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The challenge of coprescription of antiplatelet therapy and oral anticoagulants
The coexistence of symptomatic carotid artery stenosis and nonvalvular atrial fibrillation (NVAF) in the recently reported 85year old man [1] bears out the findings of the study which documented a 24.3% prevalence of high-grade (50% or more) carotid artery stenosis among 103 consecutive NVAF patients (mean age 69) who presented with stroke [2]. Among these patients with high-grade stenosis 66.7% had stenosis ipsilateral to the cerebral infarct [2]. Given the fact that patients with symptomatic carotid artery stenosis are at high risk of stroke recurrence and/or worsening neurological disability during the first 14days foll...
Source: The American Journal of Emergency Medicine - May 22, 2017 Category: Emergency Medicine Authors: Oscar M.P. Jolobe Source Type: research

Medical Treatment Strategies To Reduce Peri-operative Morbidity and Mortality after Carotid Surgery
There is a paucity of high quality evidence regarding what constitutes ‘optimal medical therapy’ for the purposes of reducing morbidity/mortality following carotid endarterectomy (CEA). All patients should be prescribed antiplatelet therapy. Low dose aspirin (75-325mg) should be continued throughout the peri-operative period and there is no evidence that higher dos es confer additional benefit. There is emerging evidence that early implementation of dual antiplatelet therapy in recently symptomatic patients (aspirin 75mg plus clopidogrel 75mg) may reduce recurrent cerebral events prior to CEA and that dual antiplatelet...
Source: Seminars in Vascular Surgery - April 27, 2017 Category: Surgery Authors: Ross Naylor Source Type: research

Medical treatment strategies to reduce perioperative morbidity and mortality after carotid surgery
There is a paucity of high-quality evidence regarding what constitutes “optimal medical therapy” for the purposes of reducing morbidity/mortality after carotid endarterectomy (CEA). All patients should be prescribed antiplatelet therapy. Low-dose aspirin (75 to 325 mg) should be continued throughout the perioperative period and there is no evidence that higher dose s confer additional benefit. There is emerging evidence that early implementation of dual antiplatelet therapy in recently symptomatic patients (aspirin 75 mg plus clopidogrel 75 mg) can reduce recurrent cerebral events before CEA and that dual antiplatelet ...
Source: Seminars in Vascular Surgery - April 27, 2017 Category: Surgery Authors: A. Ross Naylor Source Type: research

Stroke prevention.
Abstract Patients who have had a stroke are at high risk for recurrent stroke, myocardial infarction, and vascular death. Prevention of these events should be initiated promptly after stroke, because many recurrent events occur early, and should be tailored to the precise cause of stroke, which may require specific treatment. Lifestyle advice including abstinence from smoking, regular exercise, Mediterranean-style diet, and reduction of salt intake and alcohol consumption are recommended for all patients with stroke. For most patients with ischemic stroke or TIA, control of risk factors, including lowering blood p...
Source: Presse Medicale - November 1, 2016 Category: Journals (General) Authors: Isabel C, Calvet D, Mas JL Tags: Presse Med Source Type: research

Invited commentary
The key findings were that adding clopidogrel to regular aspirin therapy ≤48 hours of carotid endarterectomy (CEA) was associated with significant reductions in postoperative stroke, at the expense of increased bleeding complications.1 The latter will, inevitably, reinforce certain prejudices regarding dual-antiplatelet therapy (DAPT), even though the rate of bleeding complications was only 1.2% (DAPT) vs 0.7% (monotherapy). However, before uncritically disregarding any role for DAPT, it is worth considering why this debate is so important.
Source: Journal of Vascular Surgery - April 21, 2016 Category: Surgery Authors: A. Ross Naylor Tags: Clinical research study Source Type: research

Dual antiplatelet therapy reduces stroke but increases bleeding at the time of carotid endarterectomy
This study examined the effect of preoperative dual antiplatelet therapy (aspirin and clopidogrel) on in-hospital CEA outcomes.
Source: Journal of Vascular Surgery - February 28, 2016 Category: Surgery Authors: Douglas W. Jones, Philip P. Goodney, Mark F. Conrad, Brian W. Nolan, Eva M. Rzucidlo, Richard J. Powell, Jack L. Cronenwett, David H. Stone Tags: Clinical paper Source Type: research

Clopidogrel Use as Single Antiplatelet Therapy in Outpatients with Stable Coronary Artery Disease: Prevalence, Correlates and Association with Prognosis (from the CORONOR Study)
Conclusions: Our study shows that a significant proportion of stable CAD patients are treated with clopidogrel as SAPT in modern practice. Several correlates of such an attitude were identified. Our results suggest that this strategy is not beneficial as compared to aspirin alone in terms of ischaemic or bleeding events.Cardiology 2016;134:11-18
Source: Cardiology - January 22, 2016 Category: Cardiology Source Type: research

