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

Abstract

Randomized clinical trials (RCTs) have established that carotid endarterectomy (CEA) is beneficial in preventing stroke in both asymptomatic^1-3 and symptomatic patients^4,5 with carotid stenosis. However, the most recent of the 3 trials that established the clinical benefit of CEA compared with medical therapy in asymptomatic patients was initiated 25 years ago.^1-3 In the intervening period, new pharmacological advances, such as high-potency statins^6-9 and improved antiplatelet regimens,^10,11 as well as quality improvements in the treatment of blood pressure^12,13 and diabetes¹⁴ may be associated with the reduced stroke rate among patients with asymptomatic carotid stenosis. Empirical evidence in support of a reduction in stroke risk among patients with asymptomatic carotid stenosis has been provided by a systematic review of several studies.¹⁵ If the decrease in stroke rate among patients with carotid artery stenosis is associated with improvements in primary stroke prevention, revascularization may no longer be the preferred treatment strategy.