Factors associated with mortality in patients with asymptomatic carotid stenosis: results from the ACSRS Study
S K Kakkos1, A Nicolaides, M Griffin
1Department of Vascular Surgery, Imperial College, London, UK.
Insights
Identifying risk factors for mortality in asymptomatic carotid stenosis is crucial. Age, male gender, cardiac failure, and ECG findings predict higher risk, while antiplatelet therapy reduces it.
Area of Science:
- Cardiovascular Medicine
- Neurology
- Vascular Surgery
Background:
- Asymptomatic carotid stenosis (ACS) poses a significant risk for stroke and cardiovascular events.
- Accurate risk stratification is essential for guiding management decisions in patients with ACS.
Purpose of the Study:
- To determine the independent predictors of mortality in patients with asymptomatic internal carotid artery stenosis (>50%).
Main Methods:
- A cohort of 1,101 patients with ACS underwent duplex scanning for stenosis grading.
- Clinical and biochemical risk factors were recorded, and patients were followed for a median of 38 months.
- Endpoints included ipsilateral ischemic stroke, cardiovascular death, and all-cause mortality.
Main Results:
- Cox multivariate analysis identified age, male gender, cardiac failure, left ventricular hypertrophy (ECG), and myocardial ischemia (ECG) as independent predictors of increased mortality.
- Antiplatelet therapy was associated with a decreased risk of mortality.
- A high-risk group (1/3 of patients) had a 7-year all-cause mortality of 66%, compared to 21% in the low-risk group (P<0.0001).
- Ipsilateral stroke rates were similar between high-risk (13%) and low-risk (12%) groups.
Conclusions:
- Risk stratification models can identify high-risk patients with ACS, enabling targeted interventions.
- Findings should inform randomized controlled trials evaluating carotid endarterectomy or stenting for ACS.
- Refining indications for intervention in ACS may improve patient outcomes.
Aim:
This study determines the factors associated with mortality in patients with asymptomatic carotid stenosis.
Methods:
Patients (n=1,101) with asymptomatic internal carotid artery stenosis greater than 50% in relation to the bulb diameter were followed up for a period of 6 to 84 (median 38) months. Stenosis was graded using duplex scanning and expressed as a percentage of the carotid bulb diameter. Clinical and biochemical risk factors were recorded. The end-points were ipsilateral ischemic stroke, cardiovascular death and all cause mortality.
Results:
In a Cox multivariate analysis 6 factors emerged as independent predictors of risk. Age, male gender, cardiac failure, left ventricular hypertrophy on electrocardiogram (ECG) and myocardial ischemia on ECG were associated with increased risk. Antiplatelet therapy was associated with decreased risk. Based on these risk factors a high-risk group consisting of one third of the population with a 40% cumulative cardiovascular death rate and a 66% all cause death rate at 7 years could be identified. The remaining 2/3 consisted of a low-risk group with a 10% cumulative cardiovascular death rate and a 21% all cause death rate at 7 years (P<0.0001 compared to the high risk group). There was not any significant difference in the cumulative ipsilateral stroke rate, which was 12% in the low and 13% in the high cardiovascular risk group (Log Rank P>0.05).
Conclusions:
The methodology and findings from the ACSRS natural history study need to be applied to randomized controlled trials on the value of carotid endarterectomy or stenting in patients with asymptomatic carotid stenosis. They may help refine the indications for intervention in patients with carotid endarterectomy.
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