Medical therapy as effective as endarterectomy for asymptomatic carotid stenosis

Researchers have found in a comparative effectiveness study that 5-year stroke risk did not differ significantly for patients who had carotid endarterectomy (CEA) vs initial medical therapy for asymptomatic carotid stenosis.

Carotid endarterectomy (CEA) among asymptomatic patients involves a trade-off between a higher short-term perioperative risk in exchange for a lower long-term risk of stroke.

Researchers conducted the study to examine whether early intervention (CEA) was superior to initial medical therapy in real-world practice in preventing fatal and nonfatal strokes among patients with asymptomatic carotid stenosis.

Last relevant randomized controlled trial (RCT) began 25 years ago.The data from the modern era offer a shift in perspective, especially with consideration of competing risks.

Data analyzed were those of veterans of the US Armed Forces aged 65 years or older who received carotid imaging between January 1, 2005, and December 31, 2009. Carotid imaging performed 2005-2009, and stenosis ≥70% was treated with CEA or initial medical therapy.The data were analyzed for a pragmatic sample, and "RCT-like" sample of patients would have met inclusion criteria for RCT. The main outcome of the research was risk for fatal, nonfatal strokes.

The researchers found that there was an overall, 2.5% rate of stroke or death within 30 days of carotid endarterectomy. In the RCT-like sample, 5-year stroke risk was lower with CEA than with initial medical therapy:5.6% vs 7.8%.Risk difference: −2.3% (95% CI, −4.0% to −0.3%).When competing for risk for nonstroke death was considered, however, the risk difference decreased to −0.8% (95% CI, −2.1% to 0.5%). Among patients in the RCT-like sample meeting trial inclusion criteria, 5-year stroke risk was lower with CEA:5.5% vs 7.6%.Risk difference: −2.1% (95% CI, −4.4% to −0.2%).When competing risk was taken into account, however, the risk difference decreased to −0.9% (95% CI, −2.9% to 0.7%)

The limitations included mainly older male veterans.

Exclusions (e.g., milder stenosis, recent stroke).Perioperative mortality risk not incorporated. Some stroke deaths potentially missed.

For further reference log on to: 

Keyhani S, Cheng EM, Hoggatt KJ, Austin PC, Madden E, Hebert PL, Halm EA, Naseri A, Johanning JM, Mowery D, Chapman WW, Bravata DM. Comparative Effectiveness of Carotid Endarterectomy vs Initial Medical Therapy in Patients With Asymptomatic Carotid Stenosis. JAMA Neurol. 2020 Jun 1 [Epub ahead of print].