Carotid+Endarterectomy

ACAS (1995): Endarterectomy for asymptomatic carotid artery stenosis. Executive Committee for the Asymptomatic Carotid Atherosclerosis Study. JAMA 1995;273:1421-8. - treatment: carotid endarterectomy - control: aspirin 325 mg daily - population: asymptomatic carotid artery stenosis of 60% or greater - method: RCT - follow-up: 2.7 years mean - primary end-point: ipsilateral stroke or any perioperative stroke or death - outcome: perioperative stroke or death or subsequent ipsilateral stroke: treatment 4.0%, control 6.2%, relative risk 0.64, 95% CI 0.42-0.98, absolute risk reduction -22.4%

Patient Decision-Making with regards to surgery for asymptomatic carotid stenosis. Silver B et al, “A randomized trial of decision-making in asymptomatic carotid stenosis.” Neurology, 2012: 78(5):315-21. - RCT, hypothetical clinical scenarios presented to patients without cardiovascular disease - N=409 - Subjects: Individuals presenting to neurologic clinic, age>18, without known carotid stenosis. - Methods: 30-second videos regarding 70% asymptomatic carotid stenosis with 1 of 5 presentation formats (absolute risk, absolute event-free survival, annualized absolute risk, relative risk, and a qualitative description) delivered by 1 of 4 presenter physicians (black woman, white woman, black man, white man). Subjects then completed a one-page form regarding background demographics and their decision regarding treatment choice. - Outcomes: Most importantly, 63% of subjects presented relative risk selected surgery, compared to 43% of subjects presented absolute risk. Presentation format strongly predicted choice of surgery (qualitative [64%], relative risk [63%], absolute risk [43%], absolute event-free survival [37%], and annualized absolute risk [35%], p < 0.001). Nonsignficant trend toward increased selection of surgery with younger age (mean age 52 vs 55, p = 0.054), male gender (53% vs 45%, p = 0.08), and advanced education (42% for high school education or less vs 52% for more than high school education, p = 0.052). Gender and race of presenter, and race of subject, had no influence on the choice of treatment.

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