Letter by Naylor regarding article, "Urgent best medical therapy may obviate the need for urgent surgery in patients with symptomatic carotid stenosis".

Letter by Naylor Regarding Article, “Urgent Best Medical Therapy May Obviate the Need for Urgent Surgery in Patients With Symptomatic Carotid Stenosis” To the Editor: Shahidi et al are to be congratulated for showing that delays to carotid endarterectomy can be reduced through reconfiguring services and that strokes might be prevented by starting dual antiplatelet therapy in the referring clinic. However, I would urge a little caution before recommending that urgent aggressive best medical therapy may obviate the need for urgent carotid endarterectomy. Nearly one third of the patients in this series experienced ≥1 neurological event within 90 days of the index event (ie, there was a considerable delay in getting many of the vulnerable patients to seek medical advice). Given the compelling natural history evidence that the highest risk period for recurrent stroke is the first few days after experiencing the first transient ischemic attack, it is highly likely that some of the highest-risk patients in their region experienced a transient ischemic attack followed by an early stroke and were not referred for surgery (ie, the cohort undergoing surgery by the time they were finally referred in this series was not as high risk for stroke than if all patients had been seen as soon as possible after their first neurological event). This is not a criticism of their reconfigured service, but rather a timely reminder of just how important it is to get patients seen as soon as possible after experiencing their first neurological event. Leicester, United Kingdom, instituted a similar rapid-access service in 2008, and the median delay from first symptom to surgery has fallen to 8 days. Despite starting best medical therapy before attending the transient ischemic attack clinic and then transferring patients directly to the vascular unit for expedited surgery, 11% experienced recurrent neurological events in between hospital admission and surgery. In 2 patients, the strokes were disabling, and carotid endarterectomy could not be performed. Therefore, it remains to be seen whether implementing dual antiplatelet therapy and statins immediately after the first neurological event is able to obviate the need for urgent carotid endarterectomy. Until then, I would continue to advocate starting aggressive medical therapy and to perform carotid endarterectomy as soon as possible.