support another cause,
a study to find out just how
healthy your arteries are,
in particular, the
carotid arteries,
and whether or not they are
experiencing sever blockage.
You never know.
Doctor Fenwick Nichols
is a neurologist,
and he is a stroke specialist
at the Medical
College of Georgia
at Augusta University, and
he is helping lead the way
in a national trial to help
determine the best therapy
for those with Asymptomatic
Carotid Artery Disease.
Doctor Nichols, welcome to you.
- Thank you.
- My first question is, how
in the world do you know
you need to take part in the
trial if it's asymptomatic?
- Excellent question,
you might go
to your family practice doctor,
and he'd put a stethoscope
on your neck, and hear a
noise of the arteries here.
The French use a word,
bruit, which is just noise,
but it's where the
narrowing of the artery is,
it's like the
rapids in the river,
where the rivers
quiet in the big part,
and when it goes
through the rapids,
it makes noise
going through there.
You can hear a similar
phenomenon over a
narrowed artery.
So the physician may
put a stethoscope
on your neck and hear a bruit,
and know that you've got
some kid of narrowing there,
and send you for a test
to find out how bad it is.
- Let me ask you a
question about that sound
that they hear.
Let's say a normal sound
of a healthy artery
is a rushing river.
Is that correct?
- You pretty much don't hear
it from your stethoscope.
It's quiet.
- It's quiet.
And then, when do you
know it's problematic?
That's when you hear
the rushing river sound?
- Yes sir.
- Okay.
So let's say you hear
the rushing river sound.
How long do you have
between then and the time
that you perhaps
have a stroke or die?
- We cannot tell how
bad your narrowing is
by the quality of the sound.
We have got to do some
other measurement,
and there are several
different ways
to figure out how bad the
narrowing is in the arteries.
The most common is to
use an ultrasound test,
a carotid ultrasound,
and to physically look
at the artery using ultrasound,
and then put a doppler in
there, and measure the speed
of the artery, the flow in
the artery to figure out
how bad the narrowing is.
- But, it is a situation
where time is of the essence.
- Potentially.
It's not a crisis.
This turns out that you can
occlude the internal carotid,
completely block it, and
not get into trouble.
We are blessed with a
connection of arteries
at the base of the brain
called the Circle of Willis.
So, you can block this,
and you may be able
to shunt blood
around that blockage,
but about a third
of the population,
if you try to block
off that artery,
don't have a good
Circle of Willis,
then they will get
a stroke out of it.
- So let's take a
look at this study,
and what you're
trying to determine,
which is whether it is
better to medically manage
your condition, or to go
in there and put a stent,
or some other surgical
procedure in there.
Talk more about
those treatments,
and do you have any
indication at this point
which is better?
- That's why we're doing the
trial, because we don't know
which is better.
So this is partly
driven by the fact
that we had a very
successful trial that showed,
if you were having symptoms
from a bad narrowing,
that you had about a
25-27% risk of stroke
in the next two years,
and that if we did
an endoerectomy or
put a stent in there,
we could dramatically
lower that risk.
So we've tried to extrapolate
that to asymptomatic stenosis,
people who are not having
trouble, in the hopes
that doing an early
intervention would keep them
from progressing to stroke.
Well, the comparison trial
that we did was a trial
back in the late '80s and
early '90s called ACAST,
Asymptomatic Carotid
Artery Stenosis Trial.
And they showed a benefit
in the surgical wing
compared to the medical wing.
So the people who
were on medicines had
about twice the risk
of stroke as folks
who had the surgery.
But since that time we've had
advances in our medical care.
We've gotten a lot
better with some
of our cholesterol medicines.
We're doing a lot better job
with blood pressure lowering.
We're getting more folks
to quit cigarettes.
And we've dramatically
lowered the risk of stroke
in folks who are asymptomatic
just by getting them
on medical therapy, and we
think, we don't know yet,
that medical therapy
might be as good
as the surgical therapy
or the stenting therapy,
but that's why we're
doing this trial.
We need to find that out.
- Well, and, forgive me if
you've already answered this,
but, just very quickly, how do
you, if you're asymptomatic,
how do you determine that you're
a candidate for this study?
- So somebody has to find out
that you've got a narrowing
in your arteries.
It could be because
they heard a noise.
People who have blockages
in other arteries,
like Peripheral Artery
Disease, or Heart Disease,
may actually get their
carotid arteries looked at.
They have a higher chance
of having blockages
in other arteries.
So, if somebody looks at
them and finds the narrowing,
but it's not causing trouble,
then those are the candidates
that we are looking for.
- So you mentioned that the
risk of blocked arteries
includes stroke, death.
