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Myocardial Infarction After Carotid Stenting and Endarterectomy: Results From the Carotid Revascularization Endarterectomy Versus Stenting Trial
Study Questions:
What is the incidence and implication of myocardial infarction (MI) in patients undergoing carotid revascularization?
Methods:
The authors reported the incidence and implications of MI in patients who underwent carotid artery stenting (CAS) or carotid endarterectomy (CEA) in the CREST trial. Cardiac biomarkers and electrocardiograms (ECGs) were performed before and 6-8 hours after carotid revascularization, and if there was clinical evidence of ischemia. MI was defined as biomarker elevation plus either chest pain or ECG evidence of ischemia. The authors also evaluated the subgroup of patients who had biomarker elevation without chest pain or ECG abnormality (isolated biomarker elevation).
Results:
There were 14 MIs among patients randomized to CAS and 28 MIs among those randomized to CEA (hazard ratio [HR], 0.50; 95% confidence interval [CI], 0.26-0.94; p = 0.032). Of the MIs, one occurred after randomization but before the index procedure, 29 occurred within 24 hours of the initial carotid revascularization procedure, nine occurred between 2 and 7 days after carotid revascularization, and three occurred between 8 and 30 days after carotid revascularization. There were two ST elevation MIs, with one in each arm. Twenty patients had biomarker elevation only (8 in the CAS arm and 12 in the CEA group; HR, 0.66; 95% CI, 0.27-1.61; p = 0.36). The median biomarker elevation was 14 times the upper limit of normal compared with a 40 times the upper limit of normal in those with an adjudicated MI. Compared with patients without biomarker elevation, an increase in long-term mortality was seen with MI (HR, 3.40; 95% CI, 1.67-6.92) or isolated biomarker elevation (HR, 3.57; 95% CI, 1.46-8.68). After adjustment for baseline risk factors, both MI and biomarker elevation were independently associated with increased mortality.
Conclusions:
Patients undergoing CAS are at a lower risk of MI compared with those undergoing CEA. Patients who suffer a postprocedural MI have an exaggerated hazard of long-term mortality.
Perspective:
The lower risk of MI with CAS compared with CEA has been a consistent finding in multiple studies (Meier P, et al., BMJ 2010;340:c467). While MI in these patients is associated with an increase in long-term risk of death, there was no difference in the long-term risk of death between patients treated with either strategy, and the choice of revascularization should be determined by a careful consideration of a given patient’s risk with either procedure and informed patient choice.
Keywords: Myocardial Infarction, Biomarkers, Chest Pain, Endarterectomy, Carotid, Risk Factors, Carotid Arteries, Electrocardiography, Stents
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