Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study.
Asymptomatic embolisation for prediction of stroke in the Asymptomatic Carotid Emboli Study (ACES): a prospective observational study.
复制标题
DOI：
10.1016/s1474-4422(10)70120-4
复制
发表时间：
2010-07
期刊：
影响因子：
48
通讯作者：
Schaafsma, Arjen
中科院分区：
文献类型：
--
作者：
Markus, Hugh S.;King, Alice;Shipley, Martin;Topakian, Raffi;Cullinane, Marisa;Reihill, Sheila;Bornstein, Natan M.;Schaafsma, Arjen
手术是否对无症状颈动脉狭窄患者有益仍有争议。更好的识别可能发生卒中的患者的方法将提高颈动脉内膜切除术的风险效益比。我们的目的是调查是否使用经颅多普勒（TCD）检测无症状的栓塞信号可以预测无症状颈动脉狭窄患者的卒中风险。无症状颈动脉栓塞研究（ACES）是一项在全球26个中心至少70%的无症状颈动脉狭窄患者中进行的前瞻性观察性研究。为了检测栓塞信号的存在，患者在基线时有两个1小时的同侧大脑中动脉TCD记录，在6、12和18个月时有一个1小时的记录。随访2年。主要终点为同侧卒中和短暂性脑缺血发作。所有记录均由对患者身份不知情的研究者集中分析。招募了482名患者，其中467名具有可评价的记录。基线时，467例患者中有77例存在栓塞信号。从基线到2年，有栓塞信号的患者与无栓塞信号的患者相比，同侧卒中和短暂性脑缺血发作风险的风险比为2.54（95%CI 1.20 - 5.36; p= 0.015）。仅同侧卒中的风险比为5.57（1.61 - 19.32; p= 0.007）。从基线到2年，有栓塞信号的患者发生同侧卒中或短暂性脑缺血发作的绝对年风险为7.13%，无栓塞信号的患者为3.04%，有栓塞信号的患者发生同侧卒中的绝对年风险为3.62%，无栓塞信号的患者为0.70%。在接下来的6个月随访前记录到栓塞信号的患者与未记录到栓塞信号的患者相比，患同侧卒中和短暂性脑缺血发作的风险比为2.63（95%CI 1.01 - 6.88; p= 0.049），仅患同侧卒中的风险比为6.37（1.59 - 25.57; p= 0.009）。控制抗血小板治疗、狭窄程度和其他危险因素不会改变结果。TCD上无症状栓塞的检测可用于识别无症状颈动脉狭窄患者，这些患者具有较高的卒中和短暂性脑缺血发作风险，也具有较低的绝对卒中风险。在选择无症状颈动脉狭窄的患者时，TCD对栓塞信号的评估可能是有用的，这些患者可能从动脉内膜切除术中获益。英国心脏基金会
Whether surgery is beneficial for patients with asymptomatic carotid stenosis is controversial. Better methods of identifying patients who are likely to develop stroke would improve the risk–benefit ratio for carotid endarterectomy. We aimed to investigate whether detection of asymptomatic embolic signals by use of transcranial doppler (TCD) could predict stroke risk in patients with asymptomatic carotid stenosis. The Asymptomatic Carotid Emboli Study (ACES) was a prospective observational study in patients with asymptomatic carotid stenosis of at least 70% from 26 centres worldwide. To detect the presence of embolic signals, patients had two 1 h TCD recordings from the ipsilateral middle cerebral artery at baseline and one 1 h recording at 6, 12, and 18 months. Patients were followed up for 2 years. The primary endpoint was ipsilateral stroke and transient ischaemic attack. All recordings were analysed centrally by investigators masked to patient identity. 482 patients were recruited, of whom 467 had evaluable recordings. Embolic signals were present in 77 of 467 patients at baseline. The hazard ratio for the risk of ipsilateral stroke and transient ischaemic attack from baseline to 2 years in patients with embolic signals compared with those without was 2·54 (95% CI 1·20–5·36; p=0·015). For ipsilateral stroke alone, the hazard ratio was 5·57 (1·61–19·32; p=0·007). The absolute annual risk of ipsilateral stroke or transient ischaemic attack between baseline and 2 years was 7·13% in patients with embolic signals and 3·04% in those without, and for ipsilateral stroke was 3·62% in patients with embolic signals and 0·70% in those without. The hazard ratio for the risk of ipsilateral stroke and transient ischaemic attack for patients who had embolic signals on the recording preceding the next 6-month follow-up compared with those who did not was 2·63 (95% CI 1·01–6·88; p=0·049), and for ipsilateral stroke alone the hazard ratio was 6·37 (1·59–25·57; p=0·009). Controlling for antiplatelet therapy, degree of stenosis, and other risk factors did not alter the results. Detection of asymptomatic embolisation on TCD can be used to identify patients with asymptomatic carotid stenosis who are at a higher risk of stroke and transient ischaemic attack, and also those with a low absolute stroke risk. Assessment of the presence of embolic signals on TCD might be useful in the selection of patients with asymptomatic carotid stenosis who are likely to benefit from endarterectomy. British Heart Foundation.