Medical therapy

Carotid endarterectomy and medical therapy show similar efficacy in asymptomatic carotid stenosis

1. In patients with asymptomatic carotid stenosis, there was no significant difference between the comparative effectiveness of initial medical therapy versus carotid endarterectomy.

2. The absolute risk reduction was found to be less than half the difference in risk of fatal and non-fatal strokes from carotid endarterectomy compared to 20 years ago.

Level of evidence assessment: 1 (Excellent)

Summary of the study: Symptomatic and asymptomatic patients with carotid stenosis have been effectively treated with carotid endarterectomy for decades. However, little is known about the effectiveness of initial medical treatment, given the latest pharmacological advances of the last decade, in asymptomatic patients. This study compares the effectiveness of the two treatment regimens in preventing the 5-year risk of fatal and non-fatal strokes. The results indicate that initial medical therapy may be an appropriate treatment regimen given the presence of perioperative risks with carotid endarterectomy, among other factors.

This study managed to collect comprehensive data from a large database offering a robust sample size and, therefore, providing qualitative results that mimic real-world settings. The study was limited by the lack of inclusion of perioperative stroke in the analysis of perioperative complications of carotid endarterectomy that resulted in death. Second, the study data were extracted using specific ICD-9 codes and the lack of coding for a given case scenario may have resulted in case data being omitted from the study. Finally, the study cannot be generalized to the entire population because it mainly analyzed data on veterans.

Click to read the study in JAMA

Relevant Reading: Endarterectomy for Asymptomatic Carotid Artery Stenosis

In depth [systematic review and meta-analysis]: This study used data from the United States Department of Veterans Affairs (VA) and Medicare and was conducted from August 28, 2018 to March 2, 2020. In this study, a total of 219,979 veterans were identified, of whom 5,221 were discovered to have asymptomatic carotid stenosis. Participants were enrolled if they met the following criteria: carotid stenosis of 70% or greater (or a qualitative description of close occlusion, critical stenosis, or severe stenosis), visited an AV facility at least once between January 1 2005 and December 31, 2009, aged 65 or older, and completed a type of diagnostic carotid imaging. Study data such as patient demographics, vital signs, and laboratory data were pulled directly from the VA corporate data warehouse and Medicare data. The suicide data repository was also used to identify the death and cause of death, if necessary. A review of medical records was also performed, followed by data analysis. In summary, carotid endarterectomy and medical treatment showed similar efficacy in patients with asymptomatic carotid stenosis.

Picture: PD

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