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ACST-1: Difference between revisions
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* Uncertainty if patients achieved ideal blood pressure levels (<140/90 mm Hg) or LDL-C (<2·4 mmol/L) as recommended by JNC 7 and NCEP III guidelines. This affects their absolute risk for stroke.<ref>[http://www.ncbi.nlm.nih.gov/pubmed/20870079 Amarenco P, Labreuche J, Mazighi M. Lessons from carotid endarterectomy and stenting trials. ''Lancet''. 2010;376(9746):1028-31]</ref> | * Uncertainty if patients achieved ideal blood pressure levels (<140/90 mm Hg) or LDL-C (<2·4 mmol/L) as recommended by JNC 7 and NCEP III guidelines. This affects their absolute risk for stroke.<ref>[http://www.ncbi.nlm.nih.gov/pubmed/20870079 Amarenco P, Labreuche J, Mazighi M. Lessons from carotid endarterectomy and stenting trials. ''Lancet''. 2010;376(9746):1028-31]</ref> | ||
* Lipid-lowering therapy may have been suboptimal in the trial.<ref>Paraskevas KI, Mikhailidis DP, Veith FJ. Best medical treatment for a symptomatic carotid artery stenosis. ''Lancet''. 2011;377(9760):123; author reply 123-4</ref><!-- What criticisms exist about the paper? --> | * Lipid-lowering therapy may have been suboptimal in the trial.<ref>Paraskevas KI, Mikhailidis DP, Veith FJ. Best medical treatment for a symptomatic carotid artery stenosis. ''Lancet''. 2011;377(9760):123; author reply 123-4</ref><!-- What criticisms exist about the paper? --> | ||
* Ultrasound was used in the trial, which may be associated with its own imperfections as compared to modern imaging techniques, such as angiography.<ref>[http://www.ncbi.nlm.nih.gov/pubmed/15135590 Barnett HJ. Carotid endarterectomy. ''Lancet.'' 2004;364(9440):1122-3; author reply 1125-6.]</ref> | * Ultrasound was used in the trial, which may be associated with its own imperfections as compared to modern imaging techniques, such as angiography.<ref name=":0">[http://www.ncbi.nlm.nih.gov/pubmed/15135590 Barnett HJ. Carotid endarterectomy. ''Lancet.'' 2004;364(9440):1122-3; author reply 1125-6.]</ref> | ||
* Contemporary medical therapy has changed since the trial. Patients in the ACST did not receive best medical therapy as compared to modern practice.<ref>[http://www.ncbi.nlm.nih.gov/pubmed/25356449 Raman G, Kitsios GD, Moorthy D, ''et al. ''Management of Asymptomatic Carotid Stenosis. Rockville (MD): Agency for Healthcare Research and Quality (US); 2012 Aug.]</ref> | |||
* Medical therapy was not standardized and left to the discretion of clinicians.<ref>[http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0066325/ Jonas DE, Feltner C, Amick HR, Sheridan S, Zheng ZJ, Watford DJ, ''et al.'' Screening for Asymptomatic Carotid Artery Stenosis: A Systematic Review and Meta-Analysis for the U.S. Preventive Services Task Force. Evidence Synthesis No. 111. AHRQ Publication No. 13-05178-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2014]</ref> | |||
* Surgeons in the trial were highly selected. It's important to consider if a comparable incidence of operative complications can be achieved in local centres.<ref name=":0" /> | |||
==Funding== | ==Funding== | ||