In recent years, the number of people with abnormalities in the carotid arteries in Chinese has shown a significant upward trend, and the latest Chinese chronic prospective studies[1] show that 1/3 of Chinese adults have carotid atherosclerotic plaques of varying degrees, and with age, the incidence is getting higher and higher, more and more men than women.
Carotid atherosclerosis generally begins gradually during puberty, becomes apparent after the age of 40, and by the age of 60, almost everyone has varying degrees of carotid plaque.
Let's take a look at carotid arteriosclerosis and plaque. Are there good ways to prevent and intervene?
What are carotid artery plaques, carotid artery stenosis, carotid artery sclerosis, and what are the hazards?
Carotid plaque is a gradual worsening of the arterial arteries of the neck after arteriosclerosis, and then the formation of atherosclerosis, atherosclerosis gradually aggravated will form plaque.
Worsening of carotid plaque can lead to carotid artery blood vessel stenosis, and blood vessel stenosis can lead to ischemia, resulting in insufficient cerebral blood supply and even ischemic cerebral infarction. That is to say, carotid plaque is only part of carotid atherosclerosis.
Carotid plaques can be detected by ultrasound, and under normal circumstances, the intra-medial membrane thickness (IMT) of the carotid artery is about 0.8 mm to 1.0 mm. When its value > 1.0 mm, it is called IMT thickening, and when its value > 1.3 mm, it is called carotid plaque.
Schematic diagram of arterial plaque and stenosis
Source: Station Cool Helo
A large number of studies have shown that carotid artery plaques are more likely to occur in the carotid artery bifurcation and initiation stage, mainly because the blood flow rate is slow, lipids and inflammatory substances are easy to deposit, and eventually plaque is formed.
The Chinese Stroke Prevention and Treatment Report (2018) shows that 50% to 75% of ischemic strokes are caused by carotid artery lesions and can be life-threatening in severe cases.
A 2021 study published in the Journal of the American College of Cardiology (JACC)[3] showed that the presence of intra-plaque bleeding in carotid atherosclerotic plaques is an independent risk factor for stroke and coronary heart disease.
It can be seen that carotid artery plaques are closely related to stroke and coronary heart disease. Therefore, patients with carotid artery plaque should be actively treated to prevent stroke and coronary heart disease.
What are the classifications of carotid plaques?
Classification one: stability according to plaque
1. Fragile plaques
Easily injured, unstable, and prone to shedding, the formation of thrombuses after the rupture of such plaques can lead to acute cerebral infarction.
Causes of formation: Various causes lead to endothelial cell shedding with surface platelet aggregation, inflammatory cell infiltration, cytokines left and right, fibrous membrane rupture, large lipid core, etc., which can cause vulnerable plaque formation, thereby inducing acute cerebral infarction.
Therefore, the screening, diagnosis and treatment of vulnerable plaques are of great significance for the prevention of acute cerebral infarction.
Fragile plaques are characterized by an unspeakable, irregular surface; ultrasonography suggests low or no echo.
2. Non-fragile plaques
Stable plaque, not easy to fall off, smooth surface, regular shape. Ultrasonography shows a strong echo.
Classification two: according to the degree of stenosis of blood vessels
According to the degree of narrowing, it can be divided into
What are the risk factors for carotid plaque?
A 2019 meta-analysis[4] explored controllable risk factors for carotid plaque, and researchers included 76 correlation studies from 1962 to 2018, showing a significant correlation between nine risk factors and the presence of carotid plaque:
Hyperlipidemia, hyperhomocysteine, hypertension, hyperuricemia, smoking, metabolic syndrome, hypertriglyceridemia, diabetes mellitus, hyperglucidemia.
Four of these risk factors (hyperlipidemia, hyperhomocysteinemia, hypertension, and hyperuricemia) increase the risk of carotid plaque by at least 30%.
Do all plaques need to be treated?
Stenosis of more than 50% should be treated with medication under the guidance of a doctor;
Less than 50% of stenosis, without other diseases, can be controlled first by healthy living;
Stenosis does not exceed 50%, but there are risk factors such as diabetes, hypertension, chronic kidney disease, and low-density lipoprotein cholesterol (LDL-C) > 2.6 mmol/L after lipid testing, which needs to be controlled by taking drugs;
The degree of stenosis is greater than 70%, and there are brains that are considered surgical treatment on a case-by-case basis.
