To the Editor Brett and Levine1 recently discussed the case against identifying carotid stenosis in asymptomatic patients. We agree wholeheartedly that progress in medical therapy over the past 2 decades requires a reappraisal of whether carotid revascularization remains beneficial for such patients. In randomized trials, carotid endarterectomy (CEA) in asymptomatic patients was shown to be superior to medical management alone.2 At the time these trials were conducted, based on the observational studies available, many in the medical community had the opinion that CEA was not warranted because of the periprocedural risk; however, these trials proved that this view was incorrect. We have now entered a new period where many (including Brett and Levine) have the opinion based on observational studies that medical management has improved and revascularization in asymptomatic patients is no longer warranted. We suggest that CEA for asymptomatic stenosis not be discarded without the same rigor previously employed, that is, a high-quality randomized controlled trial to assess the relative efficacy and safety of intensive medical therapy alone, and intensive medical therapy plus CEA.
Chaturvedi S, Howard G, Meschia J. Carotid Endarterectomy for Asymptomatic Stenosis. JAMA Intern Med. 2015;175(7):1241-1242. doi:10.1001/jamainternmed.2015.1118