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#16
15.11.2008, 00:53
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В продолжение дискуссии о роли УЗДГ сонных артерий.
The Agency for Healthcare Research and Quality (AHRQ) в 2007 году опубликовало клинические рекомендации скринингу каротидного атеросклероза - "Screening for Carotid Artery Stenosis: An Update of the Evidence for the U.S. Preventive Services Task Force", где УЗДГ не рекомендуется в качестве рутинного метода обследования [Ссылки доступны только зарегистрированным пользователям ] В этом документе УЗДГ сонных аретрий не рекомендован в качестве скрининга. Эксперты AHRQ постарались ответить на 4 вопроса: Key question 1: Is there direct evidence that screening adults with duplex ultrasonography for asymptomatic CAS reduces fatal or nonfatal stroke? Key question 2: What is the accuracy and reliability of duplex ultrasonography to detect clinically important CAS? Key question 3: For people with asymptomatic CAS 60% to 99%, does intervention with carotid endarterectomy reduce CAS-related morbidity or mortality? Key question 4: Does screening or carotid endarterectomy for asymptomatic CAS 60% to 99% result in harm? 
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#17
15.11.2008, 00:59
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Подробное описание исследований приведено в основном тексте статьи.
Результаты: Key Question 1 Is there direct evidence that screening adults with duplex ultrasonography for asymptomatic CAS reduces fatal or nonfatal stroke? No studies addressing this question met our inclusion criteria. Key Question 2 What is the accuracy and reliability of ultrasonography to detect clinically important CAS? We found 2 meta-analyses on the accuracy of ultrasonography to detect clinically important stenosis. A recent meta-analysis by Nederkoorn and colleagues [Ссылки доступны только зарегистрированным пользователям ] included studies published from 1993 through 2001 and estimated the accuracy of carotid duplex ultrasonography using digital subtraction angiography as the reference standard; this meta-analysis was rated as fair quality because it had limited sources for studies and did not have information on the standard appraisal of studies. Carotid duplex ultrasonography had an estimated sensitivity of 86% (95% CI, 84% to 89%) and a specificity of 87% (CI, 84% to 90%) for detecting CAS 70% to 99% [Ссылки доступны только зарегистрированным пользователям ]. A second meta-analysis of carotid duplex ultrasonography found similar sensitivity and specificity for carotid duplex ultrasonography to detect CAS 70% or greater (90% [CI, 84% to 94%] and 94% [CI, 88% to 97%], respectively) [Ссылки доступны только зарегистрированным пользователям ]. This meta-analysis was rated good quality because of the comprehensiveness of sources and search strategies, the explicit selection criteria, and the standard appraisal of studies. To detect CAS 50% or greater, the authors suggested a cut-point that had a sensitivity of 98% and a specificity of 88%. By using a graph in that article and applying the same cut-point as was suggested for detecting CAS 70% or greater, we estimate that the sensitivity of carotid duplex ultrasonography to detect CAS 60% or greater is about 94%, with a specificity of about 92%. The reliability of carotid duplex ultrasonography is questionable. One meta-analysis noted that the measurement properties used among ultrasonography laboratories varied greatly, to a clinically important degree [Ссылки доступны только зарегистрированным пользователям ]. We found 1 meta-analysis on the accuracy of MRA and 1 meta-analysis on the accuracy of CTA in detecting clinically important carotid stenosis. The fair-quality meta-analysis by Nederkoorn and colleagues reported that MRA has about the same accuracy as ultrasonography [Ссылки доступны только зарегистрированным пользователям ]. Computed tomographic angiography has gained wide acceptance in some centers as a follow-up test to ultrasonography in confirming CAS. In certain cases, it has been used in place of vascular arteriography. A recent good-quality systematic review that used comprehensive data sources and a standard appraisal of studies found that the accuracy of CTA does not greatly differ from that of ultrasonography and MRA [Ссылки доступны только зарегистрированным пользователям ]. Although CTA is safer than angiography as a confirmatory test, it is unlikely to be a useful screening test because of its cost and because it entails radiation exposure and injection of intravenous contrast dye. Although MRA does not use contrast dye or have significant radiation exposure, it is time-consuming and costly and is also not suitable as a screening test at this time.
