Summary: “Time to Change the Guidelines for Carotid Endarterectomy?”
Summary: “Time to Change the Guidelines for Carotid Endarterectomy?”
Source: Medscape Medical News.
Published: April 28, 2025
Original Study Publication: The Lancet Neurology, April 16, 2025
Key Findings in Bullet Points:
1. OMT vs. Surgery: Optimized medical therapy (OMT) was found to be as effective as carotid endarterectomy (CEA) in preventing stroke in the majority of patients with carotid artery stenosis.
2. CAR Score Introduction: The new Carotid Artery Risk (CAR) score, using updated stroke risk data, suggests that up to 75% of current CEA candidates could be managed with OMT alone.
3. Study Population:
• 429 patients with ≥50% carotid stenosis.
• Median age: 72 years; 69% male.
• 40% symptomatic, 60% asymptomatic.
4. Treatment Arms:
• Patients received either OMT alone or OMT + CEA.
• OMT included strict lipid, blood pressure, antithrombotic, lifestyle, and diabetic management.
5. Primary Endpoint: A composite of periprocedural death, fatal/nonfatal stroke or MI, and silent brain infarctions.
6. Outcome Analysis – Win Ratio Method:
• 77.3% of patient pairs were “ties” (similar outcomes).
• OMT-only “wins”: 11.4% vs. 11.3% for OMT+CEA.
• Win ratio: 1.01 (95% CI: 0.60–1.70; P = 0.97) – showing no clear advantage for surgery.
7. Implication: Most patients with low predicted 5-year stroke risk (CAR score <20%) may safely avoid surgery.
8. Subgroup Analysis: No significant outcome differences by age, sex, diabetes, hypertension, or degree of stenosis.
9. Limitations:
• 2-year follow-up only (long-term outcomes pending).
• CAR score not yet independently validated.
• COVID-19 disrupted follow-up imaging.
• Modest sample size, limiting power for subgroup detection.
10. Expert Opinions:
• Martin Brown, MD: Advocates updating guidelines to reflect modern therapy effectiveness.
• Paul Nederkoorn, MD: Emphasizes potential impact on reducing surgical risks and healthcare costs.
• Steven Messe, MD: Notes 2-year follow-up may not be sufficient; long-term benefits of CEA might take longer to emerge.
• Commentators (Ho & Hankey): Cautiously optimistic but call for more robust data.
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