Asymptomatic fragile plaques: regardless of whether the blood lipids are abnormal or not, it is recommended to use medication to make LDL-C
Asymptomatic non-volatile plaque: control for risk factors such as hypertension, diabetes, dyslipidemia, and smoking and alcohol consumption.
What treatments are available?
1. Medication – statins and antiplatelet drugs
(1) Statins - the most basic
Statins are lipid-regulating drugs that lower LDL-C in the blood. LDL-C is the main component of the lipid core of plaques, and after decreasing, it can inhibit the growth of plaques.
And statins can improve the metabolism of vascular endothelium, so that the density of the lipid core in the plaque becomes larger, the volume becomes smaller, and the plaque becomes "hard" and stronger, so that it is not easy to break.
(2) Antiplatelet drugs
When plaques rupture, antiplatelet drugs inhibit platelet aggregation and avoid activating fibrin, thus preventing thrombosis.
Currently, if the patient has significant carotid artery stenosis (stenosis ≥ 50%), aspirin (75 to 150 mg/day) should generally be taken;
If the patient has only one or more plaques but does not cause luminal stenosis, or if there is stenosis but the degree of stenosis
Aspirin (75 to 150 mg/day) is recommended in such patients who have the following ≥ 3 risk factors and cannot be effectively corrected:
Male ≥ 50 years of age or female after menopause;
Hypertension with initial control (blood pressure after treatment in patients with hypertension
Diabetes mellitus;
Hypercholesterolemia (TC≥ 6.2 mmol/L or LDL-C ≥ 4.1 mmol/L or HDL-C
Obesity (body mass index ≥ 28);
Family history of early-onset cardiovascular disease (one or both parents in males
smoking.
In addition, patients at increased risk of bleeding (eg, on anticoagulants, history of gastrointestinal bleeding, thrombocytopenia, etc.) should avoid taking aspirin when not corrected.
2. Surgical treatment – carotid endarterectomy (CEA) and carotid stenting (CAS)
The vast majority of carotid artery stenosis does not require surgery, and when the stenosis is severe enough to affect the normal blood supply to the brain, it is necessary to evaluate and decide whether to operate. There are two commonly used surgical methods:
(1) Carotid endarterectomy (CEA)
Adjuvant carotid stenosis is indicated with ≥ 70% or angiographic stenosis ≥ 50% or asymptomatic but angiographic stenosis ≥ 70%.
(2) Carotid stenting (CAS)
That is, to put a stent in the blood vessels in the neck, and use the stent to support the narrow vascular lumen, which is a reason for the heart coronary artery to put a stent.
However, the above treatment methods are only medical interventions, and lifestyle interventions are important for the prevention of carotid plaques!
What are the healthy lifestyle adjustments?
Regardless of whether the degree of narrowing of carotid plaque exceeds 50%, it is necessary to adhere to a long-term healthy life in order to effectively control and delay the aggravation of carotid plaque.
It can even be said that there is no carotid artery plaque to live a healthy life, so as to really play a preventive role, for those who find carotid artery plaque, they should live healthily.
Eat a sensible diet
Eat more fresh vegetables and fruits, eat more coarse grains, drink more water, low salt, low fat, low sugar.
Quit smoking and alcohol
Smoking promotes coronary artery hardening, and the plaque rate is significantly higher in smokers than in non-smokers. Drink less spirits.
Exercise appropriately and sleep regularly
Gentle aerobic exercise such as brisk walking and jogging can be carried out, but it should be gradual, according to people's conditions, do not overload exercise, and stay up late less.
Aggressive treatment of underlying conditions
Diabetic patients strictly control blood sugar, hypertension, hyperlipidemia patients reduce blood pressure, blood lipid therapy.
Check regularly
Especially for men over 50 years of age, postmenopausal women and people with "three highs", it is recommended to check the carotid ultrasound once a year.
Is it possible for arterial plaque to shrink or disappear after the above aggressive treatment?
As long as reasonable treatment is adhered to under the guidance of a doctor, some plaques can shrink or even completely subside.
