What Is 'Best Medical Care' For Preventing Stroke?

By Hank Russell

NEW YORK -- Doctors have long striven for providing the best medical care for their patients, but the term "best medical care" has become so subjective that even doctors have a hard time determining what is right for the patient, and whether surgery is needed, according to Dr. Anthony J. Comerota.

"The bottom line is, with the exploding interest in carotid angioplasty stenting, we're seeing an enormous increase in a number of asymptomatic patients being treated," Dr. Comerota said at the Veith symposium on vascular medicine sponsored by the Cleveland Clinic.

According to Dr. Comerota, of the Jobst Vascular Center at the Toledo (Ohio) Hospital, between 75% and 90% of reports have shown that the patients treated were asymptomatic. He said the risks and benefits should be weighed as to whether to perform invasive surgery to provide the best medical care. Both the risk reduction of stroke and the mortality should come into play when making a decision.

"If the procedure-related stroke and death rate is not less than the best medical therapy, the procedure shouldn't be done," he said.

Dr. Comerota pointed to the recent advances in the pharmaceutical industry over the past 15 years with the development of statins, ACE inhibitors, and blood pressure medication, and combined and second-generation platelet inhibitors. "All of these have shown significant risk reduction of stroke in robust randomized trials," he said.

"With some of the recently reported data showing procedure-related morbidity in the double-digit range, there would be no hope that the patient would benefit from the procedure," Dr. Comerota continued. "So ... it's especially important to asymptomatic patients that the best medical therapy be an option."

He also cited randomized trials that showed that patients who took statins--compared with those who took a placebo--had a significant risk reduction of a stroke, and Asymptomatic Carotid Atherosclerosis Study data published a few years ago showed that the 5-year risk of patients treated with medication was only 11%.

"If we were to focus on blood pressure control to a target level, insisting that the patient's blood pressure be brought down to a diastolic of 75, there's going to be anywhere from a 40% to 80% risk reduction of stroke in the generic population of patients at high risk who have hypertension," according to Dr. Comerota.

Patients with diabetes also were likely to benefit from medical therapy. Studies have shown that those who were given glucose control medication saw a risk reduction of a cardiovascular event.

"We see these across-the-board benefits," Dr. Comerota said, adding that the use of combined platelet inhibitors also has "been shown to be beneficial. I think we're seeing a need developing here."

He concluded that carotid angioplasty and stenting procedures, compared with the use of statins and other medication used to reduce stroke, "have never been shown to [do better] to reduce the risk of stroke."