Aggressive Medical Therapy Alone Is Adequate in Certain Patients With Severe Symptomatic Carotid Stenosis

Abstract

As clinicians, our responsibility is to be honest with our patients. To achieve the goal of an honest discourse with this patient, we must inform her that it is uncertain whether she would benefit from carotid endarterectomy (CEA). Although the landmark clinical trials that compared CEA plus optimal medical therapy (OMT) with OMT alone showed robust benefit for CEA in symptomatic patients with high-grade stenosis, we should acknowledge that studies such as the North American Symptomatic Carotid Endarterectomy Trial (NASCET) used what now would be regarded as “suboptimal” medical therapy. Furthermore, the 70% to 99% cohort of NASCET was published in 1991. It is shocking that clinicians are still making CEA decisions based on data that are 22 years old! What can we learn from more contemporary stroke prevention studies that have used aggressive medical therapy? A good place to start would be the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) study1 …