What about the risk factors?
Smoking, cholesterol, other
lifestyle issues, I'm guessing?
- It's just, the big risk
factor is getting older.
We can't fix that one, but
the other ones we can work on.
So, we can treat hypertension.
The cholesterol medicines,
the statin medicines,
have really made a
big difference here.
They tend to slow
down atherosclerosis,
or hardening of the
arteries, which is really
what we're trying to fix, and
almost stop it in its tracks.
And that's one of the reasons
that we're doing so much better
with medical management now
than we were 20 years ago.
Cigarette smoking is
a real risk factor.
If we can get 'em
off cigarettes, that
definitely helps.
Genetics has a role in it,
and diabetics are a little bit
more prone to get it.
- Ultimately, though,
if you don't respond
to the medical management,
and conditions worsen,
that stent's coming, right?
- You're either gonna get
a stent, or endoerectomy,
or you're likely
to have a stroke
if you fail medical
therapy, yes sir.
- Is there a flaw in the way
the carotid artery exists
in your body that
almost lends itself
to becoming a collection area
for things that can block it?
- It is common to most
arteries in the body,
but it's really
accentuated in the carotid.
The carotid artery
comes up in the front.
That's where you feel
the pulse in your neck.
And it comes up right about
the angle of your jaw.
It splits, and gives one
branch out to the scalp,
and one branch goes
up to the brain.
So the internal
carotid is the one
that's going inside
to the brain.
It starts off with this
little dilated area
that then narrows back down,
and we call this
the carotid bulb.
It's the term for
that dilated area.
Blood comes rushing
up the common carotid.
This pipe here.
Where you hit the bifurcation,
instead of just gently
turning that way,
it literally just drives
into the guard rail,
effectively, and
ricochets that way.
So we've got this
big area over here
where you have odd flow
going through it like this,
instead of rushing through like
the cars on the interstate.
It's just a little odd vortex.
And that odd pattern of
flow basically irritates
the lining of the artery there,
so it's primed to
over-respond to any injury.
So the tars from cigarettes
or high cholesterol,
that kind of stuff,
settle out right there,
and that's where we tend to
start with atherosclerosis
in the carotid artery.
- Does family history
cone into play?
- Yeah, sometimes
it's environmental
because everybody smokes,
but sometimes it's genetics.
It may be the types of
foods we contribute as well.
- Can you do a preemptive
strike and say,
my ancestors all had blocked
carotids, I need a stent now?
(laughs)
I want to make sure I
cover all the bases here.
- The problem with, anytime
we do something with humans,
we have a potential
for a bad outcome.
When we do interventions
like surgery or stenting,
there actually is a risk
associated with doing that,
a small, but real risk
of having a stroke
or some other complication.
So, if you're not
having troubles,
just as soon not take that
risk unless you really thought
you were about to have trouble.
So what this trial is looking
at is trying to figure out is
just general medical therapy
the best for most folks?
We'll be able to figure
out a subpopulation
that needs the interventions
like endorerctomy,
or stenting, or do they
all still need endoerectomy
and stenting?
- Well, I know that we're
at the onset of the trial,
and so it's an unfair
question, but just,
do you have a hypothesis about
whether medical management
can, longterm, keep people
from having more serious issues?
- So, I run a carotid
ultrasound lab at the VA
and at Medical College, and
when I first started doing this
many moons ago, people who
had carotid atherosclerosis
tended to just get worse
as we followed them along.
And with the advent of
the cholesterol medicines,
the statins, and better
blood-pressure control,
a lot of those patients
have quit getting worse.
So, it looks like
we stabilized them.
We don't make it go away, but
they just quit getting worse,
and so they stay asymptomatic.
And that's what's giving us
the hope that medical therapy
may keep us from having to go
to these other interventions.
- And perhaps the trial
will bear that out.
When will we know?
When is this gonna be over?
- Okay, so there's five
years of enrollment,
and then four years of followup.
And we're about a year
and a half into it.
So it's gonna be several
years before we know.
- Well, I'm always
fascinated with the research
that's going on
down at MCG and AU,
and I appreciate you leading
the way on this front,
for sure, Doctor.
- Thank you, sir.
- Absolutely, hope it
leads to saved lives
and improved lives
for people out there.
We're gonna have information
as to how you can take part
in this study.
Natalie Bishop is a
research coordinator.
You can call her at the
number on your screen,
or you see the email address
where you can let them know
that you are interested in
taking part in this trial.
See if you get selected.
Doctor Fenwick
Nichols and his team
at the Medical College of
Georgia at AU are ready
to hear from you.
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