Medical Therapy, Carotid Endarterectomy on Par in Asymptomatic Carotid Stenosis

A US comparative effectiveness study suggests that, given the up-front perioperative risks associated with carotid endarterectomy (CEA) and the reduced benefit derived from revascularization, initial medical therapy may be an acceptable treatment strategy for asymptomatic carotid stenosis. The study included 5221 patients who received carotid imaging between January 1, 2005, and December 31, 2009, and followed up for 5 years; 2712 (mean age, 73.6 years; 98.8% men) received CEA and 2509 (mean age, 73.6 years; 98.8% men) received initial medical therapy within 1 year after the index carotid imaging. The observed rate of stroke or death (perioperative complications) within 30 days in the CEA cohort was 2.5%. The 5-year risk of fatal and nonfatal strokes was lower among patients randomized to CEA compared with patients randomized to initial medical therapy (5.6% vs 7.8%). In an analysis that incorporated the competing risk of death, the risk difference between the 2 cohorts was lower (risk difference, −0.8%). Among patients who met inclusion criteria of randomized clinical trials, the 5-year risk of fatal and nonfatal strokes was 5.5% among patients randomized to CEA and was 7.6% among those randomized to initial medical therapy. Accounting for competing risks resulted in a risk difference of −0.9%. The findings suggest that patients treated with CEA would now require a longer time to accrue enough stroke reduction benefit to justify the up-front risks of the surgical procedure. Source: https://jamanetwork.com/