the combination of aspirin with clopidogrel. (Level of Evidence: B) 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.
# 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 (Level of Evidence: B) and preferred over the combination of aspirin with clopidogrel. (Level of Evidence: B) 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.
# Antiplatelet agents are recommended rather than oral anticoagulation for patients with atherosclerosis of the extracranial carotid or vertebral arteries with (Level of Evidence: B) or without (Level of Evidence: C) ischemic symptoms. (For patients with allergy or other contraindications to aspirin, see Class IIa recommendation #2, this section.)
# Antiplatelet agents are recommended rather than oral anticoagulation for patients with atherosclerosis of the extracranial carotid or vertebral arteries with (Level of Evidence: B) or without (Level of Evidence: C) ischemic symptoms. (For patients with allergy or other contraindications to aspirin, see Class IIa recommendation #2, this section.)
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]====
# Full-intensity parenteral anticoagulation with unfractionated heparin or low-molecular-weight heparinoids is not recommended for patients with extracranial cerebrovascular atherosclerosis who develop transient cerebral ischemia or acute ischemic stroke. (Level of Evidence: B)
# Full-intensity parenteral anticoagulation with unfractionated heparin or low-molecular-weight heparinoids is not recommended for patients with extracranial cerebrovascular atherosclerosis who develop transient cerebral ischemia or acute ischemic stroke. (Level of Evidence: B)
# Administration of clopidogrel in combination with aspirin is not recommended within 3 months after stroke or TIA. (Level of Evidence: B)
# Administration of clopidogrel in combination with aspirin is not recommended within 3 months after stroke or TIA. (Level of Evidence: B)
===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]===
====[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]====
# In patients with extracranial cerebrovascular atherosclerosis who have an indication for anticoagulation, such as atrial fibrillation or a mechanical prosthetic heart valve, it can be beneficial to administer a vitamin K antagonist (such as warfarin, dose adjusted to achieve a target international normalized ratio [INR] of 2.5 [range 2.0 to 3.0]) for prevention of thromboembolic ischemic events. (Level of Evidence: C)
# In patients with extracranial cerebrovascular atherosclerosis who have an indication for anticoagulation, such as atrial fibrillation or a mechanical prosthetic heart valve, it can be beneficial to administer a vitamin K antagonist (such as warfarin, dose adjusted to achieve a target international normalized ratio [INR] of 2.5 [range 2.0 to 3.0]) for prevention of thromboembolic ischemic events. (Level of Evidence: C)
# For patients with atherosclerosis of the extracranial carotid or vertebral arteries in whom aspirin is contraindicated by factors other than active bleeding, including allergy, either clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) is a reasonable alternative. (Level of Evidence: C)
# For patients with atherosclerosis of the extracranial carotid or vertebral arteries in whom aspirin is contraindicated by factors other than active bleeding, including allergy, either clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) is a reasonable alternative. (Level of Evidence: C)

Revision as of 14:54, 2 October 2012

Carotid artery stenosis Microchapters

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

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Overview

Medical Therapy

Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Treatment of Hypertension[1] (DO NOT EDIT)

“

Class I

  1. Antihypertensive treatment is recommended for patients with hypertension and asymptomatic atherosclerotic ECVD to maintain blood pressure (BP) less than 140/90 mmHg. (Level of Evidence: A)

Class IIa

Except during the hyperacute period, antihypertensive treatment is probably indicated in patients with hypertension and symptomatic atherosclerotic ECVD, but the benefit of treatment to a specific BP has not been established in relation to the risk of exacerbating cerebral ischemia. (Level ofEvidence: C)

”

Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease:Control of Hyperlipidemia[1] (DO NOT EDIT)

“

Class I

  1. Treatment with a statin is recommended for all patients with atherosclerotic ECVD to lower lowdensity lipoprotein cholesterol to less than 100 mg/dL. (Level of Evidence: B)

Class IIa

  1. Treatment with a statin is reasonable for all patients with atherosclerotic ECVD who sustain ischemic stroke to reduce low-density lipoprotein cholesterol to a level less than or equal to 70 mg/dL. (Level of Evidence: B)
  2. If treatment with a statin does not achieve the goal, intensifying therapy with an additional drug from among those with evidence of improving outcomes can be effective. (Level of Evidence: B)
  3. For patients who do not tolerate statins, therapy with bile acid sequestrants and/or niacin is reasonable. (Level of Evidence: B)
 ”

Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Management of Diabetes Mellitus in Patients With Atherosclerosis of the Extracranial Carotid or Vertebral Arteries[1] (DO NOT EDIT)

“

Class IIa

  1. Diet, exercise, and glucose-lowering drugs can be useful for patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis. The stroke prevention benefit, however, of intensive glucose lowering therapy to a glycosylated hemoglobin A1c level less than 7.0% has not been established. (Level of Evidence: A)
  2. Administration of statin-type lipid-lowering medication at a dosage sufficient to reduce LDL cholesterol to a level near or below 70 mg/dL is reasonable in patients with diabetes mellitus and extracranial carotid or vertebral artery atherosclerosis for prevention of ischemic stroke and other ischemic cardiovascular events. (Level of Evidence: B)
 ”

Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease: Recommendations for Antithrombotic Therapy in Patients With Extracranial Carotid Atherosclerotic Disease Not Undergoing Revascularization[1] (DO NOT EDIT)

“

Class I

  1. 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 myocardial infarction (MI) and other ischemic cardiovascular events, although the benefit has not been established for prevention of stroke in asymptomatic patients. (Level of Evidence: A)
  2. 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 (Level of Evidence: B) and preferred over the combination of aspirin with clopidogrel. (Level of Evidence: B) 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.
  3. Antiplatelet agents are recommended rather than oral anticoagulation for patients with atherosclerosis of the extracranial carotid or vertebral arteries with (Level of Evidence: B) or without (Level of Evidence: C) ischemic symptoms. (For patients with allergy or other contraindications to aspirin, see Class IIa recommendation #2, this section.)

Class III

  1. Full-intensity parenteral anticoagulation with unfractionated heparin or low-molecular-weight heparinoids is not recommended for patients with extracranial cerebrovascular atherosclerosis who develop transient cerebral ischemia or acute ischemic stroke. (Level of Evidence: B)
  2. Administration of clopidogrel in combination with aspirin is not recommended within 3 months after stroke or TIA. (Level of Evidence: B)

Class IIa

  1. In patients with extracranial cerebrovascular atherosclerosis who have an indication for anticoagulation, such as atrial fibrillation or a mechanical prosthetic heart valve, it can be beneficial to administer a vitamin K antagonist (such as warfarin, dose adjusted to achieve a target international normalized ratio [INR] of 2.5 [range 2.0 to 3.0]) for prevention of thromboembolic ischemic events. (Level of Evidence: C)
  2. For patients with atherosclerosis of the extracranial carotid or vertebral arteries in whom aspirin is contraindicated by factors other than active bleeding, including allergy, either clopidogrel (75 mg daily) or ticlopidine (250 mg twice daily) is a reasonable alternative. (Level of Evidence: C)
 ”

References

  1. ↑ 1.0 1.1 1.2 1.3 Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL; et al. (2011). "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: executive summary. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery". Circulation. 124 (4): 489–532. doi:10.1161/CIR.0b013e31820d8d78. PMID 21282505.
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