Patient preference survey in the management of asymptomatic carotid stenosis

Abstract

Carotid stenosis accounts for 20% of ischemic strokes and can be managed with pharmacotherapy alone or in conjunction with carotid endarterectomy or stenting. The management of asymptomatic carotid stenosis is controversial amongst physicians. The aim of this study was to explore patient preferences for the potential management options using a standardized scenario to minimize clinician bias. These data will then be used to facilitate comparison with existing published data on physicians' preferences in the management of asymptomatic carotid stenosis. A patient information booklet and questionnaire was developed, validated, and distributed to patients who were identified as candidates for carotid screening duplex based on the presence of peripheral arterial, coronary, or aneurismal disease. Patients were asked to imagine their duplex revealed a 70% unilateral carotid stenosis. Five-year stroke or death risks of 11% were quoted for best medical therapy. The perioperative stroke or death rates quoted were 3% for endarterectomy and 3% to 5% for stenting, based on best current evidence. No physician interaction was allowed to minimize clinician bias. Responses for treatment preference and reasoning were analyzed using appropriate statistical methods. Results from this survey were then compared with a previously published poll of physician preference. One hundred two questionnaires were analyzed with a 94% response rate: 48% chose pharmacotherapy alone, 30% selected carotid endarterectomy, and 22% opted for stenting. The preference for pharmacotherapy alone over either intervention, and for endarterectomy, over stenting was consistent in subgroup analyses by age, gender, prior stroke, family history of stroke, and smoking status. In this scenario, patients were split equally between medical and surgical treatment of asymptomatic carotid stenosis. This was identical to a recent poll of physicians. Tools for risk assessment and the results of the SPACE2, ACST2, and ACT1 trials would benefit patients and physicians making this important treatment decision.