10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1)

A multicentre randomised trial

Alison Halliday, Michael Harrison, Elizabeth Hayter, Xiangling Kong, Averil Mansfield, Joanna Marro, Hongchao Pan, Richard Peto, John Potter, Kazem Rahimi, Angela Rau, Steven Robertson, Jonathan Streifler, Dafydd Thomas, M. E. Cooper, M. MacKay, J. Wood, G. Christopoulos, M. C. Pereira, Christian Blomstrand & 205 others C. Forssell, A. Potemkowski, C. Skiöldebrand, P. Stoor, M. Blomqvist, M. Calander, C. Forssell, F. Lundgren, H. Almqvist, L. Norgren, Bo Norrving, E. Ribbe, J. Thörne, A. Gottsäter, T. Mätzsch, M. E. Nilsson, C. Forssell, M. Lonsson, F. Lundgren, B. Stahre, L. Norgren, B. Stenberg, P. Konrad, L. Jarl, L. Lundqvist, Peter Olofsson, S. Rosfors, C. Skiöldebrand, J. Swedenborg, R. Takolander, D. Bergqvist, C. Ljungman, H. Pärsson, H. W. Kniemeyer, M. K. Widmer, R. Kuster, Rolf Kaiser, W. Nagel, D. Sege, Bruno Weder, Jianguo Nie, J. Doelman, Nadir Kemal Yilmaz, J. Buth, G. Stultiens, J. Boiten, Reinier A Boon, F. van der Linden, D. C. Busman, H. A.W. Sinnige, T. I. Yo, Gert J. de Borst, B. C. Eikelboom, L. J. Kappelle, Fernanda Tovar-Moll, R. W.H. van Reedt Dortland, T. E. Westra, H. Jaber, J. Manaa, R. B. Meftah, B. R. Nabil, T. Sraieb, Eric D Bateman, John Budd, M. Horrocks, M. Kivela, L. Shaw, R. Walker, A. A.B.Barros D'Sa, M S Simms, R. Baird, M. Campbell, S. Cole, I. T. Ferguson, Philippa J Lamont, D. Mitchell, A. Sassano, F. C.T. Smith, Kevin L Blake, P. J. Kirkpatrick, P. Martin, P C Turner, J. F. Clegg, M. Crosley, J. Hall, L. de Cossart, P. Edwards, D. Fletcher, Evelyn Stigger-Rosser, P. T. McCollum, D. Davidson, R. Levison, A. W. Bradbury, R. T.A. Chalmers, M. Dennis, J. A. Murie, C. V. Ruckley, Peter Sandercock, W. B. Campbell, T. Frankel, C. Gardner-Thorpe, N. Gutowski, Ross E Hardie, W. Honan, P. Niblett, A. Peters, B. Ridler, J. F. Thompson, I. Bone, Gregory C Welch, E. C. Grocott, P. Overstall, M. I. Aldoori, B. E.A. Dafalla, Jennifer Bryce, C. Clarke, P. T. McCollum, An-Xiao Ming, A. R. Wilkinson, J. Bamford, D. Berridge, J. Scott, R. J. Abbott, Rebecca Naylor, P. Harris, Q. P Crick Humphrey, M. Adiseshiah, M. Aukett, D. Baker, C. C.R. Bishop, A. Boutin, M. Brown, P. Burke, K. G. Burnand, A. Colchester, L. Coward, A. H. Davies, M. Espasandin, A. E.B. Giddings, G. Hamilton, C. Judge, Stavros K Kakkos, Clare McGuiness, P. Morris-Vincent, A. N. Nicolaides, T. S. Padayachee, H. Riordan, E. Sullivan, P. Taylor, M. Thompson, John H N Wolfe, C. N. McCollum, P. A. O'Neill, S. Welsh, J. Barnes, P. Cleland, M. Davis, A. Gholkar, R. Jones, V. Jaykishnam, A. D. Mendelow, J. E. O'Connell, M. S.S. Siddique, G. Stansby, R. Vivar, S. Ashley, C. Cosgrove, J. Gibson, D. C. Wilkins, A. D.B. Chant, J. Frankel, C. P. Shearman, J. Williams, G. Hall, Roger Holdsworth, J. N. Davies, B. McLean, K. R. Woodburn, G. Brown, P. Curley, L. Loizou, S. Chaturvedi, Rodrigo F Diaz, D. Radak, P. R. Todorovic, D. Kamugasha, A. Baxter, C Berry, J. Burrett, R. Collins, Michael J. Crowther, C. Davies, Bill Farrell, J. Godwin, R. Gray, C. Harwood, L. Hirt, C. Hope, S. Knight, Morgan Lay, A. Munday, A. Murawska, C. G. Peto, A. Radley, S. Richards

