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(Stroke. 2000;31:983.)
© 2000 American Heart Association, Inc.

Letters to the Editor

Supplement to the AHA Guidelines for the Management of Transient Ischemic Attacks

Seemant Chaturvedi, MD

Department of Neurology, Wayne State University, Detroit, Michigan

To the Editor:

I read with interest the recent supplement to the guidelines on management of patients with transient ischemic attacks.¹ However, with regard to carotid endarterectomy (CE), I was disappointed that Albers et al made no attempt to interpret the clinical trial results in the context of real-world surgical performance.

For example, in the updated section on CE for 50% to 69% symptomatic stenosis, the authors state that symptomatic patients with 50% to 69% benefit from surgery and that these patients should be considered for CE. However, should clinicians conclude that because patients in the surgical arm of the North American Symptomatic Carotid Endarterectomy Trial (NASCET) had a marginal statistically significant benefit (P=0.045) that this result is clinically meaningful and that this can be routinely achieved in clinical practice?

One must keep in mind that the benefit of surgery in the 50% to 69% group was very modest. For the important clinical outcome of disabling, ipsilateral stroke, the absolute difference between the medical and surgical groups was only 4.4% at 5 years, or less than 1% per year.² This modest result was achieved in the ideal setting of low-risk patients being operated on by surgeons screened for their excellence. In NASCET as a whole, the perioperative mortality was 1.1% and the stroke and death rate was 6.5%.

In terms of the real world, Wennberg et al³ analyzed CE results in over 100 000 Medicare beneficiaries in 1992–1993 and found the perioperative mortality at an average volume hospital . . . [Full Text of this Article]

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