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Immediate Better Than Deferred Carotid Endarterectomy to Reduce Risk of Stroke for Asymptomatic Patients: Presented at ESC

Michael J. Worthington

MANNHEIM-HEIDELBERG, GERMANY -- May 14, 2004 -- Immediate carotid endarterectomy (CEA) is better than deferred CEA for reducing the 5-year risk of stroke in patients with asymptomatic carotid stenosis (ACST), say researchers from Oxford, United Kingdom.

Principal investigators Drs. Dafydd Thomas and Alison Halliday, Oxford Clinical Trial Service Unit, reported on the results of the ACST Trial, the world's largest vascular surgery trial, here on May 13^th at the 13^th European Stroke Congress, in addition to their publication in this week's Lancet.

The study enrolled 3120 patients with ACST over a 10-year period. In addition to having ACST (i.e. ipsilateral carotid infarct, contralateral occlusion), patients also had other signs of high stroke risk, including diabetes, hypertension, and elevated serum cholesterol levels. Most were on some sort of medication for stroke prevention, including 1 or more of an antihypertensive, an antiplatelet agent, an anticoagulant, and a cholesterol-lowering agent.

Patients were randomized into 1 of 2 groups -- 1560 underwent immediate CEA, which was defined as CEA soon after randomization (median 1 month), and 1560 underwent deferred CEA, which was defined as a median of 2 years after randomization. At the time of CEA, less than 1% of patients in the immediate CEA group and half of the deferred CEA group presented with symptoms.

Perioperative events such as death from stroke, disabling stroke, cardiac death, non-fatal myocardial infarction, were more common in the deferred CEA group, compared to the immediate group, although not statistically different (4.5% versus 2.8%). Although the available data was limited, Dr. Halliday said there were no significant differences in CEA risk between men and women or among different age groups.

The risk of having any type of stroke or perioperative death within 5 years of the procedure was 6.42% for the immediate CEA group and 11.78% for the deferred group (P =.00001). The 5-year risks for any type of perioperative stroke were 3.77% and 10.94%, respectively (P <.00001), and for nonperioperative carotid territory stroke, the 5-year risks were 2.73% and 9.52% (P <.00001).

In summarizing which types of patients would most benefit from an immediate CEA, Dr. Thomas said, "The benefits were significant for men and women, for younger patients (<65 years) and for those aged 65 to 74 [years], although there was less benefit for patients over age 75." There was also a similar benefit for those with smaller stenoses (~70% stenosed) and more severe stenoses (~80% or 90%), he said, noting that all these patients were "tight" stenoses, which represent a higher risk for stroke.

"We really need more data on which types of patients gain worthwhile benefit and how we can generalize these findings. We're not recommending that the general population be screened to pick up asymptomatic disease, but these results are open to dangerous misinterpretation by interested groups," Dr. Thomas said, referring to the fact that surgeons may be encouraged to intervene when the benefits of CEA may outweigh the risks.


Presentation title: "Update on Asymptomatic Carotid Stenosis ACST."

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