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Very Old Can Benefit From Carotid Surgery
Lancet
12/04/2001
Elderly patients who have a 50 percent to 99 percent symptomatic carotid
stenosis have been found to benefit more from carotid endarterectomy than do
younger patients.
"These good results can only be achieved in elderly patients after a
scrupulous clinical evaluation to exclude disorders that could put the patients
at increased risk from anesthesia or of immediate cardiac complications, and
with endarterectomy done by skilled surgeons," declares Dr. Henry Barnett
and colleagues at the John P. Robarts Research Institute, London, Ontario,
Canada.
Although surgery has long been contraindicated in elderly people who are often
thought of as too frail to survive the invasive procedures the clinicians point
out that an emphasis among many doctors is to "ensure that elderly people
are given the best medical care and that they are not denied treatment
strategies known to be effective, simply because of their age."
At a conference last year of the American Heart Association, "the consensus
of the participants was that aggressive treatment can add years of useful life
in elderly patients," the report adds. "If elderly people are denied
therapy for reasons of prejudice and not of science, they may justifiably feel
that they have been abandoned on the basis of age alone."
In the current study 350 patients aged 75 years or older from the North American
Symptomatic Carotid Endarterectomy Trial were compared with those aged between
65 and 74 years, and under the age 65, for baseline characteristics and risk of
ipsilateral ischaemic stroke at two years by degree of stenosis and treatment
group.
Clinicians, found among patients with 70 percent to 99 percent stenosis, the
absolute risk reduction of ipsilateral ischaemic stroke with carotid
endarterectomy was 28.9 percent for 71 patients aged 75 years or older, 15.1
percent for 285 patients aged 65 to 74 years, and 9.7 percent for the 303
patients in youngest group.
Among patients with 50 percent to 69 percent stenosis, the absolute risk
reduction was significant only in 145 patients aged 75 years and older.
Perioperative risk of stroke and death at any degree of stenosis was 5.2 percent
for the oldest group, 5.5 percent for those aged between 65 and 74, and 7.9
percent for those under the age of 65.
The authors points out that the elderly who are not otherwise afflicted with
failing health are candidates for surgical prevention of stroke if they have
severe narrowing of the carotid artery causing their warning symptoms. They
should not be sent home to take medical measures alone.
"The odds of surgical benefit compared with medical care are heavily
stacked in favour of surgery," they conclude.
Lancet 2001;357:1154-60.
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