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December 1, 1999

National Stroke Association Guidelines to Prevent Stroke

Author Affiliations

Phil B.FontanarosaMD, Interim CoeditorIndividualAuthorMargaret A.WinkerMD, Deputy EditorIndividualAuthorStephenLurieMD PhD, Fishbein FellowIndividualAuthor


Copyright 1999 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.1999

JAMA. 1999;282(21):1999-2001. doi:10-1001/pubs.JAMA-ISSN-0098-7484-282-21-jbk1201

To the Editor: The National Stroke Association (NSA) guidelines on prevention of a first stroke address an important public health problem.1 However, the statements in the article regarding the value of carotid endarterectomy (CE) for patients with asymptomatic stenosis are highly suspect.

The guidelines state that CE is useful in individuals with asymptomatic carotid narrowing of greater than 60% if the surgery can be performed with a morbidity and mortality rate of less than 3%. This claim is based on a single study, the Asymptomatic Carotid Atherosclerosis Surgery (ACAS) trial, of dubious generalizability.2 The ACAS enrolled only select, low-risk patients. Twenty-five patients were screened clinically and from ultrasound laboratories for every 1 patient entered in the study. In addition, the surgeons in ACAS were vetted for excellence in their work: they had to provide evidence of a recent complication rate of less than 3%. Indeed, one third of the surgeons who applied were either rejected or did not complete the certification process. Overall perioperative mortality in ACAS was 0.1%. Perioperative mortality for the group of surgeons not given credentials by ACAS was 2.2%, 22 times higher than that seen in the clinical trial results. There are also performance data available suggesting that the surgical proficiency observed in ACAS is not duplicated in clinical practice. In the recently completed Aspirin and Carotid Endarterectomy Study, in which close to 1700 patients were asymptomatic, the stroke and death rate in asymptomatic patients was 4.6%, higher than the NSA threshold of less than 3% (W. Taylor, PhD, written communication September 1998).

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