Research output: Contribution to journalArticleResearchpeer-review

460 Citations (Scopus)

Abstract

Background If carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA. Methods Between 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3-2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6-11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392. Findings 1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7 versus 4·8 at 1 year (and 92·1 vs 16·5 at 5 years). Perioperative risk of stroke or death within 30 days was 3·0 (95 CI 2·4-3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1 versus 10·0 at 5 years (gain 5·9, 95 CI 4·0-7·8) and 10·8 versus 16·9 at 10 years (gain 6·1, 2·7-9·4); ratio of stroke incidence rates 0·54, 95 CI 0·43-0·68, p<0·0001. 62 versus 104 had a disabling or fatal stroke, and 37 versus 84 others had a non-disabling stroke. Combining perioperative events and strokes, net risks were 6·9 versus 10·9 at 5 years (gain 4·1, 2·0-6·2) and 13·4 versus 17·9 at 10 years (gain 4·6, 1·2-7·9). Medication was similar in both groups; throughout the study, most were on antithrombotic and antihypertensive therapy. Net benefits were significant both for those on lipid-lowering therapy and for those not, and both for men and for women up to 75 years of age at entry (although not for older patients). Interpretation Successful CEA for asymptomatic patients younger than 75 years of age reduces 10-year stroke risks. Half this reduction is in disabling or fatal strokes. Net benefit in future patients will depend on their risks from unoperated carotid lesions (which will be reduced by medication), on future surgical risks (which might differ from those in trials), and on whether life expectancy exceeds 10 years. Funding UK Medical Research Council, BUPA Foundation, Stroke Association.

Original languageEnglish
Pages (from-to)1074-1084
Number of pages11
JournalThe Lancet
Volume376
Issue number9746
DOIs
Publication statusPublished - 25 Sep 2010

