Gowri Raman, MD, MS; Denish Moorthy, MBBS, MS; Nira Hadar, MS; Issa J. Dahabreh, MD, MS; Thomas F. O'Donnell, MD; David E. Thaler, MD, PhD; Edward Feldmann, MD; Joseph Lau, MD; Georgios D. Kitsios, MD, PhD
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Grant Support: By the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services (contract 290 2007 10055 I).
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Requests for Single Reprints: Gowri Raman, MD, MS, Tufts Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Box 63, 800 Washington Street, Boston, MA 02111; e-mail, email@example.com.
Current Author Addresses: Drs. Raman and Moorthy: Tufts Center for Clinical Evidence Synthesis, Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Box 63, 800 Washington Street, Boston, MA 02111.
Ms. Hadar and Drs. Dahabreh and Lau: Center for Evidence-based Medicine, Box G-S121-8, 121 South Main Street, Brown University, Providence, RI 02912.
Dr. O'Donnell: Department of Vascular Surgery, Tufts Medical Center, Box 259, 800 Washington Street, Boston, MA 02111.
Drs. Thaler and Feldman: Department of Neurology, Tufts Medical Center, Box 314, 800 Washington Street, Boston, MA 02111.
Dr. Kitsios: Department of Internal Medicine, Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805.
Author Contributions: Conception and design: G. Raman, D. Moorthy, N. Hadar, G.D. Kitsios.
Analysis and interpretation of the data: G. Raman, D. Moorthy, N. Hadar, I.J. Dahabreh, T.F. O'Donnell, D.E. Thaler, E. Feldmann, G.D. Kitsios.
Drafting of the article: G. Raman, D. Moorthy, N. Hadar, E. Feldmann, G.D. Kitsios.
Critical revision of the article for important intellectual content: G. Raman, D. Moorthy, I.J. Dahabreh, T.F. O'Donnell, D.E. Thaler, E. Feldmann, J. Lau, G.D. Kitsios.
Final approval of the article: G. Raman, D. Moorthy, N. Hadar, I.J. Dahabreh, T.F. O'Donnell, D.E. Thaler, E. Feldmann, J. Lau, G.D. Kitsios.
Provision of study materials or patients: G. Raman, G.D. Kitsios.
Statistical expertise: G. Raman, D. Moorthy, I.J. Dahabreh, G.D. Kitsios.
Obtaining of funding: J. Lau.
Administrative, technical, or logistic support: G. Raman, D. Moorthy, J. Lau, G.D. Kitsios.
Collection and assembly of data: G. Raman, D. Moorthy, N. Hadar, D.E. Thaler, G.D. Kitsios.
Adults with asymptomatic carotid artery stenosis are at increased risk for ipsilateral carotid territory ischemic stroke.
To examine comparative evidence on management strategies for asymptomatic carotid stenosis and the incidence of ipsilateral stroke with medical therapy alone.
MEDLINE, Cochrane Central Register of Controlled Trials, U.S. Food and Drug Administration documents, and review of references through 31 December 2012.
Randomized, controlled trials (RCTs) and prospective or retrospective nonrandomized, comparative studies of medical therapy alone, carotid endarterectomy (CEA) plus medical therapy, or carotid artery stenting (CAS) plus medical therapy for adults with asymptomatic carotid stenosis, as well as single-group prospective cohort studies of medical therapy, were reviewed.
Two investigators extracted information on study and population characteristics, results, and risk of bias.
Forty-seven studies in 56 publications were eligible. The RCTs comparing CAS and CEA were clinically heterogeneous; 1 RCT reported more but not statistically significant ipsilateral stroke events (including any periprocedural stroke) in CAS compared with CEA, whereas another RCT, in a population at high surgical risk for CEA, did not. Three RCTs showed that CEA reduced the risk for ipsilateral stroke (including any periprocedural stroke) compared with medical therapy alone, but these results may no longer be applicable to contemporary clinical practice. No RCT compared CAS versus medical therapy alone. The summary incidence of ipsilateral stroke across 26 cohorts receiving medical therapy alone was 1.68% per year.
Studies defined asymptomatic status heterogeneously. Participants in RCTs did not receive best-available medical therapy.
Future RCTs of asymptomatic carotid artery stenosis should explore whether revascularization interventions provide benefit to patients treated by best-available medical therapy.
Agency for Healthcare Research and Quality.
Raman G, Moorthy D, Hadar N, Dahabreh IJ, O'Donnell TF, Thaler DE, et al. Management Strategies for Asymptomatic Carotid Stenosis: A Systematic Review and Meta-analysis. Ann Intern Med. 2013;158:676–685. doi: 10.7326/0003-4819-158-9-201305070-00007
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Published: Ann Intern Med. 2013;158(9):676-685.
High Value Care, Neurology, Stroke.
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