By Matthew E. Fink, MD
Louis and Gertrude Feil Professor and Chair, Department of Neurology, Associate Dean for Clinical Affairs, New York-Presbyterian/Weill Cornell Medical College
Dr. Fink Reports no financial relationships relevant to this field of study.
SOURCE: Keyhani S, Cheng EM, Hoggatt KJ, et al. Comparative effectiveness of carotid endarterectomy vs initial medical therapy in patients with asymptomatic carotid stenosis. JAMA Neurol 2020;77:1-12.
Multiple randomized clinical trials have demonstrated that carotid endarterectomy is beneficial in patients who have symptomatic carotid stenosis, and currently, that is the recommendation for such patients. Several trials from 25 years ago also reported that carotid endarterectomy is beneficial in patients with asymptomatic carotid artery stenosis greater than 60%. However, in the intervening years, advances in medical therapy, including statins and antiplatelet regimens, as well as significant improvement in the management of blood pressure, diabetes, diet, and exercise, have been shown to reduce stroke rate. Therefore, it is currently controversial whether carotid endarterectomy is still beneficial in asymptomatic patients with carotid artery stenosis compared to current medical management.
These investigators analyzed several large databases from the U.S. Department of Veterans Affairs that collected clinical data on veterans of the U.S. Armed Forces age 65 years or older who had carotid imaging performed between 2005 and 2009. Patients who had less than 50% stenosis or had a history of stroke or transient ischemic attack in the six months before imaging was performed were excluded from the analysis. A cohort of patients who were treated with initial medical therapy and a cohort of similar patients who were treated with carotid endarterectomy were collected and followed for up to five years. Kaplan-Meier curves were computed, and estimates of both fatal and nonfatal strokes were determined in each cohort over a five-year period of follow-up.
The study identified and followed 5,221 patients. The mean age was 73.6 years and 98.8% were men. Among the study participants, 2,509 received carotid endarterectomy and 2,479 received initial medical therapy within one year after carotid imaging. In those who underwent carotid endarterectomy, the observed rate of stroke or death as a perioperative complication was 2.5%. The five-year risk of fatal and nonfatal strokes was lower in those who underwent carotid endarterectomy compared to the patients randomized to initial medical therapy (5.6% vs. 7.8%). However, when the perioperative risks of death and perioperative stroke were included, there was no significant difference in the overall risk of stroke or death over a five-year period. The overall five-year risk of fatal and nonfatal strokes was 5.5% in patients undergoing carotid endarterectomy and 7.6% among those randomized to medical therapy. These differences were not statistically significant. Compared to trials performed more than 20 years ago, the risk reduction was less than half in the current study, and supports medical therapy as an acceptable alternative strategy for these patients.