From the Research
The next step in managing a patient with chronic small vessel ischemic changes and vascular calcification without acute hemorrhage or infarct should focus on aggressive vascular risk factor modification, including starting antiplatelet therapy and statin therapy, controlling blood pressure, and implementing lifestyle modifications. This approach is supported by the most recent and highest quality study available, which highlights the importance of addressing the underlying pathophysiology of atherosclerosis and endothelial dysfunction that contribute to small vessel disease 1. Key components of this approach include:
- Starting antiplatelet therapy with aspirin 81-100mg daily or clopidogrel 75mg daily if aspirin is contraindicated
- Controlling blood pressure to a target of <130/80 mmHg using appropriate antihypertensives such as ACE inhibitors (like lisinopril 10-40mg daily) or ARBs
- Initiating statin therapy with high-intensity options like atorvastatin 40-80mg or rosuvastatin 20-40mg daily to achieve LDL levels below 70 mg/dL, despite the potential association with increased coronary artery calcification 1
- Implementing lifestyle modifications, including smoking cessation, regular physical activity (150 minutes of moderate exercise weekly), Mediterranean or DASH diet, and limiting alcohol consumption
- Managing diabetes with a target HbA1c <7% for affected patients
- Regular follow-up with neuroimaging in 6-12 months to monitor disease progression, as cerebral small vessel disease is a major risk factor for multiple acute and chronic neurologic diseases 2. The use of statins, in particular, has been shown to have a complex relationship with vascular calcification, with potential benefits in terms of reducing the risk of atherothrombotic vascular events, despite the possibility of increasing coronary artery calcification 3, 1. Overall, a comprehensive approach that addresses the underlying pathophysiology of small vessel disease and incorporates the latest evidence on statin therapy and vascular calcification is essential for slowing disease progression and reducing the risk of future stroke or cognitive decline.