Best medical treatment for a symptomatic carotid artery stenosis

The Asymptomatic Carotid Surgery Trial (ACST-1; Sept 25, p 1074)1Halliday A Harrison M Hayter E et al.Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial.Lancet. 2010; 376: 1074-1084Summary Full Text Full Text PDF PubMed Scopus (642) Google Scholar showed a reduced 10-year stroke risk for patients undergoing carotid endarterectomy (CEA) versus no intervention. Use of antiplatelet, anticoagulant, antihypertensive, and lipid-lowering drugs was similar between the two groups, although use of lipid-lowering drugs increased from about 10% in 1993 to more than 80% in 2003. A subgroup analysis of patients on lipid-lowering therapy also showed a reduced 10-year stroke risk for CEA versus no intervention (7·6% vs 13·4%, respectively; gain 5·8%, 95% CI 2·1–9·6; p=0·002).1Halliday A Harrison M Hayter E et al.Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial.Lancet. 2010; 376: 1074-1084Summary Full Text Full Text PDF PubMed Scopus (642) Google Scholar Accumulating evidence suggests that current best medical treatment alone is sufficient for asymptomatic carotid stenosis and that no intervention (ie, CEA or carotid artery stenting [CAS]) is required.2Naylor AR Gaines PA Rothwell PM Who benefits most from intervention for asymptomatic carotid stenosis: patients or professionals?.Eur J Vasc Endovasc Surg. 2009; 37: 625-632Summary Full Text Full Text PDF PubMed Scopus (147) Google Scholar, 3Abbott AL Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis.Stroke. 2009; 40: e573-e583Crossref PubMed Scopus (542) Google Scholar, 4Spence JD Coates V Li H et al.Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis.Arch Neurol. 2010; 67: 180-186Crossref PubMed Scopus (275) Google Scholar Best medical treatment includes lifestyle modification (smoking cessation, exercise, weight loss), blood pressure control, and antiplatelet and high-dose statin therapy.2Naylor AR Gaines PA Rothwell PM Who benefits most from intervention for asymptomatic carotid stenosis: patients or professionals?.Eur J Vasc Endovasc Surg. 2009; 37: 625-632Summary Full Text Full Text PDF PubMed Scopus (147) Google Scholar, 3Abbott AL Medical (nonsurgical) intervention alone is now best for prevention of stroke associated with asymptomatic severe carotid stenosis: results of a systematic review and analysis.Stroke. 2009; 40: e573-e583Crossref PubMed Scopus (542) Google Scholar Until the British Heart Protection Study was published in 2002, the usual practice in the UK was to prescribe low-dose statin treatment mainly to patients with hyperlipidaemia.2Naylor AR Gaines PA Rothwell PM Who benefits most from intervention for asymptomatic carotid stenosis: patients or professionals?.Eur J Vasc Endovasc Surg. 2009; 37: 625-632Summary Full Text Full Text PDF PubMed Scopus (147) Google Scholar With simvastatin 10 mg/day, the most commonly used dose in the UK in the 1990s,2Naylor AR Gaines PA Rothwell PM Who benefits most from intervention for asymptomatic carotid stenosis: patients or professionals?.Eur J Vasc Endovasc Surg. 2009; 37: 625-632Summary Full Text Full Text PDF PubMed Scopus (147) Google Scholar lipid-lowering treatment in the ACST-1 trial was probably suboptimal. Thus, despite ACST,1Halliday A Harrison M Hayter E et al.Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial.Lancet. 2010; 376: 1074-1084Summary Full Text Full Text PDF PubMed Scopus (642) Google Scholar a trial of CEA versus CAS versus best medical treatment is still urgently required to define the treatment of choice for asymptomatic carotid stenosis. Additionally, predictors of high-risk asymptomatic lesions (eg, microemboli on transcranial doppler imaging)4Spence JD Coates V Li H et al.Effects of intensive medical therapy on microemboli and cardiovascular risk in asymptomatic carotid stenosis.Arch Neurol. 2010; 67: 180-186Crossref PubMed Scopus (275) Google Scholar should be identified so that intervention can be offered only to asymptomatic patients with the highest risk of future stroke. In this way billions of pounds and dollars will not be wasted on unnecessary procedures in so many asymptomatic patients for minimal gain. We declare that we have no conflicts of interest. Best medical treatment for a symptomatic carotid artery stenosis – Authors' replyFor patients with asymptomatic carotid stenosis, lifestyle changes (particularly smoking cessation) and triple medical therapy (with lipid-lowering, antihypertensive, and antiplatelet drugs) substantially reduce, but do not eliminate, the annual risk of the carotid lesion causing a serious stroke. Less definitely, they can also somewhat reduce the immediate risk of carotid endarterectomy causing perioperative stroke or death. Full-Text PDF