The ASTEROID study [5] found that LDL-C was reduced by 53% with lifestyle intervention and aggressive treatment, and plaque was reversed in 78% of patients. Another study called SATURN [6] also found that reducing LDL-C to 1.6 mmol/L resulted in a significant reduction in coronary plaque.
brief summary
In short, an unhealthy lifestyle and a lack of attention to hypertension, diabetes, and hyperlipidemia are the main reasons for accelerated exacerbation of atherosclerosis causing carotid plaque, and carotid plaque must be prevention-oriented.
Carotid plaques that have been found generally recommend medication when stenosis exceeds 50%, and the medications are mainly statins and antiplatelet drugs, but should be determined on a case-by-case basis.
Acknowledgements: This article has been professionally reviewed by Choi Ka-hsung, Chief Physician of the Department of Endocrinology
【Note】
Chief Physician of the Department of Endocrinology Cui Jiaxing's audit opinion:
Carotid plaque and carotid artery sclerosis are common diseases and frequent diseases in middle-aged and elderly people, and are also a hot spot at present.
Epidemiology: Surveys show that nearly 200 million people on the mainland have carotid plaque disease, with 40% of arterial plaques detected in adults over the age of 40 and 90% of carotid plaques in people over the age of 60.
Classification: Clinically, the severity of carotid artery lumen stenosis caused by carotid artery plaque is often divided into four levels, namely mild stenosis, moderate stenosis, severe stenosis, and occlusion.
Mild stenosis, the inner diameter of the carotid lumen is reduced by less than 50%; moderate stenosis, the inner diameter of the carotid lumen is reduced by 50% to 69%; severe stenosis, the inner diameter of the carotid lumen is reduced by 70% to 99%; carotid artery occlusion, finger carotid plaque leads to complete occlusion of carotid blood flow.
Studies have shown that for every 0.1 mm increase in the thickness of the carotid median membrane, the risk of myocardial infarction increases by 10% to 15%, and the risk of stroke increases by 13% to 18%.
Harm: If an atherosclerotic plaque is found on the carotid artery, then the small and medium-sized arteries in other parts of the body, such as the coronary arteries, cerebral cranial arteries, renal arteries, lower extremity arteries, etc., may have similar lesions - atherosclerosis, or they are not far from atherosclerosis.
Significance: Therefore, the prevention and control of carotid artery plaque can not only prevent the onset of stroke, but also reduce and prevent the occurrence and development of coronary heart disease, myocardial infarction, renal arteriosclerosis, uremia, lower extremity atherosclerotic occlusion, and amputation.
Treatment: The prevention and treatment of carotid plaque should start from the cause and prevent the transformation of stable plaque into vulnerable plaque. At the same time, it is necessary to control the growth of stable plaques, reduce the degree of narrowing of carotid arteries, and reduce plaques.
Treatment should pay attention to the principle of individualization, carotid stenting and surgical treatment of the lining is not a conventional treatment measure, and should be implemented under the guidance of multidisciplinary consultation.
Planning | Dai Dongjun
Caption | Stand cool Heero
References (swipe up and down to view)
[1] Clarke R, Du H, Kurmi O, et al. Burden of carotid artery atherosclerosis in Chinese adults: Implications for future risk of cardiovascular diseases. European Journal of Preventive Cardiology. 2017;24(6):647-656.
Hu Shengshou, Gao Runlin, Liu Lisheng, et al. Overview of China Cardiovascular Disease Report 2018[J]. Chinese Journal of Recycling, 2019(3).
[3] Saba PS, Parodi G, Ganau A. From Risk Factors to Clinical Disease: New Opportunities and Challenges for Cardiovascular Risk Prediction. J Am Coll Cardiol. 2021 Mar 23;77(11):1436-1438.
Ji Qian. Meta-analysis and systematic review of regulatory risk factors for carotid atherosclerosis[D]. Dalian Medical University,2019.]
[5] Ballantyne CM, Raichlen JS, Nicholls SJ, et al. Effect of rosuvastatin therapy on coronary artery stenoses assessed by quantitative coronary angiography: a study to evaluate the effect of rosuvastatin on intravascular ultrasound-derived coronary atheroma burden. Circulation. 2008 May 13;117(19):2458-66.
HUANG Jinyu. Interpretation of SATURN Research[J]. Zhejiang Medicine, 2012(7).
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