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Published on: February 16, 2011
Periprocedural Stroke and Myocardial Infarction as Risks for Long-Term Mortality in CREST
Michael R Jones1, George Howard2, Gary S Roubin3
1Department of Cardiology, Baptist Health Lexington, KY (M.R.J.).
Insights
Periprocedural stroke in the CREST trial significantly increases early mortality risk. Periprocedural myocardial infarction (MI) or biomarker-only events increase both early and late mortality risk over 10 years.
Area of Science:
- Cardiovascular medicine
- Neurology
- Clinical trials
Background:
- The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) previously identified increased mortality up to 4 years post-procedure for patients experiencing periprocedural stroke or cardiac events.
- This analysis extends the CREST trial's follow-up to 10 years to further evaluate long-term mortality risks associated with these events.
Purpose of the Study:
- To assess the 10-year mortality risk associated with periprocedural stroke, myocardial infarction (MI), or biomarker-only events following carotid revascularization procedures.
- To differentiate the temporal patterns of mortality risk (early vs. late) for different types of periprocedural events.
Main Methods:
- Utilized proportional hazards models to analyze 10-year mortality data from the CREST randomized controlled trial.
- Compared mortality risk in patients with and without periprocedural stroke, protocol MI, or biomarker-only events.
Main Results:
- Periprocedural stroke was associated with a 1.74-fold increased risk of death over 10 years, primarily driven by early mortality (0-90 days).
- Periprocedural MI conferred a 3.61-fold increased risk of death, with significant increases in both early and late mortality.
- Biomarker-only events showed a 2.04-fold increased overall mortality risk, with significant early risk and a suggestive increase in late risk.
Conclusions:
- Periprocedural events in the CREST trial are linked to substantial 10-year mortality increases.
- Stroke-related mortality risk is concentrated in the early post-procedure period.
- Myocardial infarction and biomarker-only events are associated with sustained increased mortality risk throughout the 10-year follow-up period, highlighting the need for strategies to mitigate these events and manage cardiac complications.
Background:
The Carotid Revascularization Endarterectomy versus Stenting Trial (CREST) previously reported increased mortality in patients who sustained a periprocedural stroke or cardiac event (myocardial infarction [MI] or biomarker only) in follow-up to 4 years. We now extend these observations to 10 years.
Methods And Results:
CREST is a randomized controlled trial designed to compare the outcomes of carotid stenting versus carotid endarterectomy. Proportional hazards models were used to assess the association between mortality and periprocedural stroke, MI, or biomarker-only events. For 10-year follow-up, patients with periprocedural stroke were at 1.74× the risk of death compared with those without stroke (adjusted hazard ratio [HR]=1.74; 95% CI, 1.21-2.50; P<0.003). This increased risk was driven by increased early (between 0 and 90 days) mortality (adjusted HR=14.41; 95% CI, 5.33-38.94; P<0.0001), with no significant increase in late (between 91 days and 10 years) mortality (adjusted HR=1.40; 95% CI, 0.93-2.10; P=0.11). Patients with a protocol MI were at 3.61× increased risk of death compared with those without MI (adjusted HR=3.61; 95% CI, 2.28-5.73; P<0.0001), with an increased hazard both early (adjusted HR=8.20; 95% CI, 1.86-36.2; P=0.006) and late (adjusted HR=3.40; 95% CI, 2.09-5.53; P<0.0001). Patients with a biomarker-only event were at 2.04× increased risk overall (adjusted HR=2.04; 95% CI, 1.09-3.84; P=0.03) than those without MI, with an increased early hazard (adjusted HR=8.44; 95% CI, 1.09-65.5; P=0.04) and a suggestive but nonsignificant association toward higher 91-day to 10-year risk (1.88; 95% CI, 0.97-3.64; P=0.062) contributing to the increased risk.
Conclusions:
In the CREST trial, patients with periprocedural events demonstrate a substantial increase in future mortality to 10 years. For stroke, this risk is largely confined to an early time frame while periprocedural MI or biomarker-only events confer a continuous increased mortality for 10 years. Strategies to reduce periprocedural events and to optimize the evaluation and management of patients with cardiac events should be considered in efforts to reduce not only early but also long-term mortality.
Clinical Trial Registration:
URL: https://www.clinicaltrials.gov . Unique identifier: NCT00004732.
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