Editor's Choice - Risk of Stroke before Revascularisation in Patients with Symptomatic Carotid Stenosis: A Pooled
Urs Fisch1, Stefanie von Felten2, Andrea Wiencierz3
1Department of Neurology and Stroke Centre, Department of Clinical Research, University Hospital, University of Basel, Basel, Switzerland.
Insights
Patients with symptomatic carotid stenosis awaiting revascularization had a lower stroke risk in recent trials compared to historical controls. Modern medical therapy may reduce the need for urgent intervention, warranting further study.
Area of Science:
- Neurology
- Cardiovascular Medicine
- Clinical Trials
Background:
- Current guidelines for symptomatic carotid stenosis favor rapid revascularization.
- These guidelines are based on older data where medical therapy was less effective.
- The risk of stroke in patients awaiting intervention needs re-evaluation with modern treatments.
Purpose of the Study:
- To assess stroke risk in patients with symptomatic carotid stenosis awaiting revascularization.
- To compare stroke risk in recent randomized controlled trials (RCTs) versus earlier RCTs.
- To evaluate predictors of stroke in this patient population.
Main Methods:
- Pooled individual patient data from four recent RCTs (stenting vs. endarterectomy) and three earlier RCTs (endarterectomy vs. medical therapy).
- Primary outcome: stroke between randomization and 120 days post-randomization.
- Analysis included patients randomized to medical therapy or awaiting intervention.
Main Results:
- 4,754 patients in recent trials and 1,227 in earlier trials were analyzed.
- In recent trials, 1.97% of patients experienced stroke while awaiting revascularization.
- Stroke risk was significantly lower in recent trials compared to earlier trials (HR 0.47, p=0.019) after adjustments.
Conclusions:
- Patients with symptomatic carotid stenosis in recent RCTs had a lower post-randomization stroke risk than historical controls.
- The benefit of carotid revascularization alongside modern medical care requires further investigation.
- Current recommendations for early revascularization remain advisable for indicated patients.
Objective:
Current guidelines recommending rapid revascularisation of symptomatic carotid stenosis are largely based on data from clinical trials performed at a time when best medical therapy was potentially less effective than today. The risk of stroke and its predictors among patients with symptomatic carotid stenosis awaiting revascularisation in recent randomised controlled trials (RCTs) and in medical arms of earlier RCTs was assessed.
Methods:
The pooled data of individual patients with symptomatic carotid stenosis randomised to stenting (CAS) or endarterectomy (CEA) in four recent RCTs, and of patients randomised to medical therapy in three earlier RCTs comparing CEA vs. medical therapy, were compared. The primary outcome event was any stroke occurring between randomisation and treatment by CAS or CEA, or within 120 days after randomisation.
Results:
A total of 4 754 patients from recent trials and 1 227 from earlier trials were included. In recent trials, patients were randomised a median of 18 (IQR 7, 50) days after the qualifying event (QE). Twenty-three suffered a stroke while waiting for revascularisation (cumulative 120 day risk 1.97%, 95% confidence interval [CI] 0.75 - 3.17). Shorter time from QE until randomisation increased stroke risk after randomisation (χ2 = 6.58, p = .011). Sixty-one patients had a stroke within 120 days of randomisation in the medical arms of earlier trials (cumulative risk 5%, 95% CI 3.8 - 6.2). Stroke risk was lower in recent than earlier trials when adjusted for time between QE and randomisation, age, severity of QE, and degree of carotid stenosis (HR 0.47, 95% CI 0.25 - 0.88, p = .019).
Conclusion:
Patients with symptomatic carotid stenosis enrolled in recent large RCTs had a lower risk of stroke after randomisation than historical controls. The added benefit of carotid revascularisation to modern medical care needs to be revisited in future studies. Until then, adhering to current recommendations for early revascularisation of patients with symptomatic carotid stenosis considered to require invasive treatment is advisable.
