Comparative Effectiveness of Carotid Endarterectomy vs Initial Medical Therapy in Patients With Asymptomatic Carotid Stenosis

作者：Salomeh Keyhani, Eric M. Cheng, Katherine J. Hoggatt, Peter C. Austin, Erin Madden, Paul L. Hebert, Ethan A. Halm, Ayman Naseri, Jason Michael Johanning, Danielle L. Mowery, Wendy W. Chapman, Dawn M. Bravata · 发表于：JAMA Neurology · 年份：2020 · DOI：10.1001/jamaneurol.2020.1427 · 被引用次数：95 · 研究领域：Cerebrovascular and Carotid Artery Diseases、Acute Ischemic Stroke Management、Intracranial Aneurysms: Treatment and Complications

Importance: Carotid endarterectomy (CEA) among asymptomatic patients involves a trade-off between a higher short-term perioperative risk in exchange for a lower long-term risk of stroke. The clinical benefit observed in randomized clinical trials (RCTs) may not extend to real-world practice. Objective: To examine whether early intervention (CEA) was superior to initial medical therapy in real-world practice in preventing fatal and nonfatal strokes among patients with asymptomatic carotid stenosis. Design, Setting, and Participants: This comparative effectiveness study was conducted from August 28, 2018, to March 2, 2020, using the Corporate Data Warehouse, Suicide Data Repository, and other databases of the US Department of Veterans Affairs. Data analyzed were those of veterans of the US Armed Forces aged 65 years or older who received carotid imaging between January 1, 2005, and December 31, 2009. Patients without a carotid imaging report, those with carotid stenosis of less than 50% or hemodynamically insignificant stenosis, and those with a history of stroke or transient ischemic attack in the 6 months before index imaging were excluded. A cohort of patients who received initial medical therapy and a cohort of similar patients who received CEA were constructed and followed up for 5 years. The target trial method was used to compute weighted Kaplan-Meier curves and estimate the risk of fatal and nonfatal strokes in each cohort in the pragmatic sample across 5 years of follo...