Asymptomatic Carotid Stenosis

See related article, p 702.In this issue of Stroke , Hirt1 reports that substantial progression of carotid stenosis predicted ipsilateral stroke or transient ischemic attack among patients randomized to medical therapy in the Asymptomatic Carotid Surgery Trial (ACST).2 This might be regarded as another justification to perform carotid endarterectomy (CEA) or stenting (CAS) in some patients with asymptomatic carotid stenosis (ACS), and Hirt’s article may help in the selection for invasive treatment of those ACS patients at highest risk of having a stroke.However, the proportion of patients with progression by ≥2 grades (which carried a high enough risk to identify patients who might benefit from invasive intervention) was small. Among the 1469 patients in the study, there were events in only 50 (3.4%), among the 117 (8%) of patients with progression by ≥2 grades of stenosis. It must also be understood that the ACST trial was conducted before the widespread implementation of intensive medical therapy that has diminished the stroke risk picture markedly.The current situation in the United States is deplorable: as many as 95% of CEA and CAS procedures are being performed in patients with asymptomatic stenoses,3 and most of these patients are more likely to be harmed than helped by these interventions. This is being justified on the basis of historical stroke risks in the ACST2 and the Asymptomatic Carotid Surgery Trial.4 These risks …