Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis

Anne L. Abbott, Alejandro M. Brunser, Athanasios Giannoukas, Robert E. Harbaugh, Timothy Kleinig, Simona Lattanzi, Holger Poppert, Tatjana Rundek, Saeid Shahidi, Mauro Silvestrini, Raffi Topakian

Research output: Contribution to journalReview ArticleResearchpeer-review

Abstract

Background: Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal. Methods: We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017. Results: Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with medical intervention alone are overall lower than for those who had CEA in these randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention. Conclusions: Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.

Original languageEnglish
Number of pages13
JournalJournal of Vascular Surgery
DOIs
Publication statusAccepted/In press - 26 Sep 2019

Keywords

  • Asymptomatic carotid stenosis
  • Carotid endarterectomy
  • Carotid stenting
  • Medical intervention
  • Stroke prevention

Cite this

Abbott, Anne L. ; Brunser, Alejandro M. ; Giannoukas, Athanasios ; Harbaugh, Robert E. ; Kleinig, Timothy ; Lattanzi, Simona ; Poppert, Holger ; Rundek, Tatjana ; Shahidi, Saeid ; Silvestrini, Mauro ; Topakian, Raffi. / Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis. In: Journal of Vascular Surgery. 2019.
@article{231923e5bd964e31b0373711e6dc8d74,
title = "Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis",
abstract = "Background: Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5{\%} of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal. Methods: We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017. Results: Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit only for selected average surgical risk men aged less than 75 to 80 years with 60{\%} or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with medical intervention alone are overall lower than for those who had CEA in these randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention. Conclusions: Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.",
keywords = "Asymptomatic carotid stenosis, Carotid endarterectomy, Carotid stenting, Medical intervention, Stroke prevention",
author = "Abbott, {Anne L.} and Brunser, {Alejandro M.} and Athanasios Giannoukas and Harbaugh, {Robert E.} and Timothy Kleinig and Simona Lattanzi and Holger Poppert and Tatjana Rundek and Saeid Shahidi and Mauro Silvestrini and Raffi Topakian",
year = "2019",
month = "9",
day = "26",
doi = "10.1016/j.jvs.2019.04.490",
language = "English",
journal = "Journal of Vascular Surgery",
issn = "0741-5214",
publisher = "Elsevier",

}

Abbott, AL, Brunser, AM, Giannoukas, A, Harbaugh, RE, Kleinig, T, Lattanzi, S, Poppert, H, Rundek, T, Shahidi, S, Silvestrini, M & Topakian, R 2019, 'Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis', Journal of Vascular Surgery. https://doi.org/10.1016/j.jvs.2019.04.490

Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis. / Abbott, Anne L.; Brunser, Alejandro M.; Giannoukas, Athanasios; Harbaugh, Robert E.; Kleinig, Timothy; Lattanzi, Simona; Poppert, Holger; Rundek, Tatjana; Shahidi, Saeid; Silvestrini, Mauro; Topakian, Raffi.

In: Journal of Vascular Surgery, 26.09.2019.

Research output: Contribution to journalReview ArticleResearchpeer-review

TY - JOUR

T1 - Misconceptions regarding the adequacy of best medical intervention alone for asymptomatic carotid stenosis

AU - Abbott, Anne L.

AU - Brunser, Alejandro M.

AU - Giannoukas, Athanasios

AU - Harbaugh, Robert E.

AU - Kleinig, Timothy

AU - Lattanzi, Simona

AU - Poppert, Holger

AU - Rundek, Tatjana

AU - Shahidi, Saeid

AU - Silvestrini, Mauro

AU - Topakian, Raffi

PY - 2019/9/26

Y1 - 2019/9/26

N2 - Background: Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal. Methods: We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017. Results: Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with medical intervention alone are overall lower than for those who had CEA in these randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention. Conclusions: Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.

AB - Background: Medical intervention (risk factor identification, lifestyle coaching, and medication) for stroke prevention has improved significantly. It is likely that no more than 5.5% of persons with advanced asymptomatic carotid stenosis (ACS) will now benefit from a carotid procedure during their lifetime. However, some question the adequacy of medical intervention alone for such persons and propose using markers of high stroke risk to intervene with carotid endarterectomy (CEA) and/or carotid angioplasty/stenting (CAS). Our aim was to examine the scientific validity and implications of this proposal. Methods: We reviewed the evidence for using medical intervention alone or with additional CEA or CAS in persons with ACS. We also reviewed the evidence regarding the validity of using commonly cited makers of high stroke risk to select such persons for CEA or CAS, including markers proposed by the European Society for Vascular Surgery in 2017. Results: Randomized trials of medical intervention alone versus additional CEA showed a definite statistically significant CEA stroke prevention benefit only for selected average surgical risk men aged less than 75 to 80 years with 60% or greater stenosis using the North American Symptomatic Carotid Endarterectomy Trial criteria. However, the most recent measurements of stroke rate with medical intervention alone are overall lower than for those who had CEA in these randomized trials. Randomized trials of CEA versus CAS in persons with ACS were underpowered. However, the trend was for higher stroke and death rates with CAS. There are no randomized trial results related to comparing current optimal medical intervention with CEA or CAS. Commonly cited markers of high stroke risk in relation to ACS lack specificity, have not been assessed in conjunction with current optimal medical intervention, and have not been shown in randomized trials to identify those who benefit from a carotid procedure in addition to current optimal medical intervention. Conclusions: Medical intervention has an established role in the current routine management of persons with ACS. Stroke risk stratification studies using current optimal medical intervention alone are the highest research priority for identifying persons likely to benefit from adding a carotid procedure.

KW - Asymptomatic carotid stenosis

KW - Carotid endarterectomy

KW - Carotid stenting

KW - Medical intervention

KW - Stroke prevention

UR - http://www.scopus.com/inward/record.url?scp=85072623481&partnerID=8YFLogxK

U2 - 10.1016/j.jvs.2019.04.490

DO - 10.1016/j.jvs.2019.04.490

M3 - Review Article

JO - Journal of Vascular Surgery

JF - Journal of Vascular Surgery

SN - 0741-5214

ER -