Medical Therapy Before Carotid Endarterectomy: Changes Over a 13-Year Period and Comparison Between Asymptomatic and Symptomatic Patients

Abstract

We evaluated the evolution of chronic medical therapy in patients admitted for carotid endarterectomy (CEA) over a 13-year period and to analyze the difference in medical treatment between symptomatic and asymptomatic patients. A retrospective study was conducted on patients treated between 2002 and 2015. The use of antiplatelets (acetylsalicylic acid [ASA], ticlopidine, and clopidogrel), oral anticoagulant therapy (OAT), statins and antihypertensives (angiotensin-converting enzyme inhibitors [ACE-I]/angiotensin receptor blockers [ARBs], β-blockers [BB]) administration was evaluated. During the study period, 852 CEAs were performed in 681 (79.9%) asymptomatic patients. Prescription rate increased significantly for ASA (+29.2%), clopidogrel (+10.3%), statins (+60.8%), ACE-I/ARBs (+31.1%), and BB (+19.3%; all P < .05). No significant modification was observed for ticlopidine and OAT (ticlopidine use was abandoned in the recent years, but this difference was not significant due to the small numbers). A lower medication intake was recorded for symptomatic patients when compared with asymptomatic patients, except for OAT and clopidogrel. Our analysis suggests that medical therapy has changed over the years for patients with carotid stenosis. Although this is a big step toward best medical therapy, preoperative drug therapy remains suboptimal in symptomatic patients.

Risk Scoring Systems to Predict Long-Term Mortality After Carotid Endarterectomy in Asymptomatic Patients: A Systematic Review

“…Although some scores seem to be better than others, several confounding factors may affect short-term and long-term mortality rate and score calibration in the development cohort. As mentioned, an improvement in medical therapy during last few decades 5,6 may have contributed to a higher survival rate at 3 and 5 years after CEA in both asymptomatic and symptomatic patients. Unfortunately, selected score did not provide satisfactory information regarding patients' medical therapy after or before CEA.…”

“…Although currently available data from randomized clinical trials show the superiority of surgery plus best medical treatment (BMT) over BMT alone, [1][2][3][4] a reduction in the risk of stroke in nonsurgical patients has been recorded, and this is probably due to the improvement in medical treatment through the last 3 decades. 5,6 Many efforts have therefore been made for identifying those patients at higher risk of neurological events who would get maximal benefit from preventive surgery. Currently published international guidelines suggest that CEA in asymptomatic patients should only be proposed if the risk of perioperative stroke is less than 3% and life expectancy after the procedure is 3 to 5 years.…”

Best Medical Treatment for Patients with Carotid Stenosis: Evidence-Based Medicine or Wishful Thinking?

“…The premature cessation of the Stent-Protected Angioplasty versus Carotid Endarterectomy 2 trial 28 suggests that it may be hard to convince patients not to take any action (ie, not to undergo CEA or CAS) to prevent a possible stroke from their carotid stenosis and just continue with BMT. One wonders what would the patients with ACS in the study by Bissacco et al 1 have said if they were offered only BMT instead of CEA.…”

“…6,7 The authors should be congratulated for their effort to apply BMT. 1 Some aspects of this study deserve some comments.…”

“…1 Prescription of acetylsalicylic acid, clopidogrel, statins, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and b-blockers increased considerably during the study period. The most impressive increase (>60%) was in the prescription rates of statins (from 11.6% in 2002 to 72.4% in 2014).…”