Asymptomatic carotid stenosis: intervention or just stick to medical therapy—the case for medical therapy

2011 ◽  
Vol 118 (4) ◽  
pp. 637-640 ◽  
Author(s):  
Jonathan Y. Streifler
Keyword(s):  
Carotid Stenosis ◽  
Medical Therapy ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid

Abstract 2956: Carotid Revascularization in Elderly Asymptomatic Patients: Are the Results Optimal?

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Rahul H Damani ◽  
Mahmoud Rayes ◽  
Pratik Bhattacharya ◽  
Seemant Chaturvedi
Keyword(s):  
Elderly Patients ◽  
Carotid Stenosis ◽  
Medical Therapy ◽  
Beta Blockers ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Carotid Revascularization ◽  
Asymptomatic Patients ◽  
Operative Complications ◽  
Best Medical Therapy

Objectives: Assess the hypothesis that patients with asymptomatic carotid stenosis older than 75 years are not on “best medical therapy” and their operative complication exceeds the AHA/ASA 3% threshold. Background: According to the Asymptomatic Carotid Atherosclerosis Study (ACAS), the Asymptomatic Carotid Surgery Trial (ACST) and recent AHA/ASA guidelines; benefits of carotid revascularization in asymptomatic patient >75 years would be offset if the operative complications rate exceed 3% and it would be more prudent to manage such patients on “best medical therapy”. How often these guidelines are being followed remains unclear. Methods: A retrospective chart review (2009-2011) at three urban, one suburban hospital within 30 miles was performed. Information of carotid revascularization (CEA & CAS) in asymptomatic elderly patients, in-hospital outcomes of stroke/death and/or MI and pre-procedural medications were evaluated. Statistical analysis with chi square testing was used. Results: A total of 114 patients met our inclusion criteria. Their features are described below.At four hospitals, the proportion of carotid revascularization done was 62% (114/185). More then quarter and one-third of patients undergoing carotid revascularization were not on statin and beta-blockers, respectively. Further, the rate of in hospital stroke was 4.4%. Conclusions: The majority of elderly patients with asymptomatic carotid stenosis patients are still undergoing carotid revascularization with operative complications that exceeded the AHA/ASA 3% threshold. More then quarter of patients in this subgroup are not on “best medical therapy”. These results reinforce the need for a new clinical trial comparing aggressive medical therapy alone vs. aggressive medical therapy and revascularization.

scholarly journals Comparative Effectiveness of Carotid Endarterectomy vs Initial Medical Therapy in Patients With Asymptomatic Carotid Stenosis

2020 ◽  
Vol 77 (9) ◽  
pp. 1110
Author(s):  
Salomeh Keyhani ◽  
Eric M. Cheng ◽  
Katherine J. Hoggatt ◽  
Peter C. Austin ◽  
Erin Madden ◽  
...  
Keyword(s):  
Carotid Endarterectomy ◽  
Carotid Stenosis ◽  
Medical Therapy ◽  
Comparative Effectiveness ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid

scholarly journals Intervention versus Aggressive Medical Therapy for Cognition in Severe Asymptomatic Carotid Stenosis

2016 ◽  
Vol 37 (10) ◽  
pp. 1889-1897 ◽  
Author(s):  
C.-J. Lin ◽  
F.-C. Chang ◽  
K.-H. Chou ◽  
P.-C. Tu ◽  
Y.-H. Lee ◽  
...  
Keyword(s):  
Carotid Stenosis ◽  
Medical Therapy ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid

Abstract 17291: Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis: CREST-2 update

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
James Meschia ◽  
Brajesh K Lal ◽  
George Howard ◽  
Gary Roubin ◽  
Robert D Brown ◽  
...  
Keyword(s):  
Carotid Stenosis ◽  
Medical Therapy ◽  
Primary Outcome ◽  
Randomized Clinical Trials ◽  
Carotid Stenting ◽  
Current Treatment ◽  
Asymptomatic Carotid Stenosis ◽  
Asymptomatic Carotid ◽  
Carotid Revascularization ◽  
Asymptomatic Patients

Purpose: The safety of revascularization for asymptomatic carotid stenosis, and the efficacy of medical therapy for stroke prevention have improved. Therefore, results of prior randomized trials may not apply to current treatment decisions. The NINDS-funded CREST-2 will compare carotid endarterectomy and intensive medical therapy (IMT) versus IMT alone (n=1240), and carotid stenting and IMT versus IMT alone (n=1240) in asymptomatic patients with≥70% stenosis. Materials & Methods: CREST-2 consists of two parallel randomized clinical trials to be conducted at a target of ≈120 centers, including within NINDS StrokeNet. The composite primary outcome is stroke or death during the peri-procedural period or ipsilateral ischemic stroke thereafter up to 4 years. Blinded assessment of cognition will be done periodically. Centrally directed IMT includes tight control of blood pressure (systolic target <140 mm Hg) and cholesterol (LDL target <70 mg/dl) as well as lifestyle coaching. Results: As of June 12, 2015, 94 centers have been approved by the Site Selection Committee. Credentialing is ongoing, with 198 approved surgeons and 64 approved interventionists; 124 additional conditionally approved interventionists will be able to submit additional cases for review under the CREST-2 Registry. The Centers for Medicare and Medicaid will offer CAS reimbursement for Registry enrollees. As of June 12, 2015, there are 39 actively enrolling centers, and 37 patients have been randomized. Conclusion: CREST-2 is designed to identify the best approach for asymptomatic carotid stenosis. The first patient was randomized in December, 2014. An update will be provided regarding the numbers of patients randomized, centers certified, as well as surgeons and interventionists fully approved. Registration: ClinicalTrials.gov Identifier: NCT02089217

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