COMMENTARY

Asymptomatic Patients With CAS: To Intervene or Not?

Frank J. Veith, MD

Disclosures

September 18, 2013

In This Article

Asymptomatic Carotid Disease

What about treatment of asymptomatic carotid disease (carotid stenosis in the neck), which doesn't cause any neurologic symptoms? It is a fairly benign disease, and the controversy is whether one should do carotid endarterectomy to prevent stroke, do carotid stenting to prevent stroke, or use best medical treatment. Best medical treatment includes statins, other drugs such as angiotensin-converting enzyme (ACE) inhibitors, better diet, better hypertension control, and better diabetic control. These comprise best medical treatment, and they have sharply decreased the incidence of stroke in patients with asymptomatic carotid stenosis. About 20 years ago, the stroke rate was 4%-6% per year. Now it is < 1% per year, probably because of all of these medical treatments, most importantly statins. Old trials have demonstrated that strokes are prevented in a small number of patients by intervening with carotid endarterectomy, but since 1990, statins and other treatments have been introduced. The old randomized trials are now obsolete, and many of us believe that most patients with asymptomatic carotid stenosis are best treated medically and not with intervention by carotid endarterectomy or carotid stenting.

When you look at the statistics over the past 5-10 years, most carotid interventions, including endarterectomy and stenting, have been in asymptomatic patients -- up to 90%. In New Jersey in 2009, 96% of all carotid stents were placed for asymptomatic disease. To me that is absurd. That is wrong. Most of those patients would have been much better off being treated medically. That is an opinion. We don't really know. We have the old randomized trials that are obsolete, which many people are still quoting as the reason for intervening on these patients. Then we have the data showing a sharply decreasing stroke rate with good medical therapy, so many of us believe that good medical therapy is best for most patients with asymptomatic carotid stenosis. If one could determine the very few patients with asymptomatic carotid stenosis who are going to have a stroke by using some nice test, then I think those patients should be intervened upon either by endarterectomy or stenting. But so far, we don't have a good way of doing that. There are some experimental methods using transcranial Doppler and other techniques that show promise, but we don't have a universally proven method for picking out the high-stroke-risk patients with asymptomatic carotid stenosis. Therefore, at the present time, I and many of my colleagues will treat most of these patients conservatively with best medical treatment. It seems to be gaining favor, although many still believe that most if not all of these patients should be treated. I think they are affected by bias.

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