Cite this

Halliday, A., Harrison, M., Hayter, E., Kong, X., Mansfield, A., Marro, J., ... Richards, S. (2010). 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): A multicentre randomised trial. The Lancet, 376(9746), 1074-1084. https://doi.org/10.1016/S0140-6736(10)61197-X
Halliday, Alison ; Harrison, Michael ; Hayter, Elizabeth ; Kong, Xiangling ; Mansfield, Averil ; Marro, Joanna ; Pan, Hongchao ; Peto, Richard ; Potter, John ; Rahimi, Kazem ; Rau, Angela ; Robertson, Steven ; Streifler, Jonathan ; Thomas, Dafydd ; Cooper, M. E. ; MacKay, M. ; Wood, J. ; Christopoulos, G. ; Pereira, M. C. ; Blomstrand, Christian ; Forssell, C. ; Potemkowski, A. ; Skiöldebrand, C. ; Stoor, P. ; Blomqvist, M. ; Calander, M. ; Forssell, C. ; Lundgren, F. ; Almqvist, H. ; Norgren, L. ; Norrving, Bo ; Ribbe, E. ; Thörne, J. ; Gottsäter, A. ; Mätzsch, T. ; Nilsson, M. E. ; Forssell, C. ; Lonsson, M. ; Lundgren, F. ; Stahre, B. ; Norgren, L. ; Stenberg, B. ; Konrad, P. ; Jarl, L. ; Lundqvist, L. ; Olofsson, Peter ; Rosfors, S. ; Skiöldebrand, C. ; Swedenborg, J. ; Takolander, R. ; Bergqvist, D. ; Ljungman, C. ; Pärsson, H. ; Kniemeyer, H. W. ; Widmer, M. K. ; Kuster, R. ; Kaiser, Rolf ; Nagel, W. ; Sege, D. ; Weder, Bruno ; Nie, Jianguo ; Doelman, J. ; Yilmaz, Nadir Kemal ; Buth, J. ; Stultiens, G. ; Boiten, J. ; Boon, Reinier A ; van der Linden, F. ; Busman, D. C. ; Sinnige, H. A.W. ; Yo, T. I. ; de Borst, Gert J. ; Eikelboom, B. C. ; Kappelle, L. J. ; Tovar-Moll, Fernanda ; van Reedt Dortland, R. W.H. ; Westra, T. E. ; Jaber, H. ; Manaa, J. ; Meftah, R. B. ; Nabil, B. R. ; Sraieb, T. ; Bateman, Eric D ; Budd, John ; Horrocks, M. ; Kivela, M. ; Shaw, L. ; Walker, R. ; D'Sa, A. A.B.Barros ; Simms, M S ; Baird, R. ; Campbell, M. ; Cole, S. ; Ferguson, I. T. ; Lamont, Philippa J ; Mitchell, D. ; Sassano, A. ; Smith, F. C.T. ; Blake, Kevin L ; Kirkpatrick, P. J. ; Martin, P. ; Turner, P C ; Clegg, J. F. ; Crosley, M. ; Hall, J. ; de Cossart, L. ; Edwards, P. ; Fletcher, D. ; Stigger-Rosser, Evelyn ; McCollum, P. T. ; Davidson, D. ; Levison, R. ; Bradbury, A. W. ; Chalmers, R. T.A. ; Dennis, M. ; Murie, J. A. ; Ruckley, C. V. ; Sandercock, Peter ; Campbell, W. B. ; Frankel, T. ; Gardner-Thorpe, C. ; Gutowski, N. ; Hardie, Ross E ; Honan, W. ; Niblett, P. ; Peters, A. ; Ridler, B. ; Thompson, J. F. ; Bone, I. ; Welch, Gregory C ; Grocott, E. C. ; Overstall, P. ; Aldoori, M. I. ; Dafalla, B. E.A. ; Bryce, Jennifer ; Clarke, C. ; McCollum, P. T. ; Ming, An-Xiao ; Wilkinson, A. R. ; Bamford, J. ; Berridge, D. ; Scott, J. ; Abbott, R. J. ; Naylor, Rebecca ; Harris, P. ; Humphrey, Q. P Crick ; Adiseshiah, M. ; Aukett, M. ; Baker, D. ; Bishop, C. C.R. ; Boutin, A. ; Brown, M. ; Burke, P. ; Burnand, K. G. ; Colchester, A. ; Coward, L. ; Davies, A. H. ; Espasandin, M. ; Giddings, A. E.B. ; Hamilton, G. ; Judge, C. ; Kakkos, Stavros K ; McGuiness, Clare ; Morris-Vincent, P. ; Nicolaides, A. N. ; Padayachee, T. S. ; Riordan, H. ; Sullivan, E. ; Taylor, P. ; Thompson, M. ; Wolfe, John H N ; McCollum, C. N. ; O'Neill, P. A. ; Welsh, S. ; Barnes, J. ; Cleland, P. ; Davis, M. ; Gholkar, A. ; Jones, R. ; Jaykishnam, V. ; Mendelow, A. D. ; O'Connell, J. E. ; Siddique, M. S.S. ; Stansby, G. ; Vivar, R. ; Ashley, S. ; Cosgrove, C. ; Gibson, J. ; Wilkins, D. C. ; Chant, A. D.B. ; Frankel, J. ; Shearman, C. P. ; Williams, J. ; Hall, G. ; Holdsworth, Roger ; Davies, J. N. ; McLean, B. ; Woodburn, K. R. ; Brown, G. ; Curley, P. ; Loizou, L. ; Chaturvedi, S. ; Diaz, Rodrigo F ; Radak, D. ; Todorovic, P. R. ; Kamugasha, D. ; Baxter, A. ; Berry, C ; Burrett, J. ; Collins, R. ; Crowther, Michael J. ; Davies, C. ; Farrell, Bill ; Godwin, J. ; Gray, R. ; Harwood, C. ; Hirt, L. ; Hope, C. ; Knight, S. ; Lay, Morgan ; Munday, A. ; Murawska, A. ; Peto, C. G. ; Radley, A. ; Richards, S. / 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1) : A multicentre randomised trial. In: The Lancet. 2010 ; Vol. 376, No. 9746. pp. 1074-1084.
@article{b692644b7c2240c69e4b79bc129e08ec,
title = "10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): A multicentre randomised trial",
abstract = "Background If carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA. Methods Between 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3-2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6-11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392. Findings 1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7 versus 4·8 at 1 year (and 92·1 vs 16·5 at 5 years). Perioperative risk of stroke or death within 30 days was 3·0 (95 CI 2·4-3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1 versus 10·0 at 5 years (gain 5·9, 95 CI 4·0-7·8) and 10·8 versus 16·9 at 10 years (gain 6·1, 2·7-9·4); ratio of stroke incidence rates 0·54, 95 CI 0·43-0·68, p<0·0001. 