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Carotid Endarterectomy and Subsequent Use of Medical Treatments

Is carotid endarterectomy associated with use of medical treatments and risk factor control in patients with ischemic stroke or TIA?

Carotid endarterectomy (CE) is a frequently performed vascular surgical procedure. Does CE influence secondary prevention measures, such as use of antithrombotic and statin drugs and control of cholesterol, glucose, and blood pressure levels?

In this partially industry-sponsored study, researchers compared 1474 patients with ischemic stroke or TIA and histories of CE to 16,993 patients with stroke or TIA but without histories of CE. Participants were selected from the Reduction of Atherothrombosis for Continued Health (REACH) registry, an international observational project that includes consecutive outpatients age 45 years with established coronary artery disease, cerebrovascular disease, or peripheral arterial disease, or with at least three atherothrombotic risk factors.

In multivariate logistic-regression analyses, history of CE was significantly associated with use of antiplatelet drugs (odds ratio, 1.6) and statins (OR, 1.8), and with a cholesterol level <200 mg/dL (OR, 1.3) but not with blood pressure and glucose levels. The findings were homogeneous across regions and treating specialists. The authors conclude that CE is associated with use of certain recurrent-stroke preventative drug classes and risk factors.

Comment: These results are informative but unsurprising. Antiplatelet and statin drugs are viewed as generally safe and beneficial in patients with cardiovascular disease, and statins in adequate doses may significantly reduce cholesterol levels. Further, symptomatic carotid artery disease is considered a coronary risk equivalent for which statins usually are recommended. However, blood pressure control (especially systolic blood pressure control in the elderly) and tight glucose control may be more difficult to achieve. A potential limitation of this study is that it does not address longitudinal adherence to medication or long-term control of risk factors. Finally, as the investigators point out, the results may not be generalizable to the community at large.

— Philip B. Gorelick, MD, MPH

Dr. Gorelick is John S. Garvin Professor and Head, Department of Neurology and Rehabilitation, University of Illinois College of Medicine at Chicago.

Published in Journal Watch Neurology January 30, 2007

Citation(s):

Touzé E et al. for the REACH Registry Investigators. Impact of carotid endarterectomy on medical secondary prevention after a stroke or a transient ischemic attack: Results from the Reduction of Atherothrombosis for Continued Health (REACH) registry. Stroke 2006 Dec; 37:2880-5.

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