Thomas L. Schwenk, MD, reviewing Chang RW et al. JAMA 2022 May 24/31
Incidence of ischemic stroke has declined from about 2% to 1% annually.
Studies that informed managing patients with asymptomatic severe carotid stenosis (i.e., 70%–99%) were conducted longer than 20 years ago. Because medical management has changed markedly (and presumably improved) in recent decades, investigators determined the stroke incidence in ≈3700 medically managed patients (mean age, 74) with severe asymptomatic carotid stenosis diagnosed between 2008 and 2012 in a large community-based, integrated healthcare system. Patients were followed to 2019 or until death, stroke, or surgical intervention.
Incidence of ipsilateral ischemic stroke was 0.9% annually and 4.7% at 5 years. Strokes were more common in patients who were older, had high-grade stenosis (i.e., 90%–99%), or had previous contralateral strokes.
COMMENT
The incidence of ipsilateral ischemic stroke had been estimated, based on the older trials, at roughly 1% annually for surgically managed patients (i.e., those who underwent carotid stenting or endarterectomy) and 2% annually for medically managed patients. Outcomes initially are worse in surgically managed patients owing to perioperative complications (e.g., stroke, cardiac events, or death), so it takes several years for surgical management to outperform medical management. Now, given these new data in medically managed patients, surgical management might never catch up. Even case-finding for asymptomatic carotid stenosis in patients with known vascular disease might not be appropriate, because aggressive medical management already would be indicated. Until we see the results of an ongoing large, randomized trial of medical versus surgical management (CREST-2. opens in new tab), expected in December 2022, the current findings might help clinicians engage with patients to make appropriate decisions for managing asymptomatic carotid stenosis, however it is detected.
CITATIONS
Chang RW et al. Incidence of ischemic stroke in patients with asymptomatic severe carotid stenosis without surgical intervention. JAMA 2022 May 24/31; 327:1974.
עברית
COMMENT
The incidence of ipsilateral ischemic stroke had been estimated, based on the older trials, at roughly 1% annually for surgically managed patients (i.e., those who underwent carotid stenting or endarterectomy) and 2% annually for medically managed patients. Outcomes initially are worse in surgically managed patients owing to perioperative complications (e.g., stroke, cardiac events, or death), so it takes several years for surgical management to outperform medical management. Now, given these new data in medically managed patients, surgical management might never catch up. Even case-finding for asymptomatic carotid stenosis in patients with known vascular disease might not be appropriate, because aggressive medical management already would be indicated. Until we see the results of an ongoing large, randomized trial of medical versus surgical management (CREST-2. opens in new tab), expected in December 2022, the current findings might help clinicians engage with patients to make appropriate decisions for managing asymptomatic carotid stenosis, however it is detected.