62 versus 104 had a disabling or fatal stroke, and 37 versus 84 others had a non-disabling stroke. Combining perioperative events and strokes, net risks were 6·9 versus 10·9 at 5 years (gain 4·1, 2·0-6·2) and 13·4 versus 17·9 at 10 years (gain 4·6, 1·2-7·9). Medication was similar in both groups; throughout the study, most were on antithrombotic and antihypertensive therapy. Net benefits were significant both for those on lipid-lowering therapy and for those not, and both for men and for women up to 75 years of age at entry (although not for older patients). Interpretation Successful CEA for asymptomatic patients younger than 75 years of age reduces 10-year stroke risks. Half this reduction is in disabling or fatal strokes. Net benefit in future patients will depend on their risks from unoperated carotid lesions (which will be reduced by medication), on future surgical risks (which might differ from those in trials), and on whether life expectancy exceeds 10 years. Funding UK Medical Research Council, BUPA Foundation, Stroke Association.",
author = "Alison Halliday and Michael Harrison and Elizabeth Hayter and Xiangling Kong and Averil Mansfield and Joanna Marro and Hongchao Pan and Richard Peto and John Potter and Kazem Rahimi and Angela Rau and Steven Robertson and Jonathan Streifler and Dafydd Thomas and Cooper, {M. E.} and M. MacKay and J. Wood and G. Christopoulos and Pereira, {M. C.} and Christian Blomstrand and C. Forssell and A. Potemkowski and C. Ski{\"o}ldebrand and P. Stoor and M. Blomqvist and M. Calander and C. Forssell and F. Lundgren and H. Almqvist and L. Norgren and Bo Norrving and E. Ribbe and J. Th{\"o}rne and A. Gotts{\"a}ter and T. M{\"a}tzsch and Nilsson, {M. E.} and C. Forssell and M. Lonsson and F. Lundgren and B. Stahre and L. Norgren and B. Stenberg and P. Konrad and L. Jarl and L. Lundqvist and Peter Olofsson and S. Rosfors and C. Ski{\"o}ldebrand and J. Swedenborg and R. Takolander and D. Bergqvist and C. Ljungman and H. P{\"a}rsson and Kniemeyer, {H. W.} and Widmer, {M. K.} and R. Kuster and Rolf Kaiser and W. Nagel and D. Sege and Bruno Weder and Jianguo Nie and J. Doelman and Yilmaz, {Nadir Kemal} and J. Buth and G. Stultiens and J. Boiten and Boon, {Reinier A} and {van der Linden}, F. and Busman, {D. C.} and Sinnige, {H. A.W.} and Yo, {T. I.} and {de Borst}, {Gert J.} and Eikelboom, {B. C.} and Kappelle, {L. J.} and Fernanda Tovar-Moll and {van Reedt Dortland}, {R. W.H.} and Westra, {T. E.} and H. Jaber and J. Manaa and Meftah, {R. B.} and Nabil, {B. R.} and T. Sraieb and Bateman, {Eric D} and John Budd and M. Horrocks and M. Kivela and L. Shaw and R. Walker and D'Sa, {A. A.B.Barros} and Simms, {M S} and R. Baird and M. Campbell and S. Cole and Ferguson, {I. T.} and Lamont, {Philippa J} and D. Mitchell and A. Sassano and Smith, {F. C.T.} and Blake, {Kevin L} and Kirkpatrick, {P. J.} and P. Martin and Turner, {P C} and Clegg, {J. F.} and M. Crosley and J. Hall and {de Cossart}, L. and P. Edwards and D. Fletcher and Evelyn Stigger-Rosser and McCollum, {P. T.} and D. Davidson and R. Levison and Bradbury, {A. W.} and Chalmers, {R. T.A.} and M. Dennis and Murie, {J. A.} and Ruckley, {C. V.} and Peter Sandercock and Campbell, {W. B.} and T. Frankel and C. Gardner-Thorpe and N. Gutowski and Hardie, {Ross E} and W. Honan and P. Niblett and A. Peters and B. Ridler and Thompson, {J. F.} and I. Bone and Welch, {Gregory C} and Grocott, {E. C.} and P. Overstall and Aldoori, {M. I.} and Dafalla, {B. E.A.} and Jennifer Bryce and C. Clarke and McCollum, {P. T.} and An-Xiao Ming and Wilkinson, {A. R.} and J. Bamford and D. Berridge and J. Scott and Abbott, {R. J.} and Rebecca Naylor and P. Harris and Humphrey, {Q. P Crick} and M. Adiseshiah and M. Aukett and D. Baker and Bishop, {C. C.R.} and A. Boutin and M. Brown and P. Burke and Burnand, {K. G.} and A. Colchester and L. Coward and Davies, {A. H.} and M. Espasandin and Giddings, {A. E.B.} and G. Hamilton and C. Judge and Kakkos, {Stavros K} and Clare McGuiness and P. Morris-Vincent and Nicolaides, {A. N.} and Padayachee, {T. S.} and H. Riordan and E. Sullivan and P. Taylor and M. Thompson and Wolfe, {John H N} and McCollum, {C. N.} and O'Neill, {P. A.} and S. Welsh and J. Barnes and P. Cleland and M. Davis and A. Gholkar and R. Jones and V. Jaykishnam and Mendelow, {A. D.} and O'Connell, {J. E.} and Siddique, {M. S.S.} and G. Stansby and R. Vivar and S. Ashley and C. Cosgrove and J. Gibson and Wilkins, {D. C.} and Chant, {A. D.B.} and J. Frankel and Shearman, {C. P.} and J. Williams and G. Hall and Roger Holdsworth and Davies, {J. N.} and B. McLean and Woodburn, {K. R.} and G. Brown and P. Curley and L. Loizou and S. Chaturvedi and Diaz, {Rodrigo F} and D. Radak and Todorovic, {P. R.} and D. Kamugasha and A. Baxter and C Berry and J. Burrett and R. Collins and Crowther, {Michael J.} and C. Davies and Bill Farrell and J. Godwin and R. Gray and C. Harwood and L. Hirt and C. Hope and S. Knight and Morgan Lay and A. Munday and A. Murawska and Peto, {C. G.} and A. Radley and S. Richards",
year = "2010",
month = "9",
day = "25",
doi = "10.1016/S0140-6736(10)61197-X",
language = "English",
volume = "376",
pages = "1074--1084",
journal = "The Lancet",
issn = "0140-6736",
publisher = "Elsevier",
number = "9746",

