To the Editor.
—The authors and collaborators of the ACAS1 are to be congratulated for rigorously conducting and analyzing a very important study. Indeed, even before its publication in JAMA, the results of this study were widely reported in the lay press and, if the three busy hospitals in which I practice are representative, widely embraced by neurologists and surgeons alike.However, several points should be emphasized. First, in calculating the primary end point, the 1.2% arteriographic stroke rate should have been applied to all 825 patients randomized to surgery, not just the 414 patients who received postrandomization arteriography or even the 724 patients who received carotid endarterectomy. This would of course decrease slightly the apparent benefit of surgery. Second, the end point of greatest interest (to the patient) is any stroke or death, because the patient who sustains this complication will care little that it was neither perioperative