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#18
15.11.2008, 01:01
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Key Question 3
For people with asymptomatic CAS 60% to 99%, does intervention with carotid endarterectomy reduce CAS-related morbidity or mortality? We identified 5 RCTs comparing carotid endarterectomy and medical management for asymptomatic CAS: the WRAMC (Walter Reed Army Medical Center) study [Ссылки доступны только зарегистрированным пользователям ], the MACE (Mayo Asymptomatic Carotid Endarterectomy) study [Ссылки доступны только зарегистрированным пользователям ], the VACS (Veterans Affairs Cooperative Study [Ссылки доступны только зарегистрированным пользователям ], ACAS [Ссылки доступны только зарегистрированным пользователям ], and ACST [Ссылки доступны только зарегистрированным пользователям ]. We selected 2 good-quality studies (ACAS and ACST) and 1 fair-quality study (VACS) for inclusion. We excluded the WRAMC study because it did not use ultrasonographic assessment of CAS, had few participants, and used unclear definitions of outcomes. We excluded the MACE study because of its small number of participants and strokes and lack of aspirin treatment in the surgical group. The 2 largest and highest-quality RCTs have shown an absolute reduction of stroke and perioperative death of approximately 5% from carotid endarterectomy compared with medical treatment for CAS 60% to 99% in selected patients with selected surgeons. This benefit includes an approximate 3% rate of perioperative stroke or death. After 4 years of follow-up, the stroke rate in VACS was lower in the carotid endarterectomy group than in the medical treatment group (8.6% vs. 12.4%). However, the incidence of perioperative stroke or death in the carotid endarterectomy group was 4.7%. When all strokes or perioperative events were considered, there was no difference between carotid endarterectomy and medical management. After 2.7 years of follow-up, the ACAS investigators calculated 5-year outcomes on the basis of Kaplan–Meier curves. They estimated that the 5-year rate of ipsilateral stroke and any perioperative stroke or death was lower in the carotid endarterectomy group than in the medical management group (5.1% vs. 11.0%; relative risk reduction [RRR], 0.53 [CI, 0.22 to 0.72]). If strokes associated with angiography were included, the difference between groups was 5.6% versus 11.0%, or an absolute difference of 5.4 percentage points over 5 years. These rates include a perioperative rate of stroke or death of 2.7% overall (1.7% for men and 3.6% for women). The estimated RRR was greater for men than for women: 0.66 and 0.17, respectively. The treatment groups did not statistically significantly differ in all-cause mortality. After 3.4 years of follow-up, the ACST investigators calculated 5-year outcomes. They estimated that the carotid endarterectomy group would have a lower 5-year rate of any stroke or perioperative death than the medical management group: 6.4% versus 11.8% (difference, 5.4 percentage points [CI, 2.96 to 7.75 percentage points]). About half of the strokes prevented by carotid endarterectomy were disabling. The perioperative rate of stroke or death was 3.1% overall and was higher for women than for men (3.7% vs. 2.4%). The groups did not statistically significantly differ in all-cause mortality. The RCTs on carotid endarterectomy for asymptomatic CAS have important limitations. The participants and surgeons in the RCTs were highly selected, which reduces the generalizability of the findings to the primary care setting. In addition, the 30-day perioperative results of the RCTs were reported as a combined outcome and did not include an important complication, acute nonfatal myocardial infarction. Another important limitation of the RCTs on treatment with carotid endarterectomy is that the medical management group in the RCTs was poorly defined, was not kept constant over the course of the study, and was probably not comparable to current standards of optimal medical management.
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#19
15.11.2008, 01:02
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Key Question 4
Does screening or treatment for asymptomatic CAS 60% to 99% with carotid endarterectomy result in harm? The potential harms of a program of screening for CAS to perform carotid endarterectomy include the harms associated with false-positive screening tests (for example, anxiety; labeling; the harms of any confirmatory work-up, such as angiography; or the harms of unnecessary carotid endarterectomy in people who do not undergo angiography) and the harms of carotid endarterectomy itself (for example, bleeding, infection, stroke, and death). The harms of angiography are discussed in the introduction to this article. We found no studies on anxiety or labeling among people with false-positive results on ultrasonography screening. We did find evidence concerning the harms of carotid endarterectomy. Carotid endarterectomy entails a clear risk for perioperative complications of carotid endarterectomy, including stroke, death, and myocardial infarction. Some observational studies have shown rates of perioperative complications that were higher than the 3% reported in the RCTs. The 30-day perioperative stroke or death rates in asymptomatic persons in the Medicare and New York City studies ranged from 2.3% to 3.7%. One Veterans Affairs study showed a perioperative stroke or death rate of 1.6% [Ссылки доступны только зарегистрированным пользователям ]. The systematic review of 103 studies found an overall stroke and death rate at 30 days of 3.0% in studies published since 1995 [Ссылки доступны только зарегистрированным пользователям ]. The observational studies that reported perioperative nonfatal myocardial infarction showed a rate of approximately 0.7% to 1.1% ([Ссылки доступны только зарегистрированным