}

Halliday, A, Harrison, M, Hayter, E, Kong, X, Mansfield, A, Marro, J, Pan, H, Peto, R, Potter, J, Rahimi, K, Rau, A, Robertson, S, Streifler, J, Thomas, D, Cooper, ME, MacKay, M, Wood, J, Christopoulos, G, Pereira, MC, Blomstrand, C, Forssell, C, Potemkowski, A, Skiöldebrand, C, Stoor, P, Blomqvist, M, Calander, M, Forssell, C, Lundgren, F, Almqvist, H, Norgren, L, Norrving, B, Ribbe, E, Thörne, J, Gottsäter, A, Mätzsch, T, Nilsson, ME, Forssell, C, Lonsson, M, Lundgren, F, Stahre, B, Norgren, L, Stenberg, B, Konrad, P, Jarl, L, Lundqvist, L, Olofsson, P, Rosfors, S, Skiöldebrand, C, Swedenborg, J, Takolander, R, Bergqvist, D, Ljungman, C, Pärsson, H, Kniemeyer, HW, Widmer, MK, Kuster, R, Kaiser, R, Nagel, W, Sege, D, Weder, B, Nie, J, Doelman, J, Yilmaz, NK, Buth, J, Stultiens, G, Boiten, J, Boon, RA, van der Linden, F, Busman, DC, Sinnige, HAW, Yo, TI, de Borst, GJ, Eikelboom, BC, Kappelle, LJ, Tovar-Moll, F, van Reedt Dortland, RWH, Westra, TE, Jaber, H, Manaa, J, Meftah, RB, Nabil, BR, Sraieb, T, Bateman, ED, Budd, J, Horrocks, M, Kivela, M, Shaw, L, Walker, R, D'Sa, AABB, Simms, MS, Baird, R, Campbell, M, Cole, S, Ferguson, IT, Lamont, PJ, Mitchell, D, Sassano, A, Smith, FCT, Blake, KL, Kirkpatrick, PJ, Martin, P, Turner, PC, Clegg, JF, Crosley, M, Hall, J, de Cossart, L, Edwards, P, Fletcher, D, Stigger-Rosser, E, McCollum, PT, Davidson, D, Levison, R, Bradbury, AW, Chalmers, RTA, Dennis, M, Murie, JA, Ruckley, CV, Sandercock, P, Campbell, WB, Frankel, T, Gardner-Thorpe, C, Gutowski, N, Hardie, RE, Honan, W, Niblett, P, Peters, A, Ridler, B, Thompson, JF, Bone, I, Welch, GC, Grocott, EC, Overstall, P, Aldoori, MI, Dafalla, BEA, Bryce, J, Clarke, C, McCollum, PT, Ming, A-X, Wilkinson, AR, Bamford, J, Berridge, D, Scott, J, Abbott, RJ, Naylor, R, Harris, P, Humphrey, QPC, Adiseshiah, M, Aukett, M, Baker, D, Bishop, CCR, Boutin, A, Brown, M, Burke, P, Burnand, KG, Colchester, A, Coward, L, Davies, AH, Espasandin, M, Giddings, AEB, Hamilton, G, Judge, C, Kakkos, SK, McGuiness, C, Morris-Vincent, P, Nicolaides, AN, Padayachee, TS, Riordan, H, Sullivan, E, Taylor, P, Thompson, M, Wolfe, JHN, McCollum, CN, O'Neill, PA, Welsh, S, Barnes, J, Cleland, P, Davis, M, Gholkar, A, Jones, R, Jaykishnam, V, Mendelow, AD, O'Connell, JE, Siddique, MSS, Stansby, G, Vivar, R, Ashley, S, Cosgrove, C, Gibson, J, Wilkins, DC, Chant, ADB, Frankel, J, Shearman, CP, Williams, J, Hall, G, Holdsworth, R, Davies, JN, McLean, B, Woodburn, KR, Brown, G, Curley, P, Loizou, L, Chaturvedi, S, Diaz, RF, Radak, D, Todorovic, PR, Kamugasha, D, Baxter, A, Berry, C, Burrett, J, Collins, R, Crowther, MJ, Davies, C, Farrell, B, Godwin, J, Gray, R, Harwood, C, Hirt, L, Hope, C, Knight, S, Lay, M, Munday, A, Murawska, A, Peto, CG, Radley, A & Richards, S 2010, '10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): A multicentre randomised trial', The Lancet, vol. 376, no. 9746, pp. 1074-1084. https://doi.org/10.1016/S0140-6736(10)61197-X

