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Five-year outcomes in men screened for carotid artery stenosis at 65 years of age - a population-based cohort study.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Objectives: The aim was to determine the prognosis of 65-year old men five years after carotid ultrasound screening, as well as risk factors for disease progression.

Material and methods: All 65-year-old men living in the county of Uppsala 2007-2009 were invited to an ultrasound examination of both carotid arteries and re-invited at age 70. The cohort was grouped into: normal carotids, plaque without significant stenosis, moderate stenosis (50-79%), and severe stenosis (80-99%). The rates of disease progression to death, significant stenosis, and neurological events were assessed, as well as risk factors and medication.

Results: Among men participating in carotid screening at age 65, 3057 were re-screened at age 70. In those with normal carotids (n=2318), 23 (1.0%) progressed to a moderate, and four (0.2%) developed a symptomatic severe stenosis. Among those with plaque (n=696), 25 (3.6%) progressed to moderate, and eight (1.1%) to severe stenosis, of whom four (0.6%) had symptoms. Of 31 with 50-79% stenosis, four (12.9%) had progressed to a severe stenosis, of whom two (6.5%) developed symptoms. Five of twelve subjects (42%) with 80-99% stenosis developed symptoms. Disease regression was present among 306 (41.4%) men. In multivariable analysis, smoking, coronary artery disease and hypercholesterolemia were associated with disease progression. The proportions of antiplatelet, statin and antihypertensive treatment in the population at age 70 were 22%, 29% and 55% respectively.

Conclusion: Men with plaques and moderate stenosis have a good prognosis, but in those with severe stenosis there was a high risk of neurological events.

Keyword [en]
carotid stenosis, atherosclerotic plaque, natural history, mortality, stroke rate
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:uu:diva-328800OAI: oai:DiVA.org:uu-328800DiVA: diva2:1137662
Projects
Screening for carotid atherosclerosis
Available from: 2017-08-31 Created: 2017-08-31 Last updated: 2017-08-31
In thesis
1. Screening for asymptomatic carotid atherosclerosis
Open this publication in new window or tab >>Screening for asymptomatic carotid atherosclerosis
2017 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Ischemic stroke is the most common cause of handicap in adults and the third most common cause of death in Sweden. Internal carotid artery atherosclerosis is an important cause and accounts for 20% of ischemic strokes. Screening for carotid atherosclerosis has been debated over the past two decades.

The aims of this thesis were (I) to study the prevalence of and risk factors associated with carotid artery atherosclerosis among 65 year old men, (II) to evaluate a simplified ultrasound protocol (the grayscale/mosaic method) for the exclusion of significant carotid artery stenosis for screening purpose, (III) to evaluate the required effect of primary preventive therapy in reducing risk of stroke among patients with asymptomatic carotid disease in order for screening to be cost-effective and (IV) to study natural history of carotid atherosclerosis and outcome five years after screening in 65-year old men.

The prevalence of atherosclerotic plaques was high (25%), while the prevalence of >50% stenosis was relatively low (2.0%). Smoking, hypertension, diabetes mellitus and coronary artery disease were independent risk factors and individuals with several risk factors had a higher prevalence of stenosis. Most of those at risk were not on any preventive medication. A simplified grayscale/mosaic method was found to have a high negative predictive value for significant carotid stenosis. The minimum stroke risk reduction effect required for preventive intervention to be cost effective was 22%. Carotid atherosclerotic plaque and stenosis 50-79% has a relatively benign development during five years if treated with BMT and risk factor adjustment. Very few progressed to symptomatic disease. More severe stenosis (80-99%) had higher rate of neurological events, and may benefit from additional intervention.

In conclusion, prevalence of silent atherosclerotic disease in carotid arteries was common among 65-year-old men. Most of those at risk had no secondary prevention. There is a simple DUS method that could be used for screening purpose. Screening for carotid disease is only cost-effective if the preventive strategy lowers the risk of stroke by 22%. Men with plaques and moderate stenosis have a good prognosis, but among those with severe stenosis there is a need for further intervention.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2017. 77 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1367
Keyword
Carotid stenosis, carotid atherosclerosis, screening, cost-effectiveness, natural history, carotid ultrasound
National Category
Medical and Health Sciences
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-328803 (URN)978-91-513-0060-3 (ISBN)
Public defence
2017-10-21, Auditorium Minus, Museum Gustavianum, Akademig. 3, Uppsala, 13:00 (English)
Opponent
Supervisors
Projects
Screening for asymptomatic carotid atherosclerosis
Available from: 2017-09-29 Created: 2017-08-31 Last updated: 2017-10-18

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