Findings from a retrospective analysis presented at the recent European Society for Vascular Surgery (ESVS) annual meeting (24–27 September, Kraków, Poland) provide evidence that—for symptomatic carotid artery stenosis patients—endarterectomy “remains a useful and relevant intervention in the era of improving medical therapy”.
Delivering these data at ESVS 2024, Sashini Iddawela (University College London Hospital NHS Trust, London, UK) initially noted that urgent carotid endarterectomy (CEA) is currently the first-line recommendation for symptomatic, significant carotid artery stenosis. There is also speculation, however, that presentation with symptomatic stenosis could be substantially reduced thanks to today’s advancements in optimal medical therapy and anti-major cardiovascular event (anti-MACE) medications.
As such, Iddawela and her colleague Daryll Baker—also of the University College London Hospital NHS Trust—undertook a study in an effort to determine whether or not patients undergoing CEA were already on optimal medical therapy prior to their index admission. They performed a retrospective analysis of patients receiving urgent CEA following development of a stroke or transient ischaemic attack (TIA) at a regional hub in Northwest London between 2021 and 2023, collecting data on these patients’ index presentation of symptomatic stenosis features at a healthcare facility.
The researchers recorded data on comorbidities and medication history—including antiplatelets, anticoagulants, antihypertensives, and diabetic control. Medications at discharge were also recorded as well as any reasons for alteration. Proportions of patients on antiplatelets, antihypertensives and statins—both pre- and post-CEA—were compared using the chi-squared test. Optimal medical therapy was defined via the standard set by ESVS 2023 guidelines for asymptomatic stenosis: antiplatelets and statins as a minimum, with an antihypertensive added on where appropriate.
A total of 124 patients were consecutively analysed. Hypertension and hyperlipidaemia were found to be the most common pre-CEA morbidities recorded (64% and 42%, respectively), followed by diabetes mellitus (36%) and ischaemic heart disease (23%). In addition, the majority of patients were on an antihypertensive agent or statin at index presentation (64% and 60%, respectively), and a 36% rate of antiplatelet use was also demonstrated across the cohort—with 77% of these patients being on aspirin monotherapy and the remainder being on clopidogrel/ticagrelor/prasugrel.
Overall, 36 patients (29%) were on a combination of an antiplatelet, antihypertensive and statin during their index presentation with symptomatic carotid stenosis. According to the researchers, there was no significant difference between the proportion of patients on antiplatelets, antihypertensives or statins pre- versus post-CEA. However, patients with ischaemic heart disease, diabetes or hypertension were observed as being significantly more likely to be on an antiplatelet (odds ratio [OR], 1.9; p<0.01), statin (OR, 1.25; p<0.01) or antihypertensive (OR, 1.76; p<0.01) at the point of their first presentation to a healthcare facility.
These findings led to the conclusions that patients undergoing CEA are generally multimorbid and are also more likely to be on cardiovascular risk-modifying therapy at their index presentation with symptomatic carotid artery stenosis. And, on this basis, the researchers aver that—even within the context of recent improvements in medical therapy for carotid disease—CEA should still be considered a useful and relevant intervention in these patients.