пользователям ], [Ссылки доступны только зарегистрированным пользователям ], [Ссылки доступны только зарегистрированным пользователям ]). Patients with more comorbid conditions had a nonfatal myocardial infarction rate of up to 3.3% [Ссылки доступны только зарегистрированным пользователям ]. The rate of nonfatal perioperative myocardial infarction reported for the surgical group in the RCTs varied from 1.9% in VACS to 0.6% in ACST ([Ссылки доступны только зарегистрированным пользователям ], [Ссылки доступны только зарегистрированным пользователям ]). The participants did not receive routine postoperative electrocardiography or serum markers of myocardial involvement. Two Medicare-based studies found variation in perioperative stroke and death among 10 states ([Ссылки доступны только зарегистрированным пользователям ], [Ссылки доступны только зарегистрированным пользователям ]). In the first study, the statewide rates ranged from 2.3% in Indiana to 6.7% in Arkansas [Ссылки доступны только зарегистрированным пользователям ]. A follow-up study for the same 10 states found similar results as those in 2001, with rates ranging from 1.4% in Georgia to 6.0% in Oklahoma [Ссылки доступны только зарегистрированным пользователям ]. Studies provided little information about rates of other complications, including the impact on quality of life. No observational study that we evaluated gave specific rates of other complications for asymptomatic patients. However, among the RCTs, the VACS reported a surgical complications rate of 3.8% for cranial nerve injuries (none of these injuries were permanent), 5.2% for hypotension, and 25% for hypertension [Ссылки доступны только зарегистрированным пользователям ].
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#20
15.11.2008, 01:12
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Для того, чтобы предотвратить 1 инвалидизирующий инсульт в течение 5 лет необходимо обследовать 11112 человек, неинвалидизирующий инсульт - 5556 человек.
Авторы работы делают вывод, что The actual stroke reduction from screening asymptomatic patients and treatment with carotid endarterectomy is unknown; the benefit is limited by a low overall prevalence of treatable disease in the general asymptomatic population and harms from treatment. И не рекомендует рутинный скрининг для поиска бессимптомного каротидного атеросклероза в общей популяции [Ссылки доступны только зарегистрированным пользователям ]
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#21
15.11.2008, 01:17
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Теперь о медикаментозной терапии бессимптомного каротидного атеросклероза (взято из ACCF/SCAI/SVMB/SIR/ASITN 2007 Clinical Expert
Consensus Document on Carotid Stenting): 1. Аспирин. В качестве первичной профилактики польза сомнительна. Эффективен в основном у женщин. Primary prevention trials show that aspirin decreases the risk of first MI in men, but has little impact on the risk of ischemic stroke. In contrast, in one large primary prevention trial in women, aspirin lowered the risk of stroke without affecting the risk of MI or death (127). Aspirin is approved for secondary prevention in persons with a history of TIA or stroke. The relative risk reduction is 16% for fatal stroke and 28% for nonfatal stroke (128). Aspirin for 3 weeks after acute stroke prevents 9 subsequent strokes per 1,000 treated; 29 months of treatment prevents 36 events per 1,000 treated. Based on randomized trials, aspirin is superior to CEA for symptomatic patients with carotid stenosis less than 50% (18,19,37,38) and for asymptomatic patients with carotid stenosis less than 60% (22,23). Early studies suggested benefit with low-dose aspirin (114–116). The risk of MI, stroke, and death within 1 to 3 months of CEA was lower for patients taking low-dose aspirin (81 mg or 325 mg daily) than for high-dose aspirin (650 mg or 1,300 mg daily) (117). There are no data to support the use of aspirin in doses greater than 325 mg daily, even in patients with recurrent TIAs despite low-dose aspirin.
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#22
15.11.2008, 01:20
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2. Статины.
The National Cholesterol Education Program (NCEP) guideline recommends statins in patients with prior TIA or stroke or carotid stenosis greater than 50% stenosis (137). The American Stroke Association (ASA) also recommends statins for patients with ischemic TIA or stroke (138). 3. Антигипертензивная терапия. Hypertension is the pre-eminent risk factor for ischemic and hemorrhagic stroke, by virtue of its direct atherogenic effects on the systemic and cerebral circulations, and by its strong association with myocardial infarction (MI) and atrial fibrillation, both of which increase the risk of cerebral embolization (94). There is a linear relationship between increasing blood pressure and increased risk of stroke, even within the normal blood pressure range. The stroke risk increases 3-fold when systolic blood pressure is greater than 160 mm Hg. The impact of systolic and diastolic blood pressure on the risk of stroke is similar, and isolated systolic hypertension is an especially important risk factor in the elderly (95). Control of blood pressure is the cornerstone of therapy to modify atherogenic risk factors, and the benefits of antihypertensive therapy extend to all patient subgroups, especially diabetics. Even small reductions in systolic (10 mm Hg) and diastolic (3 to 6 mm Hg) blood pressure result in a 30% to 42% decline in the risk of stroke (96,97). Selection of drugs should be based on Joint National Committee (JNC)-7 guidelines (98), and will be influenced by the presence of comorbid medical conditions (e.g., diabetes, left ventricular dysfunction, renal failure) and ethnicity. At least two-thirds of patients will require multiple medications to achieve blood pressure control.
