Treating Asymptomatic Patients: Truth and Illusion. William A. Gray MD Associate Professor of Medicine Columbia University New York. Can patients with carotid stenosis be identified as at risk for stroke?. Classically risk is assigned by: Clinical syndrome
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William A. Gray MD
Associate Professor of Medicine
Perhaps medical therapy has improved
enough to negate that benefit
Carotid endarterectomy versus medical management:
Perioperative stroke or death or subsequent ipsilateral stroke
Current risk with CEA is half what it was in ACST Trial.
Marquardt et al. Stroke 2010
Patients with minimal disease generally have minimal risk of stroke
An inflection point
at a PSV >250
Asymptomatic Internal Carotid Artery Stenosis Defined by Ultrasound and the Risk of Subsequent Stroke in the Elderly: The Cardiovascular Health Study. Longstreth et al Stroke. 29(11):2371-2376, November 1998.
Largest randomized trial in
asymptomatic carotid disease is omitted
(ACST, 1500 medically treated patients)
If the systematic review’s analysis had adjusted for minimum % stenosis, or had included more recent studies (REACH and ACST) the trend in stroke rates would have been in the opposite direction (p = 0.55)
Largest and most recent REACH study (N = 3164) published after the systematic review contradicts the review findings
The Change in Minimum Stenosis Thresholds in Studies Over Time Mirrors the Reported Decline In Stroke Rates
Trend sensitive to effects of early study
with more complex patients
Aichner FT, et al. Eur J Neurol2009; 16:902-908.
“CBAS should not currently undergo widespread practice, which should await results of randomized trials.”
“These and other consensus conclusions will help physicians in all specialties deal with CBAS in a rational way rather than by being guided by unsubstantiated claims.”
“ Everything has been said before, but since nobody listens we have to keep going back and beginning all over again.. ”Andre Gide, Le Traite du Narcisse1891
StampferMJet al. PrevMed. 1991 Jan;20(1):47-63.
Hulley S et al. JAMA 1998;280(7):605-613
Results are reported based on ITT analysis
Not on lipid-lowering therapy at entry
On lipid-lowering therapy at entry
Gray et al. Circulation. In press
Gray et al. Circulation 2012
Access complications greater with CEA
Patients requiring re-operation
Events may occur more than once in the same patient.
Other includes pain requiring IV analgesics (5), incision complication (3), pseudoaneurysm (2), occlusion (1)
Gray et al. Circulation 2012
Stroke Minor (1.8%)
Stroke Major (0.6%)
CAS achieves AHA guidelines in asymptomatic patientsLarge, prospective, multicenter neurologically-audited/independent adjudication single arm studies in high-surgical risk patients
EXACT/CAPTURE 2 (combined): 30-day major adverse events asymptomatic patients <80 years
Hierarchical- Includes only the most serious event for each
patient and includes only each patient first occurrence of each event.
Gray et al. CircCardiovascInterv. 2009 Jun;2(3):159-66
30 day stroke/death distribution by site
No stroke or death in 81% (134/166) of sites
Gray et al. JACC CardiovascInterv. 2011 Feb;4(2):235-46
benefit >>>risk, class I
Should be considered
benefit >>risk, class IIa
Might/may be considered
benefit >/=risk, class IIb
AnkurThapar: Imperial College, London