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ACST-1: Difference between revisions
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Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, ''et al.'' 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomized trial. ''Lancet''. 2010;376(9746):1074–84.<ref>[http://www.ncbi.nlm.nih.gov/pubmed/20870099 Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, ''et al. ''10-year stroke prevention after successful carotid endarterectomy for | Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, ''et al.'' 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomized trial. ''Lancet''. 2010;376(9746):1074–84.<ref>[http://www.ncbi.nlm.nih.gov/pubmed/20870099 Halliday A, Harrison M, Hayter E, Kong X, Mansfield A, Marro J, ''et al.'' 10-year stroke prevention after successful carotid endarterectomy for asymptomatic stenosis (ACST-1): a multicentre randomised trial. ''Lancet.'' 2010;376(9746):1074–84.]</ref> | ||
asymptomatic stenosis (ACST-1): a multicentre | |||
==Clinical Question== | ==Clinical Question== | ||
In patients with asymptomatic significant carotid artery stenosis (≥60%), does immediate carotid endarterectomy (CEA) reduce the stroke risk as compared to deferral of CEA?<!-- This should be a PICO (Population, Intervention, Comparison, Outcome) style question. As an example, the ACCORD trial's clinical question is shown below, but you should replace it with the clinical question addressed by the trial you're summarizing. --> | In patients with asymptomatic significant carotid artery stenosis (≥60%), does immediate carotid endarterectomy (CEA) reduce the stroke risk as compared to deferral of CEA?<!-- This should be a PICO (Population, Intervention, Comparison, Outcome) style question. As an example, the ACCORD trial's clinical question is shown below, but you should replace it with the clinical question addressed by the trial you're summarizing. --> | ||
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** a carotid plaque not causing significant stenosis and confers a low risk of stroke | ** a carotid plaque not causing significant stenosis and confers a low risk of stroke | ||
** patients with major life-threatening co-morbidities other than stroke | ** patients with major life-threatening co-morbidities other than stroke | ||
* poor CEA risk such as recent acute myocardial infarction and intra-cerebral | * poor CEA risk such as recent acute myocardial infarction and intra-cerebral tumors or aneurysm. | ||
* re-stenosis following previous CEA | * re-stenosis following previous CEA | ||
* emboli is likely to be from a cardiac source | * emboli is likely to be from a cardiac source | ||
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* Medical therapy was not standardized and left to the discretion of clinicians.<ref name=":1">[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> | * Medical therapy was not standardized and left to the discretion of clinicians.<ref name=":1">[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" /> | * 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" /> | ||
* It is unclear if females obtain as much benefit as males from CEA.<ref name=":2">[http://content.onlinejacc.org/article.aspx?articleid=1144187 | * It is unclear if females obtain as much benefit as males from CEA.<ref name=":2">[http://content.onlinejacc.org/article.aspx?articleid=1144187 Brott TG, Halperin JL, Abbara S, Bacharach JM, Barr JD, Bush RL, ''et al.'' 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS Guideline on the Management of Patients With Extracranial Carotid and Vertebral Artery Disease. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of NeuroInterventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery Developed in Collaboration With the American Academy of Neurology and Society of Cardiovascular Computed Tomography. ''J Am Coll Cardiol. ''2011;57(8):e16–94.] | ||
</ref><ref>[http://www.ncbi.nlm.nih.gov/pubmed/15451212 Rothwell PM. ACST: which subgroups will benefit most from carotid endarterectomy? ''Lancet''. 2004;364(9440):1122-3; author reply 1125-6]</ref> | </ref><ref>[http://www.ncbi.nlm.nih.gov/pubmed/15451212 Rothwell PM. ACST: which subgroups will benefit most from carotid endarterectomy? ''Lancet''. 2004;364(9440):1122-3; author reply 1125-6]</ref> | ||