Racial and Ethnic Variation in Carotid Artery Revascularization

Study Questions:

What are the utilization and outcomes of carotid artery stenting (CAS) and carotid endarterectomy (CEA) across racial/ethnic groups?

Methods:

The investigators compared the utilization and outcomes of CAS and CEA across racial/ethnic groups within the CARE Registry between May 2007 and December 2012. The CARE Registry is a comprehensive national registry of patients undergoing both CAS and CEA. Hierarchical adjusted logistic regression was used to produce odds ratios and 95% confidence intervals.

Results:

Between 2007 and 2012, of the 13,129 patients who underwent CAS, the majority were non-Hispanic whites (89.3%), followed by blacks (4.4%), Hispanics (4.3%), and other groups (2.0%). A similar distribution was observed among the 10,953 patients undergoing CEA (non-Hispanic whites, 92.6%; blacks, 3.5%; Hispanics, 2.8%; and other groups, 1.1%). During this time period, a trend toward a proportionate increase in CAS utilization was observed in non-Hispanic whites and other groups, whereas the opposite was observed among Hispanics and blacks. This trend persisted even when hospitals performing both CAS and CEA were exclusively analyzed. Adherence to antiplatelet and statin therapy was significantly lower among blacks post-CEA. In-hospital major adverse cardiac and cerebrovascular events (MACCE) remained comparable across groups post-CAS and CEA. At 30 days, the incidence of stroke (7.2%) and MACCE (8.8%) was higher among blacks post-CEA (p < 0.05), after risk adjustment.

Conclusions:

The authors concluded that utilization of CAS and CEA was highest among non-Hispanic whites with a trend toward increased CAS utilization over time among non-Hispanic whites and other groups, and a trend toward increased CEA utilization among Hispanics and blacks.

Perspective:

This large multicenter, multidisciplinary national registry of patients who underwent carotid revascularization reports a significant shift from CEA toward CAS in non-Hispanic whites and other groups including American Indians and Asians, but from CAS to CEA for blacks and Hispanic populations. At 30-day follow-up, the risk of stroke or MACCE was no different across groups after CAS, but was significantly higher for the black population after CEA, a risk that was also substantially higher than that observed for blacks after CAS. These variations call for additional studies to better understand the reasons behind differential utilization and outcomes, and optimization of processes to improve outcomes.

Clinical Topics: Cardiac Surgery, Dyslipidemia, Invasive Cardiovascular Angiography and Intervention, Vascular Medicine, Nonstatins, Novel Agents, Statins, Interventions and Vascular Medicine

Keywords: African Americans, Carotid Stenosis, Endarterectomy, Carotid, Ethnic Groups, Hispanic Americans, Hydroxymethylglutaryl-CoA Reductase Inhibitors, Myocardial Revascularization, Platelet Aggregation Inhibitors, Stents, Stroke


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