 It looks like it's eight o'clock. We'll go ahead and get started. My name's Russell Swann. I'm introducing on behalf of Dan, for those of you who don't know, he's a member of the VA. But he also had, him and his wife had their second baby on Friday, even as her name just says hello. I'm the honor of introducing Eileen Pong this morning. For those of you who haven't had the chance to interact with her, I know that all the residents feel that she's done an absolutely amazing job at the VA. She had the fortunate luck of being the intern when we transitioned faces back to the VA. And it happened to correlate at the same time that the surgery scheduler was on vacation for six weeks. So she had to work super overtime for a very long time. It was just an absolutely tremendous job. So I know that all the chiefs and now the residents really appreciate all your hard work. She comes to us from New Jersey. She can handle all the other guys in the program here, because she has four younger brothers. So she knows how to put up with our group. And she's going to be talking to us about should patients with hauling horse plaques have carotid ultrasounds and echocardiograms. And the other thing I'll just mention is she's a really good seer and has maintained her ski patrol license. So if you ever want to go skiing, I'd be glad to know. Thank you for that introduction, Russ. He's never seen me ski, so I don't know how he knows that. Well, you guys are good. All right, so today I'm going to talk about a topic that was inspired by a few patients that I saw really early on just in my first few weeks of the VA, which is whether when we find a hauling horse plaque in a patient, whether we should recommend or send them for carotid ultrasounds and echocardiograms. So the first patient that I'm going to talk about, maybe you can recognize the handwriting as to who evaluated this, you should. But he's an 83-year-old male who had a history of diabetes, chronic kidney disease, hypertension, and hyperlipidemia. And he came to us really for a cataract evaluation. He had seen optometry for his yearly diabetic eye exam, and then they saw he had cataracts. They sent him to us. In that intervening time, I think it was a month or so, he developed a sudden loss of vision in the bottom half of his right eye two weeks before he came to his ophthalmology visit after his optometry visit. He, his best corrected visual acuity was 2030 in the right and 2030 in the left. On the slit lamp exam, he had significant nuclear sclerosis, and on his fundus exam, he had moderate nonproliferative diabetic retinopathy, dot blot hemorrhages in both eyes. And in the right eye, he had pallor of the fundus and attenuated vessels in the superior half of the fundus, and he also had a horn-horse plaque in the superior part of his disc. And so we got a visual field, and this is his visual field, which corresponds to the location of that pallor of that attenuation and the horn-horse plaque. So, you know, we're gonna talk about what we wanna do with this patient. So, I'd like to ask you guys, we'll take a poll by raising your hands. How many of you would send this patient for a carotid ultrasound? Okay, how many of you would send this patient for echocardiogram? Okay, fewer people, that's still a significant amount of people. And how many of you would write a letter to their primary care doctor, asking them to take care of all the testing? And how many of you would order the testing yourselves if you thought it was necessary? Okay, so yeah, it's the VA, we have the power to order these tests, and we're all about efficiency here, so we approved him for cataract surgery in both eyes, and we ordered the carotid ultrasound and echocardiogram. So I'm gonna talk about another patient who actually I saw about, we saw about three days before this other patient. He's an 80-year-old guy with a history of mitral valve regurgitation and hyperlipidemia, and he presented to us for cataract evaluation because he had gradual blurring of vision in his right eye. His best corrected visual acuity was 2060 in the right and 2040 in the left, and he had significant nuclear sclerosis and PSC in the right. And this is a photo of his left fundus, and you can see that bright spot right here, with a nice little horn-horse plaque, but he didn't complain of having any blind spots or scatomas. So for this patient, I don't know if you guys would feel any differently about him, but let's take a poll again. How many people would like to order a carotid ultrasound for him? And how many people would like to order an echocardiogram? Okay, so while we did the same thing for this guy, we approved him for cataract surgery in both eyes and ordered the tests. So we'll find out what happened to these patients a little bit later on in this presentation. So the first question that I'm gonna tackle is the echocardiogram question, and then I'll move on to the carotid ultrasounds. So I think a good question that I would hope that there would be clear answers to would be, does obtaining an echocardiogram in a patient with a horn-horse plaque improve their morbidity and mortality, most likely from strokes, but potentially from other things? However, there's not any studies that really directly address this. Like an ideal study would be a randomized control trial where you take patients with horn-horse plaques and half of them you do echoes and then another half you don't and then see if that really affects their long-term outcomes. So other questions that might be easier to answer than that one would be, how often do we find things on echocardiogram when we send these patients with horn-horse plaques? And also another question is, how often do these