Comparative Review of the Treatment Methodologies of Carotid Stenosis
Int J AngiolDOI: 10.1055/s-0035-1545073The treatment of carotid stenosis entails three methodologies, namely, medical management, carotid angioplasty and stenting (CAS), as well as carotid endarterectomy (CEA). The North American Symptomatic Carotid Endarterectomy Trial (NASCET) and European Carotid Surgery Trial (ECST) have shown that symptomatic carotid stenosis greater than 70% is best treated with CEA. In asymptomatic patients with carotid stenosis greater than 60%, CEA was more beneficial than treatment with aspirin alone according to the Asymptomatic Carotid Atherosclerosis (ACAS) and Asymptomatic Carotid Stenosis Tr...
Source: International Journal of Angiology - May 18, 2015 Category: Cardiology Authors: Bae, ConeySzuchmacher, MauricioChang, John B. Tags: Review Article Source Type: research

Antithrombotic Therapy in Carotid Artery Stenosis: An Update
Carotid stenosis is generally associated with high risks of stroke and vascular events. In asymptomatic and symptomatic patients, with or without revascularization, optimal managements of carotid artery stenosis require the use of medications or lifestyle modifications (stopping smoking and monitoring hypertension, hyperlipidemia, and diabetes) to control the processes associated with atheroma to reduce the risk of embolic events. Moreover, antiplatelet therapy should be considered. There is little evidence that antiplatelet therapy is beneficial in preventing stroke or the progression of stenosis in asymptomatic patients,...
Source: European Neurology - November 7, 2014 Category: Neurology Source Type: research

Clinical Picture Ischaemic scalp ulceration and hair loss
A 46-year-old woman presented to our outpatient clinic in June, 2013, with frequent collapse, ischaemic scalp ulcerations, and hair loss (). She had undergone carotid endarterectomy in 2005, after a small right hemispheric stroke, and had no other medical history apart from hypercholesterolaemia. She had no previous dermatological or scalp problems. She took clopidogrel 75 mg, aspirin 80 mg, and simvastatin 40 mg daily.
Source: LANCET - October 11, 2014 Category: Journals (General) Authors: Çağdaş Ünlü, Jean-Paul P M de Vries Tags: Clinical Picture Source Type: research

An audit of management practices in patients with suspected temporary monocular blindness
Conclusion There is a need to improve professional awareness of the importance of starting best medical therapy and performing CEA as soon as possible after onset of TMB.
Source: British Journal of Ophthalmology - May 17, 2014 Category: Opthalmology Authors: Naylor, A. R., Robinson, T. G., Eveson, D., Burns, J. Tags: Public health, Vision, Neurology Original articles - Clinical science Source Type: research

An audit of management practices in patients with suspected temporary monocular blindness.
CONCLUSION: There is a need to improve professional awareness of the importance of starting best medical therapy and performing CEA as soon as possible after onset of TMB. PMID: 24187055 [PubMed - as supplied by publisher]
Source: The British Journal of Ophthalmology - November 1, 2013 Category: Opthalmology Authors: Naylor AR, Robinson TG, Eveson D, Burns J Tags: Br J Ophthalmol Source Type: research

Urgent Best Medical Therapy May Obviate the Need for Urgent Surgery in Patients With Symptomatic Carotid Stenosis Clinical Sciences
Conclusions— CEA can be performed in the subacute period without significantly increasing the operative risk. The urgent best medical treatment was associated with significant reduction in the risk of early NR in CEA patients. It seems that urgent aggressive best medical treatment may obviate the need for urgent CEA.
Source: Stroke - July 22, 2013 Category: Neurology Authors: Shahidi, S., Owen-Falkenberg, A., Hjerpsted, U., Rai, A., Ellemann, K. Tags: Secondary prevention, Antiplatelets, Carotid endarterectomy, Transient Ischemic Attacks Clinical Sciences Source Type: research

Progression of asymptomatic carotid stenosis despite optimal medical therapy
Background: Despite level 1 evidence in support of carotid endarterectomy vs medical therapy in selected asymptomatic patients, an alternative posture is that optimal medical therapy (OMT) has not been adequately studied and that such OMT has reduced stroke risk in asymptomatic patients to levels wherein carotid endarterectomy is no longer justified. The goal of this study was to determine the natural history of patients with asymptomatic moderate (50%-69%) carotid artery stenosis (AMCAS) in a contemporary cohort as a function of their associated medical therapy.Methods: Patients with AMCAS determined by duplex ultrasound ...
Source: Journal of Vascular Surgery - June 30, 2013 Category: Surgery Authors: Mark F. Conrad, Valy Baloum, Shankha Mukhopadhyay, Ashu Garg, Virendra I. Patel, Richard P. Cambria Tags: Clinical research studies Source Type: research

Closing the Loop: A 21-year Audit of Strategies for Preventing Stroke and Death Following Carotid Endarterectomy
The objective of this review was to identify causes of stroke/death after carotid endarterectomy (CEA) and to develop transferable strategies for preventing stroke/death after CEA, via an overview of a 21-year series of themed research and audit projects. Three preventive strategies were identified: (i) intra-operative transcranial Doppler (TCD) ultrasound and completion angioscopy which virtually abolished intra-operative stroke, primarily through the removal of residual luminal thrombus prior to restoration of flow; (ii) dual antiplatelet therapy with a single 75-mg dose of clopidogrel the night before surgery in additio...
Source: European Journal of Vascular and Endovascular Surgery - June 17, 2013 Category: Surgery Authors: A.R. Naylor, R.D. Sayers, M.J. McCarthy, M.J. Bown, A. Nasim, M.J. Dennis, N.J.M. London, P.R.F. Bell Tags: Carotid Disease Source Type: research

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