Prevalence of High-risk Plaques and Risk of Stroke in Patients With Asymptomatic Carotid Stenosis A Meta-analysis
Prevalence of High-risk Plaques and Risk of Stroke in Patients With Asymptomatic Carotid Stenosis A Meta-analysis
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DOI：
10.1001/jamaneurol.2020.2658
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发表时间：
2020-12-01
期刊：
影响因子：
29
通讯作者：
Jickling, Glen C.
中科院分区：
文献类型：
--
作者：
Kamtchum-Tatuene, Joseph;Noubiap, Jean Jacques;Jickling, Glen C.
重要性关于无症状颈动脉狭窄的治疗一直存在争议。先前的研究报道了高危斑块的影像学特征，这可能有助于优化血运重建的风险效益比。然而，在这方面，这些研究还没有提供一个准确的估计的患病率高风险斑块和相关的每年发病率同侧缺血性脑血管事件通知临床试验的设计使用风险为导向的选择患者随机化前。资料来源：系统检索PubMed和奥维德Embase，从数据库建立到2019年7月31日，资料选择前瞻性观察性研究，报道高危斑块的患病率和同侧缺血性脑血管事件的发生率，包括在内。数据分析时间为2019年12月16日至2020年1月15日。主要结果和指标高危斑块的患病率和同侧缺血事件的年发生率。结果总体而言，64项研究招募了20 751名年龄在29至95岁的参与者（平均年龄范围，55.0-76.5岁;男性比例，45%-87%）纳入荟萃分析。在所有参与者中，高危斑块的合并患病率为26.5%（95%CI，22.9%-30.3%）。785例受试者中最常见的高危斑块特征为新生血管形成（43.4%; 95% CI，31.4%-55.8%），12364例受试者中为回声透明（42.3%; 95% CI，32.2%-52.8%），3728例受试者中为富含脂质的坏死核心（36.3%; 95% CI，27.7%-45.2%）。同侧缺血性脑血管事件的总发生率为3.2起事件/100人-年（22个队列，10381例受试者;平均随访期为2.8年;范围为0.7-6.5年）。高风险斑块患者的同侧缺血性脑血管事件发生率（4.3起事件/100人-年; 95% CI，2.5-6.5起事件/100人-年）高于无高风险斑块患者（1.2起事件/100人-年; 95% CI，2.5 - 6.5起事件/100人-年）。0.6-1.8起事件/100人-年）。比值比为3.0（95% CI，2.1-4.3; I-2 = 48.8%）。在关注重度狭窄的研究中（9个队列，2128例受试者;平均随访期。2.8年;范围，1.4-6.5年），同侧缺血性脑血管事件的发生率为3.7起事件/100人-年（95% CI. 1.9-6.0起事件/100人-年）。高危斑块患者的同侧缺血性脑血管事件发生率也较高（7.3起事件/100人-年; 95% CI，2.0-15.0起事件/100人-年）（1.7起事件/100人年; 95% CI，0.6-3.3起事件/100人年），比值比为3.2（95%CI，17-5.9;I-2 = 39.6%）.结论和相关性高风险斑块在无症状颈动脉狭窄患者中很常见，并且同侧缺血性脑血管事件的相关风险高于目前公认的估计。将无症状颈动脉狭窄的常规评估扩展到狭窄级别之外可能有助于改善危险分层和优化治疗。
IMPORTANCE There is an ongoing debate regarding the management of asymptomatic carotid stenosis. Previous studies have reported imaging features of high-risk plaques that could help to optimize the risk-benefit ratio of revascularization. However, such studies have not provided an accurate estimate of the prevalence of high-risk plaques and the associated annual incidence of ipsilateral ischemic cerebrovascular events to inform the design of clinical trials using a risk-oriented selection of patients before randomization.OBJECTIVE To assess the relevance and feasibility of risk-oriented selection of patients for revascularization.DATA SOURCES A systematic search of PubMed and Ovid Embase from database inception to July 31, 2019, was performed.STUDY SELECTION Prospective observational studies that reported prevalence of high-risk plaques and incidence of ipsilateral ischemic cerebrovascular events were included.DATA EXTRACTION AND SYNTHESIS Aggregated data were pooled using random-effects meta-analysis. Data were analyzed from December 16, 2019, to January 15, 2020.MAIN OUTCOMES AND MEASURES Prevalence of high-risk plaques and annual incidence of ipsilateral ischemic events.RESULTS Overall, 64 studies enrolling 20 751 participants aged 29 to 95 years (mean age range, 55.0-76.5 years; proportion of men, 45%-87%) were included in the meta-analysis. Among all participants, the pooled prevalence of high-risk plaques was 26.5% (95% CI, 22.9%-30.3%). The most prevalent high-risk plaque features were neovascularization (43.4%; 95% CI, 31.4%-55.8%) in 785 participants, echolucency (42.3%; 95% CI, 32.2%-52.8%) in 12 364 participants, and lipid-rich necrotic core (36.3%; 95% CI, 27.7%-45.2%) in 3728 participants. The overall incidence of ipsilateral ischemic cerebrovascular events was 3.2 events per 100 person-years (22 cohorts with 10 381 participants; mean follow-up period, 2.8 years; range, 0.7-6.5 years). The incidence of ipsilateral ischemic cerebrovascular events was higher in patients with high-risk plaques (4.3 events per 100 person-years; 95% CI, 2.5-6.5 events per 100 person-years) than in those without high-risk plaques (1.2 events per 100 person-years; 95% Cl. 0.6-1.8 events per 100 person-years). with an odds ratio of 3.0 (95% CI, 2.1-4.3; I-2 = 48.8%). In studies focusing on severe stenosis (9 cohorts with 2128 participants; mean follow-up period. 2.8 years; range, 1.4-6.5 years), the incidence of ipsilateral ischemic cerebrovascular events was 3.7 events per 100 person-years (95% CI. 1.9-6.0 events per 100 person-years). The incidence of ipsilateral ischemic cerebrovascular events was also higher in patients with high-risk plaques (7.3 events per 100 person-years; 95% CI, 2.0-15.0 events per 100 person-years) than in those without high-risk plaques (1.7 events per 100 person-years; 95% CI, 0.6-3.3 events per 100 person-years), with an odds ratio of 3.2 (95% CI, 17-5.9;I-2 = 39.6%).CONCLUSIONS AND RELEVANCE High-risk plaques are common in patients with asymptomatic carotid stenosis, and the associated risk of an ipsilateral ischemic cerebrovascular event is higher than the currently accepted estimates. Extension of routine assessment of asymptomatic carotid stenosis beyond the grade of stenosis may help improve risk stratification and optimize therapy.