things that we find in echocardiogram really change management in these patients? So there's a number of studies, most of them don't have really large sample sizes, but this one had 77 patients with horn-horse plaque, amorosis, FUGAX, or retinal arterial occlusions. And they found in about 10% some significant findings on echocardiogram, but I wouldn't say that any of these would change patient management. Hopefully if you find a mechanical valve on the echo, the patient already knows they have a mechanical valve and they're being anti-coagulated. This is another study, had higher numbers, and this is actually not of horn-horse plaques, it's of central retinal artery occlusions and branch retinal artery occlusions. And they found about 50% with significant findings, but they considered significant findings to be, for example, a calcified aortic valve, which as little questionable was there that's a good embolic source that would increase your risk of stroke, and also that probably wouldn't change management. And just a little bit about mitral valve prolapse, since our one guy, he did have moderate mitral regurgitation that was known. Mitral valve prolapse, there's a question as whether to anti-coagulate these patients, because it's not clear whether or not there's increased risk of stroke from embolism with these patients. So there's some 2006 guidelines that just recommend giving them aspirin. And this is another study, so those previous two studies, they didn't really demonstrate any findings that would change management of the patients, but this one, a really small study, just 11 patients, but they found one atrial myxoma and one intracardiac thrombus. And those are the real things that, if we did find them on the echo, it'd be really good that we caught that because those patients should either be anti-coagulated or have surgery, but it's probably pretty rare. So in answer to the question of whether or not patients with hallowed horse plaques should get echocardiograms, I would say in support of that, if we do find one of these findings that require intervention, it would really make a difference in that individual patient, but I think it's probably very rare. We'd have to do a lot of echocardiograms to find anything that needs treating. So now on to carotid ultrasounds. And so here again, I thought of a question that ideally could be answered by a randomized control trial, but there aren't any of those. So then I tried to break it down into questions that actually could be answered by the available literature. So the question that we'd like to have an answer to is, does obtaining a carotid ultrasound in a patient with a hallowed horse plaque reduce future strokes? Does doing those ultrasounds result in findings that then resulted interventions that would improve patient outcomes? So, and then the questions that I broke it down into was number one, how often does carotid ultrasound in these patients demonstrate significant stenosis? And number two, if the patient with the hallowed horse plaque is found to have significant carotid stenosis, is that an indication for carotid anardorectomy? Because even if we find a lot of patients with let's say 80% stenosis on the ultrasound, but that is not an indication for anardorectomy, then what's the point of really getting that test? So, this is a study that had 237 patients with hallowed horse plaque, so that's a pretty good sample size. And they found 13% with greater than 70% stenosis of that ipsilateral internal carotid artery. And I'd say that's pretty, there are a lot of studies like this, and that's pretty average. They found maybe five to 20% with significant or severe carotid stenosis. So, I'm gonna go back to the patients that we talked about in the beginning and give you their results. So, patient number one, who had the hemorrhaginal artery occlusion that was symptomatic, he had carotid dopplers on both sides, and they showed diffuse plaques, but no significant stenosis. He also had the echo that showed no embolic source. And patient number two, who had the asymptomatic hallowed horse plaque with the photo that I showed you in his left eye, his carotid ultrasound showed plaque and greater than, oops, that's a less than sign, but greater than 70% stenosis on that same side. So, that is definitely classified as severe stenosis. And his echocardiogram showed mitral valve prolapse with mild to moderate mitral valve regurgitation, which we already mentioned, there's a questionable association between that and embolic strokes. So, we talked about question number one, which is how often do we find things on carotid ultrasound? And now I'm going to talk about number two, which is that in patients with hallowed horse plaques that are found to have severe carotid stenosis, should they have carotid anardorectomy? So there's, I found, I was able to find one study that directly addressed this. This was a retrospective case series. And they looked at 28 eyes that had hallowed horse plaques and then had ipsilateral anardorectomy. And 37 eyes that had hallowed horse plaques that were managed medically. And they kind of broke it down. They followed this group for about four years and they found that 28 of these patients or eyes got new hallowed horse plaques. One had a late stroke and one had a perioperative stroke. And then these eyes that were patients that were managed medically, they had two new hallowed horse plaques, two late strokes and one late TIA. And they didn't really talk about whether the difference between these two groups was significant. Their conclusion was that doing the surgery doesn't prevent strokes simply, I think, because one of these patients- I don't know if you saw those differences