10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1) : A multicentre randomised trial. / Halliday, Alison; Harrison, Michael; Hayter, Elizabeth; Kong, Xiangling; Mansfield, Averil; Marro, Joanna; Pan, Hongchao; Peto, Richard; Potter, John; Rahimi, Kazem; Rau, Angela; Robertson, Steven; Streifler, Jonathan; Thomas, Dafydd; Cooper, M. E.; MacKay, M.; Wood, J.; Christopoulos, G.; Pereira, M. C.; Blomstrand, Christian; Forssell, C.; Potemkowski, A.; Skiöldebrand, C.; Stoor, P.; Blomqvist, M.; Calander, M.; Forssell, C.; Lundgren, F.; Almqvist, H.; Norgren, L.; Norrving, Bo; Ribbe, E.; Thörne, J.; Gottsäter, A.; Mätzsch, T.; Nilsson, M. E.; Forssell, C.; Lonsson, M.; Lundgren, F.; Stahre, B.; Norgren, L.; Stenberg, B.; Konrad, P.; Jarl, L.; Lundqvist, L.; Olofsson, Peter; Rosfors, S.; Skiöldebrand, C.; Swedenborg, J.; Takolander, R.; Bergqvist, D.; Ljungman, C.; Pärsson, H.; Kniemeyer, H. W.; Widmer, M. K.; Kuster, R.; Kaiser, Rolf; Nagel, W.; Sege, D.; Weder, Bruno; Nie, Jianguo; Doelman, J.; Yilmaz, Nadir Kemal; Buth, J.; Stultiens, G.; Boiten, J.; Boon, Reinier A; van der Linden, F.; Busman, D. C.; Sinnige, H. A.W.; Yo, T. I.; de Borst, Gert J.; Eikelboom, B. C.; Kappelle, L. J.; Tovar-Moll, Fernanda; van Reedt Dortland, R. W.H.; Westra, T. E.; Jaber, H.; Manaa, J.; Meftah, R. B.; Nabil, B. R.; Sraieb, T.; Bateman, Eric D; Budd, John; Horrocks, M.; Kivela, M.; Shaw, L.; Walker, R.; D'Sa, A. A.B.Barros; Simms, M S; Baird, R.; Campbell, M.; Cole, S.; Ferguson, I. T.; Lamont, Philippa J; Mitchell, D.; Sassano, A.; Smith, F. C.T.; Blake, Kevin L; Kirkpatrick, P. J.; Martin, P.; Turner, P C; Clegg, J. F.; Crosley, M.; Hall, J.; de Cossart, L.; Edwards, P.; Fletcher, D.; Stigger-Rosser, Evelyn; McCollum, P. T.; Davidson, D.; Levison, R.; Bradbury, A. W.; Chalmers, R. T.A.; Dennis, M.; Murie, J. A.; Ruckley, C. V.; Sandercock, Peter; Campbell, W. B.; Frankel, T.; Gardner-Thorpe, C.; Gutowski, N.; Hardie, Ross E; Honan, W.; Niblett, P.; Peters, A.; Ridler, B.; Thompson, J. F.; Bone, I.; Welch, Gregory C; Grocott, E. C.; Overstall, P.; Aldoori, M. I.; Dafalla, B. E.A.; Bryce, Jennifer; Clarke, C.; McCollum, P. T.; Ming, An-Xiao; Wilkinson, A. R.; Bamford, J.; Berridge, D.; Scott, J.; Abbott, R. J.; Naylor, Rebecca; Harris, P.; Humphrey, Q. P Crick; Adiseshiah, M.; Aukett, M.; Baker, D.; Bishop, C. C.R.; Boutin, A.; Brown, M.; Burke, P.; Burnand, K. G.; Colchester, A.; Coward, L.; Davies, A. H.; Espasandin, M.; Giddings, A. E.B.; Hamilton, G.; Judge, C.; Kakkos, Stavros K; McGuiness, Clare; Morris-Vincent, P.; Nicolaides, A. N.; Padayachee, T. S.; Riordan, H.; Sullivan, E.; Taylor, P.; Thompson, M.; Wolfe, John H N; McCollum, C. N.; O'Neill, P. A.; Welsh, S.; Barnes, J.; Cleland, P.; Davis, M.; Gholkar, A.; Jones, R.; Jaykishnam, V.; Mendelow, A. D.; O'Connell, J. E.; Siddique, M. S.S.; Stansby, G.; Vivar, R.; Ashley, S.; Cosgrove, C.; Gibson, J.; Wilkins, D. C.; Chant, A. D.B.; Frankel, J.; Shearman, C. P.; Williams, J.; Hall, G.; Holdsworth, Roger; Davies, J. N.; McLean, B.; Woodburn, K. R.; Brown, G.; Curley, P.; Loizou, L.; Chaturvedi, S.; Diaz, Rodrigo F; Radak, D.; Todorovic, P. R.; Kamugasha, D.; Baxter, A.; Berry, C; Burrett, J.; Collins, R.; Crowther, Michael J.; Davies, C.; Farrell, Bill; Godwin, J.; Gray, R.; Harwood, C.; Hirt, L.; Hope, C.; Knight, S.; Lay, Morgan; Munday, A.; Murawska, A.; Peto, C. G.; Radley, A.; Richards, S.

In: The Lancet, Vol. 376, No. 9746, 25.09.2010, p. 1074-1084.

Research output: Contribution to journalArticleResearchpeer-review

TY - JOUR

T1 - 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1)

T2 - A multicentre randomised trial

AU - Halliday, Alison

AU - Harrison, Michael

AU - Hayter, Elizabeth

AU - Kong, Xiangling

AU - Mansfield, Averil

AU - Marro, Joanna

AU - Pan, Hongchao

AU - Peto, Richard

AU - Potter, John

AU - Rahimi, Kazem

AU - Rau, Angela

AU - Robertson, Steven

AU - Streifler, Jonathan

AU - Thomas, Dafydd

AU - Cooper, M. E.

AU - MacKay, M.

AU - Wood, J.

AU - Christopoulos, G.

AU - Pereira, M. C.

AU - Blomstrand, Christian

AU - Forssell, C.

AU - Potemkowski, A.

AU - Skiöldebrand, C.

AU - Stoor, P.

AU - Blomqvist, M.

AU - Calander, M.

AU - Forssell, C.

AU - Lundgren, F.

AU - Almqvist, H.

AU - Norgren, L.

AU - Norrving, Bo

AU - Ribbe, E.

AU - Thörne, J.

AU - Gottsäter, A.

AU - Mätzsch, T.

