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(Stroke. 2007;38:e149.)
© 2007 American Heart Association, Inc.

Letters to the Editor

Response to Letter by Cote

Julius Center of Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands

Frank L.J. Visseren, MD, PhD

Internal Medicine, Section Vascular Medicine, University Medical Center Utrecht, Utrecht, The Netherlands

L. Jaap Kappelle, MD, PhD

Department of Neurology, Rudolf magnus Institute for Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands

Ale Algra, MD, PhD

Julius Center of Health Sciences and Primary Care, and the Department of Neurology, Rudolf magnus Institute for Neuroscience, University Medical Center Utrecht, Utrecht, The Netherlands

Yolanda van der Graaf, MD, PhD

Julius Center of Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands

Response:

We thank Dr Cote for his interest in our study. We fully agree with him that optimal treatment of vascular risk factors in patients at high risk of new or recurrent vascular events is highly important. A recent study shows that vascular event rates increased with the number of symptomatic arterial disease locations after 1 year follow-up, ranging from 12.6% for patients with one, 21.1% for patients with two, and 26.3% for patients with three symptomatic aterial disease locations.¹ This points toward important predictive information in the number of vascular localization in addition to that of traditional vascular risk factors. Asymptomatic carotid artery stenosis is one of those markers in patients with various clinical manifestations of atherosclerosis, as shown in our article.

Indeed, asymptomatic carotid artery stenosis can lead to ischemic stroke. In our study we found an annual stroke risk of <1%. This low annual risk is probably because patients with previous cerebral ischemic events were excluded from analyses. Fifty patients (1.9%) had an incomplete follow-up in SMART (mean 2.7 years), which is very low and unlikely to affect the outcome of the study. During follow-up, patients (or the patient’s family) were biannually asked about important medical conditions and events during the past 6 months. Given the nature of the outcome events (myocardial infarction, ischemic stroke, vascular interventions) and the adjudication of events by 3 members of an end point committee, misclassification or under-reporting is very unlikely to happen. Adding information on the occurrence of TIAs would be interesting in concept, but given the difficulty of diagnosing TIAs this end point is not used in large intervention trials. From a prognostic point of view, only baseline data on carotid artery stenosis are relevant for predicting future vascular events.

Progression of symptomatic and asymptomatic carotid artery stenosis is indeed associated with a higher risk of ischemic stroke.^2,3,4 Close monitoring of carotid artery stenosis with duplex ultrasound has the advantage to identify patients with disease progression, which may have clinical consequences, although this remains to be studied. The domain of our study was patients with clinical manifest vascular diseases already deserving optimal risk factor management. Information on progression of carotid artery stenosis would not change that.

Acknowledgments

Disclosures

None.

References

1. Steg PG, Bhatt DL, Wilson PW, D’Agostino R Sr, Ohman EM, Rother J, Liau CS, Hirsch AT, Mas JL, Ikeda Y, Pencina MJ, Goto S. One-year cardiovascular event rates in outpatients with atherothrombosis. JAMA. 2007; 297: 1197–1206.[Abstract/Free Full Text]

2. Randomised trial of endarterectomy for recently symptomatic carotid stenosis: final results of the MRC European Carotid Surgery Trial (ECST). Lancet. 1998; 351: 1379–1387.[CrossRef][Medline] [Order article via Infotrieve]

3. Halliday A, Mansfield A, Marro J, Peto C, Peto R, Potter J, Thomas D. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet. 2004; 363: 1491–1502.[CrossRef][Medline] [Order article via Infotrieve]

4. Ballotta E, Da Giau G, Meneghetti G, Barbon B, Militello C, Baracchini C. Progression of atherosclerosis in asymptomatic carotid arteries after contralateral endarterectomy: a 10-year prospective study. J Vasc Surg. 2007; 45: 516–522.[CrossRef][Medline] [Order article via Infotrieve]

This Article Extract Full Text (PDF) All Versions of this Article: 38/11/e149    most recent STROKEAHA.107.498170v1 Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Goessens, B. M.B. Articles by van der Graaf, Y. Search for Related Content PubMed Articles by Goessens, B. M.B. Articles by van der Graaf, Y.