or not. Yeah, yeah. Well, yeah. Sometimes you don't. That's not true. Right. Yeah, I was just trying to say that in a nice way, but I do think that the reason they didn't mention any statistical tests on this part of their study was that there wasn't any significance. Yeah, so this was the study that most directly addressed the question of whether these patients should have anardorectomy, but it's not really conclusive and it doesn't help us figure out what to do. So I thought I'd look at the general guidelines for carotid anardorectomy. It's pretty clear that for patients that have symptomatic carotid stenosis and severe, so they have either TIAs or strokes and they have greater than 70% stenosis, it's really of a benefit to them to have that surgery. However, for patients that are asymptomatic and have that severe stenosis, it's not as clear. You can look at the perioperative morbidity and mortality and that's pretty high, so that means within those 30 days after having that surgery, your chances of having a disabling stroke or heart attack or dying are, I think that's high, like 5% of dying or having a major stroke in one month, so you have to weigh that versus their risk reduction of stroke over the next few years. So I would say in general, they don't really recommend surgery for asymptomatic carotid stenosis in most people, but it's very clear that for symptomatic patients they should have the surgery. But that doesn't really address the question of do we think holland-horse plaques should be categorized as symptomatic or asymptomatic? So some people would consider it to be symptomatic because you obviously see an embolus that could have come from the carotid artery. However, I did read a view article where they categorized it as asymptomatic and maybe it should depend on whether the patient has symptoms from their holland-horse plaque or not. So let's look at how we can really break this question down of how to categorize these patients with holland-horse plaques. So we can look at the stroke risk in these patients. Patients with asymptomatic stenosis have a lot lower future stroke risk and patients with symptomatic stenosis have a higher stroke risk. And we can look at the timing. With the symptomatic patients, we know that their plaque is unstable and we need to address that soon. Whereas the asymptomatic patients, we don't know if that plaque is stable or unstable or when we really need to take care of it. So I looked at one study that examined whether patients with holland-horse plaques had increased risk of stroke. And they do definitely have increased risk of stroke compared to the general population. This is pool data from two studies, one from Wisconsin and one from Australia. That shows that after 10 years, about 12% of the patients died from stroke that had holland-horse plaques. I tried to compare that to data that we had from those other studies from as to whether, how that compares the symptomatic carotid stenosis versus asymptomatic carotid stenosis. But it doesn't really match up because this is deaths from stroke and this is major stroke rates. So it's hard to tell from the stroke risk whether to categorize them as symptomatic or asymptomatic. But I think it's more clear when we look at the timing that patients with holland-horse plaques that are symptomatic from them should probably be categorized with the symptomatic carotid stenosis patients. So I talked a little bit about this, but patients for example that have a stroke and that's associated with severe carotid stenosis on that side, you know clearly that at that time that plaque is unstable. So they showed that a lot of the benefit of carotid and artorectomy is when it's done pretty soon after, weeks to maybe a few months after their event. Because after that time the plaque just gets more stable and they're not as much of a high risk for strokes. And then so when we look at the patients with holland-horse plaques and they're asymptomatic we actually don't know how long that plaque's been there. Some of these studies in this time of 33 months so it could have been there for two years and maybe they don't have a high risk of stroke anymore and they wouldn't really benefit from as much from an artorectomy. So I think really looking at this timing issue it demonstrates that it's important if we can find out whether the patient has symptoms to associate that with their holland-horse plaque. So let's say we do have someone who knows, like that guy, he was like two weeks ago I lost the lower vision in my right eye and we see his plaque there. So what will we do about that? Is that an indication for an artorectomy? So this wasn't really studied in those major an artorectomy trials. However, amaurosis fugax was included in the trials regarding whether an artorectomy is beneficial. So this is one of the really big studies comparing medical management and an artorectomy and half the patients had strokes and half had TIAs and about a quarter of the patients that had an artorectomy for TIAs or were randomized in this trial they had amaurosis fugax. So we can kind of look at that and see what can we learn about that that maybe we could apply to a holland-horse plaques. And what we learned from that is actually patients that had hemispheric TIAs meaning other symptoms from their brain with the TIA compared to patients that had amaurosis fugax. The amaurosis fugax patients had a lot lower risk of stroke, 10% versus 20%. So that kind of calls into question the benefit of intervening in these patients. However, they did find that an artorectomy did reduce the stroke risk but it didn't really reduce it by very much. Like for these hemispheric TIA patients their risk dropped