One of the most significant developments in the treatment of carotid disease over the past five years has been the use of statins. Statins reduce the stroke rate in most studies by at least 30%.
As a featured speaker at the VEITHsymposium, Peter R.F. Bell, MD, FRCS, DSC, KBE, Professor of Surgery at the University of Leicester and Honorary Consultant Surgeon at the Leicester Royal Infirmary in the United Kingdom, made the case that, given the success of statin therapy, any carotid intervention trial (surgery or stent/angioplasty) must include a comparison arm of patients on statin therapy alone.
The reason for this, he states, is that in light of the success of statins, the proper interpretation of old trial results is difficult, since these trials just compared types of interventions.
The ACST trial has shown that if the stroke and death rate from an invasive procedure exceeds 3%, the treatment is causing more strokes than it prevents.
Most randomised trials have a stroke and death rate in excess of this figure. Dr Bell criticises the presentation of the 10-year results of the ACST trial, because the trial did not compare CAE and CAS patients with a group who only has medical treatment, as it was not required in the study.
Dr Bell strongly stated that to conduct a trial comparing CEA with CAS in asymptomatic patients is wrong, as it will give license to carry out many needless procedures to the undoubted disadvantage of patients.
According to Dr Bell: "We already know that asymptomatic patients have a very low rate of stroke, and invasive treatment makes that worse in most trials. What we need to know is if properly controlled medical treatment alone gives better results than medical treatment plus CAS or CEA."
Dr Bell finished by stating, "Perhaps the protagonists of invasive treatment do not want to do such a trial because it would be bad for business if as is likely it is shown that invasive interference is unnecessary and damaging."
(Source: University of Leicester: VEITHsymposium: December 2008)