A 67-year-old woman comes to the office after a recent hospitalization. She had abrupt onset of right arm weakness and difficulty speaking a week ago while playing cards with friends. The patient's friends called 911, but her symptoms had resolved completely by the time she arrived at the hospital.
MRI of the brain showed no acute abnormalities. A carotid ultrasound showed 60% stenosis in the left internal carotid artery and 50% stenosis in the right internal carotid artery. ECG showed normal sinus rhythm with occasional atrial premature beats, and 48 hours of telemetry monitoring was unrevealing. Echocardiogram showed mild left atrial enlargement, mild left ventricular hypertrophy, and normal left ventricular systolic function.
Since discharge, the patient has had no recurrence of symptoms and has been able to resume her normal daily activities. Her other medical problems include hypertension and hyperlipidemia. She has no history of angina or coronary artery disease. Medications include lisinopril, metoprolol, amlodipine, and aspirin.
Temperature is 36.7 C (98 F) , blood pressure is 125/70 mm Hg, and pulse is 78/min; BMI is 26 kg/m². Estimated jugular venous pressure is 8 cm H₂O. There is normal S1 and S2 with a 2/6 ejection-type murmur at the right upper sternal border. Peripheral pulses are 2+ and no edema is present. The cranial nerves are intact and deep-tendon reflexes are normal. Muscle strength is symmetrically intact.
Laboratory results are as follows:
Which of the following would be the most appropriate next step to prevent future neurovascular events in this patient?

Question

A 67-year-old woman comes to the office after a recent hospitalization. She had abrupt onset of right arm weakness and difficulty speaking a week ago while playing cards with friends. The patient's friends called 911, but her symptoms had resolved completely by the time she arrived at the hospital.
MRI of the brain showed no acute abnormalities. A carotid ultrasound showed 60% stenosis in the left internal carotid artery and 50% stenosis in the right internal carotid artery. ECG showed normal sinus rhythm with occasional atrial premature beats, and 48 hours of telemetry monitoring was unrevealing. Echocardiogram showed mild left atrial enlargement, mild left ventricular hypertrophy, and normal left ventricular systolic function.
Since discharge, the patient has had no recurrence of symptoms and has been able to resume her normal daily activities. Her other medical problems include hypertension and hyperlipidemia. She has no history of angina or coronary artery disease. Medications include lisinopril, metoprolol, amlodipine, and aspirin.
Temperature is 36.7 C (98 F) , blood pressure is 125/70 mm Hg, and pulse is 78/min; BMI is 26 kg/m². Estimated jugular venous pressure is 8 cm H₂O. There is normal S1 and S2 with a 2/6 ejection-type murmur at the right upper sternal border. Peripheral pulses are 2+ and no edema is present. The cranial nerves are intact and deep-tendon reflexes are normal. Muscle strength is symmetrically intact.
Laboratory results are as follows:

Which of the following would be the most appropriate next step to prevent future neurovascular events in this patient?

Quizplus · Accepted Answer

This patient had a recent transient ischemic attack (TIA) with right-sided arm weakness, suggesting transient ischemia of the relevant areas in the left brain with 60% ipsilateral (ie, left) carotid artery stenosis and 50% contralateral (ie, right) carotid artery stenosis. The risk of subsequent stroke after TIA ranges from 13% in the first 3 months to 30% in the next 5 years. Medical management including statin and antiplatelet therapy is recommended in all patients with carotid artery stenosis. Current guidelines recommend high-intensity statin therapy (atorvastatin 40-80 mg or rosuvastatin 20-40 mg daily) for all patients age ≤75 with clinically significant atherosclerotic vascular disease and moderate-intensity therapy (eg, atorvastatin 10-20 mg, simvastatin 20-40 mg) for those age >75. Blood pressure should be controlled below a target of 130/80 mm Hg. Patients should also be counseled on lifestyle changes (eg, smoking cessation, weight loss, dietary changes) if needed. Current guidelines Carotid endarterectomy is recommended in symptomatic patients (ie, TIA, ischemic stroke in the distribution of the affected vessel within the past 6 months) with high-grade lesions (70%-99%). For patients with less severe stenosis (<70%), exact recommendations vary with different guidelines. Surgery appears to be less beneficial for women with less severe (eg, 50%-69%) ipsilateral carotid stenosis when compared with men (grade 2B evidence); as a result, such women are typically managed medically (as in this case) (Choice A). Regardless, this patient should receive statin therapy. (Choice B) Current guidelines recommend aspirin alone, clopidogrel alone, or aspirin plus dipyridamole as antiplatelet agents for stroke prevention. Aspirin in combination with clopidogrel is recommended for patients who have a stroke while on aspirin therapy and have evidence of intracranial large artery stenosis (eg, carotid siphon, middle cerebral artery, vertebral or basilar artery). (Choice C) Niacin lowers triglycerides and raises high-density lipoprotein but has no significant impact on low-density lipoprotein, which is the primary lipid risk factor for atherosclerotic disease. (Choice E) Warfarin anticoagulation is recommended for nonatherosclerotic conditions that can lead to stroke, such as atrial fibrillation or mechanical prosthetic heart valve. However, warfarin is not superior to aspirin for future stroke prevention in patients with a recent TIA/stroke due to carotid atherosclerosis and carries a much higher risk of bleeding. Educational objective: Carotid endarterectomy is indicated in symptomatic patients with high-grade carotid artery stenosis (70%-99%). Regardless of severity, patients with symptomatic carotid stenosis should receive medical therapy, including statin and antiplatelet therapy, and maintain blood pressure <130/80 mm Hg to control atherosclerotic risk factors. __________ References: Relative effects of statin therapy on stroke and cardiovascular events in men and women: secondary analysis of the Stroke Prevention by Aggressive Reduction in Cholesterol Levels (SPARCL) Study. (http://www.ncbi.nlm.nih.gov/pubmed/18617654)

A 67-Year-Old Woman Comes to the Office After a Recent