Alamowitch S, Eliasziw M, Algra A, et al. Risk, causes, and prevention of ischemic stroke in elderly patients with symptomatic internal-carotid-artery stenosis.

Abstract

Alamowitch S, Eliasziw M, Algra A, et al. Risk, causes, and prevention of ischemic stroke in elderly patients with symptomatic internal-carotid-artery stenosis. Lancet 2001;357:1154–60. Alamowitch et al. studied patients from the North American Symptomatic Carotid Endarterectomy Trial (NASCET) with symptomatic internal carotid artery (ICA) stenosis. They stratified by age and compared outcomes of patients treated with carotid endarterectomy to best medical therapy. Patients were classified into three age groups: 75 years or older, 65 to 74 years, and younger than 65 years. The first group was considered elderly. At baseline these patients were less likely than younger patients to have atherosclerotic risk factors and least likely to have severe ICA stenosis. Among surgically treated patients, the elderly group had the lowest risk of ipsilateral stroke, regardless of the degree of ICA stenosis. However, they had the highest risk of stroke with medical management, which depended on the degree of ICA stenosis (24.9% risk of stroke for 50%–69% stenosis; 36.5% risk of stroke for 70%–99% stenosis). Because elderly patients had the highest risk with medical management, the absolute risk reduction with surgical management was greatest (28.9%, P < 0.0001). In addition, among patients with 50% to 69% stenosis, reduction in risk was significant only for the oldest age group (17.3%, P = 0.0005). No significant benefit to surgical management was seen in patients with less than 50% stenosis in any age category. The greatest benefit of surgery in the elderly, compared with the younger patients, resulted from having a combination of the highest risk of ipsilateral ischemic stroke if managed medically and the lowest surgical risk, presumably because of their lower number of baseline atherosclerotic risk factors. These data should help guide choice of therapy for elderly patients and symptomatic ICA stenosis.