Antithrombotic treatment of asymptomatic carotid atherosclerosis: a medical dilemma
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IM - REVIEW
Antithrombotic treatment of asymptomatic carotid atherosclerosis: a medical dilemma Paolo Gresele1 · Francesco Paciullo1 · Rino Migliacci2 Received: 4 February 2020 / Accepted: 15 April 2020 © Società Italiana di Medicina Interna (SIMI) 2020
Abstract Carotid artery atherosclerosis (CAAS) is a common finding in asymptomatic subjects evaluated for cardiovascular (CV)-risk stratification. Besides the careful control of CV-risk factors, antithrombotic agents, and in particular aspirin, may be considered for primary prevention in patients at CV-risk. However, there is strong controversy on the use of aspirin in primary prevention. Even if several studies confirmed the association between CAAS and CV-events, CAAS is not universally recognized as an independent risk factor and the choice to use aspirin as primary prevention in these patients remains a medical dilemma. Here we review the available evidence on the prognostic value of asymptomatic CAAS for major CV-events and on the utility of antithrombotic agents in this population. We conclude that the detection of asymptomatic CAAS can not be considered as a direct indication to carry out primary prophylaxis with antithrombotic drugs, and the choice to use aspirin should be made only after the careful estimate of the individual’s CV-and hemorrhagic risk. Keywords Antiplatelet · Aspirin · Asymptomatic carotid artery stenosis · Cardiovascular risk · Primary prevention
Introduction Despite substantial improvement in atherosclerotic cardiovascular (CV) disease outcomes over the last few decades, ischemic CV events remain the leading cause of morbidity and mortality globally and much of this is attributable to the suboptimal implementation of primary prevention strategies [1]. Besides the careful control of CV-risk factors, antithrombotic agents, and in particular aspirin, may be considered for primary prevention. However, while the effectiveness of aspirin in secondary prevention is well established, controversy still exists on its use in primary prevention [2, 3]. A crucial step in the decision to prescribe aspirin for primary prevention is the evaluation of the absolute risk of a future CV event in the patient candidate to prophylaxis. When this is high the benefit of treatment * Paolo Gresele [email protected] 1
Section of Internal and Cardiovascular Medicine, Department of Medicine, University of Perugia, Strada Vicinale Via Delle Corse, S. Andrea della Fratte, 06132 Perugia, Italy
Division of Internal Medicine, Ospedale Della Valdichiana “S. Margherita”, Cortona, Italy
2
clearly outweighs the potential harm and treatment can be recommended, while when the absolute CV-risk is low the reduction in occlusive events is balanced by the increase in major bleeding and treatment becomes of uncertain net value [2, 4]. Therefore, adult patients (40–75 years old) evaluated for possible primary prevention with antithrombotics should, first of all, undergo a careful 10-year CV-risk estimate [1]. For subjects with a 10-year risk ≥ 20% there is a wide co
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