Aggressive Medical Therapy Alone Is Not Adequate in Certain Patients With Severe Symptomatic Carotid Stenosis

Abstract

The Case: A 59-year-old woman presents 4 weeks after a transient ischemic attack (left-sided weakness). Carotid ultrasound shows 80% right internal carotid artery stenosis. She takes aspirin 81 mg and atorvastatin 20 mg daily. The Questions: 1. Should the patient undergo carotid endarterectomy (CEA)? 2. Should clopidogrel be added to her therapy and the dose of atorvastatin increased to 80 mg instead of CEA? The Controversy: Aggressive medical therapy alone is not adequate in certain patients with severe symptomatic carotid stenosis? The results of the first European Carotid Surgery Trial (ECST) and the North American Symptomatic Carotid Endarterectomy Trial (NASCET) led to guidelines recommending carotid endarterectomy (CEA) for patients matching the trial characteristics, which are still current today. Thus, if you observe the guidelines, this patient should be referred for CEA. However, analysis of the trial data suggests that this is not necessarily the right decision. Rothwell et al1 developed a risk model using ECST data that predicted the future risk of stroke in patients allocated medical treatment alone and was validated in the NASCET dataset.1 The analyses showed that only patients with a 5-year risk of ipsilateral stroke of >20% benefited from CEA. The characteristics that predicted the risk of recurrent stroke included age, sex, symptom severity, time since symptoms, severity of stenosis, other vascular risk factors, and whether the stenosis was ulcerated, irregular, or smooth. A tool that uses this model is available online (http://www.stroke.ox.ac.uk/model/form1.html), and I have just used the tool to calculate the patient’s future risk of …