PT  - JOURNAL ARTICLE
AU  - Ganesh, Aravind
AU  - Bartolini, Luca
AU  - Singh, Ravinder-Jeet
AU  - Al-Sultan, Abdulaziz S.
AU  - Campbell, David J.T.
AU  - Wong, John H.
AU  - Menon, Bijoy K.
TI  - Equipoise in Management of Patients With Acute Symptomatic Carotid Stenosis (Hot Carotid)
AID  - 10.1212/CPJ.0000000000000812
DP  - 2021 Feb 01
TA  - Neurology: Clinical Practice
PG  - 25--32
VI  - 11
IP  - 1
4099  - http://cp.neurology.org/content/11/1/25.short
4100  - http://cp.neurology.org/content/11/1/25.full
AB  - Objective To explore differences in antithrombotic management of patients with acutely symptomatic carotid stenosis (“hot carotid”) awaiting revascularization with endarterectomy or stenting (CEA/CAS).Methods We used a worldwide electronic survey with practice-related questions and clinical questions about 3 representative scenarios. Respondents chose their preferred antithrombotic regimen (1) in general, (2) if the patient was already on aspirin, or (3) had associated intraluminal thrombus (ILT) and identified clinical/imaging factors that increased or decreased their enthusiasm for additional antithrombotic agents. Responses among different groups were compared using multivariable logistic regression.Results We received 668 responses from 71 countries. The majority favored CT angiography (70.2%) to evaluate carotid stenosis, CEA (69.1%) over CAS, an aspirin-containing regimen (88.5%), and a clopidogrel-containing regimen (64.4%) if already on aspirin. Whereas diverse antithrombotic regimens were chosen, monotherapy was favored by 54.4%–70.6% of respondents across 3 scenarios. The preferred dual therapy was low-dose aspirin (75–100 mg) plus clopidogrel (22.2%) or high-dose aspirin (160–325 mg) plus clopidogrel if already on aspirin (12.2%). Respondents favoring CAS more often chose ≥2 agents (adjusted odds ratio [aOR] vs CEA: 2.00, 95% confidence interval 1.36–2.95, p = 0.001) or clopidogrel-containing regimens (aOR: 1.77, 1.16–2.70, p = 0.008). Regional differences included respondents from Europe less commonly choosing multiple agents if already on aspirin (aOR vs United States/Canada: 0.57, 0.35–0.93, p = 0.023), those from Asia more often favoring multiple agents (aOR: 1.95, 1.11–3.43, p = 0.020), vs those from the United States/Canada preferentially choosing heparin-containing regimens with ILT (aOR vs rest: 3.35, 2.23–5.03, p < 0.001). Factors increasing enthusiasm for ≥2 antithrombotics included multiple TIAs (57.2%), ILT (58.5%), and ulcerated plaque (57.4%); 56.3% identified MRI microbleeds as decreasing enthusiasm.Conclusions Our results highlight the heterogeneous management and community equipoise surrounding optimal antithrombotic regimens for hot carotids.