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ARTICLES: E. A. Halm, S. Tuhrim, J. J. Wang, M. Rojas, E. L. Hannan, and M. R. Chassin Has evidence changed practice?: Appropriateness of carotid endarterectomy after the clinical trials Neurology 2007; 68: 187-194 [Abstract] [Full text] [PDF]

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Has evidence changed practice?: Appropriateness of carotid endarterectomy after the clinical trials

Seemant Chaturvedi   (1 April 2007)

Reply from the Authors

Ethan A. Halm, Stanley Tuhrim, MD, Mark R. Chassin, MD, MPH, MPP   (1 April 2007)

Has evidence changed practice?: Appropriateness of carotid endarterectomy after the clinical trials 1 April 2007
Seemant Chaturvedi, Wayne State University 8c-UHC, Department of Neurology, 4201 St. Antoine, Detroit, MI 48201 Send Correspondence to journal: Re: Has evidence changed practice?: Appropriateness of carotid endarterectomy after the clinical trials SChaturv{at}med.wayne.edu Seemant Chaturvedi	I read with interest the contribution by Halm et al regarding the ratings of carotid endarterectomy (CE)appropriateness in New York State after the multi-center CE trials had been completed in North America. [1] The authors did not mention that the largest trial of CE for asymptomatic carotid stenosis, the Asymptomatic Carotid Surgery Trial (ACST), did not show clear benefit for patients age 75 and over. [2] This finding is also reflected in the American Academy of Neurology CE review, in which clinicians are advised to consider CE for asymptomatic stenosis only in patients between ages 40-75 years. [3] It would be interesting to know what percentage of the CE cases in their population were asymptomatic and age 75 or over. If these patients were classified as "uncertain" appropriateness, how would this impact their overall conclusions? References 1. Halm EA, Tuhrim S, Wang JJ, et al. Has evidence changed practice? Appropriateness of carotid endarterectomy after the clinical trials? Neurology 2007; 68:187-194 2. MRC Asymptomatic Carotid Surgery Trial (ACST) Collaborative Group. Prevention of disabling and fatal strokes by successful carotid endarterectomy in patients without recent neurological symptoms: randomised controlled trial. Lancet 2004; 363: 1491-1502. 3. Chaturvedi S, Bruno A, Feasby T, et al. Carotid endarterectomy: An evidence-based review. Neurology 2005; 65: 794-801. Disclosure: The author reports no conflicts of interest.
Reply from the Authors 1 April 2007
Ethan A. Halm, Mount Sinai School of Medicine Box 1087, One Gustave Levy Place, NY, NY 10029, Stanley Tuhrim, MD, Mark R. Chassin, MD, MPH, MPP Send Correspondence to journal: Re: Reply from the Authors ethan.halm{at}mountsinai.org Ethan A. Halm, et al.	The appropriateness ratings that we used were formulated using the validated RAND group judgment process by a national panel of experts from the field of vascular surgery, neurosurgery, neurology, internal medicine, radiology, and vascular medicine that met in 1998. [1,4] At that time, the panel reviewed the results of all of the North American and European randomized controlled trial (RCT) results that had been published, as well as the American Heart Association/American Stroke Association guidelines on CEA. The appropriateness ratings were based on neurologic symptoms (type, severity, recency, frequency, disability), degree of carotid stenosis, type of operation (ipsilateral or contralateral to symptoms, CEA alone or combined with CABG), perioperative risk/comorbid illness burden, and the surgical teams complication rates. They did not consider age, independent of the above variables, a separate risk factor. One-third of the total sample fell into the subgroup of cases that were asymptomatic and >=75 years old. The major factor driving inappropriateness among asymptomatic patients was the degree of comorbid illness burden. Asymptomatic patients >=75 years old had the same distribution of comorbidity compared with those < 75 years old (p=.98). While age itself was not a factor in the appropriateness ratings, we found no differences in rates of inappropriate CEA comparing asymptomatic patients who were >=75 years old to all other patients (8.2% v. 8.8%, p=.34). Re-classifying all asymptomatic patients >=75 years old as having 'uncertain' appropriateness, as Dr. Chaturvedi discusses, would substantially raise the proportion considered 'uncertain'(by shifting many patients out of the 'appropriate' category). The proportion considered inappropriate would not change. Thus, our main finding, that since publication of the RCTs rates of CEA for inappropriate reasons fell from 32% to 8.6%, would not be affected. [1] Reference 4. Halm EA, Chassin MR, Tuhrim S, et al. Revisiting the appropriateness and use of carotid endarterectomy. Stroke 2003;34:1464-1472. Disclosure: The authors report no conflicts of interest.