Considerations in the Treatment of Carotid Disease: The Expanding Role of the Cath Lab Clinician

Carotid artery disease is responsible for approximately 10-20% of all ischemic strokes in the U.S.¹ The clinical indications, as well as cautions related to carotid interventions, are widely recognized. The current recommendations around identification of patients who are appropriate for carotid artery stenting (CAS) or carotid endarterectomy (CEA) describe the broad clinical indication as being those patients who demonstrate carotid narrowing of greater than 70% in most cases, and in a select sub-group, patients who demonstrate narrowing of 50-69%.¹

Over the past several years, Corazon has witnessed much attention devoted to the determination of treatment criteria for CAS and CEA as a means to minimize the known risks associated with both procedures, and also to identify which patients are most likely to benefit from each procedure. 

Recently released trial results from CREST (Carotid Revascularization Endarterectomy vs. Stenting Trial) and a soon-to-be-published article in the American Heart Association journal Stroke discuss peri-and post-procedural stroke and mortality risks associated with patients who are at increased risk.^2-3 These data reinforce the expanding focus on case selection and the management of known risk factors and complications, particularly stroke.

Patients with pre-determined vascular disease presenting for definitive treatment in the cath lab are those most commonly considered when discussing the role or importance of the integration of neuroscience expertise into the cath lab clinical staff.  While we agree that the development of the appropriate assessment skills and treatment algorithms/processes are essential to proactively care for the “elective” carotid patient, we believe that a less frequently recognized, more vulnerable patient population must be considered. Given the expansion of available treatment options, as well as the growing complexity of those treatments, the risk of peri- and post-procedural stroke can be expected to increase in the absence of focused efforts to minimize those risks.

Corazon recommends that the cath lab leader consider the following when planning for staff education.  Further strategies should be evaluated as part of an expanded effort to provide the safest environment of care possible.

Recent studies confirm that most strokes (60% to 80%) are delayed, and as such, are not identified immediately post procedure.⁴ Many times the documentation will account for the patient as ‘neurologically intact’ at the end of the case, yet deterioration in neurologic status during the post procedural phase of care often occurs.  Thus, it is essential that the cath lab staff incorporate the following into the standard care algorithm in order to quickly recognize a change in condition should one occur:

• Completion of a standard neurologic exam by the cath lab clinician both pre-procedure to establish a baseline and immediately post procedure to verify any change in condition.
• Performance of the National Institute of Health Stroke Survey (NIHSS), widely recognized as the appropriate tool for neurologic exam in patients at risk for stroke.

Also, incorporation of a “dual neuro check” during patient hand-offs.  Given that the majority of patients who experience stroke symptoms do so in the post-procedure phase, Corazon recommends that the NIHSS be completed by clinicians in tandem during patient hand-off. For instance, from the cath lab to the post procedure/recovery area, from recovery to the telemetry unit, etc. This practice will allow for the early recognition and validation of discrete findings, which can lead to more rapid response to changes in condition.

• Increased staff education. As most post-op events occur in the first 24 hours, it is important that efforts around staff training to reinforce competence in neurologic exam and a consistent approach to the assessment of these patients be extended beyond the cath lab to the peri- and post-procedural areas, and even into the telemetry unit. Corazon also recommends very basic training of support staff (patient transporters, unit secretaries, etc.) with respect to the signs and symptoms of stroke so that they are aware of the possibility of new onset stroke for patients they come in contact with. Early recognition and emergent treatment are the keys to improved outcomes in stroke; therefore, heightened awareness is essential. 

In many organizations, Corazon finds that the cath lab leadership can be a powerful force for advancing this concept and ensuring a consistency of approach. Incorporation of stroke awareness and integration of indicated protocols for the cath lab staff can be a difficult proposition. As a result, there may be staff resistance to the addition of responsibilities for which they see no need. In our experience, this resistance is largely based on fear. Corazon believes that by educating staff on the direct impact that early stroke recognition has on treatment outcomes, they will embrace the opportunity to contribute to the care of patients in this new way.

• Advanced communication of patient profile. Ideally, patients who are at greatest risk for stroke are identified in advance, and the possibility of an adverse outcome is proactively considered for all involved in the episode of care. 

