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Comment & Response |

Carotid Endarterectomy for Asymptomatic Stenosis

Seemant Chaturvedi, MD1; George Howard, PhD2; James Meschia, MD3
[+] Author Affiliations
1Department of Neurology & Stroke Program, University of Miami Miller School of Medicine, Miami, Florida
2Department of Biostatistics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
3Department of Neurology, Mayo Clinic-Florida, Jacksonville
JAMA Intern Med. 2015;175(7):1241-1242. doi:10.1001/jamainternmed.2015.1118.
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To the Editor Brett and Levine1 recently discussed the case against identifying carotid stenosis in asymptomatic patients. We agree wholeheartedly that progress in medical therapy over the past 2 decades requires a reappraisal of whether carotid revascularization remains beneficial for such patients. In randomized trials, carotid endarterectomy (CEA) in asymptomatic patients was shown to be superior to medical management alone.2 At the time these trials were conducted, based on the observational studies available, many in the medical community had the opinion that CEA was not warranted because of the periprocedural risk; however, these trials proved that this view was incorrect. We have now entered a new period where many (including Brett and Levine) have the opinion based on observational studies that medical management has improved and revascularization in asymptomatic patients is no longer warranted. We suggest that CEA for asymptomatic stenosis not be discarded without the same rigor previously employed, that is, a high-quality randomized controlled trial to assess the relative efficacy and safety of intensive medical therapy alone, and intensive medical therapy plus CEA.

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Asymptomatic carotid stenosis should be screened for & get intensive medical treatment
Posted on July 10, 2015
David Keller
none
Conflict of Interest: None Declared
The CREST-2 clinical trial will study subjects having asymptomatic carotid stenosis, and will randomize them to receive invasive treatment (such as endarterectomy or stenting), or to receive no invasive treatment. All patients will receive the same background \"intensive medical therapy\" (1).

The USPSTF recommends against screening for asymptomatic carotid stenosis for the purpose of treating it with intensive medical therapy, stating: \"There is no evidence that identification of asymptomatic carotid artery stenosis leads to any benefit from adding or increasing medication doses (beyond current standard medical therapy for cardiovascular disease prevention).\" (2) Yet, CREST-2 subjects will all be given intensive medical therapy, instead of the standard medical therapy which the USPSTF advises for them.

Dr. Chaturvedi, CREST-2 corresponding author, stated their position very clearly in an email to me dated 7/8/2015: \"You are correct that intensive medical therapy has never been tested against standard medical therapy. However, we felt that for clinical trial purposes, the \"best\" form of medical therapy should be tested.\"

So, the CREST-2 subjects will be identified by screening, and will be treated with \"intensive\" medical therapy, despite the fact that USPSTF still recommends against screening for asymptomatic carotid stenosis, or treating it with anything stronger than \"standard preventative\" medical therapy. The CREST-2 investigators are ignoring these recommendations, as should all physicians.

\"Atherogenic stenosis in any artery is an indication for intensive medical therapy\", is an unproved statement which has become axiomatic. To deny screening for asymptomatic carotid stenosis, and to fail to treat it with intensive therapy when it is discovered, do not make physiological sense. It is time for the USPSTF to get their recommendations into alignment with current best practices, as exemplified by the CREST-2 protocol.

References:

1: Chaturvedi S, Howard G, Meschia J. Carotid Endarterectomy for Asymptomatic Stenosis.JAMA Intern Med. 2015;175(7):1241-1242. doi:10.1001/jamainternmed.2015.1118.

2: United States Preventative Services Task Force web site, accessed 7/7/2015.http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/carotid-artery-stenosis-screening
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