Key result
Carotid revascularization fails to reduce death or stroke over medical therapy alone and increases MI.
Why the study?
The optimal management of asymptomatic carotid stenosis remains controversial given improvements in medical therapy, carotid artery stenting, and carotid endarterectomy. Whether adding revascularization to intensive medical treatment provides greater benefit than intensive medical treatment alone is unclear.
Does carotid revascularization plus intensive medical therapy reduce death or stroke compared with optimized medical therapy alone in patients with asymptomatic high-grade carotid stenosis?
Meta-Analysis
Does carotid revascularization plus intensive medical therapy reduce death or stroke compared with optimized medical therapy alone in patients with asymptomatic high-grade carotid stenosis?
In patients with asymptomatic high-grade carotid stenosis, adding revascularization to intensive medical therapy does not reduce death or stroke and increases the risk of myocardial infarction, supporting optimized medical therapy alone as a reasonable first-line strategy.
Introduction The optimal management of patients with asymptomatic carotid stenosis remains controversial. Improvements in medical therapy, carotid artery stenting and carotid endarterectomy, call into question the preferred management o asymptomatic carotid stenosis. Whether adding revascularization to intensive medical treatment would provide greater benefit than intensive medical treatment alone is unclear. Purpose To compare the efficacy and safety of optimized medical therapy alone versus carotid revascularization plus intensive medical therapy in patients with asymptomatic carotid stenosis. Methods A systematic review and meta-analysis of RCTs was performed across four databases. Trials comparing optimized medical therapy with revascularization, either percutaneous or surgical, in patients with asymptomatic carotid stenosis were included. Hazard ratios (HR) with 95% confidence intervals (CI) were pooled for death, any stroke, ipsilateral stroke, ipsilateral ischemic stroke, transient ischemic attack and myocardial infarction. Perioperative death or stroke was analyzed using risk ratios (RR). Random-effects meta-analyses were performed using the Hartung-Knapp-Sidik-Jonkman method, with between-study variance estimated by the Sidik-Jonkman estimator. Heterogeneity was assessed using forest plot inspection and the I² statistic. Results Four randomized controlled trials were included. Revascularization was not associated with a significant reduction in death compared with optimized medical therapy alone (HR 0.94, 95% CI 0.61-1.47; I² = 0%). Similarly, no significant reduction was observed for any stroke (HR 0.90, 95% CI 0.67-1.19; I² = 0%). No statistically significant differences were found for ipsilateral ischemic stroke (HR 0.79, 95% CI 0.19-3.30; I² = 70.7%) or overall ipsilateral stroke (HR 1.03, 95% CI 0.37-2.86; I² = 38.6%). Transient ischemic attack was also not significantly reduced with revascularization (HR 0.97, 95% CI 0.26-3.67; I² = 26.7%). In contrast, myocardial infarction occurred more frequently in the revascularization group (HR 2.26, 95% CI 1.46-3.50; I² = 0%), indicating a significantly increased risk associated with invasive treatment. Conclusion In patients with asymptomatic carotid stenosis, revascularization combined with intensive medical therapy did not reduce death or stroke compared with optimized medical therapy in patients with asymptomatic high-grade carotid stenosis. These findings likely reflect advances in optimal medical treatment. Overall, these results suggest that optimized medical therapy represents a reasonable first-line strategy for these patients in the contemporary era.
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Pinto et al. (2026) conducted a meta-analysis in Asymptomatic high-grade carotid stenosis. Carotid revascularization (percutaneous or surgical) plus intensive medical therapy vs. Optimized medical therapy alone was evaluated on Death (HR 0.94, 95% CI 0.61-1.47). Carotid revascularization plus medical therapy did not reduce death (HR 0.94, 95% CI 0.61-1.47) or any stroke (HR 0.90, 95% CI 0.67-1.19) vs medical therapy alone, but increased MI (HR 2.26).
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