How NOT to Prevent a Stroke

Julian Whitaker, MD

Carotid artery stenosis, the buildup of plaque in the arteries in the neck that supply blood to the brain, is a risk factor for stroke. Treatment options include drugs and lifestyle changes to target atherosclerosis. Two invasive procedures are also used: carotid endarterectomy, in which the artery is opened up and plaque is surgically removed, and angioplasty with insertion of a stent to keep the artery open.

But there are well-known and horrific dangers associated with both of these invasive procedures.

Disturbing Results

In a new Lancet study—merited to be important enough for early release—a research team from London looked at the data on 3,433 patients with symptomatic carotid artery stenosis (such as a transient ischemic attack, or “mini-stroke”) who had undergone carotid endarterectomy or stenting. They found that for patients who were 70 or older, the risk of having a stroke or dying within four months of stenting was 12 percent (1 in 8!)—over twice the rate for endarterectomy, which was 5.9 percent (1 in 17). And most of the strokes and deaths in both groups occurred in the first 30 days following the procedure.

This is outrageous. The harm inflicted on these patients was not caused by their disease, it was caused by their treatment! As I mentioned in the introduction, the older you are, the greater your risk of any invasive procedure, and we’ve known for years that carotid artery intervention outcomes are worse in this age group. So why include older patients? Because they’re ripe for the picking. Carotid artery stenosis dramatically increases with age, so the bulk of these procedures are done in older patients, even if the treatments do more harm than good.

Where Was Conservative Treatment?

Even more shocking, these two procedures weren’t compared to conservative treatment—it wasn’t even a consideration. You can’t possibly determine whether an intervention is really helpful unless you know the natural course of the disease, i.e., the stroke/death rates of patients who don’t undergo any invasive procedure.

I’ve noticed an increasing tendency over the years for clinical trials to simply pit one drug or intervention against another and exclude a control group. For example, they’ll test beta blockers against ACE inhibitors for blood pressure control, or they’ll evaluate coronary bypass versus angioplasty. But they don’t compare their effectiveness or dangers to a group that receives no treatment other than lifestyle changes or, in the case of surgeries, appropriate medications. They just “presume” that drugs and high-tech procedures are superior.

Better Off Without Treatment

I would submit that the stroke/death rate is actually lower inpatients treated with lifestyle changes and medication than in those who undergo either of these procedures. As harmful as endarterectomy and especially stenting were revealed to be in the Lancet study, they’re even worse in the “real world.” Thirty-day death rates associated with carotid endarterectomy among Medicare patients, for example, are considerably higher than those reported in clinical trials.

Granted, the stroke rate in our country is high. However, neither endarterectomy nor stenting appears to produce outcomes that are much better than medical treatment, especially in patients who are asymptomatic. And believe it or not, 70–80 percent of all carotid endarterectomies and a majority of carotid stenting are done on patients who have no symptoms at all.

If these facts were clearly stated, it would be evident that both of these procedures should be dramatically curtailed, if not abandoned. Of course, this isn’t going to happen. Where would this leave all the surgeons, cardiologists, invasive radiologists, and hospitals whose revenue depends on them?

Aggressive Physicians

In an aptly entitled 2010 article, The Good, the Bad, and the About-to-Get Ugly: National Trends in Carotid Revascularization, Ethan A. Halm, MD, discusses the overaggressive use of these treatments. He states, “The higher periprocedural complication rates and more limited life expectancy seen in patients undergoing CEA [carotid endarterectomy] or CAS [carotid artery stenting] in community practice greatly reduces or eliminates the potential long-term benefits of revascularization, especially among asymptomatic patients.”

Dr. Halm also points out very significant geographical variations. For example, per the latest available statistics, nine times more endarterectomies are done in Beaumont, Texas—the area with the highest usage rates—than in Honolulu, Hawaii, which has the lowest. And the carotid stenting procedure rate in St. Joseph, Michigan, is eight times the national average.

Medicare-age people in Beaumont and St. Joseph are no different from folks anywhere else—but the physicians in these areas sure are. According to Dr. Halm, “The ‘enthusiasm’ hypothesis appears to be the leading explanation. This theory posits that variations are due to the distribution of physicians in a given area that are advocates of a procedure. Health care provider enthusiasm can be driven by similarly trained physicians or a local practice style that emphasizes intervention or new technologies, as well as market ‘supply’ forces like the prevalence of physicians and hospitals who perform CEA and CAS. Prior work found that areas of high CEA use had 6-fold greater rates of high-volume surgeons.”

My Advice to You

If you or a loved one is recommended to have a carotid artery procedure, I suggest you do two things. First, if you’re 70 or older, say no to stenting. Second, ask your physician about the pros and cons of carotid endarterectomy and stenting compared to treatment with medications alone. Specifically, request scientifically documented information that indicates if you were to follow a conservative course, your risk of having a stroke or dying within four months would be greater than 1 in 17, as it is for endarterectomy, or 1 in 8, the stat for stenting.

Your request is a simple, honest one. But don’t expect to get a simple, honest answer. You will probably be told that by refusing therapy, you’re asking for a stroke, your life will be destroyed, you may not last a year—and that he “believes” the procedure is your best chance. This is, at best, dishonest and, at worst, systematically and predictably debilitating and deadly.

We’ve seen thousands of patients over the years at Whitaker Wellness who were told they would have a heart attack or stroke or even die if they didn’t submit to a “necessary” treatment. Yet, here they are years later, alive and well—despite having chosen a “dangerous” conservative approach of appropriate drugs, nutrition, exercise, supplements, and other noninvasive therapies.

Recommendation

• If you’ve been told you need carotid endarterectomy or stenting, ask the questions suggested above and get a second opinion. For information on stroke prevention and treatment at the Whitaker Wellness Institute, call (866) 944-8253.

References

• Halm EA. The good, the bad, and the about-to-get ugly: national trends in carotid revascularization. Arch Intern Med. 2010;170(14):1225–1227.
• Carotid Stenting Trialists’ Collaboration. Short-term outcome after stenting versus endarterectomy for symptomatic carotid stenosis: a preplanned meta-analysis of individual patient data. Lancet. 2010 Sep 9. [Epub ahead of print]
• Patel MR, et al. Geographic variation in carotid revascularization among Medicare beneficiaries, 2003–2006. Arch Intern Med. 2010 Jul 26;170(14):1218–1225.

Modified from Health & Healing with permission from Healthy Directions, LLC. Photocopying, reproduction, or quotation strictly prohibited without written permission from the publisher. To subscribe to Health & Healing, click here.