from 20% to 10% but the amaurosis fugax patients it went from 10 to 8.7. So that's not really a big benefit. So they kind of, so they looked at this and they decided to break the patients down into patients that were low risk for stroke and high risk for stroke and they found the patients that had a number of these risk factors they benefited a lot more for the an artorectomy. So they didn't recommend an artorectomy for amaurosis fugax in patients that were low or moderate risk for stroke. So in conclusion, I think that we can kind of apply some of what I talked about regarding the timing and regarding amaurosis fugax to whether we should get carotid ultrasounds in these patients that have hauling horse plaques. So we think that like I mentioned the main distinction is do we consider these patients with hauling horse plaques to have symptomatic or asymptomatic carotid stenosis. I do think that we should order these tests if we consider them to be symptomatic. And I do think that it's more likely that the carotid ultrasound would be beneficial if the patients have some of those risk factors for stroke in the future. And if they have symptoms from their hauling horse plaques so that we know when did this event occur. So I'm gonna go back to the cases that I talked about in the beginning. So case number one is the man who actually was symptomatic. So we saw him in July and we ordered these tests. We gave him a surgical date at the same time. And so he had both eyes done by Dan Bedis and he's doing quite well. So this other patient, he was actually the one that was asymptomatic and we scheduled him for surgery and ordered the test at the same time. But we had to postpone it a little bit after his carotid ultrasound came back with a greater than 70% stenosis. Then we found that result. We mentioned it to Vascular. Vascular wanted us to get a CT angiogram. We got the CT angiogram. We sent him back to Vascular. Vascular said they had to have a meeting about they had to present him in their conference in order to decide what to do about him. And so yeah, about two months later he had the left carotid anardorectomy. I do think the timing of this little questionable, like they said, that patients should probably have the surgery within two to six weeks of their symptoms and he doesn't have any symptoms. And I just recently saw him in clinic. He showed up. He's like, okay, I'm ready. And what he really wants is new glasses. But someone told him he has to have cataract surgery before he can have new glasses. And if he wants cataract surgery he has to take care of his neck artery. So yeah, this is the photo of him. His scar was actually a lot better before but he came in yesterday to have me take his photo and it's like this. So in conclusion, I think for that first patient that was symptomatic, I'd be more likely to order a carotid ultrasound on him. I don't think that the echo is really that much of a benefit, so I might not do that on either of the patients. And then for the second patient, I'm not really sure about whether I get the ultrasound or not, but I guess we could always order them and then leave it up to vascular surgery to decide whether they should do the surgeries or not. All right, what questions do you have? Yeah, I do think it's likely that it could be the source of the MLI because the plaque could be unstable even if it's not so large that it's impinging on the flow in the vessel. However, for those patients, there's no benefit shown with the carotid and our directivine. So we would just treat them like we would treat anyone if we just found any atherosclerosis anywhere where we would optimize their blood pressure, make sure their diabetes is under control and give them statins and aspirin. Even though that could be an embolic source, it probably wouldn't change management. Doctor. First of all, excellent presentation. Right. So that was an interesting part of this. And then as we talk about symptomatic, talk about symptomatic like it's black or white, I'll just give you an example. I had a carpenter, he was not ready to leave, he was just kind of like an afterthought. More carefully, it blew out, it was perfect. That's just symptomatic, but the process of symptomatic is symptomatic. So we forget, as we did in studies, you'd usually break great books written at one of the Dartmouth instances, because we make that line less than it's likely. Right. So I'm going to throw one other one in here, and sadly, this is also part of the bulletin. Medicine, that is, if you had this happen in someone else's shoes, and they sue you. Right. And they said you had to prevent a lesion of defensive medicine. Having been involved in defense work in a lot of trials, a trial is not the term, I'm sorry to pop people's bubbles here, but a trial is not the term necessarily, but that's the part here that's... Yes, I do think that with regards to echocardiograms, that chance of missing someone that does have major issue like an intracarcterombus or atrial maxima should play a role in deciding whether or not to order that. And also with regards to patients that have repeated amaurosis, FUGAX, some of them do go blind afterward, so. Oh, wow. Thanks, Dr. Warner. So back to your talk, and... How would medical management differ if they had significant carotid stenosis than if we just saw the, saw plaques in their arteries or just saw the whole and horse plaque? So... Yeah, I would recommend though, for patients where we see whole and horse plaques, they definitely should be started on an aspirin and a statin by their primary care doctor, and their hypertension and diabetes and lipids should be managed too. I would agree with that. Brian Stag did you have a question?