national-clinical-guidelines-for-stroke-fourth-edition
national-clinical-guidelines-for-stroke-fourth-edition
national-clinical-guidelines-for-stroke-fourth-edition
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National <strong>clinical</strong> guideline <strong>for</strong> <strong>stroke</strong><br />
5.7.1.2 Sources<br />
A–B Wardlaw et al 2006; Rerkasem and Rothwell 2011<br />
C Rerkasem and Rothwell 2009; Rothwell et al 2005; consensus<br />
D Rothwell et al 2004<br />
E Economopoulos et al 2011; Inter<strong>national</strong> Carotid Stenting Study investigators et al<br />
2010; consensus<br />
F–G Consensus<br />
5.7.2 Management of asymptomatic carotid stenosis<br />
Evidence to recommendations<br />
Surgery <strong>for</strong> asymptomatic carotid stenosis has been shown to provide sizeable relative<br />
reductions in the risk of <strong>stroke</strong> (about 50%) but, with a low overall risk of <strong>stroke</strong> in this<br />
population, the absolute risk reductions are small (about 5% over 10 years) (Chambers<br />
and Donnan 2005; Halliday et al 2010). The benefit appears to be restricted to those less<br />
than 75 years of age and may be smaller in women than in men (Chambers and Donnan<br />
2005). On the basis of the asymptomatic carotid surgery trial data, the number needed to<br />
undergo surgery to prevent one extra <strong>stroke</strong> over 10 years is about 20 and roughly twice<br />
this to prevent one extra disabling or fatal <strong>stroke</strong>.<br />
There have been significant developments in medical secondary prevention since the<br />
carotid surgery trials recruited their patients. It seems highly likely that the risk of <strong>stroke</strong><br />
and other vascular outcomes <strong>for</strong> patients would be less if these trials were conducted<br />
now. With small absolute benefits, likely made smaller still or negated by modern medical<br />
management, the consensus of the working party is that carotid endarterectomy <strong>for</strong><br />
asymptomatic stenosis cannot be considered a cost-effective intervention and should<br />
there<strong>for</strong>e not be routinely undertaken (Abbott 2009; Henriksson et al 2008). In<br />
exceptional cases asymptomatic surgery may be considered, such as in individuals who<br />
are unable to tolerate antihypertensive medication because of symptomatic cerebral<br />
hypoperfusion. Otherwise this treatment is not recommended outside <strong>clinical</strong> trials.<br />
5.7.2.1 Recommendations<br />
A Screening <strong>for</strong> asymptomatic carotid stenosis should not be per<strong>for</strong>med.<br />
B Surgery or angioplasty/stenting <strong>for</strong> asymptomatic carotid artery stenosis should not<br />
routinely be per<strong>for</strong>med unless as part of a randomised trial.<br />
C Carotid endarterectomy or stenting should not be per<strong>for</strong>med routinely in patients<br />
with asymptomatic carotid stenosis prior to coronary artery surgery.<br />
5.7.2.2 Sources<br />
A Consensus<br />
B Abbott 2009; Halliday et al 2010 consensus<br />
C Consensus<br />
74 © Royal College of Physicians 2012
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