Modern Treatment of Asymptomatic Carotid Stenosis —The Importance of Both Medical Therapy and Carotid Endarterectomy

Each year there are approximately 700  000 new ischemic strokes in the US, and 10% to 15% of them are caused by thromboembolism from a previously asymptomatic carotid stenosis (ACS). Three large randomized clinical trials, published in the 1990s and early 2000s, have demonstrated a significant benefit of carotid endarterectomy (CEA) i n preventing stroke in patients with severe ACS compared with medical therapy alone. They showed a 50% relative risk reduction in 5-year stroke rate and an approximately 1% per year absolute stroke risk reduction. Over the course of the past 2 decades, there has been significant improvement and expa nsion in medical therapy for ACS that now encompasses aggressive smoking cessation, adoption of a Mediterranean diet, treatment of obesity, regular exercise, blood pressure control, statin use, diabetes management, and antiplatelet medication. This recent expansion of medical therapy, particularly h ighlighted by the wide adoption of statin use, has led some experts to argue that medical therapy alone has decreased stroke risk in patients with ACS to such an extent that CEA is no longer justified in any patients with ACS. Notwithstanding multiple articles and rebuttals, leading to significant c ontroversy and strong opinions, many practices in the US have shifted to a more selective use of CEA in patients with ACS. Despite this trend, the risk of stroke in patients with severe ACS treated with medical therapy alone may be higher than assumed. In th...
Source: JAMA Surgery - Category: Sports Medicine Source Type: research