AU - Nilsson, M. E.

AU - Forssell, C.

AU - Lonsson, M.

AU - Lundgren, F.

AU - Stahre, B.

AU - Norgren, L.

AU - Stenberg, B.

AU - Konrad, P.

AU - Jarl, L.

AU - Lundqvist, L.

AU - Olofsson, Peter

AU - Rosfors, S.

AU - Skiöldebrand, C.

AU - Swedenborg, J.

AU - Takolander, R.

AU - Bergqvist, D.

AU - Ljungman, C.

AU - Pärsson, H.

AU - Kniemeyer, H. W.

AU - Widmer, M. K.

AU - Kuster, R.

AU - Kaiser, Rolf

AU - Nagel, W.

AU - Sege, D.

AU - Weder, Bruno

AU - Nie, Jianguo

AU - Doelman, J.

AU - Yilmaz, Nadir Kemal

AU - Buth, J.

AU - Stultiens, G.

AU - Boiten, J.

AU - Boon, Reinier A

AU - van der Linden, F.

AU - Busman, D. C.

AU - Sinnige, H. A.W.

AU - Yo, T. I.

AU - de Borst, Gert J.

AU - Eikelboom, B. C.

AU - Kappelle, L. J.

AU - Tovar-Moll, Fernanda

AU - van Reedt Dortland, R. W.H.

AU - Westra, T. E.

AU - Jaber, H.

AU - Manaa, J.

AU - Meftah, R. B.

AU - Nabil, B. R.

AU - Sraieb, T.

AU - Bateman, Eric D

AU - Budd, John

AU - Horrocks, M.

AU - Kivela, M.

AU - Shaw, L.

AU - Walker, R.

AU - D'Sa, A. A.B.Barros

AU - Simms, M S

AU - Baird, R.

AU - Campbell, M.

AU - Cole, S.

AU - Ferguson, I. T.

AU - Lamont, Philippa J

AU - Mitchell, D.

AU - Sassano, A.

AU - Smith, F. C.T.

AU - Blake, Kevin L

AU - Kirkpatrick, P. J.

AU - Martin, P.

AU - Turner, P C

AU - Clegg, J. F.

AU - Crosley, M.

AU - Hall, J.

AU - de Cossart, L.

AU - Edwards, P.

AU - Fletcher, D.

AU - Stigger-Rosser, Evelyn

AU - McCollum, P. T.

AU - Davidson, D.

AU - Levison, R.

AU - Bradbury, A. W.

AU - Chalmers, R. T.A.

AU - Dennis, M.

AU - Murie, J. A.

AU - Ruckley, C. V.

AU - Sandercock, Peter

AU - Campbell, W. B.

AU - Frankel, T.

AU - Gardner-Thorpe, C.

AU - Gutowski, N.

AU - Hardie, Ross E

AU - Honan, W.

AU - Niblett, P.

AU - Peters, A.

AU - Ridler, B.

AU - Thompson, J. F.

AU - Bone, I.

AU - Welch, Gregory C

AU - Grocott, E. C.

AU - Overstall, P.

AU - Aldoori, M. I.

AU - Dafalla, B. E.A.

AU - Bryce, Jennifer

AU - Clarke, C.

AU - McCollum, P. T.

AU - Ming, An-Xiao

AU - Wilkinson, A. R.

AU - Bamford, J.

AU - Berridge, D.

AU - Scott, J.

AU - Abbott, R. J.

AU - Naylor, Rebecca

AU - Harris, P.

AU - Humphrey, Q. P Crick

AU - Adiseshiah, M.

AU - Aukett, M.

AU - Baker, D.

AU - Bishop, C. C.R.

AU - Boutin, A.

AU - Brown, M.

AU - Burke, P.

AU - Burnand, K. G.

AU - Colchester, A.

AU - Coward, L.

AU - Davies, A. H.

AU - Espasandin, M.

AU - Giddings, A. E.B.

AU - Hamilton, G.

AU - Judge, C.

AU - Kakkos, Stavros K

AU - McGuiness, Clare

AU - Morris-Vincent, P.

AU - Nicolaides, A. N.

AU - Padayachee, T. S.

AU - Riordan, H.

AU - Sullivan, E.

AU - Taylor, P.

AU - Thompson, M.

AU - Wolfe, John H N

AU - McCollum, C. N.

AU - O'Neill, P. A.

AU - Welsh, S.

AU - Barnes, J.

AU - Cleland, P.

AU - Davis, M.

AU - Gholkar, A.

AU - Jones, R.

AU - Jaykishnam, V.

AU - Mendelow, A. D.

AU - O'Connell, J. E.

AU - Siddique, M. S.S.

AU - Stansby, G.

AU - Vivar, R.

AU - Ashley, S.

AU - Cosgrove, C.

AU - Gibson, J.

AU - Wilkins, D. C.

AU - Chant, A. D.B.

AU - Frankel, J.

AU - Shearman, C. P.

AU - Williams, J.

AU - Hall, G.

AU - Holdsworth, Roger

AU - Davies, J. N.

AU - McLean, B.

AU - Woodburn, K. R.

AU - Brown, G.

AU - Curley, P.

AU - Loizou, L.

