Two Stroke-Prevention Procedures Equally Safe

A published report provides the final details on how two stroke-prevention procedures are safe and equally beneficial for men and women at risk for stroke, though their effectiveness does vary by age, say researchers at the University of Alabama at Birmingham School of Public Health in collaboration with other North American stroke investigators.

In findings reported online in The New England Journal of Medicine, the researchers say the age of patients made a difference in comparing the two prevention procedures, and physicians should consider this and many other factors when tailoring their treatment plans for patients at risk for stroke.

Carotid Revascularization Endarterectomy vs. Stenting Trial (CREST) compares endarteroctomy, a surgical procedure to clear blocked blood flow and prevent stroke, with carotid stenting, a newer procedure that involves threading a stent and expanding a small protective device in the artery to widen the blocked area and capture dislodged plaque.

The overall safety and efficacy of the two procedures essentially is the same with equal benefits for men and women, for patients who previously have had a stroke and for those who have not, researchers say. The most notable finding in the study is the role of patient age in accounting for differences in treatment outcomes, says George Howard, DrPH, chair of biostatistics in the School of Public Health and a CREST coinvestigator.

CREST investigators did see more heart attacks in the surgical group, 2.3% compared with 1.1% in the stenting group, and they did see more strokes in the stenting group, 4.1% vs. 2.3% for the surgical group in the weeks following the procedure. Overall the study found a lower stroke rate following surgery and a lower heart attack rate after stenting a year after their procedure.

“The age-difference issue is one of the most important findings of the study, though the two treatments really were practically identical in their benefit of patients at age 70," Howard says. “At younger and younger ages, the benefit of stenting became better and better than surgery. However, this benefit of stenting was offset by better outcomes of surgery at older and older ages.”

Because people with carotid atherosclerosis also usually have atherosclerosis in the coronary arteries that supply the heart, the CREST trial tracks the rate of heart attacks, in addition to stroke and death. The average age of CREST patients is 69.

In CREST, approximately one half of the 2,502 patients had recent symptoms due to carotid disease such as a minor stroke, often called a transient ischemic attack, indicating a high risk for future stroke. The other half of patients had no symptoms, but they were found to have narrowing of the carotid artery on one of a variety of tests assessing stroke risk.

Source: University of Alabama at Birmingham