====== Asymptomatic Carotid Atherosclerosis Study ======

A large trial that randomized patients in good health with asymptomatic stenosis (calculated in the same manner as the NASCET study) ≥ 60% to CEA plus aspirin, or aspirin alone85 found a reduced 5- year risk of ipsilateral stroke if CEA was performed with < 3% perioperative morbidity and mortality and is added to aggressive management of modifiable risk factors.

CEA reduced 5-year stroke risk by 66% in males, 17% in females (not statistically significant), and 53% overall (males & females lumped together). 

CEA did not significantly protect against major stroke or death (P=0.16) (half of the strokes were not disabling) and was somewhat protective against any stroke or death (P=0.08). The study group was 95% Caucasian, and 66% were male. Excluded patients (age>79 yrs, unstable CAD, uncontrolled HTN) may have been a higher risk. Surgeons were carefully selected and the surgical morbidity (1.5%) and mortality (0.1%) was very low. Surprisingly, ≈ half of the total morbidity (1.2%) was related to angiography. The implication is that for a generally healthy white male with ACAS > 60%, management with CEA (when performed by a surgeon with a low complication rate, as described) reduces his annual risk of all strokes from 0.5% to 0.17% (the reduction of risk for severe stroke is less). The benefit of CEA is realized within less than one year after the CEA. This is in contrast to the [[ACST]] trial and is most likely due to the lower perioperative event rate. The risk of mortality from other causes (including MI) is ≈ 3.9% per year. Combined stroke and death rates in community hospitals, while improved over the last 20 yrs, remains higher at ≈ 6.3% than at centers used in this study.

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The largest multicenter randomized trial to date revealed a moderate benefit for immediate CEA vs. medical management in patients age < 75 with asymptomatic stenosis ≥ 60%.

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The large trial that randomized patients in good health with asymptomatic stenosis (calculated in the same manner as the NASCET study) ≥ 60% to CEA plus aspirin, or aspirin alone found a reduced 5- year risk of ipsilateral stroke if CEA was performed with < 3% perioperative morbidity and mortality and is added to aggressive management of modifiable risk factors.