AHA Scientific Sessions 2026 Abstract · Nov 2, 2026
Medical Therapy With or Without Carotid Revascularization for Asymptomatic Carotid Stenosis: A Meta Analysis of Randomized Controlled Trials
By Ehsan M, Alkhamis ASAS, Deepa M et al.
Background The role of carotid revascularization in asymptomatic carotid stenosis remains controversial, particularly as contemporary medical therapy has improved. Although carotid endarterectomy (CEA) and carotid artery stenting (CAS) may reduce future stroke risk, any long-term benefit must be weighed against early periprocedural harm. Research Question Is there any benefit to CEA with medical therapy compared to medical therapy alone for long term stroke reduction in patients with asymptomatic carotid artery stenosis? Methods We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating revascularization plus medical therapy versus medical therapy alone in patients with asymptomatic carotid stenosis. The primary outcome was stroke at follow-up. Secondary outcomes included transient ischemic attack (TIA), myocardial infarction (MI), and all-cause mortality at follow-up and at 30 days. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using random-effects Mantel-Haenszel models. Results Eight RCT were included in our study. For the primary outcome, CEA plus medical therapy was associated with a significantly lower risk of stroke at follow-up compared with medical therapy alone (RR 0.64, 95% CI 0.55–0.74). In contrast, CAS plus medical therapy was not associated with a significant reduction in stroke at follow-up compared with medical therapy alone (RR 0.87, 95% CI 0.28–2.69).For CEA, the long-term stroke benefit was accompanied by a reduction in TIA at follow-up (RR 0.57, 95% CI 0.34–1.00; p=0.04), with no significant difference in MI (RR 2.89, 95% CI 0.90–9.27) or mortality (RR 0.82, 95% CI 0.61–1.09). However, CEA was associated with higher early procedural risk, including increased 30-day stroke (RR 3.76, 95% CI 2.08–6.80) and 30-day mortality (RR 5.38, 95% CI 1.84–15.75). No significant difference was found regarding 30-day MI (RR 2.90, 95% CI 0.58–14.52) or 30-day TIA (RR 1.30, 95% CI 0.34-4.88) between the two groups. No significant mortality benefit was associated with CAS compared to medical therapy alone (RR 0.76, 95% CI 0.55–1.05). At 30 days, CAS was associated with increased stroke risk compared with medical therapy alone (RR 9.80, 95% CI 1.30–75.40), while 30-day mortality was imprecise and not statistically significant (RR 3.06, 95% CI 0.13–75.05). Conclusion CEA plus medical therapy reduced long-term stroke compared with medical therapy alone, but at the cost of higher early stroke and mortality. CAS did not demonstrate a significant long-term stroke reduction and was associated with increased 30-day stroke risk, although estimates were limited by fewer trials and wide confidence intervals. These findings suggest that the net benefit of revascularization differs by procedure and should be weighed against early procedural harm when selecting asymptomatic patients for intervention.