MI risk an ‘important consideration’ in carotid disease management
MedWire News: Myocardial infarction (MI), whether clinical or detectable only as biomarker elevation, predicts mortality after carotid intervention, report the CREST investigators.
This suggests that "individualized patient risk for such events may be an important consideration in the choice of CAS [carotid artery stenting] or CEA [carotid endarterectomy] and the choice of carotid revascularization or medical therapy," say Thomas Brott (Mayo Clinic, Jacksonville, Florida, USA) and team.
CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) showed an increased risk for stroke after CAS but a higher risk for MI after CEA, versus the alternative procedure.
Cardiac biomarkers were assessed in 88% of the 2502 patients in the study, revealing subclinical MI in eight CAS patients and 12 who were assigned to CEA. In addition, 14 patients in the CAS group and 28 in the CEA group had a clinical MI within 30 days of the procedure.
During 4 years of follow-up, patients who suffered MI, whether clinical or subclinical, were 3.67 times more likely to die than were those with no evidence of MI. This association was independent of confounders including age, diabetes, and history of cardiovascular disease.
The increased mortality risk was also evident for patients with subclinical MI only, the team reports in the journal Circulation. This conferred a 2.87-fold increase in risk relative to normal cardiac biomarker levels, after accounting for confounders.
In an accompanying editorial, Scott Kinlay (Veterans Affairs Boston Healthcare System, Massachusetts, USA) highlighted the "major deficiency" in current knowledge of managing patients with carotid artery disease - that of the effect of optimal modern medical therapy.
Advances in optimal medical therapy since it was first tested against carotid surgery have probably reduced the relative benefits of revascularization, he said.
"In clinical practice, the balance of risks may require true grit on the part of operators and surgeons to refer to other specialties or decline revascularization in favor of optimal medical therapy alone," said Kinlay.
"As a profession, the future of carotid revascularization depends on our courage to test optimal medical therapy with and without revascularization in randomized trials against mechanistic and patient-orientated outcomes."
MedWire (www.medwire-news.md) is an independent clinical news service provided by Springer Healthcare Limited. © Springer Healthcare Ltd; 2011
By Eleanor McDermid