Does the Modern Concept of ‘Best Medical Therapy’ Render Carotid Surgery Obsolete?

Abstract

Few operations have aroused such intense scientific scrutiny as carotid endarterectomy (CEA). Despite the provision of level I (Grade A) evidence supporting the role of CEA in symptomatic and asymptomatic patients, its role still generates widely conflicting opinions around the globe. The latest controversies relate to; (i) recent improvements in the concept of ‘best medical therapy’, (ii) continued scepticism about the overall generalisability of the operative risks reported in the international trials and (iii) the emergence of angioplasty as an alternative to surgery. This article will focus on an increasingly popular viewpoint (especially among stroke physicians) that improvements in best medical therapy (BMT) now render carotid surgery (and thus by implication, angioplasty) obsolete. While the European Carotid Surgery Trial (ECST), the North American Symptomatic Carotid Endarterectomy trial (NASCET), the Asymptomatic Carotid Atherosclerosis Study (ACAS) and the Asymptomatic Carotid Surgery Trial (ACST) were recruiting, the concept of BMT was relatively primitive. To many clinicians it simply meant stopping smoking, starting aspirin and treating hypertension/angina ‘as best possible’. Few were prescribed lipid-lowering drugs and many hypertensive patients simply did not achieve satisfactory control of blood pressure. Moreover, the responsibility for ensuring implementation of BMT was often delegated to a junior member of the team. So what has changed? Improvements in what currently constitutes ‘modern’ BMT can be summarised as; (i) alternative (dual) antiplatelet therapy, (ii)