Optimized medical therapy versus revascularization in high-grade asymptomatic carotid stenosis: a systematic review and meta-analysis of randomized controlled trials
A Castro Pinto, B Resende, E Mata, J Gameiro, F Cordeiro, L Goncalves, A LourencoAbstract
Introduction
The optimal management of patients with asymptomatic carotid stenosis remains controversial. Improvements in medical therapy, carotid artery stenting and carotid endarterectomy, call into question the preferred management o asymptomatic carotid stenosis. Whether adding revascularization to intensive medical treatment would provide greater benefit than intensive medical treatment alone is unclear.
Purpose
To compare the efficacy and safety of optimized medical therapy alone versus carotid revascularization plus intensive medical therapy in patients with asymptomatic carotid stenosis.
Methods
A systematic review and meta-analysis of RCTs was performed across four databases. Trials comparing optimized medical therapy with revascularization, either percutaneous or surgical, in patients with asymptomatic carotid stenosis were included. Hazard ratios (HR) with 95% confidence intervals (CI) were pooled for death, any stroke, ipsilateral stroke, ipsilateral ischemic stroke, transient ischemic attack and myocardial infarction. Perioperative death or stroke was analyzed using risk ratios (RR). Random-effects meta-analyses were performed using the Hartung-Knapp-Sidik-Jonkman method, with between-study variance estimated by the Sidik-Jonkman estimator. Heterogeneity was assessed using forest plot inspection and the I² statistic.
Results
Four randomized controlled trials were included. Revascularization was not associated with a significant reduction in death compared with optimized medical therapy alone (HR 0.94, 95% CI 0.61-1.47; I² = 0%). Similarly, no significant reduction was observed for any stroke (HR 0.90, 95% CI 0.67-1.19; I² = 0%). No statistically significant differences were found for ipsilateral ischemic stroke (HR 0.79, 95% CI 0.19-3.30; I² = 70.7%) or overall ipsilateral stroke (HR 1.03, 95% CI 0.37-2.86; I² = 38.6%). Transient ischemic attack was also not significantly reduced with revascularization (HR 0.97, 95% CI 0.26-3.67; I² = 26.7%). In contrast, myocardial infarction occurred more frequently in the revascularization group (HR 2.26, 95% CI 1.46-3.50; I² = 0%), indicating a significantly increased risk associated with invasive treatment.
Conclusion
In patients with asymptomatic carotid stenosis, revascularization combined with intensive medical therapy did not reduce death or stroke compared with optimized medical therapy in patients with asymptomatic high-grade carotid stenosis. These findings likely reflect advances in optimal medical treatment. Overall, these results suggest that optimized medical therapy represents a reasonable first-line strategy for these patients in the contemporary era.