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To the Editor: The National Stroke Association (NSA) guidelines on prevention of a first stroke address an important public health problem.¹ However, the statements in the article regarding the value of carotid endarterectomy (CE) for patients with asymptomatic stenosis are highly suspect.

The guidelines state that CE is useful in individuals with asymptomatic carotid narrowing of greater than 60% if the surgery can be performed with a morbidity and mortality rate of less than 3%. This claim is based on a single study, the Asymptomatic Carotid Atherosclerosis Surgery (ACAS) trial, of dubious generalizability.² The ACAS enrolled only select, low-risk patients. Twenty-five patients were screened clinically and from ultrasound laboratories for every 1 patient entered in the study. In addition, the surgeons in ACAS were vetted for excellence in their work: they had to provide evidence of a recent complication rate of less than 3%. Indeed, one third of the surgeons . . . [Full Text of this Article]

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