It sounds like the ultimate trick question, where the correct answer is, of course, C: none of the above.
But the choice between stroke, myocardial infarction (MI), or another cardiovascular end point, such as need for revascularization, is something now faced by patients confronted by at least a couple of somewhat different clinical situations where treatment of their vascular disease could be done by either endovascular stenting or open surgery. (Sometimes the third option is medical management and no surgery, but these are cases too advanced for medicine alone to work).
One of these situations is severe carotid artery stenosis (especially when the patient already had a stroke or transient ischemic attack). Last year, results from CREST, the largest randomized study to compare the two main treatment options for these patients, cartoid artery stenting or open surgery by endarterectomy, showed that overall the two treatments led to similar 4-year outcomes based on the cumulative rate of death, stroke, or MI. But more detailed results, hinted at in last year’s report and then expanded on earlier this month at the International Stroke Conference, showed that the choice is a lot more nuanced, and in many ways boils down to what a patient would rather risk, having a MI or stroke. Carotid-artery stenting produced more strokes, especially in women and older patients (65 or older). Carotid endarterectomy produced more MIs, especially in men.
The gut reaction has generally been to regard strokes as a worse outcome, but now other new data from CREST, also reported at the stroke conference, prove it’s true. Dr. Joshua M. Stolker reported on the health-status outcomes from CREST. In part, this showed that CREST patients who had a stroke following their intervention had significant decrements in seven of eight quality-of-life measures on the Short Form-36, compared to a decrement in just one SF-36 measure among the patients who had a MI. Patients with major strokes had decrements in all eight subdomains, but even patients with minor strokes had significant decrements in three or four subdomains, so even a minor stroke was quantitatively worse for patients, on average, than a MI.
The analysis “confirmed what a lot of us already suspected,” Dr. Stolker said when he gave his report.
The stroke or MI choice seen in CREST was reminiscent of the results seen in 2009 from the SYNTAX trial, the most recent study to compared coronary artery bypass surgery with coronary stenting. Interesting, in SYNTAX the adverse event profile was somewhat flipped. In this case it was the CABG patients who underwent open surgery who had a significantly increased rate of stroke during follow-up compared with stented patients. The excess risk faced by patients treated with the endovascular intervention was an increased rate of a need for revascularization therapy down the road.
As far as I know, no follow-up study examined the health impact of the strokes that occurred in SYNTAX and the impact of revascularization, but it’s hard to imagine that the result would be different from what was found in CREST. A stroke is a stroke, and a nasty outcome for patients regardless of their medical history.
—Mitchel Zoler (on Twitter @mitchelzoler)