This story reports on carotid stenting as a possible alternative to endarterectomy. By framing it as stent vs. surgery, it assumes, however, that intervention needs to be done. While the evidence supports intervention for patients with symptoms of stroke, it is much less clear for patients who have carotid stenosis but no symptoms. By presenting the medical turf battle over ownership of this procedure, it provides some insight regarding the possibility of untoward enthusiasm for this intervention. The risk of stroke or death one year after stenting or surgery is presented as comparable at 10%. No comparison of risks was given for the use of blood-thinning or blood pressure drugs. In fact, non-surgical approaches (drugs or watchful waiting) received only a one-line mention in this story – almost as if they are out-moded ideas. Overall, the piece provided some context for following developments in this area of medicine.
Cost of stenting procedure put at $10 -15K; later mention of
Medicare restriction of coverage criteria.
Mentions 10% risk of stroke or death following stenting, though data source is not mentioned. Mentions side effects without
rates. Includes report from one patient of perceived benefit. Therefore incomplete.
See above – the piece does not provide
absolute rates for harms or side effects for various treatment options.
Does explain the weight placed on data from a randomized
clinical trial; careful read reveals that these data are not yet available. Not clear about the source of the data supporting
claim for comparable stroke and death rates for both stent and surgery. Does not make clear that the question about whether
or not to intervene really depends on whether the patient has stroke symptoms. If they have had a stroke or transient
ischemic attack, intervention is beneficial. The evidence for treating asymptomatic stenosis is much less clear.
Provides natural history. While harboring an element of disease mongering in terms of stroke concern it also
contains a flavor of over-enthusiasm by physicians to intervene; mentions the element of competition among specialties for
this piece of the medical care pie. The framing of the story implies that the falls and “unwell” feeling were caused by the
patient’s carotid blockage, which may not really be the case.
Good job pointing out medical turf battle over ownership of this procedure, and
industry sponsorship of symposium.
Mentions endarterectomy having
comparable outcome; single mention of medical treatment with no mention of outcome; no data for watchful waiting. Therefore,
incomplete.
Very clear presentation of FDA
approval of devices made by two manufacturers and that others are awaiting full approval.
Explains carotid stenting as
relatively new; piece later goes on to mention newer stenting systems with implanted filters
Systematic, Criteria-Driven
The tale of two “negative” studies. Or, how spin is applied to make research findings look more impressive. A must read. https://johnmandrola.substack.com/p/the-tale-of-two-negative-studies
The @nytimes chose to interview one of the editors of the @AnnalsofIM (publisher of this paper) who "gushed with extraordinary glee: It’s huge! There are very few things that reduce your mortality by 30%."
Turns out coffee is not one of those few things despite all that glee. https://twitter.com/garyschwitzer/status/1533202075928215558
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