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#23
15.11.2008, 01:30
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В целом антигипертензивная терапия, на мой взгляд, не зависит от наличия/отсутствия каротидного атеросклероза, поэтому в соответствии с рекомендациями по АГ BHS (Management of hypertension in adults in primary care: partial update
This is a partial update of NICE Clinical Guideline 18, published August 2004) при возрасте менее 55 лет - иАПФ (БРА при непереносимости иАПФ), более 55 - антагонист кальция (АКК) или диуретик. При неэффективности к иАПФ добавляем АКК или диуретик, на третьей ступени назначаем иАПФ+АКК+Д. P.S. Европейский гайд по АГ лично мной используется редко, т.к. содержит ряд спекулятивных тезисов, часто основанных на мнении экспертов и зачастую результатах единичных работ, обсервационных исследований т.д., качество которых лично меня не устраивает.
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#24
15.11.2008, 07:17
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Уважаемый Игорь!
Спасибо за интересный обзор проблемы. То, что УЗИ каротид не является скрининговым методом обследования для безвыборочной популяции и рутинным обследованием при АГ для меня очевидно. В учреждении, где работает уважаемая Юлия, есть возможность направить всех гипертоников на УЗИ каротид, в этом криминала нет. Вызывает недоумение тот факт, что УЗИ бесплатно, а липидный спектр платный, но это причуды крупных пафосных учреждений. Мне кажется лучше, чтобы было наоборот, липидный спектр важнее для всеобщего обследования кардиопациентов, чем УЗИ каротид, ИМХО. Я работаю в обычной районной поликлинике, у нас нет допплера вообще, а липидный спекрт платный.
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#25
15.11.2008, 11:30
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Цитата:
Я прошу прощения за отсутствие ссылок, я их специально не собирал, но целый ряд статей доказывают о благоприятном воздействии на атероматоз иАПФ и ББ, может и поэтому ББ рекомендуется всем после инфаркта (иАПФ не всем), так что при доказанном атеросклерозе при АГ ББ тоже назначать не совсем бездоказательно. По рекомендации АСС/АНА и пр. "А" для назначения статинов достаточно ЛПНП более 2,6 ммоль/л.
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#27
15.11.2008, 15:31
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Цитата:
Renin-Angiotensin-Aldosterone System Blockers ACE inhibitors in all patients indefinitely; start early in stable high-risk patients (anterior MI, previous MI, Killip class greater than or equal to II [S3 gallop, rales , radiographic CHF], LVEF less than 0.40). Angiotensin receptor blockers in patients who are intolerant of ACE inhibitors and with either clinical or radiological signs of heart failure or LVEF less than 0.40. Aldosterone blockade in patients without significant renal dysfunction§ or hyperkalemia|| who are already receiving therapeutic doses of an ACE inhibitor, have LVEF less than or equal to 0.40, and have either diabetes or heart failure. Сравните с ВВ из того же источника: Beta-Blockers Start in all patients. Continue indefinitely. Observe usual contraindications.
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#28
15.11.2008, 15:57
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Цитата:
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#29
15.11.2008, 16:01
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Цитата:
Впрочем, похоже Вы правы. Вот цитата из гайда ECS по СТЕМИ: ACE inhibitor: oral formulation on first day to all patients for whom it is not contraindicated CLASS: IIa Level of evidence: A to high-risk patients CLASS: I Level of evidence: A Все таки получается не всем, раз 2а - надо еще подумать. _____________________
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#30
15.11.2008, 16:42
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Цитата:
Применение β-блокаторов, начатое в остром периоде заболевания, при отсутствии серьезных побочных эффектов должно продолжаться и после выписки из стационара неопределенно долго. ИМХО, то же самое имеется в виду в рекомендациях АСС/АНА. Но "неопределенно долго" и "неопределенно" в данном случае мне не кажутся абсолютными синонимами. "Неопределенно долго" я понимаю, как достаточно долго, но без четких временных границ, то есть ближе к without any limit of time, хотя не абсолютно. Возможно, я ошибаюсь
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Линейный вид
