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Asymptomatic Carotid Stenosis: The Glass Is Half Occupied
In the half century or so since C. Miller Fisher first recognized the clinical significance of carotid artery disease, its management has changed dramatically, but never more so than in the past few years. Several important trials have now firmly established the effectiveness of surgery for more severe symptomatic carotid stenosis. In a Perspective paper in this issue [1], Drs. Brott and Toole summarize the results of the recent Asymptomatic Carotid Artery Study (ACAS), pushing the management envelope one step further by comparing the effectiveness of surgery with that of medical management in asymptomatic carotid disease. Although surgery in this trial was not as effective as it appears to be in symptomatic patients, Brott and Toole come away with the view that in asymptomatic patients, the surgical glass is at least half full. In light of the subtleties and complexities of the issue, we invited additional commentary on the ACAS—thus, the Perspective paper of Dr. Barnett and colleagues, also in this issue [2]. These authors see the surgical glass, although not dry, as half empty, largely on the basis of the associated surgical risks.
What, then, are the prospects for medical management? The paper by Cote and colleagues in this issue [3] reports that aspirin, unfortunately, is unlikely to be the medical answer. So be it; the search for optimal management continues.
Frank Davidoff, MD
Editor
- Copyright ©2004 by the American College of Physicians
