Published Online
on March 15, 2007

A more recent version of this article appeared on May 1, 2007

This Article Full Text (PDF) CME: Take the course for this article: Stroke: May 2007, Volume 38, Number 5 All Versions of this Article: 38/5/1470    most recent STROKEAHA.106.477091v1 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 Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Goessens, B. M.B. Search for Related Content PubMed PubMed Citation Articles by Goessens, B. M.B. Related Collections Risk Factors Carotid Stenosis Carotid endarterectomy

Submitted on November 4, 2006
Accepted on December 5, 2006

Asymptomatic Carotid Artery Stenosis and the Risk of New Vascular Events in Patients With Manifest Arterial Disease. The SMART Study

Bertine M.B. Goessens MSc; Frank L.J. Visseren MD, PhD; L. Jaap Kappelle MD, PhD; Ale Algra MD, PhD; Yolanda van der Graaf MD, PhD^*; for the SMART Study Group

From the Julius Center for Health Sciences and Primary Care (B.M.B.G., A.A., Y.v.d.G.), UMC Utrecht, The Netherlands; Internal Medicine, Section of Vascular Medicine (F.L.J.V.), UMC Utrecht, The Netherlands; and the Department of Neurology (L.J.K., A.A.), Rudolph Magnus Institute for Neuroscience, UMC Utrecht, The Netherlands.

^* To whom correspondence should be addressed. E-mail: y.vandergraaf{at}umcutrecht.nl.

Background and Purpose--The frequency of asymptomatic carotid artery stenosis (CAS) increases with age from 0.5% in individuals below 50 years of age to 5% to 10% in individuals over 65 years of age in the general population. Its prognostic value has been examined in the general population but less often in patients with clinical manifestations of arterial disease other than retinal or cerebral ischemia. We examined the relationship between asymptomatic CAS and the risk of subsequent events in this specific group of patients.

Methods--This study involved 2684 consecutive patients with clinical manifestations of arterial disease or type 2 diabetes mellitus, but without a history of cerebral ischemia, enrolled in the SMART study (Second Manifestations of ARTerial disease). The degree of asymptomatic CAS was assessed with Duplex scanning and defined on the basis of the blood flow velocity patterns at baseline in both carotid arteries. None of the patients underwent carotid endarterectomy or endovascular intervention. During the follow-up period, vascular events (vascular death, ischemic stroke, and myocardial infarction) were documented in detail. Data were analyzed with Cox proportional hazards regression and adjusted for age, gender, and classic vascular risk factors.

Results--Asymptomatic CAS of 50% or greater was present in 221 (8%) patients. During a mean follow up of 3.6 years (SD=2.3), a first vascular event occurred in 253 patients (9%). The cumulative incidence rate for the composite of subsequent vascular events after 5 years was 12.3% (95% CI=10.7 to 13.9), for cerebral infarction 2.2% (95% CI=1.4 to 2.8), and for myocardial infarction 8.0% (95% CI=6.6 to 9.4). Adjusted for age and gender, asymptomatic CAS of 50% or greater was related to a higher risk of subsequent vascular events (hazard ratio=1.5, 95% CI=1.1 to 2.1), in particular of vascular death (hazard ratio=1.8, 95% CI=1.2 to 2.6). After additional adjustment for vascular risk factors, the hazard ratios remained essentially the same.

Conclusion--Asymptomatic carotid artery stenosis is an independent predictor of vascular events, especially vascular death, in patients with clinical manifestations of arterial disease or type 2 diabetes but without a history of cerebral ischemia.

Key words: asymptomatic carotid artery stenosis • cardiovascular disease • recurrent events

This article has been cited by other articles:

				A. L. Abbott Medical (Nonsurgical) Intervention Alone Is Now Best for Prevention of Stroke Associated With Asymptomatic Severe Carotid Stenosis: Results of a Systematic Review and Analysis Stroke, October 1, 2009; 40(10): e573 - e583. [Abstract] [Full Text] [PDF]

				J. Herrmann, D. Mannheim, C. Wohlert, D. Versari, F. B. Meyer, J. P. McConnell, M. Gossl, L. O. Lerman, and A. Lerman Expression of lipoprotein-associated phospholipase A2 in carotid artery plaques predicts long-term cardiac outcome Eur. Heart J., August 17, 2009; (2009) ehp309v1. [Abstract] [Full Text] [PDF]

				N. Singh, A. R. Moody, D. J. Gladstone, G. Leung, R. Ravikumar, J. Zhan, and R. Maggisano Moderate Carotid Artery Stenosis: MR Imaging-depicted Intraplaque Hemorrhage Predicts Risk of Cerebrovascular Ischemic Events in Asymptomatic Men Radiology, August 1, 2009; 252(2): 502 - 508. [Abstract] [Full Text] [PDF]

				D. C. Crawford, A. S. Nord, M. D. Badzioch, J. Ranchalis, L. A. McKinstry, M. Ahearn, C. Bertucci, C. Shephard, M. Wong, M. J. Rieder, et al. A common VLDLR polymorphism interacts with APOE genotype in the prediction of carotid artery disease risk J. Lipid Res., March 1, 2008; 49(3): 588 - 596. [Abstract] [Full Text] [PDF]

				R. Cote Cerebrovascular Events in Individuals With Asymptomatic Carotid Disease Stroke, November 1, 2007; 38(11): e148 - e148. [Full Text] [PDF]

				J. Golledge Asymptomatic Carotid Stenosis Stroke, November 1, 2007; 38(11): e150 - e150. [Full Text] [PDF]