PubMed · 10732939
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L R Caplan. 2000-03-15. Multiple potential risks for stroke.. https://doi.org/10.1001/jama.283.11.1479
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OBJECTIVE: To determine whether carotid endarterectomy is superior to best medical therapy in preserving cognition, and whether low Mini-Mental State Examination (MMSE) scores predict TIA, stroke, myocardial infarction, or death. METHODS: Subjects participating in the Asymptomatic Carotid Atherosclerosis Study were administered the MMSE at periodic intervals. Group means were calculated at randomization, 1 and 3 months later, and every 6 months thereafter. The group means were compared by treatment and over time. A proportional hazard regression model incorporating postrandomization MMSE score as a predictor variable was used to estimate risk of death, stroke, or other outcome events. RESULTS: There was no intergroup difference in mean MMSE score during 5 years of observation. For individual patients, the relationship between a low postrandomization score on the MMSE and increased risk of death was significant (p </= 0.0001). Patients who experienced stroke after randomization also had a significant and persistent reduction in MMSE score (p </= 0.0001). CONCLUSIONS: Carotid endarterectomy had no impact on MMSE score in this study. Patients with low postrandomization MMSE scores had a greater likelihood of death. Stroke reduced MMSE scores and may portend cognitive impairment. The authors recommend the routine inclusion of cognitive testing in future clinical trials designed to evaluate prophylaxis or acute therapy of stroke.
OBJECTIVES: To perform an analytical overview of the risk factors, pathogenesis of stroke and the strategies for the management of concomitant coronary artery disease and carotid artery stenosis (CAS). Four strategies were analysed; CABG in the presence of CAS, combined (CE+CABG), reverse (CABG+CE<3 months) and prior staged (CE+CABG<3 months). METHODS: A literature search formed the basis of a reference database. Outcome was assessed by the 30-day permanent stroke and mortality rate for the different approaches. Accrued rates of permanent stroke and mortality rate were expressed in terms of mean stroke and mortality rate (MSR, MMR). Data was analysed comparatively and expressed in terms of P value, odds ratio and confidence limits. RESULTS: 33 different risk factors for stroke at CABG were identified. Significant factors included: ascending aortic atheroma, emergency procedures, impaired left ventricular function, cardioplegia and peripheral vascular disease. Risk of stroke at CABG increased with higher grade CAS (50 vs. 80%, P=0.009). Pathogenesis of stroke at CABG is multifactorial; the role of flow limiting CAS is controversial and other mechanisms are implicated. Analysis of the four strategies revealed that in the Prior Stage (n=573) the MSR was 1.5% and MMR 5.9%, in the Unprotected CABG+CAS series the MSR was 3.8% (n=840) and MMR (n=596) 4.4%, in the Reverse stage series (n=83) the MSR was 2.4%, and MMR 4.8%. For Combined procedures (n=3,295) the MSR was 3.9% and MMR 4.5%. Comparative analysis indicated a significant reduction in stroke for Prior vs. Combined (1.5 vs. 3.9%, P=0.007, odds 0.39, CI 0.2-0.77) with a higher mortality (5.9 vs. 4.5%, P=0.1, odds 1.41, Cl 0.96-2.06, NS). The stroke rate in the Prior stage also remained significantly lower compared to the Unprotected CABG group both mixed (P=0.015) and asymptomatic CAS (P=0.047). When total risks (MSR+MMR), were analysed, similar results were found between the groups; Prior 7.4%, Reverse stage 7.2%, Combined 8.4%, Unprotected CABG+ >50% CAS 11.5%. CONCLUSIONS: Stroke at CABG is due to multiple risk factors, one of which is high-grade carotid stenosis. Pathophysiology of stroke, although multifactorial, supports embolism rather than flow limitation as the primary mechanism. Lack of randomised trials has made it impossible to draw firm conclusions regarding the best management strategy. There was no significant difference in the overall stroke and mortality risk between the various strategies, however, subgroup analysis suggests that, when carefully selected, patients do better by staging the operations. In our opinion patients without severe cardiac disease should be considered for Prior staging and the rest for Combined procedure. The role of reverse staging needs further evaluation.