AU - Chaturvedi, S.

AU - Diaz, Rodrigo F

AU - Radak, D.

AU - Todorovic, P. R.

AU - Kamugasha, D.

AU - Baxter, A.

AU - Berry, C

AU - Burrett, J.

AU - Collins, R.

AU - Crowther, Michael J.

AU - Davies, C.

AU - Farrell, Bill

AU - Godwin, J.

AU - Gray, R.

AU - Harwood, C.

AU - Hirt, L.

AU - Hope, C.

AU - Knight, S.

AU - Lay, Morgan

AU - Munday, A.

AU - Murawska, A.

AU - Peto, C. G.

AU - Radley, A.

AU - Richards, S.

PY - 2010/9/25

Y1 - 2010/9/25

N2 - Background If carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA. Methods Between 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3-2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6-11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392. Findings 1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7 versus 4·8 at 1 year (and 92·1 vs 16·5 at 5 years). Perioperative risk of stroke or death within 30 days was 3·0 (95 CI 2·4-3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1 versus 10·0 at 5 years (gain 5·9, 95 CI 4·0-7·8) and 10·8 versus 16·9 at 10 years (gain 6·1, 2·7-9·4); ratio of stroke incidence rates 0·54, 95 CI 0·43-0·68, p<0·0001. 62 versus 104 had a disabling or fatal stroke, and 37 versus 84 others had a non-disabling stroke. Combining perioperative events and strokes, net risks were 6·9 versus 10·9 at 5 years (gain 4·1, 2·0-6·2) and 13·4 versus 17·9 at 10 years (gain 4·6, 1·2-7·9). Medication was similar in both groups; throughout the study, most were on antithrombotic and antihypertensive therapy. Net benefits were significant both for those on lipid-lowering therapy and for those not, and both for men and for women up to 75 years of age at entry (although not for older patients). Interpretation Successful CEA for asymptomatic patients younger than 75 years of age reduces 10-year stroke risks. Half this reduction is in disabling or fatal strokes. Net benefit in future patients will depend on their risks from unoperated carotid lesions (which will be reduced by medication), on future surgical risks (which might differ from those in trials), and on whether life expectancy exceeds 10 years. Funding UK Medical Research Council, BUPA Foundation, Stroke Association.

AB - Background If carotid artery narrowing remains asymptomatic (ie, has caused no recent stroke or other neurological symptoms), successful carotid endarterectomy (CEA) reduces stroke incidence for some years. We assessed the long-term effects of successful CEA. Methods Between 1993 and 2003, 3120 asymptomatic patients from 126 centres in 30 countries were allocated equally, by blinded minimised randomisation, to immediate CEA (median delay 1 month, IQR 0·3-2·5) or to indefinite deferral of any carotid procedure, and were followed up until death or for a median among survivors of 9 years (IQR 6-11). The primary outcomes were perioperative mortality and morbidity (death or stroke within 30 days) and non-perioperative stroke. Kaplan-Meier percentages and logrank p values are from intention-to-treat analyses. This study is registered, number ISRCTN26156392. Findings 1560 patients were allocated immediate CEA versus 1560 allocated deferral of any carotid procedure. The proportions operated on while still asymptomatic were 89·7 versus 4·8 at 1 year (and 92·1 vs 16·5 at 5 years). Perioperative risk of stroke or death within 30 days was 3·0 (95 CI 2·4-3·9; 26 non-disabling strokes plus 34 disabling or fatal perioperative events in 1979 CEAs). Excluding perioperative events and non-stroke mortality, stroke risks (immediate vs deferred CEA) were 4·1 versus 10·0 at 5 years (gain 5·9, 95 CI 4·0-7·8) and 10·8 versus 16·9 at 10 years (gain 6·1, 2·7-9·4); ratio of stroke incidence rates 0·54, 95 CI 0·43-0·68, p<0·0001. 62 versus 104 had a disabling or fatal stroke, and 37 versus 84 others had a non-disabling stroke. Combining perioperative events and strokes, net risks were 6·9 versus 10·9 at 5 years (gain 4·1, 2·0-6·2) and 13·4 versus 17·9 at 10 years (gain 4·6, 1·2-7·9). Medication was similar in both groups; throughout the study, most were on antithrombotic and antihypertensive therapy. Net benefits were significant both for those on lipid-lowering therapy and for those not, and both for men and for women up to 75 years of age at entry (although not for older patients). Interpretation Successful CEA for asymptomatic patients younger than 75 years of age reduces 10-year stroke risks. Half this reduction is in disabling or fatal strokes. Net benefit in future patients will depend on their risks from unoperated carotid lesions (which will be reduced by medication), on future surgical risks (which might differ from those in trials), and on whether life expectancy exceeds 10 years. Funding UK Medical Research Council, BUPA Foundation, Stroke Association.

UR - http://www.scopus.com/inward/record.url?scp=77957189028&partnerID=8YFLogxK

U2 - 10.1016/S0140-6736(10)61197-X

DO - 10.1016/S0140-6736(10)61197-X

M3 - Article

VL - 376

SP - 1074

EP - 1084

JO - The Lancet

JF - The Lancet

SN - 0140-6736

IS - 9746

ER -