RS08 - Real World Use of Medical Therapy in Moderate Asymptomatic Carotid Stenosis

Objectives: Despite level one evidence of the benefit of carotid endarterectomy in the prevention of stroke in patients with severe asymptomatic carotid stenosis (ACS), there has been a trend towards recommending optimal medical therapy (OMT) alone. This recommendation has been promulgated based on the observation that Statins reduce the overall stroke risk in the general population, but the success of this treatment strategy is dependent on patient and provider adherence. In current practice, patients with moderate ACS are all treated with OMT. The objective of this study was to evaluate adherence to OMT in a cohort of patients with moderate ACS under observation.

Methods: Consecutive carotid duplex ultrasounds were reviewed for the years 2019 and 2020. Those with moderate (50-69%) ACS based on Society for Vascular Surgery (SVS) guidelines were included in the study. Patients were assessed for OMT at the time of the indexed duplex, the first follow-up visit, and at each subsequent follow-up visit until the end of the study. OMT was defined as abstinence from smoking, aspirin or other anti-platelet use, and statin or other lipid lowering therapy. Patients were stratified based upon their ability to achieve OMT and each component was evaluated to identify shortfalls in therapy.

Results: 323 duplex ultrasounds with moderate ACS were identified. 181(56.0%) were on OMT at the time of the first duplex, this increased to 208(64.4%) by the first follow-up visit and 223(69.0%) by study completion. There were 142(44.0%) carotids with moderate ACS that were not on OMT at the time of the index duplex, 54(38.0%) of which achieved OMT over a median follow-up time of 2.52 years. By the end of follow up, 112(78.9%) were taking aspirin or another anti-platelet, 118(83.1%) were on statin or other lipid lowering therapy, and 49(34.5%) were abstinent from smoking. Pre-duplex smoking was independently associated with failure to achieve OMT (HR 0.48, p=0.024) (Table1, Fig1).

Conclusions: Among patients with moderate ACS that were not previously on OMT, the rate of OMT achievement is poor. Although advances in lipid management through statin therapy have been praised for their role in improving the effectiveness of OMT, smoking cessation represents an important target for improving uptake, and as a result effectiveness of OMT.