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Randomized Controlled Trial
. 2018 Nov;11(11):e004663.
doi: 10.1161/CIRCOUTCOMES.117.004663.

Periprocedural Stroke and Myocardial Infarction as Risks for Long-Term Mortality in CREST

Michael R Jones  1 , George Howard  2 , Gary S Roubin  3 , Joseph L Blackshear  4 , David J Cohen  5 , Donald E Cutlip  6 , Pierre P Leimgruber  7 , David Rhodes  2 , Ronald J Prineas  8 , Stephen P Glasser  9 , Brajesh K Lal  10 , Jenifer H Voeks  11 , Thomas G Brott  12 ; CREST Investigators
Affiliations
Randomized Controlled Trial

Periprocedural Stroke and Myocardial Infarction as Risks for Long-Term Mortality in CREST

Michael R Jones et al. Circ Cardiovasc Qual Outcomes. 2018 Nov.

Abstract

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.

Keywords: cerebrovascular disease; mortality; myocardial infarction; stroke; survival.

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Conflict of interest statement

DISCLOSURES

Dr. Cohen reports research grant support from Medtronic, Abbott Vascular, and Boston, Scientific as well as consulting income from Medtronic. The other authors report no conflicts.

Figures

Figure 1.
Figure 1.
Kaplan-Meier curves depicting all-cause mortality from revascularization (CEA and CAS) to 10 years in patients without (black line) and with (red line) periprocedural stroke.
Figure 2.
Figure 2.
Kaplan-Meier curves depicting all-cause mortality from revascularization (CEA and CAS) to 10 years in patients without cardiac events (black line), with biomarker only events (green line), and with protocol MI (red line).
See this image and copyright information in PMC

Comment in

References

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