Effective stroke prevention in patients with symptomatic carotid stenosis.
Patients with recently symptomatic carotid stenosis require effective medical treatment, and some require surgical removal of the carotid plaque. Randomized controlled trials have shown that endarterectomy reduces the overall risk of stroke in patients with severe carotid stenosis and, to a lesser extent, in patients with moderate stenosis. However, operating on all patients is not necessarily the most effective approach. The effectiveness of endarterectomy could be improved by selecting patients more rigorously. To do this, we first need to use data from existing randomized controlled trials to precisely determine the overall effect of surgery for different degrees of stenosis, identify subgroups in which benefit is increased, and use risk modeling to identify individuals at particularly high risk of stroke without surgery. Such an approach will also be useful in targeting angioplasty and stenting in patients in whom endarterectomy is not possible.