Does aggressive medical therapy trump cerebral revascularization?

NEJM has just published an RCT of INTRAcranial stenting for symptomatic intracranial arterial stenosis vs. aggressive medical therapy.  It showed WORSE outcomes for stenting.

For me, this begs the question of whether NASCET (symptomatic; published 1998) and ACAS (asymptomatic; published 1995) CEA trials need to be repeated, up against aggressive medical Rx.

How was aggressive medical Rx defined in the trial?

Aggressive Medical Management

The rationale for the medical-management regimen and details on the management of risk factors in the study patients have been published previously.21-23…  we targeted a systolic blood pressure of less than 140 mm Hg (<130 mm Hg in the case of patients with diabetes) and an LDL cholesterol level of less than 70 mg per deciliter (1.81 mmol per liter). We provide the aspirin, clopidogrel, one drug from each major class of antihypertensive agents, rosuvastatin, and the lifestyle program to the study patients.

Medical therapy was probably less aggressive in the NASCET study:

Leave a Reply