The following criteria, which have been identified as indicators of increased risk, should be clearly and consistently communicated to the clinical and operational teams:

• Patients who are symptomatic from carotid disease;
• Patients with a history of prior cerebrovascular accident (CVA) and/or transient ischemic attack (TIA) who are now asymptomatic;
• Patients diagnosed with contralateral carotid occlusion;
• Patients on antiplatelet therapy;
• Patients of advanced age;
• Patient who smoke;
• Patients with co-morbid conditions such as cancer, heart disease, hypertension, or diabetes.  
• Collaboration with physicians across all care delivery areas. Corazon encourages cath lab leaders to work with their physicians as a way to increase the likelihood of early symptom recognition, should the patient suffer an ischemic event while in the cath lab. In some cases, the interventional cardiologist may be resistant to the idea of a hospital-wide stroke team, for example, or to the integration of established care protocols for the evaluation and treatment of stroke. Many clinicians are inclined to treat the patient with new onset stroke alone, and without the benefit of the expedited treatment track that most commonly results when a hospital stroke or rapid response team is involved. 
• One additional goal should be to ensure the following intra-procedural practices are implemented, if not already:  
• Intervention to be performed awake and under regional anesthesia whenever possible.
• Utilization of EEG and SSEP monitoring during intervention.
• Consideration of the performance of an appropriate completion study.
• Ready access to transcranial Doppler, as this testing modality has been shown to be sensitive in detecting cerebral emboli.
• Integration of any existing “stroke alert” protocols into the cath lab environment. If protocols aren’t already being used, we encourage cath lab leaders to identify either internal or external experts who can either provide the required protocols or assist in their development.
• Structured and comprehensive education for staff, designed to develop the skills necessary to perform an accurate and comprehensive neurologic exam.
• Regular and rigorous evaluation and reinforcement of existing processes. This will ensure not only the accurate recognition of a neurologic deterioration, but also the rapid activation of necessary clinical support teams to ensure appropriate care.
• Implementation of a system to ensure regular and ongoing assessment of staff competence with respect to care of the neurologic patient.

As interventional treatment options for carotid disease expand, so does the responsibility for cath lab leaders. Stroke has evolved from a largely medically managed, supportive care event, to one for which many varied treatment options are available. The successful treatment of stroke, as measured by decreased mortality, decreased long-term disability, and the optimization of functional outcomes, is largely dependent on the early recognition of symptoms and the immediate initiation of appropriate treatment. And indeed, the staff in the cath lab is, many times, in the best position to most quickly notice a change in condition, indicative of new onset stroke, for patients being treated for carotid disease. 

We encourage leaders to embrace the opportunity to proactively address the issue of stroke in the cath lab. Often this significant clinical possibility is overlooked. For each minute of interrupted cerebral blood flow, 2 million brain cells die.⁵ Early recognition and timely initiation of appropriate care protocols can make the difference between a life of dependence and disability post event, or a full recovery and independent living. 

In order to be prepared to offer patients the best possible care, especially in the case of a post- or peri-procedure stroke, a proactive and comprehensive approach to the care process is necessary. Only then can cardiac programs have the capability to provide the highest level of care to not only the “routine” patients, but to those who experience an unanticipated neurologic event as well. 

Stacey is a Vice President at Corazon, Inc., offering program development for the heart, vascular, neuro, and orthopedics specialties, and providing consulting, recruitment, interim management, and IT solutions to clients across the country and in Canada. To learn more, visit www.corazoninc.com or call (412) 364-8200. To reach Stacey, email slang@corazoninc.com.  

References

1. Carotid Stenosis. Now@NEJM. September 20, 2013. Available online at https://blogs.nejm.org/now/index.php/carotid-stenosis/2013/09/20/. Accessed November 27, 2013.
2. Hill MD, Brooks W, Mackey A, Clark WM, Meschia JF, Morrish WF, et al; CREST Investigators. Stroke after carotid stenting and endarterectomy in the Carotid Revascularization Endarterectomy versus Stenting Trial (CREST). Circulation. 2012 Dec 18; 126(25): 3054-3061. 
3. Touzé E, Trinquart L, Felgueiras R, Rerkasem K, Bonati LH, Meliksetyan G, et al.; Carotid Stenting Trialists’ Collaboration. A clinical rule (sex, contralateral occlusion, age, and restenosis) to select patients for stenting versus carotid endarterectomy: systematic review of observational studies with validation in randomized trials. Stroke. 2013 Dec; 44(12): 3394-3400. doi: 10.1161/STROKEAHA.113.002756. Epub 2013 Oct 17.
4. Guptill JT, Mehta RH, Armstrong PW, Horton J, Laskowitz D, James S, et al. Stroke after primary percutaneous coronary intervention in patients with ST-segment elevation myocardial infarction: timing, characteristics, and clinical outcomes. Circ Cardiovasc Interv. 2013 Apr; 6(2): 176-183.
5. National Stroke Association. Fact Sheets. Stroke 101 and Prevention: Stroke 101. Available for download at https://www.stroke.org/site/PageServer?pagename=
6. factsheets. Accessed December 3, 2013.